07 LC 28
3427
Senate
Bill 150
By:
Senators Hill of the 32nd and Thomas of the 54th
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Chapter 4 of Title 26 of the Official Code of Georgia Annotated, relating
to pharmacists and pharmacies, so as to require pharmacies to submit certain
performance and cost data to the Department of Community Health; to amend Title
31 of the Official Code of Georgia Annotated, relating to health, so as to
provide for the establishment of a website to provide consumers with information
on the cost and quality of health care in Georgia; to provide for the submission
of data elements from health care facilities, pharmacies, nursing homes, and
assisted living facilities; to provide for rules and regulations; to provide for
the establishment of the Georgia Patient Safety Corporation; to provide for its
membership and duties; to provide for the establishment of a central data base
of electronic medical records; to provide for grants, subsidies, and other
incentives for certain individuals to obtain health care coverage; to require
health care facilities to submit certain performance and cost data to the
Department of Community Health; to provide that health records are the property
of the patient; to amend Title 28 of the Official Code of Georgia Annotated,
relating to the General Assembly, so as to create the Georgia Health Care
Overview Committee; to provide for its composition, officers, duties, and
powers; to provide for cooperation by certain entities with such committee; to
provide for certain expenditures of funds by such committee; to amend Title 33
of the Official Code of Georgia Annotated, relating to insurance, so as to
comprehensively revise the laws of Georgia concerning the provision of health
insurance; to provide that preferred provider arrangements shall not have
differences in coinsurance percentages applicable to benefit levels for services
provided by preferred and nonpreferred providers which differ by more than 40
percentage points; to provide that preferred provider arrangements shall not
have a coinsurance percentage applicable to benefit levels for services provided
by nonpreferred providers which exceeds 50 percent of the benefit levels under
the policy for such services; to provide that an insured under a group accident
and sickness policy may include dependents up to age 25 or until two years after
ceasing to be a dependent, whichever is earlier; to provide that employers who
employ persons who also work for other employers may enter into arrangements to
contribute to the employees´ health care coverage under such other
employers; to provide for the promulgation of rules and regulations; to provide
for the creation of the Georgia Health Insurance Exchange; to provide for
definitions; to provide for the selection, filling of vacancies, terms of
office, and powers and responsibilities of a board of directors; to provide for
the selection of officers of the board of directors; to provide for an exchange
director and staff; to provide for enrollment and coverage election of eligible
individuals; to provide for the participation of plans in the exchange; to
provide underwriting rules; to provide for certain continuation of coverage; to
provide for the resolution of certain disputes; to provide for participating
employer plans and agreements; to provide for commissions for insurance
producers using the exchange; to provide certain forms and require certain
information to be filed concerning insurance coverage for employees; to
authorize selected out-of-state insurers to offer health insurance plans in
Georgia; to provide for certain notices; to authorize the Commissioner of
Insurance to adopt certain rules and regulations; to provide for related
matters; to amend Title 45 of the Official Code of Georgia Annotated, relating
to public officers and employees, so as to provide that the Board of Community
Health shall establish certain health insurance plans for state employees; to
provide that the board shall provide for certain incentives with regard to such
plans; to provide incentives for electronic prescribing and electronic
submission of claims; to amend Article 7 of Chapter 4 of Title 49 of the
Official Code of Georgia Annotated, known as the "Georgia Medical Assistance Act
of 1977," so as to provide incentives for electronic prescribing and electronic
submission of claims; to provide that a health care entity which is not in
compliance with certain data reporting requirements is not eligible to provide
Medicaid services; to provide for related matters; to provide effective dates;
to repeal conflicting laws; and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Chapter
4 of Title 26 of the Official Code of Georgia Annotated, relating to pharmacists
and pharmacies, is amended in Article 6, relating to pharmacies, by adding a new
Code section to the end of such article to read as follows:
"26-4-119.
(a)
All pharmacies licensed under this article shall submit outcome data as well as
pricing information to the Department of Community Health as specified by such
department pursuant to Code Section 31-5A-7. Such data shall be submitted at
least annually or more frequently, as specified by the Department of Community
Health.
(b)
No pharmacy or its employees or agents shall be held liable for civil damages or
subject to criminal penalties either for the reporting of patient data to the
Department of Community Health or for the release of such data by the department
pursuant to Code Section 31-5A-7."
SECTION
2.
Title
31 of the Official Code of Georgia Annotated, relating to health, is amended by
adding to the end of Chapter 5A, relating to the Department of Community Health,
new Code sections to read as follows:
"31-5A-7.
(a)
The department shall provide for the establishment of a website to be known as
'www.georgiahealthcare.com' or a similar name, as determined by the department,
for the purpose of providing consumers information on the cost and quality of
health care in Georgia. The consumer information shall include:
(1)
Performance and outcome data and pricing comparisons for selected medical
conditions, surgeries, and procedures in hospitals and ambulatory surgical
centers in Georgia to assist consumers in choosing a health care facility that
best serves their needs;
(2)
Cost comparison information on certain prescription drugs at different
pharmacies in Georgia; and
(3)
Cost comparison information on nursing homes and assisted living facilities in
Georgia.
Subject
to appropriations by the General Assembly, the website shall be developed,
hosted, and maintained by a private or other entity selected through a request
for proposals process. Such website shall be operational and available to the
public no later than January 1, 2008.
(b)
The department shall adopt rules and regulations establishing the data elements
required to be submitted by health care facilities, pharmacies, nursing homes,
and assisted living facilities in order to obtain information relating to number
of hospitalizations at a facility for a certain procedure, average lengths of
stay, readmission rates, mortality rates, complication/infection rates, facility
profiles, average charges, and wholesale and retail prices for certain
prescription drugs to populate the website established pursuant to subsection
(a) of this Code section. The data shall include, but not be limited to, case
mix data; patient admission and discharge data; hospital emergency department
data, which shall include the number of patients treated in the emergency
department of a licensed hospital reported by patient acuity level; data on
hospital acquired infections as specified by rule; data on complications; data
on readmissions, with patient and provider specific identifiers included; actual
charge data by diagnostic groups; financial data; accounting data; operating
expenses; expenses incurred for rendering services to patients who cannot or do
not pay; interest charges; depreciation expenses based on the expected useful
life of the property and equipment involved; and demographic data. Data may be
obtained from documents such as, but not limited to, leases, contracts, debt
instruments, itemized patient bills, medical record abstracts, and related
diagnostic information. Reported data elements shall be reported in accordance
with rules and regulations established by the department. The department shall
promulgate standards for the electronic format of data and may require such data
to be submitted in accordance with interoperability agreements. Data submitted
shall be certified by the chief executive officer or an appropriate and duly
authorized representative or employee of the licensed facility that the
information submitted is true and accurate. Specifications for data to be
collected under this Code section shall be developed by the department with
input from the Georgia Patient Safety Corporation established pursuant to Code
Section 31-5A-8, affected entities, consumers, purchasers, and such other
interested parties as may be determined by the department.
(c)
The department shall determine which medical conditions and procedures,
performance outcomes, and patient charge data to include on the website. When
determining which conditions and procedures to include, the department shall
consider such factors as volume, severity of the illness, urgency of admission,
individual and societal costs, whether the condition is acute or chronic,
variation in costs, variation in outcomes, and magnitude of variations and other
relevant information. When determining which performance outcomes to include,
the department shall consider such factors as volume of cases, average patient
charges, average lengths of stay, complication rates, mortality rates, and
infection rates, among others, which shall be adjusted for case mix and
severity, if applicable; provided, however, the department may also consider
such additional measures that are adopted by the federal Centers for Medicare
and Medicaid Studies, the National Quality Forum, the Joint Commission on
Accreditation of Healthcare Organizations, the federal Agency for Healthcare
Research and Quality, or a similar national entity that establishes standards to
measure the performance of health care providers or by other states.
Performance outcome indicators shall be risk adjusted or severity adjusted, as
applicable, using nationally recognized risk adjustment methodologies,
consistent with the standards of the Agency for Healthcare Research and Quality
and as selected by the department. When determining which patient charge data
to include, the department shall consider such measures as average charge,
average net revenue per adjusted patient day, average cost per adjusted patient
day, and average cost per admission, among others.
(d)
The department shall identify those prescription drugs for which price
information shall be collected. Such information shall include recent average
wholesale prices and retail prices. If a prescription drug is available in a
generic form, price data shall be reported for the generic drug and its brand
name equivalent.
(e)
The website shall be designed and operated to allow consumers to conduct an
interactive search that allows them to view and compare the information for
specific health care facilities, pharmacies, nursing homes, and assisted living
facilities. Such information shall be made available by geographic area and by
provider. The website shall include such additional information as is
determined necessary by the department to ensure that the website enhances
informed decision making among consumers, including definitions of all of the
data and terms, descriptions of each procedure, appropriate guidance on how to
use the data, and an explanation of why the data may vary between facilities.
The department may include a notice on the website that the pricing information
is based on a compilation of charges for the average patient and that each
patient´s bill may vary from the average depending on the severity of
illness, length of stay, and other factors. This notice may include a statement
indicating that, at certain facilities, the charges may be negotiable for
certain patients based upon the patient´s ability to pay.
(f)
Portions of patient records obtained or generated by the department containing
the name, residence or business address, telephone number, social security or
other identifying number, or photograph of any person or the spouse, relative,
or guardian of such person, or any other identifying information which is
patient specific or otherwise identifies the patient, either directly or
indirectly, are confidential and exempt from the provisions of Article 4 of
Chapter 18 of Title 50, relating to inspection of public records.
(g)
The department shall cooperate with local health agencies and the Department of
Human Resources with regard to health care data collection and dissemination and
shall cooperate with state agencies in any efforts to establish an integrated
health care data base.
(h)
The department shall be authorized to establish rules and regulations to
implement the provisions of this Code section.
31-5A-8.
(a)
There is created a body corporate and politic to be known as the Georgia Patient
Safety Corporation which shall be deemed to be an instrumentality of the state,
and not a state agency, and a public corporation. Venue for the corporation
shall be in Fulton County.
(b)
The purpose of the corporation is to serve as a learning organization dedicated
to assisting health care providers in this state to improve the quality and
safety of health care rendered and to reduce harm to patients. The corporation
shall promote the development of a culture of patient safety in the health care
system in this state. The corporation shall not regulate health care providers
in this state. In fulfilling its purpose, the corporation shall work with a
consortium of patient safety centers and other patient safety
programs.
(c)
The corporation shall be governed by a board of directors composed of 13 members
appointed by the Governor as follows:
(1)
One representative from the board of regents affiliated with a medical school in
Georgia;
(2)
Two representatives with expertise in patient safety issues for the health
insurer and health maintenance organization with the largest market shares,
respectively, as measured by premiums written in this state for the most recent
calendar year;
(3)
One representative of an authorized medical malpractice insurer in this state;
(4)
Two representatives of hospitals in this state;
(5)
Four physicians;
(6)
One nurse;
(7)
One dentist; and
(8)
One pharmacist.
Members
shall be residents of the State of Georgia, shall be prominent persons in their
businesses or professions, and shall not have been convicted of any felony
offense. Members shall serve terms of five years, except that of the initial
members appointed, five shall be appointed for initial terms of two years, four
shall be appointed for initial terms of four years, and four shall be appointed
for initial terms of five years. Any vacancy occurring on the board shall be
filled by the Governor by appointment for the unexpired term. The members shall
elect from their membership a chairperson and vice chairperson. Upon approval by
the chairperson, members of the board shall be reimbursed for actual and
reasonable expenses incurred for each day´s service spent in the
performance of the duties of the corporation. A majority of members in office
shall constitute a quorum for the transaction of any business and for the
exercise of any power or function of the corporation.
(d)
The department shall provide staff to assist the corporation in its
establishment.
(e)
The corporation shall be authorized to:
(1)
Secure staff necessary to properly administer the corporation;
(2)
Collect, analyze, and evaluate patient safety data and quality and patient
safety indicators, medical malpractice closed claims, and adverse incidents
reported to the Department of Human Resources for the purpose of recommending
changes in practices and procedures that may be implemented by health care
practitioners and health care facilities to improve health care quality and to
prevent future adverse incidents. Notwithstanding any other provision of law,
the Department of Human Resources shall make available to the corporation any
adverse incident report submitted pursuant to Code Section 31-8-93. To the
extent that adverse incident reports submitted are considered confidential and
exempt from disclosure, the confidential and exempt status of such reports shall
be maintained by the corporation;
(3)
Establish a patient safety reporting system to: identify potential systemic
problems that could lead to adverse incidents; enable publication of system-wide
alerts of potential harm; and facilitate development of both facility specific
and state-wide options to avoid adverse incidents and improve patient safety.
The reporting system shall record any potentially harmful event that could have
had an adverse result but, through chance or intervention, in which harm was
prevented submitted by hospitals, birthing centers, ambulatory surgical centers,
nursing homes, assisted living facilities, and other providers. The reporting
system shall be voluntary and anonymous and independent of mandatory reporting
systems used for regulatory purposes;
(4)
Work collaboratively with the appropriate state agencies in the development of
electronic health records;
(5)
Provide for access to an active library of evidence based medicine and patient
safety practices, together with the emerging evidence supporting their retention
or modification, and make this information available to health care
practitioners, health care facilities, and the public;
(6)
Develop and recommend core competencies in patient safety that can be
incorporated into the undergraduate and graduate curricula in schools of
medicine, nursing, and allied health in the state;
(7)
Develop and recommend programs to educate the public about the role of health
care consumers in promoting patient safety;
(8)
Provide recommendations for interagency coordination of patient safety efforts
in the state;
(9)
Assess the patient safety culture at volunteering hospitals and recommend
methods to improve the working environment related to patient safety at these
hospitals;
(10)
Inventory the information technology capabilities related to patient safety of
health care facilities and health care practitioners and recommend a plan for
expediting the implementation of patient safety technologies state
wide;
(11)
Recommend continuing medical education regarding patient safety to practicing
health care practitioners;
(12)
Study and facilitate the testing of alternative systems of compensating injured
patients as a means of reducing and preventing medical errors and promoting
patient safety;
(13)
Provide recommendations to the department on data elements to be collected from
health care entities and on performance and outcome data and pricing information
to be included on the department´s website in accordance with Code Section
31-5A-7; and
(14)
Conduct other activities identified by the board of directors to promote patient
safety in this state.
(f)
The corporation shall submit an annual report to the Governor, President of the
Senate, Speaker of the House of Representatives, and the chairpersons of the
Health and Human Services Committees of the Senate and the House of
Representatives.
(g)
Subject to appropriations by the General Assembly, the corporation shall provide
for the establishment of a central data base accessible through a website for
the purpose of providing a clearing-house of electronic medical records
accessible to health care providers, patients, and others as determined by the
corporation. The data base shall include, at a minimum, vaccination records and
prescription drug records. The corporation shall be authorized to coordinate
with the Department of Human Resources, and the Department of Human Resources
shall be authorized to share and release vaccination records maintained in the
vaccination registry established pursuant to Code Section 31-12-3.1 to the
corporation or its agent as long as any such release is in compliance with the
federal Health Insurance Portability and Accountability Act of 1996, P. L.
104-191. The corporation shall be authorized to issue a request for proposals
to select a private or other entity to develop, host, and maintain such data
base and website.
31-5A-9.
Subject
to appropriations by the General Assembly, the department shall be authorized to
provide grants, subsidies, and other incentives for individuals to obtain health
care coverage whose family income exceeds the income requirements for
eligibility for health services under Medicaid, but whose family income does not
exceed 200 percent of the federal poverty level and are not able to afford
health insurance from their employers. Such grants, subsidies, and other
incentives may include, but not be limited to, programs to provide preventive
care for children, Pap smears, mammograms, prostate exams, biannual physical
exams, copayments for hospitals, coverage of deductibles, and
outreach."
SECTION
3.
Said
title is further amended in Article 1 of Chapter 7, relating to regulation of
hospitals and related institutions, by adding to the end of such article a new
Code section to read as follows:
"31-7-17.
(a)
For purposes of this Code section, 'health care facility' means all hospitals
and ambulatory surgical or obstetrical facilities, as such terms are defined in
Code Section 31-6-2.
(b)
All health care facilities licensed under this article which receive any state
funds shall submit performance and outcome data as well as pricing information
to the Department of Community Health as specified by such department pursuant
to Code Section 31-5A-7. Such data shall be submitted at least annually or more
frequently, as specified by the Department of Community Health.
(c)
No health care facility or other reporting entity or its employees or agents
shall be held liable for civil damages or subject to criminal penalties either
for the reporting of patient data to the Department of Community Health or for
the release of such data by such department pursuant to Code Section
31-5A-7.
(d)
A health care facility which is not in compliance with this Code
section:
(1)
May be subject to consequences pursuant to Code Section 49-4-158;
and
(2)
May be subject to having its certificate of need modified or sanctioned by the
Department of Community Health as may be authorized pursuant to Article 3 of
Chapter 6 of this title."
SECTION
4.
Said
title is further amended by revising subsection (b) of Code Section 31-33-3,
relating to costs of copying and mailing health records, as
follows:
"(b)
The rights granted to a patient or other person under this chapter are in
addition to any other rights such patient or person may have relating to access
to a patient´s
records;
however, nothing in this chapter shall be construed as granting to a patient or
person any right of ownership in the records, as such records are owned by and
are the property of the provider.
A
patient´s records shall be deemed to be owned by the patient. A provider
shall furnish to any patient one copy of his or her medical records per calendar
year, upon request and without charge, in paper or electronic format at the
providerʹs
discretion."
SECTION
5.
Title
28 of the Official Code of Georgia Annotated, relating to the General Assembly,
is amended by adding a new chapter to read as follows:
"CHAPTER
12
28-12-1.
There
is created as a joint committee of the General Assembly the Georgia Health Care
Overview Committee to be composed of five members of the House of
Representatives appointed by the Speaker of the House and five members of the
Senate appointed by the Senate Committee on Assignments. The members of the
committee shall serve two-year terms concurrent with their terms as members of
the General Assembly. The chairperson of the committee shall be appointed by
the Senate Committee on Assignments from the membership of the committee, and
the vice chairperson of the committee shall be appointed by the Speaker of the
House of Representatives from the membership of the committee. The chairperson
and vice chairperson shall serve terms of two years concurrent with their terms
as members of the General Assembly. Vacancies in an appointed member´s
position or in the offices of chairperson or vice chairperson shall be filled
for the unexpired term in the same manner as the original
appointment.
28-12-2.
The
state auditor, the Attorney General, and all other agencies of state government,
upon request by the committee, shall assist the committee in the discharge of
its duties. The committee may employ not more than two staff members and may
secure the services of independent accountants, engineers, and
consultants.
28-12-3.
The
Georgia Patient Safety Corporation shall cooperate with the committee, its
authorized personnel, the Attorney General, the state auditor, the state
accounting officer, and other state agencies. The Georgia Patient Safety
Corporation shall submit to the committee such reports and data as the committee
shall reasonably require of it. The Attorney General is authorized to bring
appropriate legal actions to enforce any laws specifically or generally relating
to the Georgia Patient Safety Corporation.
28-12-4.
The
committee shall:
(1)
Evaluate the performance of the Georgia Patient Safety Corporation consistent
with the following criteria:
(A)
Prudent, legal, and accountable expenditure of public funds;
(B)
Efficient operation; and
(C)
Performance of statutory responsibilities;
(2)
Periodically inquire into and review the operations of the Georgia Patient
Safety Corporation as well as periodically review and evaluate the success with
which such entity is accomplishing its statutory duties and functions;
and
(3)
On or before the first day of January of each year, and at such other times as
it deems necessary, submit to the General Assembly a report of its findings and
recommendations based upon the review of the Georgia Patient Safety
Corporation.
28-12-5.
(a)
The committee is authorized to expend state funds available to the committee for
the discharge of its duties. Said funds may be used for the purposes of
compensating staff, paying for services of independent accountants, engineers,
and consultants, and paying all other necessary expenses incurred by the
committee in performing its duties.
(b)
The members of the committee shall receive the same compensation, per diem,
expenses, and allowances for their service on the committee as is authorized by
law for members of interim legislative study committees.
(c)
The funds necessary for the purposes of the committee shall come from the funds
appropriated to and available to the legislative branch of
government."
SECTION
6.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by revising subsection (b) of Code Section 33-30-23, relating to standards for
preferred provider arrangements, as follows:
"(b)
Such arrangements shall not:
(1)
Unfairly deny health benefits for medically necessary covered
services;
(2)
Have differences in benefit levels payable to preferred providers compared to
other providers which unfairly deny benefits for covered services;
(3)
Have differences in coinsurance percentages applicable to benefit levels for
services provided by preferred and nonpreferred providers which differ by more
than
30
40
percentage points;
(4)
Have a coinsurance percentage applicable to benefit levels for services provided
by nonpreferred providers which exceeds
40
50
percent of the benefit levels under the policy for such services;
(5)
Have an adverse effect on the availability or the quality of services;
and
(6)
Be a result of a negotiation with a primary care physician to become a preferred
provider unless that physician shall be furnished, beginning on and after
January 1, 2001, with a schedule showing common office based fees payable for
services under that arrangement."
SECTION
7.
Said
title is further amended by revising paragraph (4) of Code Section 33-30-4,
relating to required provisions of group accident and sickness policies
generally, as follows:
"(4)
A provision that, with respect to termination of benefits for, or coverage of,
any person who is a dependent child of an insured, the child shall continue to
be insured up to and including age 25
or until two
years after such child´s status as a dependent ends, whichever is
earlier, so long as the coverage of the
member continues in
effect,
and
the child remains a dependent of the insured parent or
guardian,
and the child, in each calendar year since reaching any age specified for
termination of benefits as a dependent, has been enrolled for five calendar
months or more as a full-time student at a postsecondary institution of higher
learning or, if not so enrolled, would have been eligible to be so enrolled and
was prevented from being so enrolled due to illness or
injury. This paragraph shall not apply to
group policies under which an employer provides coverage for dependents of its
employees and pays the entire cost of the coverage without any charge to the
employee or dependents; and".
SECTION
8.
Said
title is further amended by revising paragraph (8) of subsection (b) of Code
Section 33-30-6, relating to required provisions of blanket accident and
sickness policies, as follows:
"(8)
A provision that, with respect to termination of benefits for, or coverage of,
any person who is a dependent child of an insured, the child shall continue to
be insured up to and including age 25
or until two
years after such child´s status as a dependent ends, whichever is
earlier, so long as the coverage of the
insured parent or guardian continues in
effect,
and
the child remains a dependent of the parent or
guardian,
and the child, in each calendar year since reaching any age specified for
termination of benefits as a dependent, has been enrolled for five months or
more as a full-time student at a postsecondary institution of higher learning
or, if not so enrolled, would have been eligible to be so enrolled and was
prevented from being so enrolled due to illness or
injury."
SECTION
9.
Said
title is further amended by adding a new Code Section 33-30-16 to read as
follows:
"33-30-16.
(a)
Employers who employ persons who are also employed by other employers shall be
authorized to enter into arrangements with such other employers to provide group
health insurance coverage for such employees by contributing to the cost of such
health care insurance provided by such other employers.
(b)
The commissioner shall promulgate such rules and regulations as necessary to
regulate and enable such contributions to group health care insurance coverage
by additional employers of an insured."
SECTION
10.
Said
title is further amended by adding a new Chapter 62 to read as
follows:
"CHAPTER
62
33-62-1.
As
used in this chapter, the term:
(1)
'Applicant' means an individual seeking to participate in the Georgia Health
Insurance Exchange.
(2)
'Carrier' means any person or organization subject to the authority of the
Commissioner that provides one or more health benefit plans or insurance in this
state and includes an insurer, a hospital and medical services corporation, a
fraternal benefit society, a health maintenance organization, and a multiple
employer welfare arrangement.
(3)
'COBRA' means the Consolidated Omnibus Budget Reconciliation Act of 1985,
approved April 7, 1986 (100 Stat. 231; 29 U.S.C. Section 1161, et
seq.).
(4)
'Commissioner' means the Commissioner of Insurance.
(5)
'Creditable coverage' means continual coverage of the applicant under any of the
following health plans with no lapse in coverage of more than 63 days
immediately prior to the date of application:
(A)
A group health plan;
(B)
Health insurance coverage;
(C)
Part A or Part B of Title XVIII of the Social Security Act, approved July 30,
1965 (79 Stat. 291; 42 U.S.C. Section 1395c, et seq.; or 42 U.S.C. Section
1395j, et seq., respectively);
(D)
Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 291; 42
U.S.C. Section 1396, et seq.), other than coverage consisting solely of benefits
under Section 1928;
(E)
Chapter 55 of Title 10 of the United States Code (10 U.S.C. Section 1071, et
seq.);
(F)
A medical care program of the Indian Health Service or of a tribal
organization;
(G)
A state health benefits risk pool;
(H)
A health plan offered under Chapter 89 of Title 5 of the United States Code (5
U.S.C. Section 8901, et seq.);
(I)
A public health plan (as defined in federal or state regulation);
(J)
A health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C.
Section 2504(e)); or
(K)
Any other qualifying coverage required by HIPAA, as it may be amended, or
regulations under that Act.
Creditable
coverage does not include coverage consisting solely of coverage of excepted
benefits.
(6)
'Dependent' means:
(A)
The spouse of the principal insured; or
(B)(i)
An individual who is related to the principal insured by birth, marriage, or
adoption; and
(ii)
Who also meets the definition of a dependent as set forth in the United States
Internal Revenue Code (26 U.S.C. Section 152).
(7)
'Eligible individual' means an individual who is eligible to participate in the
Georgia Health Insurance Exchange by reason of meeting one or more of the
following qualifications:
(A)
The individual is a Georgia resident, meaning that the individual is and
continues to be legally domiciled and physically residing on a permanent and
full-time basis in a place of permanent habitation in Georgia that remains the
person´s principal residence and from which the person is absent only for
temporary or transitory purposes. A person who is a full-time student attending
an institution outside of Georgia may maintain his or her Georgia
residency.
(B)
The individual is not a Georgia resident but is employed, at least 20 hours a
week on a regular basis, at a Georgia location by a bona fide employer, and the
individual´s employer does not offer a group health insurance plan, or the
individual is not eligible to participate in any group health insurance plan
offered by the individual´s employer;
(C)
The individual, whether a resident or not, is enrolled in, or eligible to enroll
in, a participating employer plan;
(D)
The individual is self-employed in Georgia and, if a nonresident self-employed
individual, the individual´s principal place of business is in
Georgia;
(E)
The individual is a full-time student attending an institution of higher
education located in Georgia; or
(F)
The individual, whether a resident or not, is a dependent of another individual
who is an eligible individual.
(8)
'Employer' means any individual, partnership, association, corporation, business
trust, or person or group of persons employing one or more persons and filing
payroll tax information on such person or persons.
(9)
'Excepted benefits' means coverage such as Medicare Supplement Insurance;
specified disease insurance; dental only or vision only insurance; accident only
insurance; hospital confinement indemnity coverage; coverage issued as a
supplement to liability insurance; long-term care insurance; workers
compensation insurance; loss of income insurance; coverage for medical expenses
included as part of any auto, property, casualty or other liability insurance;
and credit or disability insurance.
(10)
'Exchange' means the Georgia Health Insurance Exchange established by this
chapter.
(11)
'Federal health coverage tax credit eligible individual' means any individual
who is eligible for benefits under section 201 of the Trade Act of 2002,
approved August 6, 2002 (116 Stat. 933; 26 U.S.C. Section 35(c) (2003)), as
amended.
(12)
'HIPAA' means the Health Insurance Portability and Accountability Act of 1996,
approved August 21, 1996 (Pub. L. 104-191; 110 Stat. 1136).
(13)
'Participating employer plan' means a group health plan, as defined in federal
law (Section 706 of ERISA (29 U.S.C. Section 1186)), that is sponsored by an
employer and for which the plan sponsor has entered into an agreement with the
Georgia Health Insurance Exchange, in accordance with the provisions of Code
Section 33-62-11, for the Georgia Health Insurance Exchange to offer and
administer health insurance benefits for enrollees in the plan.
(14)
'Participating individual' means a person who has been determined by the Georgia
Health Insurance Exchange to be, and continues to remain, an eligible individual
for purposes of obtaining coverage under participating insurance plans offered
through the Georgia Health Insurance Exchange.
(15)
'Participating insurance plan' means a health benefit plan offered through the
Georgia Health Insurance Exchange.
(16)
'Plan year' means the period of time during which the insured is covered under a
health benefit plan, as stipulated in the contract governing the
plan.
(17)
'Preexisting conditions provision' means a provision in a health benefit plan
that limits, denies, or excludes benefits for a period of time for an enrollee
for expenses or services related to a medical condition that was present before
the date the coverage commenced, whether or not any medical advice, diagnosis,
care, or treatment was recommended or received before that date. The time
period for a preexisting conditions provision begins when an application for
insurance is made or when an applicant is in a waiting period for coverage under
any plan. Genetic information shall not be treated as a preexisting condition
in the absence of a diagnosis of the condition related to such
information.
(18)
'Producer' means a person required to be licensed in Georgia to sell, solicit,
or negotiate insurance.
(19)
'Rate' means the premiums or fees charged by a health benefit plan for coverage
under the plan.
(20)
'Self-funded health benefit plan' means a health insurance plan, not subject to
regulation by this state or any other state, that is paid in whole or in part by
the employer from its own assets or from a funded welfare benefit plan, provided
that such plan does not shift any risk or liability for benefit payments to an
insurer or other carrier other than through reinsurance or stop-loss
coverage.
33-62-2.
(a)
There is hereby chartered and established by the State of Georgia the Georgia
Health Insurance Exchange as a body corporate and an independent instrumentality
of the State of Georgia, created to effectuate public purposes provided for in
this chapter, but with a legal existence separate from that of the State of
Georgia.
(b)
The Georgia Health Insurance Exchange is hereby recognized as a not for profit
corporation in accordance with the provisions of the laws of Georgia and shall
seek recognition of the same status by the United States in accordance with the
provisions of the United States Internal Revenue Code (26 U.S.C. Section
501(c)).
(c)
The Georgia Health Insurance Exchange is created for the limited purpose of
providing the residents of Georgia, and such other individuals as may, from time
to time, also be eligible to participate, with greater access to, and choice and
portability of, health insurance products.
(d)
The Georgia Health Insurance Exchange shall operate in accordance with all
requirements and restrictions set forth in this chapter and all other applicable
laws of Georgia and the United States.
(e)
All eligible individuals shall be permitted to obtain health insurance benefits
through the Georgia Health Insurance Exchange, subject to the provisions of this
chapter.
33-62-3.
(a)
The exchange shall be governed by a board of directors. The board of directors
shall consist of three members appointed by the Governor, three members
appointed by the Senate Committee on Assignments, and three members appointed by
the Speaker of the House of Representatives. The initial appointees to the
board of directors shall be appointed to terms of office beginning July 1, 2007.
Each appointing authority shall designate one of the authority´s initial
appointees to serve a term of office ending on June 30, 2009; one appointee
to serve a term of office ending on June 30, 2010; and one appointee to serve a
term of office ending on June 30, 2011. Thereafter, successors shall be
appointed by the appropriate appointing authority for three-year terms of office
beginning on July 1 following the expiration of the previous member´s term
of office and ending on June 30 three years later.
(b)
Vacancies on the board of directors shall be filled by appointment by the
appropriate appointing authority for the unexpired term of office. Members
shall be eligible to succeed themselves in office.
(c)
The board of directors shall at its initial meeting and the first meeting of
each calendar year thereafter select from among its members a chairperson and a
vice chairperson. The board of directors shall also select at the same times a
secretary who shall not be required to be a member of the board of
directors.
(d)
The board of directors shall appoint an exchange director, who
shall:
(1)
Be a full-time employee of the Georgia Health Insurance Exchange;
(2)
Administer all of the Georgia Health Insurance Exchange´s activities and
contracts;
(3)
Supervise the staff of the Georgia Health Insurance Exchange; and
(4)
Perform such other functions and duties as directed by the board of directors
consistent with this chapter.
(e)
The exchange director shall serve at the pleasure of the board of
directors.
(f)
The board of directors shall be authorized to employ staff and other
professionals to assist the board in carrying out the provisions of this
chapter.
33-62-4.
(a)
The exchange shall:
(1)
Publicize the existence of the exchange and disseminate information on
eligibility requirements and enrollment procedures for the
exchange;
(2)
Establish and administer procedures for enrolling eligible individuals in the
exchange, including:
(A)
Creating a standard application form to collect information necessary to
determine the eligibility and previous coverage history of an applicant;
and
(B)
Preparing and distributing certificate of eligibility forms and application
forms to insurance producers and the general public;
(3)
Establish and administer a website at which individuals can examine the various
health insurance options available to them and which contains a program or
programs designed to assist individuals, after inputting basic information about
themselves and any covered dependents, in determining the cost of the various
health insurance options available to them and which health insurance options
provide the best coverages at the least cost for the individuals;
(4)
Establish and administer procedures for the election of coverage by
participating individuals, in accordance with Code Section 33-62-6, during open
season periods and outside of open season periods upon the occurrence of any
qualifying event specified in subsection (d) of Code Section 33-62-6, including
preparing and distributing to participating individuals:
(A)
Descriptions of the coverage, benefits, limitations, copayments, and premiums
for all participating plans; and
(B)
Forms and instructions for electing coverage and arranging payment for
coverage;
(5)
Collect and transmit to the applicable participating plans all premium payments
or contributions made by or on behalf of participating individuals, including
developing mechanisms to:
(A)
Receive and process automatic payroll deductions for participating individuals
enrolled in participating employer plans;
(B)
Enable participating individuals to pay, in whole or part, for coverage through
the exchange by electing to assign to the exchange any federal earned income tax
credit payments due the participating individual; and
(C)
Receive and process any federal or state tax credits or other premium support
payments for health insurance as may be established by law;
(6)
Upon request, issue certificates of previous coverage in accordance with the
provisions of HIPAA to all such individuals who cease to be covered by a
participating insurance plan;
(7)
Establish procedures to account for all funds received and disbursed by the
exchange, including:
(A)
Maintaining a separate, segregated management account for the receipt and
disbursement of monies allocated to fund the administration of the exchange;
and
(B)
Maintaining a separate, segregated operations account for:
(i)
The receipt of all premium payments or contributions made by or on behalf of
participating individuals; and
(ii)
The distribution of premium payments to participating plans and of commissions
or payments to licensed insurance producers and such other organizations as are
permitted under Code Section 33-62-12 to receive payments for their services in
enrolling eligible individuals or groups in the exchange; and
(8)
Submit to the Commissioner, following the end of each plan year, the report of
an independent audit of the exchange´s accounts for the plan
year.
33-62-5.
The
exchange shall have the power to:
(1)
Contract with vendors to perform one or more of the functions specified in Code
Section 33-62-4;
(2)
Contract with private or public social service agencies to administer
application, eligibility verification, enrollment, and premium payments for
specified groups or populations of eligible individuals or participating
individuals;
(3)
Contract with employers to act as the plan administrator for participating
employer plans, subject to the provisions of Code Section 33-62-11, and to
undertake the obligations required by federal law of a plan
administrator;
(4)
Set and collect fees from participating individuals, participating employer
plans, and participating insurance plans sufficient to fund the cost of
administering the exchange;
(5)
Seek and directly receive grant funding from the United States government,
departments or agencies of this state, county or municipal governments, or
private philanthropic organizations to defray the costs of operating the
exchange;
(6)
Establish and administer rules and procedures governing the operations of the
exchange;
(7)
Establish one or more service centers within this state to facilitate
enrollment;
(8)
Sue and be sued or otherwise take any necessary or proper legal action;
and
(9)
Establish bank accounts and borrow money.
33-62-6.
(a)
Any eligible individual may apply to participate in the exchange. An employer;
a labor union; and an educational, professional, civic, trade, church,
synagogue, or social organization that has eligible individuals as employees or
members may apply on behalf of those eligible persons. Upon determination by
the exchange that an individual is eligible in accordance with the provisions of
this chapter to participate in the exchange, he or she may enroll, or, when
applicable, be enrolled by that individual´s parent or legal guardian, in a
participating insurance plan offered through the exchange during the next open
season period or, when applicable, at such other times as are specified in
subsection (d) of this Code section.
(b)
From November 1 to November 30 of each year, the exchange shall administer an
open season during which any eligible individual may enroll in any health
benefit plan offered through the exchange, subject to the provisions of Code
Section 33-62-8, without a waiting period, and may not be declined
coverage.
(c)
The first 90 days after the exchange begins to accept applications shall be
considered the initial open season.
(d)
An eligible individual may enroll in a health benefit plan offered through the
exchange, subject to the provisions of Code Section 33-62-8, without a waiting
period, and may not be declined coverage, at a time other than the annual open
season for any of the following reasons, provided the individual does so within
63 days of the triggering event:
(1)
The individual loses coverage in an existing health insurance plan due to the
death of a spouse, parent, or legal guardian;
(2)
The individual or a covered dependent loses coverage in an existing health
insurance plan due to a change in the individual´s employment
status;
(3)
The individual or a covered dependent loses coverage in an existing health
insurance plan because of a divorce, separation, or other change in familial
status;
(4)
The individual loses coverage in an existing health insurance plan because he or
she achieves an age at which coverage lapses under that plan;
(5)
The individual or a covered dependent becomes newly eligible by becoming a
resident of Georgia or the individual´s place of employment has been
changed to Georgia;
(6)
The individual becomes newly eligible by becoming the spouse or dependent, by
reason of birth, adoption, court order, or a change in custody arrangement, of
an eligible individual;
(7)
The individual becomes subject to a court order requiring him or her to provide
health insurance coverage to certain dependents or enters into a new arrangement
for the custody of dependents that requires him or her to provide health
insurance for those dependents; or
(8)
The individual loses coverage in a plan offered through the exchange by reason
of the plan terminating participation in the exchange prior to the end of the
plan year.
33-62-7.
(a)
No health benefit plan may be offered through the exchange unless the
Commissioner has first certified to the exchange that:
(1)
The carrier seeking to offer the plan is licensed to issue health insurance in
this state and is in good standing; and
(2)
The plan meets the requirements of this Code section, and the plan and the
carrier are in compliance with all other applicable health insurance laws of
this state.
(b)
No plan shall be certified that excludes from coverage any individual otherwise
determined by the exchange as meeting the eligibility requirements for
participating individuals.
(c)
The certification of plans to be offered through the exchange shall not be
subject to any state law requiring competitive bidding.
(d)
Each certification shall be valid for a uniform term of at least one year but
may be made automatically renewable from term to term in the absence of notice
of either:
(1)
Withdrawal by the Commissioner; or
(2)
Discontinuation of participation in the exchange by the plan or
carrier.
(e)
Certification of a plan may be withdrawn only after notice to the carrier and
opportunity for hearing. The Commissioner may, however, decline to renew the
certification of any carrier at the end of a certification term.
(f)
Each plan certified by the Commissioner as eligible to be offered through the
exchange shall contain a detailed description of benefits offered, including
maximums, limitations, exclusions, and other benefit limits.
(g)
Each plan certified by the Commissioner as eligible to be offered through the
exchange shall provide, subject to the plan´s deductibles and coinsurance
or copayment schedule, major medical coverage that includes the
following:
(1)
Hospital benefits;
(2)
Surgical benefits;
(3)
In-hospital medical benefits;
(4)
Ambulatory patient benefits;
(5)
Prescription drug benefits; and
(6)
Mental health benefits.
(h)
Carriers shall offer plans through the exchange at standard rates based on age,
geography, and family composition and that are determined to be actuarially
sound in the judgment of the Commissioner.
(i)
The rates determined for the first plan year for which the plan is offered
through the exchange may be adjusted by the carrier for subsequent plan years
based on experience and any later modifications to plan benefits, provided that
any adjustments in rates shall be made in advance of the plan year for which
they will apply and on a basis which, in the judgment of the Commissioner, is
consistent with the general practice of carriers that issue health benefit plans
to large employers.
(j)
The exchange shall not decline or refuse to offer, or otherwise restrict the
offering to any participating individual, any plan that has obtained, in a
timely fashion in advance of the annual open season, certification by the
Commissioner in accordance with the provisions of this Code
section.
(k)
The Exchange shall not sponsor any insurance or benefit plan, or contract with
any carrier to offer any insurance or benefit plan, as a participating plan that
has not first been certified by the Commissioner in accordance with the
provisions of this Code section.
(l)
The exchange shall not impose on any participating plan, or on any carrier or
plan seeking to participate in the exchange, any terms or conditions, including
any requirements or agreements with respect to rates or benefits beyond, or in
addition to, those terms and conditions established and imposed by the
Commissioner in certifying plans under the provisions of this Code
section.
(m)
The Commissioner shall establish and administer regulations and procedures for
certifying plans to participate in the exchange in accordance with the
provisions of this Code section.
33-62-8.
The
following rules shall govern the imposition by carriers of any preexisting
condition provisions and rating surcharges with respect to any participating
individual covered by any participating insurance plan:
(1)
Current
participants. Except as otherwise
specified in paragraphs (3) and (4) of this Code section, during any open
season, a participating individual who elects to choose a different
participating insurance plan or plan option for the next plan year shall not be
subject to any preexisting condition provisions and shall be charged the
standard rate of the new participating insurance plan or plan option for persons
of the participating individual´s age and geographic area, and the same
criteria shall apply to any election by a participating individual of coverage
for any dependent who is also a participating individual;
(2)
New participants with
creditable coverage. A new participating
individual with 18 or more months of creditable coverage who enrolls in a
participating insurance plan shall not be subject to any preexisting condition
provisions and shall be charged the applicable age and geography adjusted
standard rate for the participating insurance plan;
(3)
New participants with
partial creditable coverage. A new
participating individual with creditable coverage of between two and 17 months
may enroll in a participating insurance plan, but the participating individual
may be subject to one or more preexisting condition provisions, for a period not
to exceed 12 months, the number of such months to be reduced by the number of
months of creditable coverage, or may be charged a premium not to exceed 125
percent of the otherwise applicable age and geography adjusted standard rate for
the participating insurance plan, or both, and any such rate surcharge shall not
be applied during the third or subsequent years of the individual´s
enrollment in any participating insurance plan;
(4)
New participants
without creditable coverage. A new
participating individual with two months or less of creditable coverage may
enroll in a participating insurance plan, but the participating individual may
be subject to one or more preexisting condition provisions, for a period not to
exceed 12 months, the number of such months to be reduced by the number of
months of creditable coverage, or may be charged a premium not to exceed 150
percent of the otherwise applicable age and geography adjusted standard rate for
the participating insurance plan, or both, and any such rate surcharge shall not
be applied during the third or subsequent years of the individual´s
enrollment in any participating insurance plan;
(5)
Newly eligible
dependents. In cases where an individual
is enrolled in a plan offered through the exchange as a newly eligible dependent
of a participating individual by reason of birth, adoption, court order, or a
change in custody arrangement, either during open season or outside of open
season in accordance with paragraph (6) of subsection (d) of Code Section
33-62-6, a carrier shall not impose any preexisting condition provisions or any
change in the rate charged to the participating individual, except for such
difference, if any, in the participating insurance plan´s standard rates
that reflect the addition of a new dependent to the participating
individual´s coverage;
(6)
Creditable
coverage. Periods of creditable coverage
with respect to an individual shall be established through presentation of
certifications or in such other manner as may be specified in federal or state
law;
(7)
Waiver of preexisting
condition exclusion. For new
participating individuals without creditable coverage, or with only limited
creditable coverage as defined in paragraphs (3) and (4) of this Code section, a
carrier may elect to waive the imposition of preexisting condition provisions
and instead extend the applicable rate surcharge for an additional year beyond
the time provided for in those paragraphs; and
(8)
Federal health
coverage tax credit eligible individuals.
For purposes of this Code section, any federal health coverage tax credit
eligible individual shall be deemed to have 18 months of creditable
coverage.
33-62-9.
(a)
Any participating individual may continue to participate in any participating
insurance plan as long as the individual remains an eligible individual, subject
to the carrier´s rules regarding cancellation for nonpayment of premiums or
fraud, and shall not be cancelled or nonrenewed because of any change in
employer or employment status, marital status, health status, age, membership in
any organization, or other change that does not affect eligibility as defined in
this chapter.
(b)
A participating individual who is not a resident of this state and who ceases to
be an eligible individual due to a qualifying event shall be deemed to remain an
eligible individual and shall be deemed to remain a participating individual for
a period not to exceed 36 months from the date of the qualifying event
if:
(1)
The qualifying event consists of a loss of eligible individual status due
to:
(A)
Voluntary or involuntary termination of employment for reasons other than gross
misconduct; or
(B)
Loss of qualified dependent status for any reason; and
(2)
The participating individual elects to remain a participating individual and
notifies the exchange of such election within 63 days of the qualifying
event.
33-62-10.
(a)
The Commissioner shall establish procedures for resolving disputes arising from
the operation of the exchange in accordance with the provisions of this chapter,
including disputes with respect to:
(1)
The eligibility of an individual to participate in the exchange;
(2)
The imposition of a coverage surcharge on a participating individual by a
participating plan; and
(3)
The imposition of a preexisting condition provision on a participating
individual by a participating plan.
(b)
In cases where a carrier, in accordance with the provisions of this chapter,
imposes a preexisting condition exclusion or a premium surcharge in connection
with enrollment of a participating individual in a participating insurance plan
offered by the carrier, and the participating individual disputes the imposition
of such an exclusion or surcharge, the participating individual may request that
the Commissioner issue a determination as to the validity or extent of such
exclusion or surcharge under the provisions of this chapter. The Commissioner,
or his or her designee, shall issue such a determination within 30 days of the
request being filed with the Department of Insurance. If either the
participating individual or the carrier disagrees with the outcome, he or she
may submit a request for a hearing to the Commissioner in accordance with
Chapter 13 of Title 50.
33-62-11.
(a)
Any employer may apply to the exchange to be the sponsor of a participating
employer plan.
(b)
Any employer seeking to be the sponsor of a participating employer plan shall,
as a condition of participation in the exchange, enter into a binding agreement
with the exchange, which shall include the following conditions:
(1)
The sponsoring employer designates the exchange director to be the plan´s
administrator for the employer´s group health plan, and the exchange
director agrees to undertake the obligations required of a plan administrator
under federal law;
(2)
Only the coverage and benefits offered by participating insurance plans shall
constitute the coverage and benefits of the participating employer
plan;
(3)
Any individuals eligible to participate in the exchange by reason of their
eligibility for coverage under the employer´s participating employer plan,
regardless of whether any such individuals would otherwise qualify as eligible
individuals if not enrolled in the participating employer plan, may elect
coverage under any participating insurance plan, and neither the employer nor
the exchange shall limit such individuals´ choice of coverage from among
all the participating insurance plans;
(4)
The employer reserves the right to offer benefits supplemental to the benefits
offered through the exchange, but any supplemental benefits offered by the
employer shall constitute a separate plan or plans under federal law for which
the exchange director shall not be the plan administrator and for which neither
the exchange director nor the exchange shall be responsible in any
manner;
(5)
The employer agrees that, for the term of the agreement, the employer will not
offer to individuals eligible to participate in the exchange by reason of their
eligibility for coverage under the employer´s participating employer plan
any separate or competing group health plan offering the same or substantially
similar benefits as those provided by participating insurance plans through the
exchange, regardless of whether any such individuals would otherwise qualify as
eligible individuals if not enrolled in the participating employer
plan;
(6)
The employer reserves the right to determine the criteria for eligibility,
enrollment, and participation in the participating employer plan and the terms
and amounts of the employer´s contributions to that plan, so long as for
the term of the agreement with the exchange, the employer agrees not to alter or
amend any criteria or contribution amounts at any time other than during an
annual period designated by the exchange for participating employer plans to
make such changes in conjunction with the exchange´s annual open
season;
(7)
The employer agrees to make available to the exchange any of the employer´s
documents, records, or information, including copies of the employer´s
federal and state tax and wage reports, that the Commissioner reasonably
determines are necessary for the exchange to verify:
(A)
That the employer is in compliance with the terms of its agreement with the
Exchange governing the employer´s sponsorship of a participating employer
plan;
(B)
That the participating employer plan is in compliance with applicable laws
relating to employee welfare benefit plans, particularly those relating to
nondiscrimination in coverage; and
(C)
The eligibility, under the terms of the employer´s plan, of those
individuals enrolled in the participating employer plan; and
(8)
The employer agrees to also sponsor a 'cafeteria plan' as permitted under
federal law (26 U.S.C. Section 125) for all employees eligible for coverage
under the employer´s participating employer plan.
(c)
The exchange may not enter into any agreement with any employer with respect to
any employer participating plan if such agreement does not, at a minimum,
incorporate the conditions specified in subsection (b) of this Code
section.
(d)
The exchange may not enter into any agreement with any employer with respect to
any participating employer plan to provide the participating employer plan with
any additional or different services or benefits not otherwise provided or
offered to all other participating employer plans.
(e)
Beginning with the first plan year following the establishment of the exchange,
the State of Georgia through the Department of Community Health shall enter into
an agreement with the exchange to be the sponsor of a participating employer
plan on behalf of any person eligible for health insurance benefits paid in
whole or in part by the State of Georgia by reason of current or past employment
by the state or by reason of being a dependent of such person.
33-62-12.
(a)
In cases when a producer licensed in this state enrolls an eligible individual
or group in the exchange, the plan chosen by each individual shall pay the
producer a commission on premium either in an amount determined by the board of
directors of the exchange or in the amount or amounts voluntarily agreed to by
the various carriers and producers.
(b)
In cases when a membership organization enrolls its eligible members, or the
eligible members of its member entities, in the exchange, the plan chosen by
each individual shall pay the organization a fee equal to the commission
specified in subsection (a) of this Code section. Nothing in this Code section
shall be deemed either to require a membership organization that enrolls persons
in the exchange to be licensed by this state as an insurance producer or to
permit such an organization to provide any other services requiring licensure as
an insurance producer without first obtaining such license.
33-62-13.
(a)
Each employer in the State of Georgia shall annually file with the Commissioner
a form for each employee employed within this state indicating the health
insurance coverage status of the employee and the employee´s dependents,
including the source of coverage and the name of the insurer or plan sponsor,
and, if no coverage is indicated:
(1)
The employee´s election, in lieu of insurance coverage, to post a bond or
establish an account in accordance with Code Section 33-66-15;
(2)
The employee´s election to apply or not apply for coverage through the
exchange; and
(3)
The employee´s election to be considered or not to be considered for any
publicly financed health insurance program or premium subsidy program
administered by this state.
(b)
Each form shall be signed by the individual to whom it pertains.
(c)
Each self-employed individual in this state shall annually file the same form
with the Commissioner.
(d)
The commissioner of human resources shall annually file the same form with the
Commissioner of Insurance on behalf of all individuals receiving benefits under
the Medicaid and PeachCare programs, excepting such individuals who are also
covered by Part A or Part B of Title XVIII of the federal Social Security Act
(79 Stat. 291; 42 U.S.C. Section 1395c, et seq., or 1395j, et seq.,
respectively).
(e)
For purposes of this Code section, health insurance coverage shall not include
any coverage consisting solely of one or more excepted benefits.
(f)
The Commissioner shall prepare and distribute such forms.
33-62-14.
(a)
A carrier shall not issue or renew an individual health benefit plan, other than
through the exchange established under Code Section 33-62-2, after the first day
of the plan year following the first regular open season conducted by the
exchange in accordance with Code Section 33-62-6.
(b)
A carrier shall not issue or renew a group health benefit plan to a small
employer with 50 or fewer employees, other than through the exchange established
under Code Section 33-62-2, after the first day of the plan year following
the first regular open season conducted by the exchange in accordance with Code
Section 33-62-6.
(c)
Subsections (a) and (b) of this Code section shall not apply to any health
benefit plan that consists solely of one or more excepted
benefits."
SECTION
11.
Said
title is further amended by adding a new Chapter 63 to read as
follows:
"CHAPTER
63
33-63-1.
The
General Assembly recognizes the need for individuals, employers, and other
purchasers of health insurance coverage in this state to have the opportunity to
choose health insurance plans that are more affordable and flexible than
existing market policies offering accident and sickness insurance coverage.
Therefore, the General Assembly seeks to increase the availability of health
insurance coverage by allowing insurers authorized to engage in the business of
insurance in selected states to issue accident and sickness policies in
Georgia.
33-63-2.
The
selected out-of-state insurers shall not be required to offer or provide state
mandated health benefits required by Georgia law or regulations in health
insurance policies sold to Georgia residents.
33-63-3.
(a)
Each written application for participation in an out-of-state health benefit
plan shall contain the following language in boldface type at the beginning of
the document:
'This
policy is primarily governed by the laws of
(insert state
where the master policy is filed);
therefore, all of the rating laws applicable to policies filed in this state do
not apply to this policy, which may result in increases in your premium at
renewal that would not be permissible in a Georgia-approved policy. Any
purchase of individual health insurance should be considered carefully since
future medical conditions may make it impossible to qualify for another
individual health policy. For information concerning individual health coverage
under a Georgia-approved policy, please consult your insurance agent or the
Georgia Department of Insurance.'
(b)
Each out-of-state health benefit plan shall contain the following language in
boldface type at the beginning of the document:
'The
benefits of this policy providing your coverage are governed primarily by the
laws of a state other than Georgia. While this health benefit plan may provide
you a more affordable health insurance policy, it may also provide fewer health
benefits than those normally included as state mandated health benefits in
policies in Georgia. Please consult your insurance agent to determine which
state mandated health benefits are excluded under this policy.'
33-63-4.
The
Commissioner shall be authorized to conduct market conduct and solvency
examinations of all out-of-state companies seeking to offer health benefit plans
in this state or who have been given approval to offer health benefit plans in
this state. Such examinations shall be conducted in the same manner and under
the same terms and conditions as for companies located in this
state.
33-63-5.
The
Commissioner shall adopt rules and regulations necessary to implement this
chapter, including, but not limited to, determining which health insurance
companies located in other states shall be authorized to offer plans to Georgia
residents and determining the manner of approving the health benefit plans
offered by such companies."
SECTION
12.
Title
45 of the Official Code of Georgia Annotated, relating to public officers and
employees, is amended by revising Code Section 45-18-2, relating to the
authority of the Board of Community Health to establish health insurance plans,
as follows:
"45-18-2.
(a)(1)
The board is authorized to establish a health insurance plan for employees of
the state and to adopt and promulgate rules and regulations for its
administration, subject to the limitations contained in this article. The health
insurance plan
may
shall
provide for group hospitalization and surgical and medical insurance against the
financial costs of hospitalization, surgery, and medical treatment and care and
may also include, among other things, prescribed drugs, medicines, prosthetic
appliances, hospital inpatient and outpatient service benefits, dental benefits,
vision care benefits, and medical expense indemnity benefits, including major
medical benefits.
(2)
Among the health insurance plans offered, the board shall provide for the
availability of a high deductible health plan (HDHP) that is health savings
account (HSA) eligible.
(3)
The board shall provide incentives for state employees who participate in health
insurance plans offered by the board to undertake health management and disease
management programs including, but not limited to, health management credits and
disease management credits.
(4)
If there is a generic drug available, any prescription drug program offered by
the board to state employees shall provide for full reimbursement for such drug
and shall provide that the insured may obtain the brand name drug only upon the
payment of the difference between the cost for such brand name drug and the cost
of such generic drug.
(b)
If a retiring or retired employee or the beneficiary of such retiring or retired
employee exercises eligibility under board regulations to continue coverage
under the plan and the retiring or retired employees or the beneficiary is
eligible to participate in the insurance program operated by or on behalf of the
federal government under the provisions of 42 U.S.C.A. 1395, as amended, the
coverage available under the health insurance plan shall be subordinated to the
coverage available under such federal program. The board is authorized to
promulgate regulations to establish the premium paid by the retired employee or
beneficiary to reflect the subordination of coverage."
SECTION
13.
Said
title is further amended by revising Code Section 45-18-11, relating to the
procedure for presentation of claims and payment of benefits, as
follows:
"45-18-11.
(a)
Any benefits payable under the plan may be made either directly to the attending
physicians, hospitals, medical groups, or others furnishing the services upon
which a claim is based or to the covered employee, upon presentation of valid
bills for such services, subject to such provisions to facilitate payment as may
be made by the board.
(b)
The claims must be presented in writing to the board or its designee within two
years from the date the service was rendered or else no benefits will be owed or
paid.
(c)
All drafts or checks issued by the board or the board´s designee shall be
void if not presented and accepted by the drawer´s bank within six months
of the date the draft or check was drawn. If the payee or member does not
present the draft or check for acceptance during the seven years following the
date the draft or check was issued, the draft or check will be void, funds will
be retained in the insurance fund, and further payments for such claim will not
be owed or paid.
(d)
The board shall ensure that for claims submitted on or after July 1, 2007:
(1)
Claims submitted electronically by a provider to the board, the department, or
an agent thereof shall be paid or denied within 30 days; and
(2)
Incentive payments of $0.20 per prescription will be paid for each electronic
data prescription drug order accepted and fulfilled by such pharmacist or
pharmacy."
SECTION
14.
Article
7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated, known as
the "Georgia Medical Assistance Act of 1977," is amended by revising Code
Section 49-4-146, relating to time for action on claim, as follows:
"49-4-146.
(a)
Except as provided in subsection (b), the
The
Department of Community Health, within three months of receiving a claim
submitted on or after July 1, 1978, shall pay or deny the claim.
(b)
For claims submitted on or after July 1, 2007:
(1)
Claims submitted electronically by a provider to the Department of Community
Health or its agent shall be paid or denied within 30 days; and
(2)
Incentive payments of $0.20 per prescription will be paid for each electronic
data prescription drug order accepted and fulfilled by such pharmacist or
pharmacy."
SECTION
15.
Said
article is further amended by adding a new Code section to the end of such
article, to read as follows:
"49-4-158.
A
health care entity which is not in compliance with Code Section 31-7-17 shall
not be eligible to be a provider of medical assistance pursuant to this article.
No contract shall be entered into or renewed on or after January 1, 2008,
between the department or a care management organization providing services
under this article and a health care entity which is not in compliance with Code
Section 31-7-17 for the purpose of providing services pursuant to this
article."
SECTION
16.
For
purposes of making appointments to the board of directors of the Georgia Health
Insurance Exchange, this Act shall become effective upon its approval by the
Governor or upon its becoming law without such approval. For all other
purposes, this Act shall become effective on July 1, 2007.
SECTION
17.
All
laws and parts of laws in conflict with this Act are repealed.