07 LC 37
0455S
The
Senate Insurance and Labor Committee offered the following substitute to SB
73:
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Article 3 of Chapter 20A of Title 33 of the Official Code of Georgia
Annotated, relating to managed health care plans, so as to provide for continued
access to care for all managed health care plan enrollees subsequent to the
termination of physician and facility contracts; to provide definitions; to
provide for related matters; to repeal conflicting laws; and for other
purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Article
3 of Chapter 20A of Title 33 of the Official Code of Georgia Annotated, relating
to managed health care plans, is amended by revising Code Section 33-20A-60,
relating to definitions, as follows:
"33-20A-60.
As
used in this article, the term:
(1)
'Agent' as
used in this article shall not include an
agent or agency as defined in Code Section 33-23-1.
(2)
'Carrier' means an accident and sickness insurer, fraternal benefit society,
hospital service corporation, 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 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.
(3)
'Claimant' means any provider, facility, or individual making a claim under a
health benefit plan on behalf of an enrollee.
(4)
'Commissioner' means the Commissioner of Insurance.
(5)
'Enrollee' has the same meaning as provided in Code Section
33-20A-3.
(6)
'Facility' means an institution providing health care services or a health care
setting including, but not limited to, hospitals and other licensed inpatient
centers; ambulatory surgical or treatment centers; skilled nursing centers; and
residential treatment centers.
(6)(7)
'Health benefit plan'
has the
same meaning as provided in Code
Section 33-24-59.5
means any
hospital or medical insurance policy or certificate, health care plan contract
or certificate, qualified higher deductible health plan, health maintenance
organization subscriber contract, any health benefit plan established pursuant
to Article 1 of Chapter 18 of Title 45, any dental or vision care plan or
policy, or managed care plan; but health benefit plan does not include any
health benefit plan established pursuant to Article 7 of Chapter 4 of Title 49;
policies issued in accordance with Chapter 31 of this title; disability income
policies; or any plan under Chapter 9 of Title 34, relating to workers´
compensation.
(7)(8)
'Physician or
facility contract' means any contract
between a physician
or
facility and a carrier or a carrier´s
network, physician panel, intermediary, or representative providing the terms
under which the physician
or
facility agrees to provide health care
services to an enrollee pursuant to a health benefit plan.
(8)(9)
'Postpayment audit' means an investigation by a health benefit plan, carrier,
insurer, or panel, or agent thereof, of whether a claim was properly paid to a
claimant.
(9)(10)
'Retroactive denial of a previously paid claim' or 'retroactive denial of
payment' means any attempt by a carrier retroactively to collect payments
already made to a claimant with respect to a claim, or any portion thereof, by
requiring repayment of such payments, by reducing other payments currently owed
to the claimant, by withholding or setting off against future payments, or in
any other manner reducing or affecting the future claim payments to the
claimant."
SECTION
2.
Said
article is further amended by revising Code Section 33-20A-61, relating to
physician contracts, as follows:
"33-20A-61.
(a)
Every physician
or
facility contract entered into, amended,
extended, or renewed after July 1,
2002
2007,
by a
carrier shall contain a specific
provision which shall provide that, in the event that
an
insurance carrier, plan, network, panel, or any agent
thereof
the
contract should terminate
a
physician´s contract and thereby
affect any enrollee´s opportunity to continue receiving health care
services from that physician
or
facility under the plan, any such enrollee
who is
suffering from and receiving active health care services for a chronic or
terminal illness or who is an inpatient
shall have the right to continue to receive health care services from that
physician or
facility for a period of up to 60 days
from the date of the termination of the physician´s
or
facility´s contract. Any enrollee
who is pregnant and receiving treatment in connection with that pregnancy at the
time of the termination of that enrollee´s physician´s contract
or
facility´s contract shall have the
right to continue receiving health care services from that physician
or
facility throughout the remainder of that
pregnancy, including six weeks´ postdelivery care. During such
continuation of coverage period, the physician
and the
facility shall continue providing such
services in accordance with the terms of the contract applicable at the time of
the termination, and the carrier, plan, network, panel, and all agents thereof
shall continue to meet all obligations of such physician´s
or
facility´s contract. The enrollee
shall not have the right to the continuation provisions provided in this Code
section if the physician´s
or
facility´s contract is terminated
because of the suspension or revocation of the physician´s
or
facility´s license or if the carrier,
plan, network, panel, or any agent thereof determines that the physician
or
facility poses a threat to the health,
safety, or welfare of enrollees.
(b)
Every
physician contract entered into, amended, extended, or renewed after July 1,
2002, by a carrier shall contain a specific provision which shall provide that,
in the event that a physician should terminate his or her contract with an
insurance carrier, plan, network, panel, or any agent thereof and thereby affect
any enrollee´s opportunity to continue receiving health care services from
that physician under the plan, any such enrollee who is suffering from and
receiving active health care services for a chronic or terminal illness or who
is an inpatient shall have the right to receive health care services from that
physician for a period of up to 60 days from the date of the termination of the
physician´s contract. Any enrollee who is pregnant and receiving health
care services in connection with that pregnancy at the time of the termination
of that enrollee´s physician´s contract shall have the right to
continue receiving health care services from that physician throughout the
remainder of that pregnancy, including six weeks´ postdelivery care.
During such continuation of coverage period, the physician shall continue
providing such services in accordance with the terms of the contract applicable
at the time of the termination, and the carrier, plan, network, panel, and all
agents thereof shall continue to meet all obligations of such physician´s
contract. The enrollee shall not have the right to the continuation provisions
provided in this Code section if the physician terminates his or her contract
because of the suspension or revocation of the physician´s license or for
reasons related to the quality of health care services rendered or issues
related to the health, safety, or welfare of
enrollees.
Not later than
30 calendar days prior to the effective termination date or, if the carrier does
not have 30 days, as soon as reasonably possible, the carrier shall provide
written notice to the affected enrollees of the specific termination date of the
physician or facility contract. Such notice shall include an explanation of
enrollees´ continued access to care rights. For purposes of identifying
affected enrollees pursuant to this subsection, a carrier shall consider at
least one of the following:
(1)
The number of visits to the physician or facility within the previous 12
months;
(2)
Serial referrals for the same type of care from the physician or facility within
the previous 12 months; or
(3)
Receipt of periodic preventive care by the same physician or facility within the
previous 12 months.
(c)
Not later than 30 days prior to the effective termination date or, if the
carrier does not have 30 days, as soon as reasonably possible, the carrier shall
provide written notice to the Commissioner of the specific termination date of
the physician or facility contract. The Commissioner may, at his or her
discretion, extend the period of continued access to care subsequent to a
provider or facility contract termination provided in this Code section for up
to an additional 60 day period.
(d)
In the event that the carrier has given notice to the affected enrollees as
required in subsection (b) of this Code section and the contract between the
carrier and the physician or facility does not terminate, the carrier shall
provide written notice on a timely basis to the enrollees who received the
original notice that the physician or facility contract remains in
effect."
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.