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-.11A - Group Health Insurance Enhanced Conversion Privilege

Current through Rules and Regulations filed through June 27, 2024
(1) Definitions.
				For the purpose of this Rule, the following definitions shall apply:
(a) "Continuation Coverage" shall mean any
				coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986
				(COBRA) or continuation benefits under O.C.G.A. §
										33-24-21.1 or §
										33-24-21.2.
(b) "Eligible Dependent" shall mean a
				dependent of a qualifying eligible individual, including a spouse, covered
				under the qualifying eligible individual's most recent group health insurance
				policy or contract, or continuation coverage thereof, who meets the
				requirements of paragraphs (g) 1. through 5. Eligible dependents shall include
				any dependents who would otherwise not qualify for coverage because they have
				less than 18 months previous creditable coverage, provided:
1. They were born, adopted, or placed for
				adoption during coverage under the most recent group policy or continuation
				coverage of the qualifying eligible individual: and
2. They were enrolled under such coverage
				within thirty-one (31) days of birth, adoption, or placement for
				adoption.
(c) "Group
				Pool Rate" shall mean the average base rate for employees, members, and
				enrollees, or dependents of such individuals, for all groups in the insurer's
				group pool in this state, determined over a period of twelve months and
				adjusted for benefit design but unadjusted for any demographic and experience
				factors relating to qualified eligible individuals in the enhanced conversion
				pool. In determining pool rates, the insurer must take into account all actual
				and anticipated experience data of the entire group pool itself (excluding the
				enhanced conversion pool) 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 all qualifying eligible individuals
				enrolling in enhanced conversion coverage.
(d) "Managed Care Organization" shall mean an
				insurer which is a health maintenance organization or a provider-sponsored
				health care corporation.
(e) "Model
				Low Option" shall mean a minimum benefit option for use by insurers or managed
				care organizations for the purpose of offering a choice of coverage that is
				more limited in nature than the model standard option, but which constitutes
				creditable coverage. The model low option shall be associated with the policy
				form template prescribed in Form
GHBAS-1
for managed care
				organizations, Form
GHIAS-2
for coverage under a preferred
				provider arrangement, or Form
GHIAS-1
for all other types of
				coverage, and with a schedule of benefits prescribed by Plan C in Form
GHBAS-S
for managed care organizations or by Plan A in Form
GHIAS-S
for all other types of coverage.
(f) "Model Standard Option" shall mean a
				minimum benefit option for use by insurers or managed care organizations for
				the purpose of offering comprehensive coverage comparable to a standard option
				of coverage in the individual health insurance market in this state. The model
				standard option shall be associated with the policy form template prescribed in
				Form
GHBAS-1
for managed care organizations, Form
GHIAS-2
for coverage under a preferred provider arrangement,
				or Form
GHIAS-1
for all other types of coverage, and with a
				schedule of benefits prescribed by Plan D in Form
GHBAS-S
for
				managed care organizations or by Plan B in Form
GHIAS-S
for
				all other types of coverage.
(g)
				"Qualifying Eligible Individual" shall mean any Georgia domiciliary who meets
				all of the following:
1. As of the date on
				which the individual seeks coverage under this section, the aggregate period of
				previous creditable coverage is 18 months or more;
2. The individual's most recent coverage was
				under a group plan, or continuation coverage thereof;
3. The individual's insurance under the group
				plan has been terminated for any reason, including discontinuance of the group
				plan in its entirety or with respect to an insured class, except for nonpayment
				of premium contribution pertaining to the qualifying eligible
				individual;
4. With regard to such
				an individual's coverage under a group plan or continuation thereof, a
				qualifying event has occurred on or after October 30, 1997;
5. The individual is not eligible for, nor
				has declined, any of the following:
(i)
				Coverage under a group health insurance policy or contract, or other employer
				sponsored health benefit arrangement, including continuation coverage under
				COBRA or O.C.G.A. §§
												33-24-21.1 or
				33-24-21.2;
(ii) Medicare; or
(iii) The state plan under Medicaid or any
				successor program;
6.
				The individual is not enrolled in or covered under any other creditable health
				insurance coverage, including individual health insurance policies or blanket
				accident and sickness insurance pertaining to student health coverage;
				and
7. The individual is one of the
				following:
(i) A current or former employee,
				member, or enrollee covered under the group health policy or contract and
				continuation thereof, if applicable;
(ii) The surviving spouse, if any, of a
				deceased covered employee, member, or enrollee, with or without
				dependents;
(iii) The spouse, or a
				former spouse, with or without dependents, of a covered employee, member, or
				enrollee upon a qualifying event of the spouse while the employee, member, or
				enrollee remains insured under the group policy or continuation thereof, by
				ceasing to be a qualified family member under the group policy, such as a
				result of a valid decree of divorce; or
(iv) An otherwise eligible dependent upon
				reaching limiting age or otherwise losing dependent status under the group
				policy or continuation thereof, or under the enhanced conversion policy of
				another qualifying eligible individual.
(h) "Qualifying Event" shall mean loss of
				creditable coverage resulting from either:
(i)
				Exhaustion of continuation coverage to the maximum extent eligible under
				federal or state law; or
(ii)
				Termination of coverage under a group health insurance policy or contract, in
				the event such a qualifying eligible individual is not eligible for any
				continuation coverage.
(I) "Schedule of
				Benefits" shall mean the outline of benefit levels for a policy, including but
				not limited to the types of benefits covered and associated cost-sharing
				provisions.