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 120-2-44 - PREFERRED PROVIDER ARRANGEMENTS › Rule 120-2-44-.04 - Required Policy Provisions

Current through Rules and Regulations filed through June 27, 2024
(1) Preferred provider arrangements shall
				contain provisions for the continuous review of the utilization of services and
				facilities, and costs.
(2) Each
				individual policy or group preferred provider insurance policy shall contain a
				provision that the policyholder is entitled to a grace period of not less than
				thirty-one (31) days for the payment of any premium due except the first,
				during which grace period the coverage shall continue in force, unless the
				group or individual policyholder shall have given the health care insurer
				notice of discontinuance thirty (30) days in advance of the date of
				discontinuance and in accordance with the terms of the policy. The policy may
				provide that the group or individual policyholder may be liable to the health
				care insurer for payment of a pro rata premium for the time the coverage was in
				force during such grace period.
(3)
				Any contract between a health care insurer and the various health care
				providers shall state that an insured shall be held harmless for provider
				utilization review decisions over which he has no control. In the absence of
				such hold harmless agreement, the agreement shall be deemed to be included
				therein.
(4) If the preferred
				provider insurance policy or health benefit plan defines a specific service
				area, the insurer shall not terminate the members coverage because an
				individual policyholder or group member moves out of the service
				area.
(5) Differentials in
				coinsurance percentages which are applicable to benefit levels for services
				provided by preferred and nonpreferred providers may not exceed thirty
				percentage points. The coinsurance percentage applicable to benefit levels for
				services provided by non-preferred providers may not be greater than forty
				percent (40) of the benefit levels under the policy for such services. Examples
				of acceptable coinsurance percentages payable by an insured for preferred and
				nonpreferred providers, respectively, are 0, 30; 5, 35; 10, 40; 20, 40; 30,
				40.
(6) Individual preferred
				provider insurance policies, outlines of coverage or preferred provider
				insurance certificates shall contain a brief and prominent notice in boldface
				type reflecting the limitations of the preferred provider policy or health plan
				benefit. Such warning shall be placed on the face page of the policy, outline
				of coverage or certificate and refer to the differentials in coinsurance
				percentages payable by the insureds for preferred and nonpreferred provider
				services, service area requirements, and emergency care services.
(7) Preferred Provider Insurance policies or
				certificates shall fully disclose the limitations, differentials, penalties,
				incentives or other arrangements by which the insurer provides for a primary
				care physician or other health care provider, as defined by the insurance
				policy or certificate, to act as a gatekeeper, if any. A gatekeeper shall not
				be used to restrict access to services or non-preferred providers under the
				individual preferred provider policy or group preferred provider
				certificate.
(8) Preferred Provider
				Insurance policies or certificates shall fully disclose the use of discrete
				dollar copayments which apply to any covered health care benefits under the
				policy or certificate. Discrete dollar copayments may be imposed by an insurer
				in a Preferred Provider Insurance policy or certificate and need not be
				considered in the determination of percentage differential limitations
				described in O.C.G.A. Section
				33-30-23. Such copayments, if
				applicable, shall be reasonable in relation to the covered benefits to which
				they apply, shall serve as an incentive rather than a barrier to access of
				appropriate care and shall not work so as to unfairly deny necessary health
				care services.
O.C.G.A. Secs.
				  33-2-9, 30-23-30,
				  33-30-27.