07 LC 28
3235
Senate
Bill 28
By:
Senators Hill of the 32nd, Thomas of the 54th, Rogers of the 21st, Goggans of
the 7th, Hudgens of the 47th and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
provide a short title; to comprehensively revise the laws of Georgia concerning
the provision of health insurance; to amend Title 33 of the Official Code of
Georgia Annotated, relating to insurance, so as to provide for the development
of consumer driven health insurance plans by the Commissioner of Insurance; to
provide for exemptions for certain health insurance plans from premium taxes; to
allow such plans to include wellness and health promotion programs; to provide
that such programs shall not be considered unfair trade practices; to provide
for the deductibility of certain health insurance premiums for state income tax
purposes; 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 27 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 related matters; to create the Georgia Health
Security Underwriting Authority; to provide alternative mechanism coverage for
the availability of individual health insurance; to provide definitions; to
provide for an assignment group underwriting board; to provide for powers,
duties, and authority of the board; to provide for the selection of an
administrator or administrators; to provide for the duties of the Commissioner
of Insurance with respect to the board and assignment group; to provide for the
establishment of rates; to provide for eligibility for and termination of
coverage; to provide for minimum assignment group benefits; to provide for
certain exclusions for preexisting conditions; to provide for funding; to
provide for complaint procedures; to provide for audits; to provide for certain
reports; to provide for related matters; to repeal the Georgia High Risk Health
Insurance Plan; to provide for legislative findings; 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 require certain
individuals to prove ability to pay for medical expenses; to provide for escrow
accounts for such individuals; 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 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 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 and pharmacies; 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 Article 1 of Chapter 18 of Title 45 of the Official
Code of Georgia Annotated, relating to the state employees´ health
insurance plan, so as 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 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
provide for related matters; to amend Titles 33 and 48 of the Official Code of
Georgia Annotated, relating, respectively, to insurance and revenue and
taxation, so as to provide for additional exemptions for certain health plans
with respect to state and local insurance premium taxes; to provide for related
matters; to provide for a sales tax exemption for a limited period of time with
respect to certain sales of tangible personal property or services to a
qualified small business; to provide that the taxable net income of any taxpayer
of this state shall not include premiums paid for high deductible health plans
established and used with a health savings account; to provide for income tax
credits with respect to certain qualified health insurance expenses or certain
contributions related thereto; to provide for an income tax credit with respect
to qualified health information technology expenses; to provide for procedures,
conditions, and limitations; to provide for powers, duties, and authority of the
state revenue commissioner with respect to the foregoing; to provide for the
obtaining and maintaining of certain creditable health insurance coverage as a
condition of claiming certain exemptions and receiving refunds; to provide for
alternate bonding requirements; to provide for other matters relative to the
foregoing; to provide effective dates; to provide for applicability; to provide
for an automatic repeals under certain circumstances; to repeal conflicting
laws; and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
PART
I.
SECTION 1-1.
SECTION 1-1.
This
Act shall be known and may be cited as the "Insuring Georgia´s Families
Act."
PART
II.
SECTION 2-1.
SECTION 2-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by striking Chapter 51 in its entirety and inserting in lieu thereof a new
Chapter 51 to read as follows:
"Chapter
51
33-51-1.
This
chapter shall be known and may be cited as the 'Georgia Consumer Driven Health
Insurance Plan.'
33-51-2.
It
is the intent of this chapter to authorize the Commissioner of Insurance to
establish guidelines for plan designs for the development of health insurance
products which will be affordable to Georgians and to increase the availability
of health insurance coverage by encouraging the promotion of these types of
plans by accident and sickness insurers licensed to transact such insurance in
this state. It is the intent of this chapter that plan designs include high
deductible health insurance plans as required under the rules of the federal
Internal Revenue Service related to the establishment of health savings
accounts.
33-51-3.
The
Commissioner shall develop guidelines for consumer driven health insurance plans
which are designed to qualify under federal and state requirements as high
deductible health insurance plans for use with health savings accounts and which
shall include, but shall not be limited to, nominal copayment provisions,
reasonable lifetime benefit maximums, and choices of deductible amounts and
other policy provisions and limits which comply with federal requirements under
the applicable provisions of the federal Internal Revenue Code for high
deductible health insurance plans sold in connection with health savings
accounts.
33-51-4.
(a)
The Commissioner shall be authorized to request information and data from any
available source and to request the assistance of accident and sickness insurers
and providers of health care services in order to develop guidelines for
consumer driven health insurance plans.
(b)
The Commissioner shall be authorized to encourage and promote the marketing of
consumer driven health insurance plans by accident and sickness insurers in this
state.
(c)
The Commissioner shall be authorized to promulgate such rules and regulations as
he or she deems necessary and appropriate for the design, promotion, and
regulation of these products, including rules and regulations for the expedited
review of standardized policies and rates by insurers, advertisements and
solicitations, and other matters deemed relevant by the
Commissioner.
33-51-5.
(a)
Health insurance policies sold under this chapter shall be exempt from any and
all otherwise applicable premium taxes under Code Section 33-8-4.
(b)
Health insurance policies sold under this chapter shall be exempt from any and
all otherwise applicable county and municipal taxes under Code Section 33-8-8.1
or 33-8-8.2, as applicable, depending on the type of insurer.
33-51-6.
Policies
sold under this chapter may be designed with out of network differentials that
exceed the normal maximum differential allowed under paragraph (3) of subsection
(b) of Code Section 33-30-23 or the coinsurance limitation applicable to
nonpreferred providers under paragraph (4) of subsection (b) of Code Section
33-30-23 so long as the percentage reimbursement for nonpreferred providers for
out of network benefits is at least 50 percent.
33-51-7.
(a)
Insurers are allowed to include wellness and health promotion programs in
policies designed and sold under this chapter in keeping with federal
requirements under high deductible health insurance plans, provided that such
programs are approved by the Commissioner of Insurance.
(b)
Insurers which include and operate wellness and health promotion programs in
their high deductible health insurance policies in keeping with federal
requirements shall not be considered to be engaging in unfair trade practices
under Code Section 33-6-4 with respect to references to the practices of illegal
inducements, unfair discrimination, or rebating.
33-51-8.
Effective
January 1, 2008, and applicable to all taxable years beginning on and after
January 1, 2008, health insurance premiums for individuals who purchase
qualified policies under this chapter shall be fully deductible from the gross
income of those individuals on Georgia state income tax
returns."
PART
III.
SECTION 3-1.
SECTION 3-1.
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, to read 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."
PART
IV.
SECTION 4-1.
SECTION 4-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by revising paragraph (4) of Code Section 33-30-4, relating to required
provisions of group accident and sickness policies generally, to read 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
27 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
4-2.
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, to read 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
27 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."
PART
V.
SECTION 5-1.
SECTION 5-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is 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."
PART
VI.
SECTION 6-1.
SECTION 6-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by revising subparagraph (b)(15)(D) of Code Section 33-6-4, relating to the
enumeration of unfair methods of competition and unfair or deceptive acts or
practices, to read as follows:
"(D)
It is unfairly discriminatory to terminate group coverage for a
subject of
family violence
dependent
because coverage was originally issued in the name of the
perpetrator
of the family violence
insured
and
(i)
the
perpetrator
insured
has divorced, separated from, or lost custody of the
subject of
family violence, or the perpetrator´s
dependent; and
(ii) the insured´s coverage has
terminated voluntarily or involuntarily. If termination results from an act or
omission of the
perpetrator
insured,
the subject
of family violence
dependent
shall be deemed a qualifying eligible individual under Code Section 33-24-21.1
or
33-29A-2 and may obtain continuation and
conversion
of such coverages
alternative
mechanism coverage for the availability of individual health insurance coverage,
as contemplated by Section 2741 of the federal Public Health Service Act, 42
U.S.C. Section 300gg-41, notwithstanding
the act or omission of the
perpetrator.
A person may request and receive family violence information to implement the
continuation and conversion of coverages under this
subparagraph
insured."
SECTION
6-2.
Said
title is further amended by revising Code Section 33-24-21.1, relating to group
accident and sickness contracts, to read as follows:
"33-24-21.1.
(a)
As used in this Code section, the term:
(1)
'Creditable coverage' under another health benefit plan means medical expense
coverage with no greater than a 90 day gap in coverage under any of the
following:
(A)
Medicare or Medicaid;
(B)
An employer based accident and sickness insurance or health benefit
arrangement;
(C)
An individual accident and sickness insurance policy, including coverage issued
by a health maintenance organization, nonprofit hospital or nonprofit medical
service corporation, health care corporation, or fraternal benefit
society;
(D)
A spouse´s benefits or coverage under medicare or Medicaid or an employer
based health insurance or health benefit arrangement;
(E)
A conversion policy;
(F)
A franchise policy issued on an individual basis to a member of a true
association as defined in subsection (b) of Code Section 33-30-1;
(G)
A health plan formed pursuant to 10 U.S.C. Chapter 55;
(H)
A health plan provided through the Indian Health Service or a tribal
organization program or both;
(I)
A state health benefits risk pool;
(J)
A health plan formed pursuant to 5 U.S.C. Chapter 89;
(K)
A public health plan; or
(L)
A Peace Corps Act health benefit plan.
(2)
'Eligible dependent' means a person who is entitled to medical benefits coverage
under a group contract or group plan by reason of such person´s dependency
on or relationship to a group member.
(3)
'Group contract or group plan' is synonymous with the term 'contract or plan'
and means:
(A)
A group contract of the type issued by a nonprofit medical service corporation
established under Chapter 18 of this title;
(B)
A group contract of the type issued by a nonprofit hospital service corporation
established under Chapter 19 of this title;
(C)
A group contract of the type issued by a health care plan established under
Chapter 20 of this title;
(D)
A group contract of the type issued by a health maintenance organization
established under Chapter 21 of this title; or
(E)
A group accident and sickness insurance policy or contract, as defined in
Chapter 30 of this title.
(4)
'Group member' means a person who has been a member of the group for at least
six months and who is entitled to medical benefits coverage under a group
contract or group plan and who is an insured, certificate holder, or subscriber
under the contract or plan.
(5)
'Insurer' means an insurance company, health care corporation, nonprofit
hospital service corporation, medical service nonprofit corporation, health care
plan, or health maintenance organization.
(6)
'Qualifying eligible individual' means:
(A)
A Georgia domiciliary, for whom, as of the date on which the individual seeks
coverage under this Code section, the aggregate of the periods of creditable
coverage is 18 months or more; and
(B)
Who is not eligible for coverage under any of the following:
(i)
A group health plan, including continuation rights under this Code section or
the federal Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA);
(ii)
Part A or Part B of Title XVIII of the federal Social Security Act;
or
(iii)
The state plan under Title XIX of the federal Social Security Act or any
successor program.
(b)
Each group contract or group plan delivered or issued for delivery in this
state, other than a group accident and sickness insurance policy, contract, or
plan issued in connection with an extension of credit, which provides hospital,
surgical, or major medical coverage, or any combination of these coverages, on
an expense incurred or service basis, excluding contracts and plans which
provide benefits for specific diseases or accidental injuries only, shall
provide that members and qualifying eligible individuals whose insurance under
the group contract or plan would otherwise terminate shall be entitled to
continue their hospital, surgical, and major medical insurance coverage under
that group contract or plan for themselves and their eligible
dependents.
(c)
Any group member or qualifying eligible individual whose coverage has been
terminated and who has been continuously covered under the group contract or
group plan, and under any contract or plan providing similar benefits which it
replaces, for at least six months immediately prior to such termination, shall
be entitled to have his or her coverage and the coverage of his or her eligible
dependents continued under the contract or plan. Such coverage must continue
for the fractional policy month remaining, if any, at termination plus three
additional policy months upon payment of the premium by cash, certified check,
or money order, at the option of the employer, to the policyholder or employer,
at the same rate for active group members set forth in the contract or plan, on
a monthly basis in advance as such premium becomes due during this coverage
period. Such premium payment must include any portion of the premium paid by a
former employer or other person if such employer or other person no longer
contributes premium payments for this coverage. At the end of such period, the
group member shall have the same conversion rights that were available on the
date of termination of coverage in accordance with the conversion privileges
contained in the group contract or group plan.
(d)(1)
A group member shall not be entitled to have coverage continued if: (A)
termination of coverage occurred because the employment of the group member was
terminated for cause; (B) termination of coverage occurred because the group
member failed to pay any required contribution;
or
(C) any discontinued group coverage is immediately replaced by similar group
coverage including coverage under a health benefits plan as defined in the
federal Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001,
et seq.; or
(D)
Further, a
group member shall not be entitled to have coverage continued
if the group contract or group plan was
terminated in its entirety or was terminated with respect to a class to which
the group member belonged. This subsection shall not affect conversion rights
available to a qualifying eligible individual under any contract or
plan.
(2)
A qualifying eligible individual shall not be entitled to have coverage
continued if the most recent creditable coverage within the coverage period was
terminated based on one of the following factors: (A) failure of the qualifying
eligible individual to pay premiums or contributions in accordance with the
terms of the health insurance coverage or failure of the issuer to receive
timely premium payments; (B) the qualifying eligible individual has performed an
act or practice that constitutes fraud or made an intentional misrepresentation
of material fact under the terms of coverage; or (C) any discontinued group
coverage is immediately replaced by similar group coverage including coverage
under a health benefits plan as defined in the federal Employee Retirement
Income Security Act of 1974, 29 U.S.C. Section 1001, et seq. This subsection
shall not affect conversion rights available to a group member under any
contract or plan.
(e)
If the group contract or group plan terminates while any group member or
qualifying eligible individual is covered or whose coverage is being continued,
the group administrator, as prescribed by the insurer, must notify each such
group member or qualifying eligible individual that he or she must exercise his
or her conversion rights
and rights to
alternative mechanism coverage for the availability of individual health
insurance coverage, as contemplated by Section 2741 of the federal Public Health
Service Act, 42 U.S.C. Section
300gg-41, within:
(1)
Thirty days of such notice for group members who are not qualifying eligible
individuals; or
(2)
Sixty-three days of such notice for qualifying eligible
individuals.
(f)
Every group contract or group plan, other than a group accident and sickness
insurance policy, contract, or plan issued in connection with an extension of
credit, which provides hospital, surgical, or major medical expense insurance,
or any combination of these coverages, on an expense incurred or service basis,
excluding policies which provide benefits for specific diseases or for
accidental injuries only, shall contain a conversion privilege
provision.
(g)
Eligibility
for the converted policies or contracts shall be as follows:
(1)
Any qualifying eligible individual whose insurance and its corresponding
eligibility under the group policy, including any continuation available,
elected, and exhausted under this Code section or the federal Consolidated
Omnibus Budget Reconciliation Act of 1986 (COBRA), has been terminated for any
reason, including failure of the employer to pay premiums to the insurer, other
than fraud or failure of the qualifying eligible individual to pay a required
premium contribution to the employer or, if so required, to the insurer directly
and who has at least 18 months of creditable coverage immediately prior to
termination shall be entitled, without evidence of insurability, to convert to
individual or group based coverage covering such qualifying eligible individual
and any eligible dependents who were covered under the qualifying eligible
individual´s coverage under the group contract or group plan. Such
conversion coverage must be, at the option of the individual, retroactive to the
date of termination of the group coverage or the date on which continuation or
COBRA coverage ended, whichever is later. The insurer must offer qualifying
eligible individuals at least two distinct conversion options from which to
choose. One such choice of coverage shall be comparable to comprehensive health
insurance coverage offered in the individual market in this state or comparable
to a standard option of coverage available under the group or individual health
insurance laws of this state. The other choice may be more limited in nature
but must also qualify as creditable coverage. Each coverage shall be filed,
together with applicable rates, for approval by the Commissioner. Such choices
shall be known as the 'Enhanced Conversion Options';
(2)
Premiums for the enhanced conversion options for all qualifying eligible
individuals shall be determined in accordance with the following
provisions:
(A)
Solely for purposes of this subsection, the claims experience produced by all
groups covered under comprehensive major medical or hospitalization accident and
sickness insurance for each insurer shall be fully pooled to determine the group
pool rate. Except to the extent that the claims experience of an individual
group affects the overall experience of the group pool, the claims experience
produced by any individual group of each insurer shall not be used in any manner
for enhanced conversion policy rating purposes;
(B)
Each insurer´s group pool shall consist of each insurer´s total claims
experience produced by all groups in this state, regardless of the marketing
mechanism or distribution system utilized in the sale of the group insurance
from which the qualifying eligible individual is converting. The pool shall
include the experience generated under any medical expense insurance coverage
offered under separate group contracts and contracts issued to trusts, multiple
employer trusts, or association groups or trusts, including trusts or
arrangements providing group or group-type coverage issued to a trust or
association or to any other group policyholder where such group or group-type
contract provides coverage, primarily or incidentally, through contracts issued
or issued for delivery in this state or provided by solicitation and sale to
Georgia residents through an out-of-state multiple employer trust or
arrangement; and any other group-type coverage which is determined to be a group
shall also be included in the pool for enhanced conversion policy rating
purposes; and
(C)
Any other factors deemed relevant by the Commissioner may be considered in
determination of each enhanced conversion policy pool rate so long as it does
not have the effect of lessening the risk-spreading characteristic of the
pooling requirement. Duration since issue and tier factors may not be
considered in conversion policy rating. Notwithstanding subparagraph (A) of
this paragraph, the total premium calculated for all enhanced conversion
policies may deviate from the group pool rate by not more than plus or minus 50
percent based upon the experience generated under the pool of enhanced
conversion policies so long as rates do not deviate for similarly situated
individuals covered through the pool of enhanced conversion
policies;
(3)(1)
Any group member who is not a qualifying eligible individual and whose insurance
under the group policy has been terminated for any reason, including failure of
the employer to pay premiums to the insurer, other than eligibility for medicare
(reaching a limiting age for coverage under the group policy) or failure of the
group member to pay a required premium contribution, and who has been
continuously covered under the group contract or group plan, and under any
contract or plan providing similar benefits which it replaces, for at least six
months immediately prior to termination shall be entitled, without evidence of
insurability, to convert to individual or group coverage covering such group
member and any eligible dependents who were covered under the group
member´s coverage under the group contract or group plan. Such conversion
coverage must be, at the option of the individual, retroactive to the date of
termination of the group coverage or the date on which continuation or COBRA
coverage ended, whichever is later. The premium of the basic converted policy
shall be determined in accordance with the insurer´s table of premium rates
applicable to the age and classification of risks of each person to be covered
under that policy and to the type and amount of coverage provided. This form of
conversion coverage shall be known as the 'Basic Conversion
Option';
and
Option.'
(4)(2)
Nothing in this Code section shall be construed to prevent an insurer from
offering additional options to qualifying eligible individuals or group
members.
(h)
Each group certificate issued to each group member or qualifying eligible
individual, in addition to setting forth any conversion rights, shall set forth
the continuation right in a separate provision bearing its own caption. The
provisions shall clearly set forth a full description of the continuation and
conversion rights available, including all requirements, limitations, and
exceptions, the premium required, and the time of payment of all premiums due
during the period of continuation or conversion.
(i)
This Code section shall not apply to limited benefit insurance policies. For
the purposes of this Code section, the term 'limited benefit insurance' means
accident and sickness insurance designed, advertised, and marketed to supplement
major medical insurance. The term limited benefit insurance includes accident
only, CHAMPUS supplement, dental, disability income, fixed indemnity, long-term
care, medicare supplement, specified disease, vision, and any other accident and
sickness insurance other than basic hospital expense, basic medical-surgical
expense, and comprehensive major medical insurance coverage.
(j)
The Commissioner shall adopt such rules and regulations as he or she deems
necessary for the administration of this Code section. Such rules and
regulations may prescribe various conversion plans, including minimum conversion
standards and minimum benefits, but not requiring benefits in excess of those
provided under the group contract or group plan from which conversion is made,
scope of coverage, preexisting limitations, optional coverages, reductions,
notices to covered persons, and such other requirements as the Commissioner
deems necessary for the protection of the citizens of this state.
(k)
This Code section shall apply to all group plans and group contracts delivered
or issued for delivery in this state on or after July 1, 1998, and to group
plans and group contracts then in effect on the first anniversary date occurring
on or after July 1, 1998."
SECTION
6-3.
Said
title is further amended by striking Chapter 29A, relating to individual health
insurance coverage availability and assignment systems, and inserting a new
Chapter 29A to read as follows:
"CHAPTER
29A
33-29A-1.
(a)
It is the intention of this chapter to provide an acceptable alternative
mechanism for the availability of individual health insurance coverage, as
contemplated by Section 2741 of the federal Public Health Service Act, 42 U.S.C.
Section 300gg-41. This chapter shall be construed and administered so as to
accomplish such intention.
(b)
Any reference in this chapter to any federal statute shall refer to that federal
statute as it existed on January 1, 1997, including its amendment by the federal
Health Insurance Portability and Accountability Act of 1996, P.L.
104-191.
33-29A-2.
(a)
As used in this chapter, the term:
(1)
'Administrator' shall have the same meaning as the term 'administrator' as
defined in Code Section 33-23-100.
(2)
'Assignment group' means the assignment group administered by the Georgia Health
Security Underwriting Authority.
(3)
'Assignment group coverage' means coverage offered by plan administrators on
behalf of the assignment group to eligible persons.
(4)
'Board' means the board of directors of the Georgia Health Security Underwriting
Authority created under this chapter.
(5)
'Commissioner' means the Commissioner of Insurance.
(6)
'Covered person' means any individual resident of this state, excluding
dependents, who is eligible to receive benefits from any insurer.
(7)
'Creditable coverage' and 'eligible individual' have the same meanings as
specified in Sections 270l and 2741 of the federal Public Health Service Act, 42
U.S.C. Sections 300gg and 300gg-41.
(8)
'Department' means the Department of Insurance.
(9)
'Dependent' shall have the same meaning as provided in paragraph (3) of
subsection (a) of Code Section 33-29-2 or as qualified in paragraph (4) of Code
Section 33-30-4.
(10)
'Family member' means a parent, grandparent, brother, or sister, whether such
relationship is established by birth or by law.
(11)
'Health insurance' means any hospital or medical expense incurred policy,
nonprofit health care services plan contract, health maintenance organization,
subscriber contract, or any other health care plan or insurance arrangement that
pays for or furnishes medical or health care services, whether by insurance or
otherwise, when sold to an individual or as a group policy. This term does not
include limited benefit insurance policies.
(12)
'Health insurance issuer' and 'health maintenance organization' have the same
meaning as specified in Section 2791 of the federal Public Health Service Act,
42 U.S.C. Section 300gg-92.
(13)
'Health insurer' means any health insurance issuer which is not a managed care
organization.
(14)
'Insurance arrangement' or 'self-insurance arrangement' means a plan, program,
contract, or other arrangement through which health care services are provided
by an employer to its officers, employees, or other personnel, but does not
include health care services covered through an insurer.
(15)
'Insured' means a person who is a legal resident of this state and who is
eligible to receive benefits from the assignment group. The term 'insured' may
include dependents and family members.
(16)
'Limited benefit insurance' means accident and sickness insurance designed,
advertised, and marketed to supplement major medical insurance. The term
'limited benefit insurance' includes accident only, CHAMPUS supplement, dental,
disability income, fixed indemnity, long-term care, medicare supplement,
specified disease, vision, limited benefit, or credit insurance; coverage issued
as a supplement to liability insurance; insurance arising out of a workers´
compensation or similar law; automobile medical-payment insurance; or insurance
under which benefits are payable with or without regard to fault and which is
statutorily required to be contained in any liability insurance policy or
equivalent self-insurance, and includes any other accident and sickness
insurance other than basic hospital expense, basic medical-surgical expense, and
comprehensive major medical insurance coverage.
(17)
'Managed care organization' means a health maintenance organization or a
nonprofit health care corporation.
(18)
'Market share' means the percentage of the total number of covered persons
living in Georgia included in health insurance and health plans insured,
reinsured, and administered by a payor.
(19)
'Medicare' means coverage provided by Part A and Part B of Title XVIII of the
federal Social Security Act, 42 U.S.C. Section 1395c, et seq.
(20)
'Payor' means any entity that is authorized in this state to write health
insurance or that provides health insurance in this state. For the purposes of
this chapter, the term 'payor' includes an insurance company; nonprofit health
care services plan; health care corporation or surviving health care corporation
as defined in Code Section 33-20-3; fraternal benefits society; health
maintenance organization; any other entity providing a plan of health insurance
or health benefits subject to state insurance regulation; association plans; and
any administrator paying or processing health benefit claims in
Georgia.
(21)
'Physician' means a person licensed to practice medicine in
Georgia.
(22)
'Plan administrator' means a payor selected by the Georgia Health Security
Underwriting Authority to provide administrative services or accept assignments
of insureds.
(23)
'Plan of operation' means the plan of operation of the assignment group and
includes the articles, bylaws, and operating rules of the assignment group that
are adopted by the board.
(24)
'Resident' means an individual who has been legally domiciled in Georgia for a
minimum of 24 months; provided, however, that, for a federally defined eligible
individual, there shall be no such time period requirement to establish
residency.
(b)
Any other term which is used in this chapter and which is also defined in
Section 2791 of the federal Public Health Service Act, 42 U.S.C. Section
300gg-92, and not otherwise defined in this chapter shall have the same meaning
specified in said Section 2791.
33-29A-3.
(a)
There is created a body corporate to be known as the 'Georgia Health Security
Underwriting Authority' which shall be deemed to be a public corporation. The
Georgia Health Security Underwriting Authority shall have perpetual existence,
and any change in the name or composition of the assignment group or Georgia
Health Security Underwriting Authority shall in no way impair the obligations of
any contracts existing under this chapter.
(b)
The authority shall be governed by a board of directors whose members shall be
appointed as follows:
(1)
The Commissioner, the Speaker of the House of Representatives, and the Senate
Committee on Assignments shall each appoint two members of the board for
staggered four-year terms. One of the board members appointed by each of the
above persons or officers shall have a two-year initial term and one shall have
a four-year initial term as designated by the person or officer making such
appointment at the time of such appointment. Thereafter, successors to such
members shall be appointed to and serve four-year terms. Such appointees shall
be persons affiliated with payors admitted and authorized to write health
insurance in this state or who are otherwise familiar with health insurance
matters; and
(2)
The Governor shall appoint one person representing the medical provider
community, such as a physician licensed to practice medicine in this state, who
shall serve a four-year initial term.
(c)
The appointed members of the board shall elect one of their own members to serve
as chairperson.
(d)
If a vacancy occurs on the board, the person or officer who made the appointment
shall fill the vacancy for the unexpired term with a person who has the
appropriate qualifications to fill that position on the board.
(e)
A member of the board shall not be liable for an action or omission performed in
good faith in the performance of the powers and duties under this chapter, and a
cause of action shall not arise against a member for such action or
omission.
33-29A-4.
(a)
The initial members of the board of directors of the Georgia Health Security
Underwriting Authority shall submit to the Commissioner a plan of operation for
the assignment group that will assure the fair, reasonable, and equitable
administration of the assignment group.
(b)
In addition to the other requirements of this chapter, the plan of operation
must include procedures for:
(1)
Operation of the assignment group;
(2)
Selecting a plan administrator or multiple plan administrators;
(3)
Creating a fund, under management of the authority, for administrative
expenses;
(4)
Handling, accounting, and auditing of money and other assets of the assignment
group;
(5)
Developing and implementing a program to foster public awareness of the plan and
to publicize the existence of the assignment group, the eligibility requirements
for coverage under the assignment group, and the enrollment
procedures;
(6)
Creation of a grievance committee to review complaints presented by applicants
for coverage from the assignment group and insureds who receive coverage from
the assignment group; and
(7)
Other matters as may be necessary and proper for the execution of the
authority´s powers, duties, and obligations under this
chapter.
(c)
After notice and hearing, the Commissioner shall approve the plan of operation
if the Commissioner determines that the plan is suitable to assure the fair,
reasonable, and equitable administration of the assignment group.
(d)
The plan of operation shall become effective on the date it is approved by the
Commissioner.
(e)
If the initial members of the board fail to submit a suitable plan of operation
within 180 days following the appointment of the initial members, the
Commissioner, after notice and hearing, may adopt all necessary and reasonable
rules to provide a plan for the assignment group. The rules adopted under this
subsection shall continue in effect until the initial members submit, and the
Commissioner approves, a plan of operation as provided under this Code
section.
(f)
The board shall amend the plan of operation as necessary to carry out the
provisions of this chapter. All amendments to the plan of operation shall be
submitted to the Commissioner for approval before becoming part of the
plan.
33-29A-5.
(a)
The Georgia Health Security Underwriting Authority is authorized to exercise any
of the authority that a corporation in this state may exercise under the laws of
this state.
(b)
The Georgia Health Security Underwriting Authority shall have the power
to:
(1)
Develop a means, in this chapter referred to as the assignment group, through
the assignment of risks to provide health benefits coverage to persons who are
eligible for that coverage under this chapter;
(2)
Enter into contracts that are necessary to carry out its powers and duties under
this chapter including, with the approval of the Commissioner, entering into
contracts with similar pools in other states for the joint performance of common
administrative functions or with other organizations for the performance of
administrative functions;
(3)
Sue and be sued, including taking any legal action necessary or proper to
recover or collect assessments due the assignment group;
(4)
Institute any legal action necessary to recover any amounts erroneously or
improperly paid by the assignment group, to recover any amounts paid by the
assignment group as a mistake of fact or law, and to recover other amounts due
the assignment group;
(5)
Establish appropriate rates, rate schedules, rate adjustments, expense
allowances, and agents´ referral fees and to perform any actuarial function
appropriate to the operation of the assignment group;
(6)
Adopt policy forms, endorsements, and riders and applications for
coverage;
(7)
Develop a means for plan administrators to issue insurance policies subject to
this chapter and the plan of operation;
(8)
Appoint appropriate legal, actuarial, and other committees that are necessary to
provide technical assistance in operating the assignment group and performing
any of the functions of the assignment group;
(9)
Employ and set the compensation of any persons necessary to assist the
assignment group in carrying out its responsibilities and
functions;
(10)
Borrow money as necessary to implement the purposes of the assignment group;
and
(11)
Require plan administrators to employ cost containment measures and
requirements, including, but not limited to, preadmission screening, second
surgical opinion, concurrent utilization case management, disease-state
management, and other risk reduction practices for the purpose of maximizing
effectiveness and cost savings to the assignment group, its insureds, and
payors. Plan administrators shall report at least annually on these programs
and document savings and improved health outcomes for eligible
individuals.
(c)
Not later than June 30 of each year, the authority shall make an annual report
to the Governor, the Senate Insurance and Labor Committee, the House Committee
on Insurance, and the Commissioner. The report shall summarize the activities
of the assignment group in the preceding calendar year, including information
regarding net written and earned premiums, plan enrollment, administration
expenses, and paid and incurred losses of plan administrators on behalf of
persons eligible for coverage under the assignment group.
(d)
The board shall establish a methodology to assure that the widest practicable
and equitable distribution of risk among payors is achieved and that a variety
of plan design offerings are available through plan administrators.
(e)
The board shall establish in its plan of operation means by which to compensate
plan administrators for accepting assignments from the assignment
group.
33-29A-6.
(a)
After completing a competitive bidding process as provided by the plan of
operation, the board may select one or more payors or plan administrators
certified by the board to administer the assignment group and offer assignment
group coverage.
(b)
The board shall establish criteria for evaluating the bids submitted. The
criteria shall include:
(1)
A payor´s or plan administrator´s proven ability to handle accident
and sickness insurance;
(2)
The efficiency of a payor´s or plan administrator´s claims paying
procedures;
(3)
An estimate of total charges for administering the assignment
group;
(4)
A payor´s or plan administrator´s ability to administer the assignment
group in a cost-efficient manner; and
(5)
The financial condition and stability of the payor or plan
administrator.
(c)
The plan administrator shall perform such functions relating to the assignment
group as may be assigned to it, including:
(1)
Providing health benefits coverage according to specifications adopted by the
board to persons who are eligible for that coverage under this
chapter;
(2)
Performing eligibility and administrative claims payment functions for the
assignment group;
(3)
Establishing a billing procedure for collection of premiums from persons insured
by the assignment group;
(4)
Performing functions necessary to assuring timely payment of benefits to persons
covered under the assignment group, including:
(A)
Providing information relating to the proper manner of submitting a claim for
benefits to the assignment group and distributing claim forms; and
(B)
Evaluating the eligibility of each claim for payment by the assignment
group;
(5)
Submitting regular reports to the board relating to the operation of the
assignment group; and
(6)
Determining after the close of each calendar year the net written and earned
premiums, expenses of administration, and paid and incurred losses of the
assignment group for that calendar year and reporting such information to the
board and the Commissioner on forms prescribed by the Commissioner.
33-29A-7.
The
Commissioner may by rule and regulation establish additional powers and duties
of the board and may adopt other rules and regulations as are necessary and
proper to implement this chapter. The Commissioner by rule and regulation shall
provide the procedures, criteria, and forms necessary to implement, collect, and
deposit assessments made and collected under Code
Section 33-29A-12.
33-29A-8.
(a)
Rates and rate schedules may be adjusted for appropriate risk factors, including
age and variation in claim costs, and the board may consider appropriate risk
factors in accordance with established actuarial and underwriting
practices.
(b)
The Georgia Health Security Underwriting Authority shall determine the standard
risk rate by considering the premium rates charged by insurers offering health
insurance coverage to individuals. The standard risk rate shall be established
using reasonable actuarial techniques and shall reflect anticipated experience
and expenses for such coverage. The initial assignment group rate may not be
less than 125 percent and may not exceed 200 percent of rates established as
applicable for individual standard rates. Subsequent rates shall be established
to provide fully for the expected costs of claims, including recovery of prior
losses, expenses of operation, investment income of claim reserves, and any
other cost factors subject to the limitations described in this subsection;
however, in no event shall assignment group rates exceed 200 percent of rates
applicable to individual standard risks.
(c)
All rates and rate schedules shall be submitted to the Commissioner for
approval, and the Commissioner must approve the rates and rate schedules of the
plans offered by the plan administrators on behalf of the assignment group
before assignment of risks to such plan´s use by the assignment group. The
Commissioner in evaluating the rates and rate schedule of the assignment group
shall consider the factors provided for in this Code section.
(d)
No information submitted by an applicant in connection with an application for
insurance under this chapter shall be submitted or released to a medical
information bureau.
33-29A-9.
(a)
Any individual person who is and continues to be a legal resident of Georgia as
defined in paragraph (24) of subsection (a) of Code Section 33-29A-2 shall be
eligible for coverage from the assignment group if evidence is provided
of:
(1)
A notice of rejection or refusal to issue substantially similar insurance for
health reasons by two insurers. A rejection or refusal by an insurer offering
only stop-loss, excess loss, or reinsurance coverage with respect to the
applicant shall not be sufficient evidence under this subsection;
(2)
A refusal by an insurer to issue insurance except at a rate exceeding the
assignment group rate;
(3)
In the case of an individual who is eligible for coverage under the federal
Health Insurance Portability and Accountability Act of 1996, P. L. 104-191, the
individual´s maintenance of health insurance coverage for the previous 18
months with no gap in coverage greater than 90 days of which the most recent
coverage was through an employer sponsored plan;
(4)
In the case of an individual who is eligible for coverage under the federal
Health Insurance Portability and Accountability Act of 1996, P. L. 104-191, the
individual´s maintenance of health insurance coverage through this
state´s 'Enhanced Conversion Options,' 'Georgia Health Insurance Assignment
System,' or 'Georgia Health Benefits Assignment System' at a rate exceeding the
assignment group rate with no gap in coverage since such coverage lapsed of more
than 90 days; or
(5)
Legal domicile in Georgia and eligibility for the credit for health insurance
costs under Section 35 of the federal Internal Revenue Code of
1986.
(b)
Each dependent of a person who is eligible for coverage from the assignment
group shall also be eligible for coverage from the assignment group unless that
person is enrolled in or is eligible to enroll in any form of health insurance
or insurance arrangement, whether public or private. In the case of a child who
is the primary insured, resident family members shall also be eligible for
coverage if they are the siblings, parents, or guardians of the
child.
(c)
A person may maintain assignment group coverage for the period of time the
person is satisfying a preexisting waiting period under another health insurance
policy or insurance arrangement intended to replace the assignment group
policy.
(d)
A person is not eligible for coverage from the assignment group if the
person:
(1)
Has in effect on the date assignment group coverage takes effect, or is eligible
to enroll in, health insurance coverage from an insurer or insurance
arrangement;
(2)
Is eligible for other health care benefits at the time application is made to
the assignment group, including COBRA continuation, except:
(A)
Coverage, including COBRA continuation, other continuation, or conversion
coverage, maintained for the period of time the person is satisfying any
preexisting condition waiting period under an assignment group policy;
or
(B)
Individual coverage conditioned by the limitation described by paragraphs (1)
through (3) of subsection (a) of this Code section;
(3)
Has terminated coverage in the assignment group within 12 months of the date
that application is made to the assignment group, unless the person demonstrates
a good faith reason for the termination;
(4)
Is confined in a county jail or imprisoned in a state or federal
prison;
(5)
Has premiums that are paid for or reimbursed under any government sponsored
program or by any government agency or health care provider, except as an
otherwise qualifying full-time employee, or dependent thereof, of a government
agency or health care provider, except as provided in paragraph (5) of
subsection (a) of this Code section;
(6)
Has premiums that are paid for or reimbursed by a nongovernmental third-party
organization with interest in placing individuals in high risk pools or similar
pools;
(7)
Has had prior coverage with the assignment group terminated for nonpayment of
premiums or fraud; or
(8)
Has voluntarily terminated coverage outside the assignment group within six
months of the date that application is made to the assignment group unless the
person demonstrates a good faith reason for the termination. If a person
otherwise eligible for assignment group coverage has declined or terminated
COBRA continuation or other continuation or conversion coverage, except for
basic conversion coverage as provided in subsection (g) of Code Section
33-24-21.1, such person is still eligible to apply for assignment group
coverage, but a preexisting condition exclusion shall apply and last for a
period of 18 months.
(e)
Assignment group coverage shall cease:
(1)
On the date a person is no longer a resident of this state, except for a child
who is a dependent according to provisions of paragraph (3) of subsection (a) of
Code Section 33-29-2 or paragraph (4) of Code Section 33-30-4 and who is
financially dependent upon the parent, a child for whom a person may be
obligated to pay child support, or a child of any age who is disabled and
dependent upon the parent;
(2)
On the date a person requests coverage to end;
(3)
Upon the death of the covered person;
(4)
On the date state law requires cancellation of the policy;
(5)
At the option of the assignment group, 30 days after the assignment group sends
to the person any inquiry concerning the person´s eligibility, including an
inquiry concerning the person´s residence, to which the person does not
reply;
(6)
On the thirty-first day after the day on which a premium payment for assignment
group coverage becomes due if the payment is not made before that date;
or
(7)
At such time as the person ceases to meet the eligibility requirements of this
Code section.
(f)
A person who ceases to meet the eligibility requirements of this Code section
may have his or her coverage terminated by the payor or plan administrator at
the end of the policy period.
33-29A-10.
(a)
The assignment group shall offer assignment group coverage consistent with major
medical expense coverage to each eligible person who is not eligible for
medicare. The board, with the approval of the Commissioner, shall
establish:
(1)
The coverages to be provided by the assignment group;
(2)
At least two health benefit products to be offered by the assignment group, one
of which shall be a plan utilizing a high deductible health plan (HDHP) that is
health savings account (HSA) eligible and one of which shall be a managed care
plan. All health benefit products offered shall require participation by the
insureds in disease and health management programs and shall provide varying
benefits based upon the insureds´ compliance with such
programs;
(3)
The applicable schedules of benefits; and
(4)
Any exclusions to coverage and other limitations.
(b)
The benefits provisions of the assignment group´s health benefits coverages
shall include the following:
(1)
All required or applicable definitions;
(2)
A list of any exclusions or limitations to coverage;
(3)
A description of covered services required under the assignment group;
and
(4)
The deductibles, coinsurance options, and copayment options that are required or
permitted under the assignment group.
(c)
The board may adjust deductibles and the time periods governing preexisting
conditions to preserve the financial integrity of the assignment group. Plan
administrators may petition the board in a manner provided for in rules adopted
by the board and approved by the Commissioner to address solvency concerns and
matters affecting the financial integrity of coverage provided by plan
administrators. If the board makes such an adjustment, it shall report in
writing that adjustment together with its reasons for the adjustment to the
Commissioner. The report shall be submitted not later than the thirtieth day
after the date the adjustment is made.
(d)
Benefits otherwise payable under assignment group coverage shall be reduced by
amounts paid or payable through any other health insurance or insurance
arrangement and by all hospital and medical expense benefits paid or payable
under any workers´ compensation coverage, automobile insurance whether
provided on the basis of fault or no-fault, and by any hospital or medical
benefits paid or payable under or provided pursuant to any state or federal law
or program.
(e)
The assignment group and the plan administrators shall have a cause of action
against an eligible person for the recovery of the amount of benefits paid that
are not for covered expenses. Benefits due from the assignment group and plan
administrators may be reduced or refused as an offset against any amount
recoverable under this subsection.
(f)
Notwithstanding other provisions of this Code section and so long as the minimum
standards set forth in this Code section are met, the board and plan
administrators may offer additional major medical plans of coverage to eligible
individuals that reflect those otherwise available to the private health
insurance market, including, but not limited to, such plans as may be designed
in the future to meet the need for affordable coverage for eligible
individuals.
33-29A-11.
(a)
Except as otherwise provided by this Code section, assignment group coverage
shall exclude charges or expenses incurred during the first 12 months following
the effective date of coverage with regard to any condition for which medical
advice, care, or treatment was recommended or received during the six-month
period preceding the effective date of coverage.
(b)
The preexisting conditions limitation provided in this Code section shall be
reduced by aggregated creditable coverage that was in effect up to a date not
more than 90 days before application for coverage in the assignment
group.
(c)
An eligible individual who is eligible for enrollment in the assignment group as
a result of the federal Health Insurance Portability and Accountability Act of
1996, P. L. 104-191, and has 18 months of prior creditable coverage, the most
recent of which is employer sponsored coverage, shall be eligible for coverage
without regard to the 12 month preexisting conditions limitation.
(d)
An eligible individual who is eligible for the credit for health insurance under
Section 35 of the federal Internal Revenue Code of 1986 shall be eligible
for coverage without regard to the 12 month preexisting conditions limitation
only if he or she had three months of prior creditable coverage as of the date
on which the individual seeks to enroll in assignment group coverage, not
counting any period prior to a 63 day break in coverage.
33-29A-12.
(a)
Plan administrators shall participate in the assignment group by accepting
direct assignments of eligible individuals for coverage.
(b)
The board with review and approval of the Commissioner shall develop an
accounting method to estimate future and determine actual claims of payors
accepting direct assignment of risks from the assignment group along with
administrative costs of the assignment group and plan
administrators.
(c)
The General Assembly shall provide an initial appropriation in order to carry
out the administrative powers and duties of the assignment group.
(d)
The board, after completing its duties under subsection (b) of this Code
section, shall report to the Governor, the House Committee on Insurance, the
Senate Insurance and Labor Committee, the House Committee on Appropriations, and
the Senate Appropriations Committee the anticipated operational costs for the
assignment group in its first two years of making assignments of risks as
provided in this chapter and shall request such appropriations as may be
necessary to carry out the board´s duties.
(e)
The board shall evaluate the impact of tax reduction strategies and incentives,
high deductible health plans, mandatory disease management programs, and other
risk-reduction methodologies in reducing claims and present recommendations to
the Governor, the House Committee on Insurance, the Senate Insurance and Labor
Committee, the House Committee on Appropriations, and the Senate Appropriations
Committee for funding the future operational expenses of the assignment
group.
(f)
The funding mechanism outlined in this Code section shall be modified only by
general law.
(g)
The board shall have authority to evaluate and apply for all grants and
resources, public and private, for which it may qualify to execute its powers
and duties under this chapter, including, but not limited to, start-up funds for
state high risk pools under the federal Deficit Reduction Act of 2005 or related
legislation to extend such funding and funds as they are available for expansion
of coverage to persons eligible for federal health coverage tax
credits.
(h)
If any source of funding for the assignment group should cease, the board is
authorized to take actions including, but not limited to, implementing a
moratorium on enrollment of nonfederally eligible individuals, ceding assignment
or conversion of coverage to federally eligible individuals to currently
operating federally approved programs, and taking ratings and benefit design
actions not otherwise prohibited by law to preserve the financial integrity of
the assignment group and its plan administrators."
33-29A-13.
An
applicant or participant in coverage from the assignment group is entitled to
have complaints against the assignment group reviewed by a grievance committee
appointed by the board. The grievance committee shall report to the board after
completion of the review of each complaint. The board shall retain all written
complaints regarding the assignment group at least until the third anniversary
of the date the assignment group received the complaint.
33-29A-14.
(a)
The state auditor shall conduct annually a special audit of the assignment
group. The state auditor´s report shall include a financial audit and an
economy and efficiency audit.
(b)
The state auditor shall report the cost of each audit conducted under this
chapter to the board. The board shall then promptly remit that amount to the
state auditor for deposit to the general fund.
33-29A-15.
Until
December 31, 2007, or such time as the assignment group is able to issue
coverage to eligible individuals, whichever occurs later, and notwithstanding
other changes in law contained in this chapter, persons eligible as a result of
the federal Health Insurance Portability and Accountability Act of 1996, P. L.
104-191, shall continue to be issued health insurance coverage through this
state´s 'Georgia Health Insurance Assignment System,' 'Georgia Health
Benefits Assignment System,' or 'Enhanced Conversion Options' under rules and
procedures established under this chapter or under Code Section 33-24-21.1 prior
to July 1, 2007.
33-29A-16.
Coverages
available under the assignment group must be made available not later than
January 1, 2008, except as provided in Code Section
33-29A-15."
SECTION
6-4.
Said
title is further amended by revising paragraph (2) of subsection (b) of Code
Section 33-30-15, relating to continuation of similar coverage, to read as
follows:
"(2)
Once such creditable coverage terminates, including termination of such
creditable coverage after any period of continuation of coverage required under
Code Section 33-24-21.1 or the provisions of Title X of the Omnibus Budget
Reconciliation Act of 1986, the insurer must
offer a
conversion policy
provide notice
of eligibility for coverage under the state´s alternative mechanism for the
availability of individual health insurance coverage as provided under Chapter
29A of this title, as contemplated by Section 2741 of the federal Public Health
Service Act, 42 U.S.C. Section 300gg-41,
to the eligible employee, member, subscriber, enrollee, or
dependent."
SECTION
6-5.
Said
title is further amended by repealing and reserving Chapter 44, relating to high
risk health insurance plans.
PART
VII.
SECTION 7-1.
SECTION 7-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is 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, 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.
33-62-15.
(a)
Effective January 1, 2008, the following individuals who are over the age of 18
and have not yet attained the age of 65 and whose annual gross income exceeds
300 percent of the federal poverty level for the immediately preceding calendar
year shall offer proof of their ability to pay for medical care for themselves
and their dependents:
(1)
Residents of Georgia; or
(2)
Within 63 days of establishing residency, individuals who become residents of
Georgia.
(b)
Individuals subject to the requirement in subsection (a) of this Code section
shall be deemed to be in compliance with said requirement if they:
(1)
Indicated coverage under any health benefit plan in accordance with Code
Section 33-62-13;
(2)
Demonstrate proof of financial security in accordance with subsection (c) of
this Code section; or
(3)
Demonstrate proof of coverage under a high deductible major medical health
insurance plan.
(c)
Pursuant to paragraph (2) of subsection (b) of this Code Section, individuals
electing to demonstrate proof of financial security to pay for medical
expenditures shall present to the commissioner of revenue a bond in the amount
of $10,000.00 or shall deposit with the commissioner of revenue $10,000.00 in an
escrow account that shall bear interest at a rate established by the
commissioner of revenue.
(d)
If, in any calendar year, an individual subject to the requirement in subsection
(a) of this Code section fails to comply with said requirement, the commissioner
of revenue shall establish an escrow account in the name of said individual
and:
(1)
Shall retain and deposit in said account all such funds as may be owed to said
individual by the State of Georgia, including, but not limited to, any
overpayment by said individual of any taxes imposed by the State of
Georgia;
(2)
Shall obtain an order for the attachment of the wages of said individual to
satisfy the requirements of this Code section; or
(3)
Both paragraphs (1) and (2) of this subsection.
(e)
With respect to any escrow account established in accordance with this Code
section, either by reason of an individual making the election specified in
subsection (c) of this Code section or by reason of an individual being subject
to subsection (d) of this Code section:
(1)
The amount deposited, retained, or collected shall not exceed $10,000.00 in the
aggregate for any such individual;
(2)
Nothing in this Code section shall be construed to authorize the commissioner of
revenue to retain any amount for such purposes that otherwise would be paid to a
claimant agency or agencies of the State of Georgia as debts;
(3)
Moneys shall be disbursed by the commissioner of revenue only to pay for medical
claims for health care services provided to the individual during the period
when the individual was not in compliance with subsection (a) of this Code
section;
(4)
The commissioner of revenue shall close the account and remit the remaining
funds to the individual within six months of receiving notification that the
individual has:
(A)
Elected to comply with the requirement of subsection (a) of this Code section by
submitting proof of insurance coverage in accordance with paragraph (1) of
subsection (b) of this Code section; or
(B)
Is no longer subject to subsection (a) of this Code section by reason of no
longer being a resident of this state; and
(5)
If the commissioner of revenue determines that an individual for whom an account
has been established has not been a resident of this state for a consecutive
period of 36 months or more, the commissioner of revenue shall close the account
and remit the remaining funds to the individual or, if the commissioner of
revenue cannot locate the individual, shall dispose of the funds in accordance
with the provisions of law concerning unclaimed property.
(f)
Any judgment payable by an individual to a hospital, physician, or other health
care provider for charges incurred during a period when the individual failed to
comply with subsection (a) of this Code section shall include an order
permitting the attachment of the wages of such individual to satisfy such
judgment."
PART
VIII.
SECTION 8-1.
SECTION 8-1.
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,
to read 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."
PART
IX.
SECTION 9-1.
SECTION 9-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is revised
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."
PART
X.
SECTION 10-1.
SECTION 10-1.
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
10-2.
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; and
(2)
Cost comparison information on certain prescription drugs at different
pharmacies 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 and pharmacies 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 and pharmacies. 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 health care 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, and ambulatory surgical
centers 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
10-3.
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
10-4.
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
10-5.
Article
1 of Chapter 18 of Title 45 of the Official Code of Georgia Annotated, relating
to the state employees´ health insurance plan, is 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 15 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
10-6.
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 15 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
10-7.
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."
PART
XI.
SECTION 11-1.
SECTION 11-1.
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 Health Security Underwriting Authority, the Georgia Patient Safety
Corporation, and the Georgia Health Insurance Exchange shall cooperate with the
committee, its authorized personnel, the Attorney General, the state auditor,
the state accounting officer, and other state agencies. The Georgia Health
Security Underwriting Authority, the Georgia Patient Safety Corporation, and the
Georgia Health Insurance Exchange shall submit to the committee such reports and
data as the committee shall reasonably require of them. The Attorney General is
authorized to bring appropriate legal actions to enforce any laws specifically
or generally relating to the Georgia Health Security Underwriting Authority, the
Georgia Patient Safety Corporation, and the Georgia Health Insurance
Exchange.
28-12-4.
The
committee shall:
(1)
Evaluate the performance of the Georgia Health Security Underwriting Authority,
the Georgia Patient Safety Corporation, and the Georgia Health Insurance
Exchange 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 Health
Security Underwriting Authority, the Georgia Patient Safety Corporation, and the
Georgia Health Insurance Exchange as well as periodically review and evaluate
the success with which such entities are accomplishing their 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 Health Security
Underwriting Authority, the Georgia Patient Safety Corporation, and the Georgia
Health Insurance Exchange.
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."
PART
XII.
SECTION 12-1.
SECTION 12-1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by adding new subsections (c) and (d) in Code Section 33-8-4, relating to amount
and method of computing tax on insurance premiums generally, to read as
follows:
"(c)
Insurers may claim an exemption from otherwise applicable state premium taxes as
provided for in subsection (a) of this Code section in an amount equal to 2 1/4
percent of the premiums such insurers collect during the applicable tax year
from Georgia residents on premiums paid for high deductible health plans sold or
maintained in connection with a health savings account under the applicable
provisions of Section 223 of the Internal Revenue Code.
(d)
Insurers may claim an exemption from otherwise applicable state premium taxes as
provided for in subsection (a) of this Code section in an amount equal to 2 1/4
percent of the premiums such insurers collect during the applicable tax year
from Georgia residents on premiums paid for other health plans which are not
otherwise exempt under subsection (c) of this Code section."
SECTION
12-2.
Said
title is further amended by adding a new subsection (a.1) in Code Section
33-8-8.2, relating to amount and method of computing local insurance premium
taxes on insurance companies other than life insurance companies, to read as
follows:
"(a.1)
Insurers may claim an exemption from otherwise applicable local premium taxes as
provided for in subsection (a) of this Code section in an amount equal to 2.5
percent of the premiums such insurers collect during the applicable tax year
from Georgia residents on premiums paid for high deductible health plans sold or
maintained in connection with a health savings account under the applicable
provisions of Section 223 of the Internal Revenue Code."
SECTION
12-3.
Title
48 of the Official Code of Georgia Annotated, relating to revenue and taxation,
is amended by adding a new paragraph in subsection (a) of Code Section 48-7-27,
relating to computation of taxable net income, to read as follows:
"(13.1)
An amount equal to 100 percent of the premium paid by the taxpayer during the
taxable year for high deductible health plans established and used with a health
savings account under the applicable provisions of Section 223 of the Internal
Revenue Code to the extent the deduction has not been included in federal
adjusted gross income, as defined under the Internal Revenue Code of 1986, and
the expenses have not been included in itemized nonbusiness
deductions;".
SECTION
12-4.
Said
title is further amended by adding new Code sections to read as
follows:
"48-7-29.13.
(a)
As used in this Code section, the term:
(1)
'Qualified health insurance expense' means the expenditure of funds for health
insurance premiums for high deductible health plans that include, at a minimum,
catastrophic health care coverage which are established and used with a health
savings account under the applicable provisions of Section 223 of the Internal
Revenue Code.
(2)
'Taxpayer' means an employer who employs directly, or who pays compensation to
individuals which compensation is reported on Form 1099, 25 or fewer
persons.
(b)
A taxpayer which does not provide health care coverage shall be allowed a credit
against the tax imposed by Code Section 48-7-20 or 48-7-21 for contributions to
the health savings account of an employee or compensated individual who incurs
qualified health insurance expenses in an amount not to exceed the actual amount
contributed to all participating employees or compensated individuals or
$500.00, whichever is less, if such contributions are made available to all of
its employees and compensated individuals.
(c)
In no event shall the total amount of the tax credit under this Code section for
a taxable year exceed the taxpayer´s income tax liability. Any unused tax
credit shall be allowed the taxpayer against succeeding years´ tax
liability. No such credit shall be allowed the taxpayer against prior
years´ tax liability.
(d)
The commissioner shall be authorized to promulgate any rules and regulations
necessary to implement and administer the provisions of this Code
section.
48-7-29.14.
(a)
As used in this Code section, the term:
(1)
'Qualified health insurance expense' means the expenditure of funds for health
insurance premiums for high deductible health plans that include, at a minimum,
catastrophic health care coverage, which are established and used with a health
savings account under the applicable provisions of Section 223 of the Internal
Revenue Code.
(2)
'Taxpayer' means an employee who is employed directly or a person who is paid
compensation which is reported on Form 1099 at a business where 25 or fewer
persons are employed or compensated by the employer.
(b)
A taxpayer shall be allowed a credit against the tax imposed by Code Section
48-7-20 for qualified health insurance expenses in an amount not to exceed the
actual amount expended or $250.00, whichever is less, if such health insurance
is made available to all of the employees and compensated individuals of the
employer.
(c)
In no event shall the total amount of the tax credit under this Code section for
a taxable year exceed the taxpayer´s income tax liability. Any unused tax
credit shall be allowed the taxpayer against succeeding years´ tax
liability. No such credit shall be allowed the taxpayer against prior
years´ tax liability.
(d)
The commissioner shall be authorized to promulgate any rules and regulations
necessary to implement and administer the provisions of this Code
section."
SECTION
12-5.
Said
title is further amended by adding a new Code section to read as
follows:
"48-7-29.15.
(a)
As used in this Code section, the term:
(1)
'Qualified health information technology expense' means the expenditure of funds
by a taxpayer for health information technology hardware or software used
directly in the establishment and maintenance of electronic medical records
accessible at a website established by the Department of Community Health
pursuant to Code Section 26-4-80 or 31-33-9.
(2)
'Taxpayer' means a physician, pharmacy, or hospital which incurs qualified
health information technology expenses.
(b)
A taxpayer shall be allowed a credit against the tax imposed by Code Section
48-7-20 or 48-7-21 for qualified health information technology expenses in an
amount not to exceed the actual amount expended or $5,000.00, whichever is
less.
(c)
In no event shall the total amount of the tax credit under this Code section for
a taxable year exceed the taxpayer´s income tax liability. Any unused tax
credit shall be allowed the taxpayer against succeeding years´ tax
liability. No such credit shall be allowed the taxpayer against prior
years´ tax liability.
(d)
The commissioner shall be authorized to promulgate any rules and regulations
necessary to implement and administer the provisions of this Code
section.
(e)
This Code section shall be repealed by operation of law on January 1,
2009."
SECTION
12-6.
Said
title is further amended in Code Section 48-8-3, relating to exemptions from
sales and use tax, by replacing "; or" at the end of paragraph (84) with a
semicolon; by replacing the period at the end of paragraph (85) with "; or"; and
by adding a new paragraph to read as follows:
"(86)(A)
For the period commencing January 1, 2008, and ending on December 31, 2011,
sales of tangible personal property or services to a qualified small
business.
(B)
As used in this paragraph, the term 'qualified small business' means any small
business located in this state which qualifies for and receives the state income
tax credit with respect to qualified health insurance expenses pursuant to Code
Section 48-7-29.13.
(C)
Any person making a sale of tangible personal property or services to a
qualified small business shall collect the tax imposed on this sale unless the
purchaser furnishes such person with an exemption determination letter issued by
the commissioner certifying that the purchaser is entitled to purchase the
tangible personal property or services without paying the tax.
(D)
The commissioner is authorized to promulgate rules and regulations deemed
necessary in order to administer and effectuate this
paragraph."
PART
XIII.
SECTION 13-1.
SECTION 13-1.
For
the purpose of appointing the initial board of directors of the Georgia Health
Insurance Exchange, Part VII of this Act shall become effective upon its
approval by the Governor or upon its becoming law without such approval. For
all other purposes, Part VII of this Act shall become effective on July 1, 2007.
Part XII of this Act shall become effective on January 1, 2008, and Sections
12-4 and 12-5 of this Act shall be applicable to all taxable years beginning on
or after January 1, 2008. The remaining parts of this Act shall become
effective on July 1, 2007.
SECTION
13-2.
All
laws and parts of laws in conflict with this Act are repealed.