07 SB109/CSFA/1
Senate
Bill 109
By:
Senators Hudgens of the 47th, Shafer of the 48th, Brown of the 26th, Hawkins of
the 49th, Thomas of the 54th and others
AS
PASSED SENATE
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 certain definitions; to include plan administrators in prompt
pay requirements; 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 revising Code Section 33-23-100, relating to the definition of administrator,
as follows:
"33-23-100.
(a)
As used in this article, the term:
(1)
'Administrator' means any business entity that, directly or indirectly, collects
charges, fees, or premiums; adjusts or settles claims, including investigating
or examining claims or receiving, disbursing, handling, or otherwise being
responsible for claim funds;
and
or
provides underwriting or precertification and preauthorization of
hospitalizations or medical treatments for residents of this state for or on
behalf of any insurer, including business entities that act on behalf of
multiple
a single or
multiple employer self-insurance health
plans,
and
plan or
a self-insured
municipalities
municipality
or other political
subdivisions
subdivision.
Licensure is also required for administrators who act on behalf of self-insured
plans providing workers´ compensation benefits pursuant to Chapter 9 of
Title 34. For purposes of this article, each activity undertaken by the
administrator on behalf of an insurer or the client of the administrator is
considered a transaction and is subject to the provisions of this
title.
(2)
'Business entity' means a corporation, association, partnership, sole
proprietorship, limited liability company, limited liability partnership, or
other legal entity.
(b)
Notwithstanding the provisions of subsection (a) of this Code section, the
following are exempt from licensure as long as such entities are acting directly
through their officers and employees:
(1)
An employer on behalf of its employees or the employees of one or more
subsidiary or affiliated corporations of such employer;
(2)
A union on behalf of its members;
(3)
An insurance company licensed in this state or its affiliate unless the
insurer or
its affiliate
administrator
is placing business with a nonaffiliate
is
administering services on behalf of a
nonaffiliated
insurer,
single or multiple employer self-insured health plan, or a self-insured
municipality or other political
subdivision
not
licensed in this state;
(4)
An insurer which is not authorized to transact insurance in this state if such
insurer is administering a policy lawfully issued by it in and pursuant to the
laws of a state in which it is authorized to transact insurance;
(5)
A life or accident and sickness insurance agent or broker licensed in this state
whose activities are limited exclusively to the sale of insurance;
(6)
A creditor on behalf of its debtors with respect to insurance covering a debt
between the creditor and its debtors;
(7)
A trust established in conformity with 29 U.S.C. Section 186 and its trustees,
agents, and employees acting thereunder;
(8)
A trust exempt from taxation under Section 501(a) of the Internal Revenue Code
and its trustees and employees acting thereunder or a custodian and its agents
and employees acting pursuant to a custodian account which meets the
requirements of Section 401(f) of the Internal Revenue Code;
(9)
A bank, credit union, or other financial institution which is subject to
supervision or examination by federal or state banking authorities;
(10)
A credit card issuing company which advances for and collects premiums or
charges from its credit card holders who have authorized it to do so, provided
that such company does not adjust or settle claims;
(11)
A person who adjusts or settles claims in the normal course of his or her
practice or employment as an attorney and who does not collect charges or
premiums in connection with life or accident and sickness insurance coverage or
annuities;
(12)
A business
entity that acts solely as an administrator of one or more bona fide employee
benefit plans established by an employer or an employee organization, or both,
for whom the insurance laws of this state are preempted pursuant to the federal
Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et
seq.
An insurance
company licensed in this state or its affiliate if such insurance company or its
affiliate is solely administering limited benefit insurance. For the purpose of
this paragraph, the term 'limited benefit insurance' means accident or sickness
insurance designed, advertised, and marketed to supplement major medical
insurance, specifically: accident only, CHAMPUS supplement, disability income,
fixed indemnity, long-term care, or specified
disease; or
(13)
An association that administers workers´ compensation claims solely on
behalf of its members.
(c)
A business entity claiming an exemption shall submit an exemption notice on a
form provided by the Commissioner. This form must be signed by an officer of
the company and submitted to the department by December 31 of the year prior to
the year for which an exemption is to be claimed. Such exemption notice shall
be updated in writing within 30 days if the basis for such exemption
changes.
(d)
Obtaining a license as an administrator does not exempt the applicant from other
licensing requirements under this title.
(e)
Obtaining a license as an administrator subjects the applicant to the provisions
of Code Sections 33-24-59.5 and 33-24-59.13.
(f)
In the event that a self-insured health plan fails to fund properly the plan to
allow the administrator to pay any outside claim, then the administrator shall
not be subject to Code Sections 33-24-59.5 and 33-24-59.13 if:
(1)
The administrator provides evidence, to the Commissioner´s satisfaction,
that the plan was not properly funded to allow the administrator to pay any
outside claim; and
(2)
The administrator provides the Commissioner with written documentation whereby
the administrator agrees to terminate the agreement to provide administrative
services with the offending self-insurance plan for one year from the time of
the Commissioner´s
finding."
SECTION
2.
Said
title is further amended by revising paragraph (3) of subsection (a) of Code
Section 33-24-59.5, relating to timely payment of health benefits, as
follows:
"(3)
'Insurer' means an accident and sickness insurer, fraternal benefit society,
nonprofit hospital service corporation, nonprofit medical service corporation,
health care corporation, health maintenance organization, provider sponsored
health care corporation, or any similar entity and any self-insured health
benefit plan
or the plan
administrator of any health benefit plan established pursuant to Article 1 of
Chapter 18 of Title 45 or any other administrator as defined in paragraph (1) of
subsection (a) of Code Section 33-23-100
not subject
to the exclusive jurisdiction of the federal Employee Retirement Income Security
Act of 1974, 29 U.S.C. Section 1001, et
seq., which entity provides for the
financing or delivery of health care services through a health benefit
plan, or
the plan administrator of any health benefit plan established pursuant to
Article 1 of Chapter 18 of Title 45
or for
administering a health benefit
plan."
SECTION
3.
Said
title is further amended by revising paragraph (1) of subsection (b) of Code
Section 33-24-59.5, relating to timely payment of health benefits, as
follows:
"(b)(1)
All benefits under a health benefit plan will be payable by the insurer which is
obligated to finance or deliver health care services under that plan upon such
insurer´s receipt of written proof of loss or claim for payment for health
care goods or services provided. The insurer shall accept electronic claims and
within 15 working days
for electronic
claims or 30 calendar days for paper
claims after such receipt mail to the
insured or other person claiming payments under the plan payment for such
benefits or a letter or notice which states the reasons the insurer may have for
failing to pay the claim, either in whole or in part, and which also gives the
person so notified a written itemization of any documents or other information
needed to process the claim or any portions thereof which are not being paid.
Where the insurer disputes a portion of the claim, any undisputed portion of the
claim shall be paid by the insurer in accordance with this chapter. When all of
the listed documents or other information needed to process the claim has been
received by the insurer, the insurer shall then have 15 working days within
which to process and either mail payment for the claim or a letter or notice
denying it, in whole or in part, giving the insured or other person claiming
payments under the plan the insurer´s reasons for such
denial."
SECTION
4.
Said
title is further amended by adding a new Code Section 33-24-59.13 to the end of
Article 1 of Chapter 24, relating to general provisions concerning
insurance, to read as follows:
"33-24-59.13.
(a)
As used in this Code section, the term:
(1)
'Benefits' shall have the same meaning as provided in Code Section
33-24-59.5.
(2)
'Facility' shall have the same meaning as provided in Code Section
33-20A-3.
(3)
'Health benefit plan' shall have the same meaning as provided in Code Section
33-24-59.5.
(4)
'Health care provider' shall have the same meaning as provided in Code Section
33-20A-3.
(5)
'Insurer' means an accident and sickness insurer, fraternal benefit society,
nonprofit hospital service corporation, nonprofit medical service corporation,
health care corporation, health maintenance organization, provider sponsored
health care corporation, or any similar entity and any self-insured health
benefit plan or the plan administrator of any health benefit plan established
pursuant to Article 1 of Chapter 18 of Title 45 or any other administrator as
defined in paragraph (1) of subsection (a) of Code Section 33-23-100, which
entity provides for the financing or delivery of health care services through a
health benefit plan or for administering a health benefit plan.
(b)(1)
All benefits under a health benefit plan will be payable by the insurer which is
obligated to finance or deliver health care services under that plan upon such
insurer´s receipt of written proof of loss or claim for payment for health
care goods or services provided. The insurer shall within 15 working days for
electronic claims or 30 calendar days for paper claims after such receipt mail
to the facility or health care provider claiming payments under the plan payment
for such benefits or a letter or notice which states the reasons the insurer may
have for failing to pay the claim, either in whole or in part, and which also
gives the person so notified a written itemization of any documents or other
information needed to process the claim or any portions thereof which are not
being paid. Where the insurer disputes a portion of the claim, any undisputed
portion of the claim shall be paid by the insurer in accordance with this
chapter. When all of the listed documents or other information needed to
process the claim has been received by the insurer, the insurer shall then have
15 working days within which to process and either mail payment for the claim or
a letter or notice denying it, in whole or in part, giving the facility or
health care provider claiming payments under the plan the insurer´s reasons
for such denial.
(2)
Receipt of any proof, claim, or documentation by an entity which administers or
processes claims on behalf of an insurer shall be deemed receipt of the same by
the insurer for purposes of this Code section.
(c)
Each insurer shall pay to the facility or health care provider claiming payments
under the health benefit plan interest equal to 18 percent per annum on the
proceeds or benefits due under the terms of such plan for failure to comply with
subsection (b) of this Code section."
SECTION
5.
All
laws and parts of laws in conflict with this Act are repealed.