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 120-2-75 - REGULATION OF PROVIDER SPONSORED HEALTH CARE CORPORATIONS › Rule 120-2-75-.05 - Participation in Fund

Current through Rules and Regulations filed through June 27, 2024
(1) Each provider sponsored health care
				corporation shall obtain a certificate of authority from the Commissioner prior
				to establishing, maintaining and operating a health care plan in this State. In
				addition to the documents and information set forth in O.C.G.A. §
									33-20-8, each provider sponsored
				health care corporation must also accompany its application for a certificate
				of authority with the following documents and information:
(a) A copy of the applicant's Charter or
				Articles of Incorporation, and all amendments thereto;
(b) A copy of the Applicant's Bylaws or other
				similar document regulating the conduct of the internal affairs of the
				applicant;
(c) A list of the names,
				addresses, official positions and biographical information of the persons who
				are to be responsible for the conduct of affairs and day-to-day operations of
				the applicant, including all members of the Board of Directors or the governing
				body or committee and the principal officers of the applicant and the names and
				addresses of each person entitled to cast five percent (5%) or more of the
				votes for selection of members of applicant's governing body;
(d) A copy of any contract form made or to be
				made between any provider, facility, class or providers and the applicant, and
				a copy of any contract made or to be made between the applicant and persons
				listed in subparagraph (c) above;
(e) A detailed description of the type of
				benefits to be furnished, including information concerning division of benefits
				into classes or kinds and reasons for division of benefits into classes and
				kinds;
(f) Every contract, policy,
				certificate or evidence of coverage, rider, endorsement, application or outline
				of coverage which it intends to use prior to use;
1. Basic rates and rating methodology
				accompanied by an actuarial certification, including assumptions upon which
				proposed levels and methods of reimbursement or other considerations for the
				health care services are based. The Actuarial Certification should state that
				the consideration for services is adequate, and makes provision for expected
				medical expenses, administrative expenses and margins for
				contingencies.
(g)
				Financial and other statements showing the applicant's assets, liabilities,
				sources of financial support, and sources of ability to cause health care
				services to be delivered to its enrollees, subscribers and covered
				dependents;
(h) A statement or map
				reasonably describing the counties or geographic area or areas to be served;
				listings of the providers by category and specialty within those counties or
				areas and such other detail as the Commissioner may reasonably require to
				ensure that services are available and accessible and to ensure continuity of
				service;
(i) A description of the
				internal grievance procedures to be utilized for the investigation and
				resolution of complaints and grievances by enrollees or subscribers and covered
				dependents;
(j) A description of
				the proposed quality assurance program, including the formal organizational
				structure, methods for developing criteria, and procedures for comprehensive
				evaluation of the quality of care rendered to enrollees, subscribers and
				covered dependents;
(k) A security
				deposit in the amount of at least $100,000.00 as required pursuant to O.C.G.A.
				§
										33-3-8(b)(1);
(l) Form GID-3 Appointment of Attorney for
				Service of Process naming a natural person who is a resident of the State of
				Georgia, giving business and home address;
(m) A signed agreement stating that the
				provider sponsored health care corporation shall distribute certain information
				on a periodic basis to enrollees and subscribers regarding wellness services
				and preventive care offered by the provider sponsored health care corporation.
				Such information shall be submitted to the Office of Commissioner of Insurance
				for approval at least ninety (90) days before it is expected to be distributed
				to enrollees and subscribers.