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-.11 - Group Health Insurance Conversion Privilege

Current through Rules and Regulations filed through June 27, 2024
(1) A group policy and any other group
				insurance coverage by whatever name called delivered or issued for delivery in
				this State or which covers Georgia residents through an out-of-state multiple
				employer trust or arrangement, by an insurer, nonprofit health care corporation
				or a Health Maintenance Organization (HMO) which provides hospital, surgical,
				or major medical coverage, or any combination of these coverages, on an expense
				incurred or service provided basis, but not a policy which provides benefits
				for specific diseases or for accidental injuries only shall provide that an
				insured employee, member, or enrollee whose insurance under the group policy
				has been terminated for any reason, including discontinuance of the group
				policy in its entirety or with respect to an insured class, and who has been
				continuously insured under the group policy (and under any group policy
				providing similar benefits which it replaces) for at least six (6) months
				immediately prior to termination, shall be entitled to have issued by the
				insurer an individual policy of health insurance (hereafter referred to as the
				`converted policy'). An employee, member, or enrollee shall not be entitled to
				have a converted policy issued if termination of the insurance under the group
				policy occurred because (i) the employee, member, or enrollee failed to pay any
				required contribution, (ii) any discontinued group coverage was immediately
				replaced by similar group coverage unless such person was declined coverage
				under the replacing group coverage, or (iii) an HMO enrollee's coverage was
				terminated in accordance with Rule
				120-2-33-.06 of the Rules and
				Regulations of the Georgia Insurance Department. Issuance of a converted policy
				shall be subject to the following conditions:
(a) Time Limit: Evidence of Insurability.
				Written application for the converted policy shall be made and the first
				premium paid to the insurer not later than thirty-one (31) days after such
				termination. The converted policy shall be issued without evidence of
				insurability.
(b) Effective Date of
				Coverage: Scope of Coverage. The effective date of the converted policy shall
				be the day following the termination of insurance under the group policy. The
				converted policy shall cover the employee, member or enrollee and any
				dependents who were covered by the group policy on the date of termination of
				insurance.
(c) Optional Coverage.
				The insurer shall not be required to issue a converted policy under the plans
				specified herein to any person if such person is or could be covered by
				Medicare of the United States Social Security Act as added by the Social
				Security Amendments of 1965, or as later amended or superseded. Furthermore,
				except as required under subparagraph (c)3. below, the insurer shall not be
				required to issue a converted policy covering any person if:
1. such person is covered for similar
				benefits by an insurer under another hospital, surgical, medical, or major
				medical expense insurance policy or hospital or medical service subscriber
				contract or medical practice or other prepayment plan or by any other plan or
				program; or such person is eligible for similar benefits (whether or not
				covered therefore) under any arrangement of coverage for individuals in a
				group, whether on an insured or uninsured basis; or similar benefits are
				provided for or available to such person, pursuant to or in accordance with the
				requirements or any state or federal law; or
2. the benefits provided or available under
				the sources referred to in subparagraph 1. above for such person, together with
				the benefits provided by the converted policy, would result in overinsurance
				according to the insurer's standards. The insurer's standards must bear some
				reasonable relationship to actual health care costs in the area in which the
				insured lives at the time of conversion and must be filed with the commissioner
				prior to their use in denying coverage.
3. Notwithstanding subparagraphs 1. and 2.
				above, overinsurance shall not exist, for the purpose of issuing a conversion
				policy to any insured person, if no other coverage, including other group
				insurances on the person, fully covers preexisting conditions. When full
				coverage for preexisting conditions is provided under other similar coverage,
				then the insurer may nonrenew the conversion policy or the coverage of any
				person insured in accordance with subparagraph (14) of this Rule.