reglab/statecodes huggingface dataset:
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.12 - Delivery of Policies and Notices

Current through Rules and Regulations filed through June 27, 2024
Any policies, certificates, booklets, termination notices, or
				  other written communications delivered by the participating carrier to the
				  health plan purchasing cooperative for delivery to its policyholders or
				  certificate holders shall be delivered by the health plan purchasing
				  cooperative promptly after receipt of instructions from the carrier to deliver
				  them.
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-5,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.13 - Notification Required

Current through Rules and Regulations filed through June 27, 2024
The health plan purchasing cooperative shall provide, upon
				  enrollment, a written notice approved by the participating carrier, to
				  individuals covered by such carrier, advising them of the identity of and
				  relationship between the health plan purchasing cooperative, the member
				  employer, and the carrier. Where a health plan purchasing cooperative collects
				  funds, it must identify and state separately in writing to the member or person
				  paying any charge or premium for health benefit plan coverage, the amount of
				  any such charge or premium specified by the carrier for such coverage, and
				  separately, the amount charged for administrative fees by the health plan
				  purchasing cooperative.
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-5,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.14 - Areas of Service

Current through Rules and Regulations filed through June 27, 2024
(1) As part of its application for a
				certificate of authority, a health plan purchasing cooperative shall file with
				the Commissioner a description of the entire service area of the health plan
				purchasing cooperative. All changes to a service area shall be filed for
				approval with the Commissioner at least sixty (60) days prior to such effective
				change.
(2) A health plan
				purchasing cooperative serving any part of a single metropolitan statistical
				area in Georgia, as most recently defined and established by the U.S. Office of
				Management and Budget, shall serve every county which is either entirely or
				partially located within such single metropolitan statistical area. A health
				plan purchasing cooperative may serve contiguous counties outside of the single
				metropolitan statistical area; however:
(a) If
				such contiguous county is located in another single metropolitan service area
				not served by the health plan purchasing cooperative (regardless of whether or
				not it is part of a consolidated metropolitan statistical area), the health
				plan purchasing cooperative may not serve such county unless it serves the
				entire single metropolitan statistical area in which it is located;
				and
(b) If such contiguous county
				is partially located in the single metropolitan service area served by the
				health plan purchasing cooperative, and partially located in another single
				metropolitan service area not served by the health plan purchasing cooperative,
				the health plan purchasing cooperative may then serve only the entire
				contiguous county that is partially in each single metropolitan service
				area.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.15 - Choice of Health Benefit Plans; Enrollment

Current through Rules and Regulations filed through June 27, 2024
(1) A health plan purchasing cooperative
				shall contract with at least two (2) unaffiliated carriers with Certificates of
				Authority from the Commissioner for participation in the health plan purchasing
				cooperative to ensure that employers and enrollees have a choice from among a
				reasonable number of competing carriers and types of health benefit plans. The
				Commissioner may, upon a demonstration of good cause by the health plan
				purchasing cooperative, waive the requirement to have at least two (2)
				unaffiliated participating carriers throughout any or all portions of the
				health plan purchasing cooperative's service area.
(2) A health plan purchasing cooperative may
				establish criteria relating to choice of health benefit plans offered by the
				health plan purchasing cooperative. Provided that the criteria is consistent
				and uniform with regard to market type, a health plan purchasing cooperative
				may require each member of a specific market type to choose one plan for all
				eligible employees, or may permit all eligible employees of all members of a
				specific market type to choose one plan out of all plans offered by the health
				plan purchasing cooperative, or may permit any additional limitations by
				members on employee choice of health benefit plans, provided that such
				limitations apply consistently to all members in a specific market type without
				regard to health status related factors.
(3) Criteria described in paragraph (2) of
				this Rule shall include procedures for annual or rolling open enrollment
				periods in which members or employees may elect to enroll in any health benefit
				plan available through the health plan purchasing cooperative. Such criteria
				shall describe enrollment procedures for newly eligible employees and late
				entrants, and shall demonstrate compliance with Rule 120-2-67 regarding
				crediting of prior coverage.
(4)
				Health plan purchasing cooperatives, subject to any written agreement with a
				participating carrier or licensed third-party administrator to the contrary,
				shall be responsible for the issuance of certifications of creditable coverage
				pursuant to Rule
				120-2-67-.12.
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-5,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.16 - Additional Powers of and Restrictions on Purchasing Cooperative

Current through Rules and Regulations filed through June 27, 2024
(1) A health plan
				purchasing cooperative may do any of the following:
(a) Set reasonable fees, which may vary by
				employer size, for membership in the health plan purchasing cooperative that
				will finance reasonable and necessary costs incurred in administering the
				health plan purchasing cooperative;
(b) Contract with independent third parties
				licensed by the Commissioner for any service necessary to carry out the powers
				and duties authorized or required by Title 33, Chapter 30A of the Official Code
				of Georgia and this Regulation Chapter;
(c) Contract with licensed insurance agents
				to market and service health benefit plans made available through the health
				plan purchasing cooperative to its members, provided that compensation for
				agents shall not vary based on the actual or expected experience or health
				status of the member or persons to which coverge is sold;
(d) Establish written standards to be met by
				participating carriers, including but not limited to benefit design, access,
				quality assurance, data collection, and cost, and accept or reject proposals
				from carriers for participation in the health plan purchasing cooperative based
				on such articulated standards, provided that carriers shall be responsible for
				determining the benefits, rates and underwriting criteria applicable to health
				benefit plans and for securing reinsurance, if any;
(e) Negotiate with participating carriers the
				administrative expense component of the premium rates charged for coverage
				offered through the health plan purchasing cooperative;
(f) Provide other services to members
				pursuant to O.C.G.A. § 33- 30A-2(b) provided that any insurance coverage
				offered by the health plan purchasing cooperative shall have complied with all
				applicable requirements of Title 33 of the Official Code of Georgia;
				and
(g) Establish written standards
				with participating carriers for the intake, processing, and resolution of
				member grievances pertaining to a health benefit plan and addressed or appealed
				to the health plan purchasing cooperative.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.17 - Rating

Current through Rules and Regulations filed through June 27, 2024
(1) Small Employer
				Rating Requirements. Participating carriers offering coverage to small
				employers through a health plan purchasing cooperative must comply with the
				rating requirements of Rule
				120-2-10-.12(5)
				and must consistently use the same set of rating factors otherwise used for
				small group health insurance coverage issued outside of a health plan
				purchasing cooperative in developing rates for health benefit plans issued or
				renewed through the health plan purchasing cooperative. Small employer members
				shall be considered small groups, and experience from health benefit plans
				issued by a participating carrier to small employer members of a health plan
				purchasing cooperative shall be part of that carrier's small group pool.
				Participating carriers shall adhere to every provision of Rule
				120-2-10-.12(5) in
				the following manner, unless specifically directed otherwise by the following:
(a) Every small employer member covered by a
				participating carrier shall be treated as a small group for purposes of Rule
				120-2-10-.12(5),
				in which premiums for small employers are based on pool rates and deviated by
				any of the allowable factors, and individual employees are subject to premium
				quotes made for each small employer; or
(b) In lieu of subparagraph (a), all rates
				for use with all employees and dependents of employees of small employer
				members in a health plan purchasing cooperative may be developed on a composite
				basis for factors specified in Rule
				120-2-10-.12(5)(b),
				provided that:
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.18 - Contribution and Participation Rules

Current through Rules and Regulations filed through June 27, 2024
(1) A health plan purchasing cooperative may
				set contribution rules for members in each market type served by the
				cooperative, which require a minimum percentage of premium contribution from
				each member for each eligible employee or dependent. A health plan purchasing
				cooperative may set separate minimum contribution rules for employees and
				dependents.
(2) A health plan
				purchasing cooperative may set minimum employee participation rules for members
				of each market type served by the cooperative, and shall consistently require
				such minimum participation levels for members of each market type. In any case,
				the minimum participation rule for small employers shall meet the requirements
				of Rule 120-2-10-.12(9).
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.19 - Contracts with Members and Participating Carriers

Current through Rules and Regulations filed through June 27, 2024
(1) Contracts or
				written service agreements between the health plan purchasing cooperative and a
				participating carrier shall:
(a) Establish,
				on a consistent and uniform basis, a policyholder, which shall be either the
				health plan purchasing cooperative or each of its members;
(b) Provide that the participating carrier
				will issue a certificate of coverage, or equivalent document, specifying the
				essential features of coverage under the health benefit plan to each enrolled
				employee; and
(c) Specify how all
				premiums will be transmitted, applicable penalties and grace periods for
				payments, and underwriting criteria or other standards pertaining to the
				business underwritten by such carrier in the health plan purchasing
				cooperative.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.20 - Renewability; Termination of Agreement

Current through Rules and Regulations filed through June 27, 2024
(1) For purposes of renewability, health plan
				purchasing cooperatives, members, and participating carriers shall be subject
				to Rule 120-2-67-.09
				with regard to renewability and non-termination of coverage, and coverage under
				a health plan purchasing cooperative shall be considered coverage under a true
				association for such purposes. In particular:
(a) With respect to Rule
				120-2-67-.09, the health plan
				purchasing cooperative shall be considered the policyholder;
(b) The written agreement or contract between
				the health plan purchasing cooperative and participating carriers shall specify
				the terms of renewal and shall define the date of renewal; and
(c) The health plan purchasing cooperative is
				responsible for assuring continuity and renewal of coverage for members under
				Rule 120-2-67-.09
				in the event a participating insurer no longer participates in a health plan
				purchasing cooperative, and shall not exclude a member from coverage under any
				health benefit plan at any time.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.21 - Examination by Commissioner; On-Site Visits

Current through Rules and Regulations filed through June 27, 2024
(1) A health plan purchasing cooperative
				shall, at the request of the Commissioner, respond in writing within fifteen
				(15) working days to any complaint received by the Commissioner concerning the
				health plan purchasing cooperative. If, in the Commissioner's discretion, the
				frequency or severity of such complaints or infractions justify an examination
				of the health plan purchasing cooperative's practices and procedures, any such
				examination by the Commissioner, or any person designated by the Commissioner,
				shall be at the expense of the health plan purchasing cooperative. In addition
				to any other remedy available to the Commissioner, failure by the health plan
				purchasing cooperative to willingly and fully cooperate with this rule may
				result in either suspension, revocation or refusal to renew a certificate of
				authority by the Commissioner.
(2)
				The Commissioner or his or her designated representative is authorized to make
				a complete on-site examination of the affairs of each health plan purchasing
				cooperative as often as is deemed necessary. Whenever the Commissioner shall
				deem it expedient, he or she shall examine, by use of an examiner duly
				authorized by him or her, the affairs, transactions, accounts, records,
				documents, assets, liabilities, of a health plan purchasing cooperative and any
				other facts relative to its business methods, management, and dealings with
				policyholders, certificate holders, and members.
(3) Any health plan purchasing cooperative
				being examined shall provide to the Commissioner or his or her designee
				convenient and free access, at all reasonable hours at their offices, to all
				books, records, documents and other papers relating to the health plan
				purchasing cooperative's business affairs.
(4) At the direction of the Commissioner, the
				health plan purchasing cooperative shall pay the fees and expenses of the
				examination. The examiner shall file a consolidated account for the examination
				with the Commissioner.
(5) Nothing
				in this Rule shall limit or abridge any other investigatory powers of the
				Commissioner vested in him or her by Title 33 of the Official Code of
				Georgia.
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-5,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.22 - Penalties

Current through Rules and Regulations filed through June 27, 2024
Any health plan purchasing cooperative, carrier, agent,
				  representative, officer or employee of such carrier, failing to comply with the
				  requirements of this Regulation Chapter shall be subject to such penalties as
				  may be appropriate under the insurance laws of this State.
O.C.G.A. Secs.
				  33-2-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES › Rule 120-2-79-.23 - Severability

Current through Rules and Regulations filed through June 27, 2024
If any rule or portion of a Rule in this chapter or the
				  applicability thereof to any particular circumstances is held invalid by a
				  court of competent jurisdiction, the remainder of the Rules or the
				  applicability of such provision to other persons or circumstances shall not be
				  affected.
O.C.G.A. Secs.
				  33-2-9,
				  33-30A-5,
				  33-30A-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.01 - Scope

Current through Rules and Regulations filed through June 27, 2024
(1) This Regulation
				Chapter shall apply to licensed insurers, including, but not limited to, health
				maintenance organizations and health care corporations offering managed care
				plans in this State.
(2) Insurers
				with approved or proposed policy contracts containing preferred provider
				arrangements subject to O.C.G.A. Title 33, Chapter 30, Article Two, shall be
				subject to this Regulation Chapter and shall be considered managed care
				entities. Preferred Provider Organization plans shall be subject to the
				provisions of this Regulation Chapter as may be reasonably applied to covered
				benefits and services offered through a managed care entity's contracting,
				participating preferred providers.
(3) Where enrollees of managed care plans
				choose to obtain covered benefits or services outside the panel of contracting
				or preferred providers, a managed care entity shall not be held responsible for
				access, credentialing, quality of care or other issues not under the insurer's
				control because of lack of provider contracting status. Managed care entities
				should disclose plan provisions and limitations regarding benefits, access and
				quality issues in these instances.
(4) Nothing in this Regulation Chapter shall
				be construed to permit any person other than a licensed insurer to offer a
				managed care plan or other insurance product or allow an entity or person to
				transact insurance in this State without a Certificate of Authority as provided
				in O.C.G.A. Title 33, Chapter 3.
(5) Nothing in this Regulation Chapter or
				O.C.G.A. Title 33, Chapter 20A shall be construed to create new classes of
				insurance pursuant to O.C.G.A. §
									33-3-5 or new lines of insurance
				pursuant to Title 33, Chapter 7.
O.C.G.A. Secs.
				  33-2-9,
				  33-3-2,
				  33-3-5,
				  33-20A-3,
				  33-20A-4,
				  33-20A-5.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.02 - Definitions

Current through Rules and Regulations filed through June 27, 2024
Definitions under this Regulation Chapter shall have the
				  meaning as set forth in the Georgia Insurance Code or the Rules and Regulations
				  of the Office of Commissioner of Insurance, unless indicated below:
(a) "Appeal" shall mean a formal request,
				either orally, or in writing or by electronic transmission, to reconsider a
				determination not to certify an admission, extension of stay, or other health
				care service or procedure, and shall include both formal standard appeals and
				expedited appeals.
(b) "Complaint"
				shall mean a communication from the enrollee or member either orally, in
				writing or by electronic transmission concerning dissatisfaction by the
				enrollee or member with the health plan or its providers.
(c) "Grievance Procedure" shall mean a
				hearing provided to the enrollee, pursuant to O.C.G.A. §
									33-20A-5(3)(B)(ii),
				regarding denial of payment in whole or in part for a health care service,
				treatment or claim, following exhaustion of all standard appeals requirements
				contained in O.C.G.A. Title 33, Chapter 46 or the Rules and Regulations of the
				Office of Commissioner of Insurance Chapter 120-2-58.
(d) "Managed Care Contractor" shall have the
				meaning set forth at O.C.G.A. §
									33-20A-3(5)  and
				shall include entities unaffiliated with a managed care entity providing
				network administrative, credentialling, utilization review or medical
				management services for the operation of one or more managed care
				plans.
(e) "Managed Care Entity"
				shall have the meaning set forth at §
									33-20A-3(6)  and
				shall include all insurers, health maintenance organizations, health care
				corporations, multiple employer welfare arrangements, or other entities which
				are subject to licensure by the Commissioner.
(f) "Stabilize", with respect to an emergency
				medical condition, shall mean to provide such medical treatment of the
				condition necessary to assure, within reasonable medical probability, that no
				material deterioration of the condition is likely to result from or occur
				during the transfer of the individual to or from a facility.
O.C.G.A. Secs.
				  33-2-9,
				  33-20A-2,
				  33-20A-4,
				  33-20A-5.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.03 - Application

Current through Rules and Regulations filed through June 27, 2024
(1) Managed care
				entities may make application for a managed care plan or plans to be certified
				under this Regulation Chapter by submitting Form GID PPA-1 with a filing fee of
				$500.00.
(2) The Commissioner shall
				have ninety (90) days after receipt of the application in which to review the
				application. During this period the Commissioner may request additional
				information as necessary. The Commissioner may extend the time in which to
				review an application by contacting the applicant in writing and he or she is
				not required to act on an incomplete application.
(3) Managed care entities with previously
				approved managed care plans in use in this state as of the effective date of
				this Regulation Chapter must submit applications for certification no later
				than ninety (90) days after the effective date of this Regulation Chapter.
				Managed care entities making timely filing of an application for certification
				of previously approved managed care plans may continue to offer such plans
				until the Commissioner determines such plans do not comply with the
				requirements of the Patient Protection Act or this Regulation
				Chapter.
(4) Managed care entities
				making application for certification of managed care plans which are not yet
				approved may not offer such managed care plans until the application for
				certification under this Regulation Chapter is approved and the managed care
				product is approved in accordance with other requirements under O.C.G.A. §
									33-24-9 as well as any other
				applicable laws and Regulation Chapters. This requirement for prior
				certification shall apply to all managed care plans not offered by the
				effective date of this Regulation Chapter.
(5) Within the discretion of the
				Commissioner, managed care entities which have attained accreditation or which
				use managed care contractors accredited by national boards, committees or other
				accepted industry standard setting organizations may satisfy some or all of the
				requirements for certification.
O.C.G.A. Secs.
				  33-2-9,
				  33-20A-2,
				  33-20A-4,
				  33-20A-5.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.04 - Modification of Operation of Plan after Certification

Current through Rules and Regulations filed through June 27, 2024
(1) A managed care
				entity shall file supporting documentation for any substantial modification of
				its managed care plan or plans with the Commissioner. Such documentation shall
				describe changes in operations and update any previous filings made by the
				managed care entity for the affected managed care plan or plans. Substantial
				modification includes, but is not limited to, the following:
(a) Broad substitution, merger or other
				change in hospital, physician network or ancillary services provider or
				network;
(b) Changes in
				subcontracting providers for utilization review or administrative services;
				or
(c) Other changes affecting the
				content, rules or procedures of any of the above entities.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.05 - Reporting Requirements

Current through Rules and Regulations filed through June 27, 2024
(1) Managed care entities with annual and
				quarterly statement requirements which report premiums and claims, enrollment,
				utilization of services, numbers of contracting providers and numbers of
				complaints and grievances shall continue to capture and report this information
				on standard financial and other required reporting formats as they relate to
				managed care plans under this Regulation Chapter.
(2) Managed care entities not subject to
				specific reporting requirements for their managed care plans shall gather and
				prepare such information on a quarterly and annual basis as is necessary to
				capture and report, including, but not limited to:
(a) premiums and claims;
(b) enrollment;
(c) utilization of services; and
(d) numbers of contracting providers;
				and
(e) numbers of complaints and
				grievances.
These reports shall be marked as "Patient Protection Act
				  Statistical Reports" and shall bear the name and NAIC number of the reporting
				  entity, and shall be submitted as supplements to normal quarterly and annual
				  financial reports presently required. The Commissioner, at his or her
				  discretion, may specify additional reporting requirements for managed care
				  plans.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.06 - Emergency Services, Stabilization

Current through Rules and Regulations filed through June 27, 2024
(1) As used in this section, the term
				"emergency services" or "emergency condition" shall have the same meaning as
				set forth in O.C.G.A. §
									33-20A-3(2).
(2) No managed care plan may require, as a
				condition of receiving emergency services, that a covered person seek
				prospective authorization. This prohibition against prior authorization extends
				to such time as the covered person is stabilized for such emergency
				condition.
(3) A managed care
				entity shall include provisions in its managed care plans describing:
(a) Coverage for emergency
				services;
(b) Any out of pocket,
				copayment, or other expenses which may accrue to a covered person;
(c) Provisions for out of network and out of
				service area emergency services;
(d) The terms "authorization" or "prospective
				authorization" as they relate to the covered person, including how such
				authorization procedures will apply and be administered if sought by the
				covered person in an emergency even though not required; and
(e) A covered person's or provider's review
				or appeal rights in accordance with O.C.G.A. Title 33, Chapter 46 and the Rules
				and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58, in
				the event that the managed care entity does not pay for emergency services
				obtained by the covered person.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.08 - Quality Assurance

Current through Rules and Regulations filed through June 27, 2024
(1) A managed care entity shall disclose the
				quality assurance program in effect with documentation specified in Form GID
				PPA-1.
(2) The managed care entity
				must demonstrate, to the satisfaction of the Commissioner, that its quality
				assurance program includes organizational arrangements and ongoing procedures
				for the identification, evaluation, resolution and follow up of potential and
				actual problems in health care administration and delivery to enrollees. The
				program should include, but not be limited to procedures to:
(a) monitor and resolve complaints;
(b) monitor provider performance;
(c) monitor patient satisfaction;
(d) establish appropriate quality indicators
				based on current standards of the relevant health care profession;
(e) meet reasonable thresholds with regard to
				quality indicators;
(f) credential
				network providers according to established standards;
(g) ensure access to network providers by
				maintaining sufficient numbers of primary care physicians and other types of
				providers within the managed care entity's service area; and
(h) detect both under utilization and over
				utilization of services.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.09 - Confidentiality

Current through Rules and Regulations filed through June 27, 2024
A managed care entity shall demonstrate, as provided in Form
				  GID PPA-1, that it has in place procedures designed to assure compliance with
				  all applicable state and federal laws regarding the confidentiality of patient
				  information and reporting requirements.
O.C.G.A. Secs.
				  33-2-9,
				  33-20A-2,
				  33-20A-4,
				  33-20A-5,
				  33-20A-8.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.10 - Examination

Current through Rules and Regulations filed through June 27, 2024
The Commissioner is authorized to examine insurers and other
				  entities in matters related to managed care plans under the Patient Protection
				  Act and this Regulation Chapter.
O.C.G.A. Secs.
				  33-2-9,
				  33-2-11,
				  33-20A-2,
				  33-20A-4,
				  33-20A-5.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.11 - Penalties

Current through Rules and Regulations filed through June 27, 2024
Any person failing to comply with the requirements of this
				  Regulation Chapter shall be subject to such penalties as may be appropriate
				  under the insurance laws of this State.
O.C.G.A. Sec.
				  33-2-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.12 - Severability

Current through Rules and Regulations filed through June 27, 2024
If any section or portion of a section of this rule or the
				  applicability thereof to any person or circumstance is held invalid by a court,
				  the remainder of the rule or the applicability of such portion to other persons
				  or circumstances shall not be affected thereby.
O.C.G.A. Sec.
				  33-2-9.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.01 - Authority

Current through Rules and Regulations filed through June 27, 2024
This Regulation Chapter is issued pursuant to the authority
				  vested in the Commissioner of Insurance by O.C.G.A. §§
									33-2-9 and
				  33-29A-1
et
				  seq.
O.C.G.A. Secs.
				  33-2-9,
				  33-29A-,
et
				  seq.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.02 - Purpose

Current through Rules and Regulations filed through June 27, 2024
The purpose of this Regulation Chapter is to implement
				  O.C.G.A. §
									33-29A-1
et
				  seq.
and related provisions of the federal Health Insurance
				  Portability and Accountability Act of 1996.
O.C.G.A. Secs.
				  33-2-9,
				  33-29A-1,
et
				  seq.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.04 - Georgia Health Insurance Assignment System

Current through Rules and Regulations filed through June 27, 2024
(1) The standard benefit schedules developed
				by the Commissioner in accordance with O.C.G.A. §
									33-29A-4 shall be designated as
				Plan A and Plan B respectively. The model policy form template for Plans A and
				B is designated as Form GHIAS-1, and schedule of benefits for Plans A and B is
				designated as Form GHIAS-S.
(2) A
				health insurer who participates in the Georgia Health Insurance Assignment
				System (GHIAS) must file policy forms necessary for providing the coverage
				required by the GHIAS no later than thirty (30) days following either the
				effective date of this Regulation Chapter, or the date of notice from the
				Commissioner that the health insurer is subject to the provisions of O.C.G.A.
				§
									33-29A-1
et
				seq.
, whichever is later. Coverage provided pursuant to assignment
				by the GHIAS that is effective prior to the approval of the policy form shall
				be subject to the requirements of this Regulation Chapter and shall be amended
				pursuant to any modifications required by the Commissioner for approval of the
				filing. Such coverage made effective prior to approval of filing shall not be
				in violation if the policy form is filed within thirty (30) days as
				required.
(3) Methods of Filing.
(a) A participating health insurer may file
				policy forms prepared in accordance with Form GHIAS-1 and the schedule of
				benefits in Form GHIAS-S . Such policy forms shall be deemed approved upon the
				date the Commissioner receives the filing, provided they conform to the
				template form; or
(b) A
				participating health insurer may file policy forms with contractual language
				substantially similar to the model policy form template for approval, but must
				include the same benefits prescribed in the model policy form template and the
				same schedule of benefits prescribed in Forms GHIAS-1 and GHIAS-S . Such
				filings must include a description which specifically outlines the variances in
				language between the model policy form template and the filed form. A policy
				form filing with variances from the model policy form template prescribed in
				Form GHIAS-1 may not contain any provisions which are less beneficial than the
				relevant template provisions with regard to qualifying eligible individuals or
				eligible dependents.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.05 - Georgia Health Benefits Assignment System

Current through Rules and Regulations filed through June 27, 2024
(1) The standard health benefit plans
				developed by the Commissioner in accordance with O.C.G.A. §
									33-29A-5 shall be designated as
				Plan C and Plan D respectively. The model policy form template for Plans C and
				D are designated as Form GHBAS-1, and the schedule of benefits for Plans C and
				D is designated as Form GHBAS-S.
(2) A managed care organization who
				participates in the Georgia Health Benefits Assignment System (GHBAS) must file
				policy forms necessary for providing the coverage required by the GHBAS no
				later than thirty (30) days following either the effective date of this
				Regulation Chapter, or the date of notice from the Commissioner that the
				managed care organization is subject to the provisions of O.C.G.A. §
									33-29A-1
et
				seq.
, whichever is later. Coverage provided pursuant to assignment
				by the GHBAS that is effective prior to the approval of the policy form shall
				be subject to the requirements of this Regulation Chapter and shall be amended
				pursuant to any modifications required by the Commissioner for approval of the
				filing. Such coverage made effective prior to approval of filing shall not be
				in violation if the policy form is filed within thirty (30) days as
				required.
(3) Methods of Filing.
(a) A participating managed care organization
				may file policy forms prepared in accordance with Form GHBAS-1 and the schedule
				of benefits in Form GHBAS-S . Such policy forms shall be deemed approved upon
				the date the Commissioner receives the filing, provided they conform to the
				template form; or
(b) A
				participating managed care organization may file policy forms with contractual
				language substantially similar to the model policy form template for approval,
				but must include the same benefits prescribed in the model policy form template
				and the same schedule of benefits prescribed in Forms GHBAS-1 and GHBAS-S .
				Such filings must include a description which specifically outlines the
				variances in language between the model policy form template and the filed
				form. A policy form filing with variances from the model policy form template
				prescribed in Form GHIAS-1 may not contain any provisions which are less
				beneficial than the relevant template provisions with regard to qualifying
				eligible individuals or eligible dependents.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.06 - Optional Policies or Plans

Current through Rules and Regulations filed through June 27, 2024
(1) A health insurer or managed care
				organization may offer, in addition to the standard policies or plans, other
				additional individual health insurance policies or plans approved by the
				Commissioner for use in this state. A health insurer or managed care
				organization may also offer additional policies or plans with benefit options
				based on the standard plans but with different benefit schedules, provided such
				policies are filed with the Commissioner for approval. In the event a health
				insurer or managed care organization elects to offer such optional plans to
				qualifying eligible individuals and eligible dependents, the health insurer or
				managed care organization must assure that:
(a) both the standard and optional policies
				or plans are presented in a written offer of coverage and there is no unfair
				inducement to persuade the applicant in his or her selection;
(b) all optional policies or plans are made
				available to all qualifying eligible individuals and eligible dependents
				applying for coverage under the assignment system and assigned to the health
				insurer or managed care organization;
(c) all optional policies or plans comply
				with Rules
				120-2-81-.11,
				.12,
				.13,
				.14,
				.15,
				.18, and
				.19; and
(d) all optional policies or plans are
				accompanied by a certification from the health insurer or managed care
				organization which asserts the following:
"This policy option is not a standard plan developed by the
				  Commissioner of Insurance of the State of Georgia. Unlike the standard plans,
				  it may not contain maximum rate limitations and benefits as guaranteed by state
				  law and regulation. Should you have questions regarding any differences between
				  this policy and the standard plan, you may contact [name of health insurer or
				  managed care organization] at [phone number]".
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.07 - Premium Rates for Standard Policies or Plans

Current through Rules and Regulations filed through June 27, 2024
(1) Maximum premium rates are specified in
				Form GHIAS-R for Plans A and B, and in Form GHBAS-R for Plans C and D. All
				premium rates utilized by the health insurer or managed care organization for
				standard policies or plans must be filed for approval and shall include premium
				modes available. All participating health insurers and managed care
				organizations shall offer a monthly premium mode and may offer additional, less
				frequent, modes.
(2) Actual
				premiums charged to any eligible individual may not exceed the maximum premium
				rates specified in Forms GHIAS-R and GHBAS-R . If premium modes that are less
				frequent than monthly are offered, the actual premiums charged through such
				modes may not exceed the maximum premium rates specified in Forms GHIAS-R and
				GHBAS-R discounted by the modal factors that the health insurer or managed care
				organization would typically apply to other policies for that premium
				mode.
(3) If a health insurer
				offers standard policies with preferred provider arrangements as permitted by
				this Regulation Chapter, the maximum rate charged may not exceed the maximum
				premium rates specified in Form GHIAS-R for Plans A and B discounted by the
				same factor that the health insurer would typically apply to other policies
				with preferred provider arrangements.
(4) Premium rates shall reflect, at a
				minimum, single male and female rating tiers and one family tier for any number
				of dependents. The Commissioner may prescribe additional tiers on Forms GHIAS-R
				and GHBAS-R if deemed necessary for the effective maintenance of the GHIAS and
				GHBAS.
O.C.G.A. Secs.
				  33-2-9,
				  33-29A-1,
et
				  seq.
Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.09 - Administration

Current through Rules and Regulations filed through June 27, 2024
(1) The
				Commissioner shall administer the GHIAS and the GHBAS or may designate an
				administrator to perform any specific tasks necessary for the administration of
				the GHIAS and the GHBAS.
(2) The
				Commissioner may require that costs associated with administration of the GHIAS
				and the GHBAS be reimbursed by the participating health insurers and managed
				care organizations. The amount of such reimbursement and method of payment
				shall be specified by the Commissioner and may be included as a share of
				premium payments made to health insurers or managed care organizations
				participating in GHIAS or GHBAS.
O.C.G.A. Secs.
				  33-2-9,
				  33-29A-1,
et
				  seq.