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 120-2-81 - INDIVIDUAL HEALTH INSURANCE ASSIGNMENT SYSTEMS › Rule 120-2-81-.08 - Individual Applications and Assignments

Current through Rules and Regulations filed through June 27, 2024
(1) Applications for coverage must be
				submitted to the Commissioner, or to a designated administrator appointed by
				the Commissioner, prior to assignment to a participating health insurer or
				managed care organization. Certificates of creditable coverage sufficient to
				establish status as a qualified eligible individual shall be submitted with the
				application if available.
(2)
				Qualifying eligible individuals must use application forms for assignment
				included in Form APP-ASSIGN . The Commissioner, or the Commissioner's
				designated administrator, shall furnish such applications to licensed insurance
				agents or to other individuals upon request.
(3) An application form may be completed and
				submitted either by a licensed insurance agent or directly by the applicant. If
				the application for coverage in GHIAS or GHBAS using Form APP-ASSIGN is
				prepared and submitted by a licensed insurance agent, the participating health
				insurer or managed care organization to which the applicant is assigned and who
				issues a health insurance policy or benefit plan as a result of that assignment
				shall compensate that agent only for the procurement, preparation, and
				submission of such application at a commission rate of not less than 3 percent
				of the premiums received by the issuing health insurer or managed care
				organization for coverage issued to the applicant.
(4) After initial review, the Commissioner,
				or the designated administrator, shall enter the application into either the
				GHIAS or the GHBAS as appears appropriate.
(5) An applicant entered into the GHIAS will
				be assigned to a participating health insurer using a randomized assignment
				selection process established and maintained by the Commissioner, or an
				alternate method as deemed necessary by the Commissioner, that is based on the
				pro rata premium volume of individual health insurance business done in Georgia
				by each such health insurer. Assignments shall become final, and credited to
				the health insurer's share, upon final determination of eligibility and payment
				of the initial premium.
(6) An
				applicant entered into the GHBAS will be assigned to a participating managed
				care organization using a randomized assignment selection process established
				and maintained by the Commissioner, or an alternate method as deemed necessary
				by the Commissioner, that is based on the pro rata premium volume of individual
				health benefits business done in Georgia by each such managed care
				organization. Assignments shall become final, and credited to the health
				insurer's share, upon final determination of eligibility and payment of the
				initial premium. If the applicant does not reside within a geographic area
				normally served by a participating managed care organization to which the
				applicant is initially assigned, the assignment selection process shall be
				repeated until a participating managed care organization is selected that
				serves the area in which the applicant resides. If no participating managed
				care organization serves the area in which the applicant resides, the applicant
				will be entered into the GHIAS and assigned to a participating health
				insurer.
(7) The Commissioner or
				designated administrator shall notify the participating health insurer or
				managed care organization of an assignment and shall deliver the application to
				the assigned participating health insurer or managed care organization. The
				participating health insurer or managed care organization to which the
				applicant is assigned shall be responsible for verification of the information
				contained in the application and determining whether the applicant is an
				eligible individual. Upon determination that the applicant is an eligible
				individual, the participating health insurer or managed care organization to
				which the applicant is assigned shall, in writing, promptly offer the applicant
				a choice of the standard policies or plans (and optional policies or plans, if
				applicable). A participating health insurer or managed care organization shall
				make such determination and written offer no later than ten (10) business days
				after the health insurer or managed care organization is notified by the
				Commissioner of such assignment.
(8) If the participating health insurer or
				managed care organization determines that the applicant is not an eligible
				individual, the determination, along with a detailed explanation for the
				decision, must be furnished to the applicant, and to the Commissioner or the
				designated administrator, no later than ten business (10) days after the health
				insurer or managed care organization is notified by the Commissioner of such
				assignment.
(9) The written offer
				of coverage by a participating health insurer or managed care organization to
				an assigned applicant shall include copies of the appropriate schedule of
				benefits for each standard policy or plan as indicated on Form GHIAS-S or
				GHBAS-S, as well as a premium rate table for each policy or plan, as found in
				Forms GHIAS-R or GHBAS-R . The health insurer or managed care organization
				shall use the enrollment form prescribed in Form GHIAS-E or GHBAS-E for
				enrolling the applicant. The applicant must select the desired policy or plan
				and pay the initial premium within thirty (30) days of receiving such offer.
				Upon selection by the applicant and payment of the initial premium, the policy
				or plan shall be promptly issued and shall be made effective on the date
				specified by this Regulation Chapter.
(10) Upon issuance of each health insurance
				policy or benefit plan, the participating health insurer or managed care
				organization shall notify the Commissioner, or the designated administrator, in
				writing and provide a copy of the completed enrollment form. Assignments will
				then be adjusted as policies are actually issued to assure that no
				participating health insurer or managed care organization issues coverage to a
				significantly disproportionate share of assigned applicants. Failure to
				promptly process applications, issue policies or benefit plans, and notify the
				Commissioner, could result in a disproportionate share of applicants being
				assigned to the participating health insurer or managed care organization. The
				participating health insurer or managed care organization shall promptly notify
				the Commissioner when it is determined that no policy or benefit plan will be
				purchased by the applicant.
O.C.G.A. Secs.
				  33-2-9,
				  33-29A-1,
et
				  seq.