05 LC 21
8359S
The
House Committee on Insurance offers the following substitute to HB
290:
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 33 of the Official Code of Georgia Annotated, relating to insurance,
so as to provide an exception to the requirement that major medical insurance
policies or plans provide for carry-over deductibles; to remove the requirement
that managed care plans obtain certain acknowledgments; to enact the "Georgia
Telemedicine Act"; to provide for related matters; to repeal conflicting laws;
and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by striking paragraph (14) of Code Section 33-6-5, relating to other unfair
methods of competition and unfair and deceptive acts or practices, and inserting
in lieu thereof a new paragraph (14) to read as follows:
"(14)
On and after July 1, 1992, no insurer, as defined in paragraph (4) of Code
Section 33-1-2, shall issue, cause to be issued, renew, or provide coverage
under any major medical insurance policy or plan containing a calendar year
deductible or similar plan benefit period deductible which does not provide for
a carry-over of the application of such deductible as provided in this
paragraph. If all or any portion of an
insured́s
or
membeŕs
cash deductible for a calendar year or similar plan benefit period is applied
against covered expenses incurred by the insured or member during the last three
months of the deductible accumulation period, the
insured́s
or
membeŕs
cash deductible for the next ensuing calendar year or similar benefit plan
period shall be reduced by the amount so applied. The provisions of this
paragraph shall apply to major medical insurance policies or plans which have a
benefit plan period of less than 24
months, except
policies or plans designed and issued to be compatible with a health savings
account as set out in 26 U.S.C. Section 223 or a spending account as defined in
Chapter 30B of this
title."
SECTION
2.
Said
title is further amended by striking paragraph (1) of Code Section 33-20A-5,
relating to standards for certification, and inserting in lieu thereof a new
paragraph (1) to read as follows:
"(1)
DISCLOSURE TO
ENROLLEES AND PROSPECTIVE ENROLLEES.
(A)
A managed care entity shall disclose to enrollees and prospective enrollees who
inquire as individuals into a plan or plans offered by the managed care entity
the information required by this paragraph. In the case of an employer
negotiating for a health care plan or plans on behalf of his or her employees,
sufficient copies of disclosure information shall be made available to employees
upon request. Disclosure of information under this paragraph shall be readable,
understandable, and on a standardized form containing information regarding all
of the following for each plan it offers:
(i)
The health care services or other benefits under the plan offered as well as
limitations on services, kinds of services, benefits, or kinds of benefits to be
provided, which disclosure may also be published on an Internet service site
made available by the managed care entity at no cost to such
enrollees;
(ii)
Rules regarding copayments, prior authorization, or review requirements
including, but not limited to, preauthorization review, concurrent review,
postservice review, or postpayment review that could result in the
patient́s
being denied coverage or provision of a particular service;
(iii)
Potential liability for cost sharing for
out of
network
out-of-network
services,
including,
but not limited
to,
providers, drugs, and devices or surgical procedures that are not on a list or a
formulary;
(iv)
The financial obligations of the enrollee, including premiums, deductibles,
copayments, and maximum limits on out-of-pocket expenses for items and services
(both in and out of network);
(v)
The number, mix, and distribution of participating providers. An enrollee or a
prospective enrollee shall be entitled to a list of individual participating
providers upon request, and the list of individual participating providers shall
also be updated at least every 30 days and may be published on an Internet
service site made available by the managed care entity at no cost to such
enrollees;
(vi)
Enrollee rights and responsibilities, including an explanation of the grievance
process provided under this article;
(vii)
An explanation of what constitutes an emergency situation and what constitutes
emergency services;
(viii)
The existence of any limited utilization incentive plans;
(ix)
The existence of restrictive formularies or prior approval requirements for
prescription drugs. An enrollee or a prospective enrollee shall be entitled,
upon request, to a description of specific drug and therapeutic class
restrictions;
(x)
The existence of limitations on choices of health care providers;
(xi)
A statement as to where and in what manner additional information is
available;
(xii)
A statement that a summary of the number, nature, and outcome results of
grievances filed in the previous three years shall be available for inspection.
Copies of such summary shall be made available at reasonable costs;
and
(xiii)
A summary of any agreements or contracts between the managed care plan and any
health care provider or hospital as they pertain to the provisions of Code
Sections 33-20A-6 and 33-20A-7. Such summary shall not be required to include
financial agreements as to actual rates, reimbursements, charges, or fees
negotiated by the managed care plan and any health care provider or hospital;
provided, however,
that
such summary may include a disclosure of
the category or type of compensation, whether capitation, fee for service, per
diem, discounted charge, global reimbursement payment, or otherwise, paid by the
managed care plan to each class of health care provider or hospital under
contract with the managed care plan.
(B)
Such information shall be disclosed to each enrollee under this article at the
time of enrollment and at least annually thereafter.
(C)
Any managed care plan licensed under Chapter 21 of this title is deemed to have
met the certification requirements of this paragraph.
(C.1)
Any managed care plan licensed in this state shall obtain a signed
acknowledgment from each enrollee at the time of enrollment and upon any
subsequent product change elected by an enrollee acknowledging that the enrollee
has been informed of the following:
(i)
The number, mix, and distribution of participating providers. An enrollee shall
be entitled to a list of individual participating providers and the list shall
be updated at least every 30 days and may be published on an Internet service
site made available by the managed care entity at no cost to such
enrollee;
(ii)
The existence of limitations and disclosure of such limitations on choices of
health care providers; and
(iii)
A summary of any agreements or contracts between the managed care plan and any
health care provider or hospital as they pertain to the provisions of Code
Sections 33-20A-6 and 33-20A-7. Such summary shall not be required to include
financial agreements as to actual rates, reimbursements, charges, or fees
negotiated by the managed care plan and any health care provider or hospital;
provided, however, such summary may include a disclosure of the category or type
of compensation, whether capitation, fee for service, per diem, discounted
charge, global reimbursement payment, or otherwise, paid by the managed care
plan to each class of health care provider or hospital under contract with the
managed care plan.
(D)
A managed care entity which negotiates with a primary care physician to become a
health care provider under a managed care plan shall furnish that physician,
beginning on and after January 1, 2001, with a schedule showing fees payable for
common office based services provided by such physicians under the
plan;"
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.