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 120-2-10 - REGULATIONS REGARDING INSURANCE CONTRACT › Rule 120-2-10-.12 - Small Group Health Insurance Access and Pooling

Current through Rules and Regulations filed through June 27, 2024
(1) Definitions. The terms used in this Rule
				are defined as follows:
(a) "Anticipated
				Group Premium" shall mean the premium expected to be generated on each new and
				existing group over a period of the next twelve (12) months including only
				deviations permitted pursuant to subparagraphs (b), (d), (e) and (f) of
				paragraph (5) of this Rule.
(b)
				"Anticipated Pool Premium" shall mean the total amount of premium expected to
				be generated on all new or existing groups over a period of the next twelve
				(12) months. The anticipated pool premium shall equal the sum of all
				anticipated group premiums for all small groups in an insurer's pool.
(c) "Dependent" shall mean any dependent of
				an employee, member, or enrollee, including children, adopted children, and
				non-custodial children, as permitted in O.C.G.A. §§
										33-24-28(b)  and
				33-30-4(3) and
				(4), or a spouse, or other family member
				eligible for coverage under the terms of the group health insurance policy or
				contract because of that person's dependency on the employee, member, or
				enrollee.
(d) "Eligible employees,
				members or enrollees" shall mean persons who are actively employed with a small
				group and are eligible for coverage under the employment rules of the small
				group or who are otherwise, except for dependents, eligible for coverage under
				a group health insurance policy, without regard to claims experience or any
				health status related factor.
(e)
				"Existing Group" shall mean a small group that is insured by an insurer and
				part of that insurer's small group pool.
(f) "Group Health Insurance" shall mean any
				major medical insurance, medical expense coverage, hospital expense coverage,
				comprehensive health benefit plan, or managed health care plan issued by an
				insurer to small groups, other than a blanket accident and sickness policy, a
				health insurance policy written as part of workers' compensation equivalent
				coverage or supplemental to a liability policy, a credit insurance policy, or
				any limited benefit insurance policy as defined in O.C.G.A. §
										33-30-12(e)(4).
				Group health insurance shall include all types of policies, contracts, or
				certificates, as applicable, or other comparable group-type coverage as
				specified in Rule
				120-2-10-.10(2),
				actively marketed or issued in this state to small groups, including the
				following:
1. Group health insurance policies
				or certificates issued pursuant to group insurance contracts;
2. Group health insurance policies issued or
				marketed to association groups or trusts, except bona fide associations as
				defined in O.C.G.A. §
											33-30-1(b)  and
				as specified in subparagraph (10) of this Rule;
3. Group health insurance policies issued to
				multiple employer trusts established in or out of this state; and
4. Except for policies excluded under
				O.C.G.A. §
											33-30-12(e),
				individual health insurance policies which provide as a minimum primary or
				basic medical or hospital expense benefits and are spon- sored in any manner by
				an employer or other group insurance policyholder.
(g) "Insured" shall mean any employee,
				member, enrollee, or dependent of an employee, member or enrollee insured under
				group health insurance issued to a small group.
(h) "New Entrant" shall mean an eligible
				employee, member, enrollee or dependent not previously covered by the existing
				group insurance contract or policy and who is either a late enrollee or does
				not have previous creditable coverage as defined by O.C.G.A. §
										33-30-15(a)(2).
A New Entrant shall not include the following
				  individuals:
1. a "newly eligible
				employee" as defined by O.C.G.A. §
											33-30-15(a)(4);
2. an insured covered under the group's prior
				group health insurance contract or policy, provided that such contract or
				policy constitutes previous creditable coverage; or
3. newborn children or newly adopted children
				enrolled as permitted in O.C.G.A. §
											33-30-15(e)  and
				Rule Chapter 120-2-67.
(i) "New Group" shall mean a small group that
				is not currently insured by an insurer or any affiliated insurer.
(j) "Policyholder" shall mean, with respect
				to group health insurance coverage, the small group to which a group health
				insurance policy or contract is issued in accordance with O.C.G.A. §
										33-30-1, including, but not
				limited to, an employer or employer groups issued certificates of coverage
				through a multiple employer trust.
(k) "Pool Rate" shall mean the average rate
				for employees, members, and enrollees, or dependents of such individuals, in
				all small groups within an insurer's small group health insurance pool, to be
				determined and used over a period of the next twelve months and adjusted for
				benefit design but unadjusted for factors specified in paragraph (5). In
				determining pool rates, the insurer must take into account all actual and
				anticipated experience data of the entire pool itself as well as other
				experience data of the insurer or data available generally, and must apply
				recognized actuarial practices as to credibility, trend factors, expense
				factors, and margins. Insurers shall use pool rates to determine premiums for
				new and existing groups.
(l) "Small
				Employer" shall mean any employer that employed an average of at least two but
				not more than 50 employees on business days during the preceding calendar year
				and that employs at least two employees on the first day of the rating period.
				All employers treated as a single employer under subsection (b), (c), (m), or
				(o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one
				employer. Subsequent to the issuance of a health insurance policy or contract
				to a small employer and for the purpose of determining continued eligibility,
				the size of a small employer shall be determined annually. Except as otherwise
				specifically provided, provisions of this Act that apply to a small employer
				shall continue to apply at least until the final day of the rating period
				following the date the small employer no longer meets the requirements of this
				definition. In the case of an employer which was not in existence throughout
				the preceding calendar year, the determination of whether or not an employer is
				a small employer shall be based on the average number of employees that it is
				reasonably expected that the employer will employ on business days in the
				current calendar year. Each small employer shall be considered a small
				group.
(m) "Small Group" shall
				mean, as defined in O.C.G.A. §
										33-30-12(a), a
				group which is a single employer, including a Small Employer, firm,
				corporation, partnership, sole proprietor, or other legitimate group as
				specified in O.C.G.A. §
										33-30-1(a)  with
				at least two and no more than fifty (50) total eligible employees, members or
				enrollees (not including dependents) on the initial application date and on
				average during the calendar quarter preceding application. In determining the
				number of eligible employees, members, or enrollees, companies that are
				affiliated companies, are eligible to file a combined tax return for purposes
				of taxation by this state, or are subsidiaries of another company and covered
				under the parent company's group health insurance contract or policy, shall be
				considered one group. Subsequent to the issuance of a health insurance policy
				or contract to a small group and for the purpose of determining continued
				eligibility, the size of a small group shall be determined annually. Except as
				otherwise specifically provided, provisions of this Rule shall continue to
				apply at least until the renewal date following the date the small group no
				longer meets the requirements of this definition. Such small groups include
				sole proprietors or employer members of a trust or an association which does
				not meet the definition in O.C.G.A. §
										33-30-1(b). For
				the purposes of applying this Rule, a small group shall be subject to this Rule
				if:
1. the majority of insured employees,
				members, or enrollees in the group are employed or reside in this state;
				or
2. if no state contains a
				majority of the insured employees, members, or enrollees in a group, the
				primary business location of the employer is in this state. If an employer
				which constitutes a small group meets subparagraphs 1. or 2. of this
				definition, it shall not be considered to be an employer in another state as
				specified in O.C.G.A. §
											33-30-1.1.
(n) "True Association" shall mean an
				association which meets the requirements of O.C.G.A. §
										33-30-1(b)  and
				any applicable Rules and Regulations issued by the Commissioner.