Rules and Regulations of the State of Georgia
 

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  • 1. In the address bar, type about:config and press Enter.
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<xmp>.</xmp> <form name="form1" method="post" action="120-2-10?urlRedirected=yes&amp;data=admin&amp;lookingfor=120-2-10" id="form1"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwUKLTY5ODkwOTM2Nw8WAh4Ec3BhbQIHFgJmD2QWAgIFDw8WAh4EVGV4dAUFNSArIDJkZGQYio5HOx5BPhMpMgQHfxh5xZYfdA==" /> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="EEBB6393" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEWCAL8tJPJDgLniKOhBALV5cpNAoa5iIEFAoznisYGAsrv5u0MAsrv4u0MAsrv3u0Mm7cS5QSZnAk4qhGXvMNT/saUa4k=" /> <div class='popup'> <div class='cnt223'> <div style="margin-bottom:6px;"> <img alt="Rules and Regulations of the State of Georgia" src="/images/new.gif"/> </div> <div class="header"> Terms and Conditions of Agreement for Access to Rules and Regulations of the State of Georgia Website </div> <div class="scroll"> <p>(Note: certain features of this site have been disabled for the general public to prevent digital piracy. If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree that you will not copy, print, or download anything from this website for any commercial use. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website.</p> <p> You agree that you will not sell, will not license, and will not otherwise make available in exchange for anything of value, anything that you download, print, or copy from this site.</p> <p> You agree that you will not copy, print, or download any portion of the regulations posted on this site exceeding a single chapter of regulations for sale, license, or other transfer to a third party, except that you may quote a reasonable portion of the regulations in the course of rendering professional advice.</p> <p> If you violate this agreement, or if you access or use this website in violation of this agreement, you agree that Lawriter will suffer damages of at least $20,000. </p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." THE STATE OF GEORGIA AND LAWRITER EXPRESSLY DISCLAIM ALL WARRANTIES, INCLUDING THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT AND ARE NOT LIABLE TO ANY PERSON FOR ANY ERRORS IN INACCURACIES CONTAINED IN THIS WEBSITE. </p> <p> If you accept these terms enter the information below and click “I AGREE”.</p> </div> <table border="0" style="width: 810px"> <tr> </tr> <tr> <td style="vertical-align: text-top; width: 243px;"> Full Name:</td> <td style="width: 532px; vertical-align:super;"> <input name="firstName" type="text" id="firstName" class="txt" /> <span id="lbl_fname"><font color="Red"></font></span> </td> </tr> <tr><td style="width: 243px"> Human verification: <b> <span id="lblStopSpam">5 + 2</span>&nbsp;= </b></td><td style="width: 532px"> <input name="captcha" type="text" id="captcha" class="txt" /> <span id="lbl_captcha"><font color="Red"></font></span> &nbsp; <input name="sum" type="hidden" id="sum" value="7" /> </td></tr> </table> <input type="submit" name="Button1" value="I AGREE" id="Button1" disabled="disabled" /> <span id="alrtmsg"><font color="Red"></font></span> <input name="v1" type="hidden" id="v1" /> <input name="v2" type="hidden" id="v2" /> <input name="v3" type="hidden" id="v3" /> <p>Privacy Policy: the above information is for internal use only as related to this agreement and will not be sold or distributed.</p> </div> </div> </form> <html> <head runat="server"> <title>GA - GAC</title> <link href="_files/main.css" media="all" rel="Stylesheet" type="text/css" /> <link href="_files/treeview_old.css" media="all" rel="Stylesheet" type="text/css" /> <link href="/_files/popup.css" media="all" rel="stylesheet" type="text/css" /> <script type="text/javascript" src="/_files/treeview.js"></script> <script type="text/javascript" src="/_files/jquery-1.8.0.min.js"></script> <script type="text/javascript" src="/_files/jquery-1.10.2.js"></script> <script type="text/javascript" src="/_files/popup.js"></script> <script type="text/javascript" src="http://code.jquery.com/jquery-1.8.2.js"></script> <script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.8/jquery.min.js" /> <script type="text/javascript" src="/_files/jquery.popup.js"></script> <script type="text/javascript" src="/_files/jquery.popup.min.js"></script> <script type="text/javascript" src="/_files/ValidateForm.js"></script> <script src="https://code.jquery.com/jquery-1.11.3.js"></script> <link href="/_files/enablejs.css" rel="Stylesheet" type="text/css" /> <link href="/_files/forJavascript.css" rel="Stylesheet" type="text/css" /> <style type="text/css"> .collapse{background-image:url('/images/expcoll_right.png');} .expand{background-image:url('/images/expcoll_down.png');} </style> <script type="text/javascript"> $(document).ready(function(){ $("#History-parent").click(function(){ $("#History-Childs").toggle(); if ($('#History-parent img').hasClass('expand')) { $('#History-parent img').addClass('collapse'); $('#History-parent img').removeClass('expand'); $('#History-parent img').attr('src', '/images/expcoll_right.png'); } else { $('#History-parent img').removeClass('collapse'); $('#History-parent img').addClass('expand'); $('#History-parent img').attr('src', '/images/expcoll_down.png'); } }); $("#History-Childs").hide(); var tocnode=document.getElementById('toc-children'); if (tocnode != null) { if(tocnode.childNodes.length != 0) { document.getElementById("doc-content").style.width="72%"; document.getElementById("toc").style.width="21%"; document.getElementById("toc").style.padding="10px"; } else { document.getElementById('toc').style.display="none"; } } }); function fnsetRDVal(id) { if (id=="y") { document.getElementById("y").value="yes" document.getElementById("n").value="" } else { document.getElementById("n").value="no" document.getElementById("y").value="" } } </script> <script type="text/javascript"> function TermsCon() { var overlay = $('<div id="overlay"></div>'); overlay.show(); overlay.appendTo(document.body); $('.popup2').show(); $('#btnAgree').click(function () { $('.popup2').hide(); $("#overlay").hide(); overlay.appendTo(document.body).remove(); }); $("#btnprint").click(function () { var contents = $("#popupterms").html(); var frame1 = $('<iframe />'); frame1[0].name = "frame1"; frame1.css({ "position": "absolute", "top": "-1000000px" }); $("body").append(frame1); var frameDoc = frame1[0].contentWindow ? 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If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website. </p> <p> You agree that you will not sell or license anything that you download, print, or copy from this website.</p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." 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target="_blank"><em class="mnemonic">S</em>earch tips</a></div><ul class="breadcrumb"> <li><a href="/GAC" name="GAC" title="GAC">GA R&amp;R</a></li> <li>&raquo; <a href="/GAC/120" title="120">Department 120</a></li> <li>&raquo; <a href="/GAC/120-2" title="120-2">Chapter 120-2</a></li> <li>&raquo; Subject 120-2-10</li> </ul> </div> </div><div id="doc" class="container"> <div id="doc-content" class="content"> <h1><nllsubject>Subject 120-2-10 REGULATIONS REGARDING INSURANCE CONTRACT</nllsubject></h1> <h2><a href="/GAC/120-2-10-.01" name="120-2-10-.01" title="120-2-10-.01">Rule 120-2-10-.01 Profit-Sharing Policies</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.01(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No policy may be sold or approved for sale in Georgia on or after November 1, 1967 which provides that the policyholder will be eligible to participate in any future distribution of general corporate profits, with special advantage not available to person holding other types of policies issued by the company to individuals of the same class and equal expectation of life, nor may any policy be sold or approved for sale which provides that the policy holder will be eligible to participate in any future distribution of profits, savings, or unabsorbed portions of premium unless the requirements set for in Regulation <a title="120-2-10-.08" href="120-2-10-.08">120-2-10-.08</a> have been met.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.01(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No policy may be sold or approved for sale in Georgia after said date which uses a policy name implying or that may reasonably be construed as implying that only a limited number or a limited class of persons will be eligible to buy such policy, unless such limitation is related to actuarially sound underwriting practices.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.01(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This section is not intended to restrict or prohibit the sale in this State of insurance policies or annuities authorized by 33-14-16 and 33-25-6 of the Georgia Insurance Code, nor is it intended to restrict an insurer from issuing both participating and nonparticipating policies.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.02" name="120-2-10-.02" title="120-2-10-.02">Rule 120-2-10-.02 Coupon Policies or Policies with Annual Pure Endowment Benefits</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No policy containing pure endowment benefits during the premium paying period (whether or not evidenced by coupons, passbooks, or other devices generally identified with savings, banking or investment institutions), shall be sold or approved for sale in Georgia on or after November 1, 1967 unless it meets the following requirements: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Contains, clearly and prominently displayed in the proximity to the language used to set forth the consideration for the policy contract, the following statement or similar wording approved by the Commissioner, "the premium shown includes an additional annual (semi-annual, quarterly, monthly, weekly, etc.) premium of $________ for coupon (or pure endowment, whichever is applicable) benefits", inserting in the blank space the said additional premium.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Payment of any annual pure endowment benefits shall not be made contingent upon the payment of premiums falling due on or after the time the annual pure endowment benefit has matured.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The amount of each of the pure endowment benefits shall be expressed in dollar amounts and not as a "percentage" of any premium or benefit.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No annual pure endowment shall be described as being a guaranteed dividend, nor as earning on the premium investment.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(1)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The language and terminology of a policy which has pure endowment benefits therein shall not purport to represent the pure endowment benefit or benefits to be anything other than guaranteed insurance benefits for which premium is being paid by the policyholder.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.02(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This section shall not apply to Educational Endowment-type policies in which the amounts of annual pure endowments, payable during the endowment period, are greater than the annual premiums for the respective years in which such endowments are paid.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.03" name="120-2-10-.03" title="120-2-10-.03">Rule 120-2-10-.03 Medical or Surgical Policies-Outpatient Coverage</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In accordance with Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-29-6&amp;title=33#" target="_newtab">33-29-6</a> of the Georgia Insurance Code this rule is applicable to all individual accident and sickness policies that provide coverage for medical or surgical procedures which are required to be performed on an inpatient basis at a licensed hospital. These policies shall contain provisions on their face or by endorsement to reimburse policyholders for any otherwise covered medical or surgical procedures when such procedures are performed on an outpatient basis in a facility described in said policies.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In ordinary circumstances when the general condition of the patient would not be placed in jeopardy, admission to the hospital as a registered bed patient may not be necessary for the sole purpose of performing the procedures described herein.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All personnel and providers of services shall be currently licensed to perform the services they provide, when such services require licensure or registration under applicable State laws.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All facilities and equipment needed and used for and in the delivery of services which are required to be licensed and/or certified by law shall be so licensed and/or certified.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The medical or surgical procedures listed in paragraph (7) below may be performed on an outpatient basis unless the following situations exist which may contraindicate the use of an outpatient setting: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Presence of medical conditions which make prolonged postoperative observation by a nurse or skilled medical personnel a necessity (including but not limited to heart disease and severe diabetes).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An unrelated procedure is being done simultaneously which itself requires surgical hospitalization.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Lack of proper home postoperative care.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Another surgical procedure could follow the initial procedure (including but not limited to a one-stage breast biopsy followed by a mastectomy).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Technical difficulties as documented by admission or operative notes.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(5)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A specific State statute or State Agency Rule(s) or Regulation(s) prohibits and/or limits said procedure.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Upon the certification by the Commissioner of Human Resources to the Insurance Commissioner that any procedure listed in paragraph (7) below can no longer be legally and safely performed on an outpatient basis, the Insurance Commissioner shall issue an order suspending the listing of that procedure(s). Such suspension shall remain in effect until such time as the Commissioner of Human Resources certifies to the Insurance Commissioner that the procedure(s) so suspended may again be legally and safely performed on an outpatient basis at which time the Insurance Commissioner shall issue an order reinstating the listing of that procedure(s). A copy of any such suspension and reinstatement orders shall be kept at the offices of the Insurance Commissioner and provided at cost to any person informing the Insurance Commissioner in writing of their desire to receive copies of all such orders. The procedures listed as of the time of their performances shall be reimbursable even if suspended at a subsequent date.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.03(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The numbers as set forth below in the following subparagraphs represent the medical and surgical services and procedures as contained in the <I>Physician's Current Procedural Terminology</I> (CPT), Fourth Edition, 1977, as published by the American Medical Association, Chicago, Illinois, 60610. Subject to the above listed conditions, these listed procedures may be performed on an outpatient basis.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.04" name="120-2-10-.04" title="120-2-10-.04">Rule 120-2-10-.04 Misleading Terms Prohibited</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.04(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Words such as "Founders Plan", "Charter Policy", "Expansion Plan", or "Profit-Sharing" have a tendency to mislead a purchaser or prospective purchaser of insurance or annuity to believe that he will receive something other than an insurance policy, annuity policy, or some benefit not available to other persons of the same class and expectation of life. Therefore, the use of such words or any other words that imply special privileges or benefits to the owner or insured persons not available to other persons of the same class and expectation of life in any insurance or annuity contract is prohibited.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.04(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The use of such words in printed material or oral presentations in a context which will mislead a purchaser or prospective purchaser of insurance or annuity to believe he will receive something other than an insurance policy, annuity policy, or some benefit not available to a person of the same class and expectation of life is prohibited.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.04(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Use of the words "investment" or "profit" in a context or under such circumstances or conditions as to have the capacity and tendency to mislead a purchaser or prospective purchaser to believe that he will receive, or that it is a possibility that he will receive, something other than an insurance policy, some benefit not provided in the policy, or some benefit not available to other persons of the same class and equal expectation of life is prohibited.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.05" name="120-2-10-.05" title="120-2-10-.05">Rule 120-2-10-.05 Describing Premiums as "Deposits", "Savings", or "Investments"</a></h2> <P>The use of the words "deposit," "savings," or "investments" in any insurance or annuity contract, other printed material, or oral presentation to refer to an amount where, in fact, the amount referred to is a premium as defined in Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-1&amp;title=33#" target="_newtab">33-24-1</a> of the Georgia Insurance Code is prohibited unless:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.05(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The premium payment establishes a debtor-creditor relationship between the insurance company and the policyholder; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.05(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The terms are used in conjunction with the word "premium" in such a manner as to clearly indicate the true character of the premium payment; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.05(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The terms are used in conjunction with a deposit administration plan.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.06" name="120-2-10-.06" title="120-2-10-.06">Rule 120-2-10-.06 Filing Requirements-Life and Health Forms</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The submission of any form for approval shall be in compliance with this Rule, Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-9&amp;title=33#" target="_newtab">33-24-9</a> of the Georgia Insurance Code and any other applicable sections of the Georgia Insurance Code or the Rules and Regulations of the Georgia Insurance Department.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Forms must be submitted in duplicate. If approval is granted, one copy will be retained by the Insurance Department and the other will be returned to the insurer with an appropriate notation indicating approval.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each form must be identified by a form number which is unique to that form. This number shall be printed in the lower left-hand corner of the first page, and no other number shall appear in close proximity to the form number. If any loose leaf or alternate pages are submitted, each such page must also be identified by a unique form number.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Submissions must be made by the insurer's Home Office, Regional Home Office, legal counsel or consulting actuary, and not by agents or agencies. Any other arrangements must be requested in writing and agreed to by this Department.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each submission must be accompanied by a letter listing by number the forms being submitted together with a brief description of each. The letter should also contain or have attached any other information required by these rules.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The insurer must indicate whether or not the form being submitted has been filed with the insurer's domestic state. If it has been so filed, the insurer must indicate whether or not approval has been received from the domestic state. If not so filed, or approved, or being sold in the domestic state, the reason must be stated.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If the submission is new, the insurer should print out the unique features of the form. If the submission is to supersede any approved form or where there has been any prior submission, the insurer should state which form is being replaced and the date when such replaced form was approved or submitted, as the case may be, and should point out the material changes in the superseding form.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each form must be completed with representative specimen data in "John Doe" fashion.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If submission is made of a complete policy form plus alternate pages, the insurer should clearly indicate what substitutions are being proposed.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If the insurer submits pages providing alternate or optional benefits under policy forms previously approved, reference should be made to the form number and date of approval of the basic policy.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(11)">(11)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If the insurer submits a page which is to replace a corresponding page in a previously approved policy or policies, reference must be made to the form number and date of approval of the basic policy with which the page is proposed to be used. The new page must be completed with representative data.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(12)">(12)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any rider or endorsement form must have affixed the signature of a responsible officer of the insurer as part of such form.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(13)">(13)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No policy, annuity contract, rider, endorsement or certificate may contain any advertising or underwriting material. It is not the intent of this rule to prohibit the imprinting of registered trade marks of the insurer.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(14)">(14)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No statement may appear in an application with respect to a proxy through which one or more members of the board of directors is authorized to vote in the election of directors.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(15)">(15)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The following information is required for all life policy forms except those life forms for which there are minimum values printed in standard actuarial publications. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(15)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A detailed development of the actuarial formulas for valuation premiums and reserves; non-forfeiture factors and values; and dividends, if participating.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(15)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Sample calculations for reserves and non-forfeiture values for the age illustrated in the John Doe specimen policy.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.06(15)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Certification by a qualified actuary that reserve factors and non-forfeiture values for all ages correctly calculated by the formulas submitted.</td> </tr> </table> </td> </tr> </table> <h2><a href="/GAC/120-2-10-.07" name="120-2-10-.07" title="120-2-10-.07">Rule 120-2-10-.07 Agents, Payments for Furnishing Leads and Reference to Regulations</a></h2> <P>No insurer or agent holding a license as a permanent insurance agent or other representative of an insurer shall:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.07(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Pay, allow, or give, or offer to pay, allow, or give, directly or indirectly, any commission or other valuable consideration as a result of the sale of a life insurance or annuity policy to any person for furnishing a lead, unless such person is currently licensed in this State to sell life insurance.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.07(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Apply for a temporary life insurance license, intending at the time of application not to qualify by written examination as a permanent insurance agent, provided, however, that this shall not prohibit the issuance of temporary licenses to persons entitled thereto as provided in Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-23-8&amp;title=33#33-23-8(1)(2)" target="_newtab">33-23-8(1)(2)</a> of the Georgia Insurance Code.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.07(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Sponsor for a life insurance license a person the sponsor could reasonably be expected to know has no intention of qualifying for a license as a permanent insurance agent, or a person whom the sponsor is not in good faith considering to contract with as a permanent insurance agent.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.07(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Make any reference to the regulations of this Chapter in an attempt or effort to induce a policyholder to lapse, cancel or replace any insurance policy currently in force, or make any reference to these regulations in an attempt or effort to sell or induce any person to buy any particular kind or type of insurance policy approved for sale in Georgia.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.08" name="120-2-10-.08" title="120-2-10-.08">Rule 120-2-10-.08 Participating Policies</a></h2> <P>No participating life insurance or annuity policy shall be sold or approved for sale in Georgia on or after January 1, 1968 unless each of the following requirements has been met:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.08(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> There shall be filed with the Commissioner a participating scale or formula pursuant to which the right to and extent of participation of policyholders of such participating insurance policy shall be determined. Such participating scale or formula shall be reviewed by the Company's actuary not less frequently than each five years and shall then be amended, if necessary, to reflect the Company's current experience. Any change or amendment of such participating scale or formula shall be filed with a statement of the reasons in support of such proposed change or amendment.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.08(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> There shall be filed with the Commissioner the verified certificate of an actuary attesting that the participating scale or formula required in subsection (a) above was prepared for such policy form or series of policy forms, is actuarially sound and based upon a reasonable classification not unfairly discriminating as between policyholders within such classification.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.08(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> There shall be filed with the Commissioner a verified certificate of a duly authorized officer of the insurer attesting that the participating scale or formula required by subsection (a) above will be the basis upon which the insurer will annually determine the right to and extent of participation by the policyholders of such policy form or series of policy forms.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.08(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Completion of Schedule M, including the footnote requirement, of the Annual Statement required to be filed with the Commissioner and the certification of the actuary, together with that of other executive officers, to the Annual Statement or specifically Schedule M thereof, shall constitute compliance with (a), (b) and (c) above.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.09" name="120-2-10-.09" title="120-2-10-.09">Rule 120-2-10-.09 Life, Annuities and Accident and Sickness Insurance Policy Language Simplification Standards</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The purpose of this Rule is to establish minimum ease of reading standards, pursuant to O.C.G.A. Sections <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-2-9&amp;title=33#" target="_newtab">33-2-9</a> and <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-3-25&amp;title=33#" target="_newtab">33-3-25</a>, for language used in policies, contracts, coverage booklets provided by insurers to certificate holders, and certificates of life insurance, accident and sickness insurance, credit life insurance and credit accident and sickness insurance delivered or issued for delivery in this State on and after January 1, 1984. This Rule is not intended to increase the risk assumed by insurance companies or other entitles subject to this Rule or to supersede their obligation to comply with the substance of other insurance legislation applicable to life, annuities, accident and sickness, credit life or credit accident and sickness insurance policies. This Rule is not intended to impede flexibility and innovation in the development of policy forms or content or to lead to the standardization of policy forms or content.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> As used in this Rule: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(2)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 'Policy' or 'policy form' means any policy contract, plan or agreement of life, annuities or accident and sickness insurance, including credit life and credit accident and sickness insurance, delivered or issued for delivery in this State by any company subject to this Rule; any certificate, contract or policy issued by a fraternal benefit society; any coverage booklet provided by insurers to certificate holders or any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this State.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(2)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 'Company' or insurer' means any life or accident and sickness insurance company, fraternal benefit society, nonprofit medical service corporation, nonprofit hospital service corporation, health care plan, dental care plan, vision care plan, pharmaceutical plan, health maintenance organization, and all similar type organizations.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(2)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 'Commissioner' means the Insurance Commissioner of this State.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This Rule shall apply to all policies delivered or issued for delivery in this State by any insurer on or after the date such forms must be approved under this Rule, but nothing in this Rule shall apply to: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> any policy which is a security subject to federal jurisdiction;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> any group policy covering a group of 1,000 or more lives at date of issue, other than a group credit life insurance policy or a group credit accident and sickness insurance policy; however, this shall not exempt the language contained in any certificate issued pursuant to a group policy delivered or issued for delivery in this State;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> any group annuity contract which serves as a funding vehicle for pension, profit sharing, or deferred compensation plans;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form approved or permitted to be issued prior to the dates such forms must be approved under this Rule; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(3)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the renewal of a policy delivered or issued for delivery prior to the dates such forms must be approved under this Rule.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In addition to any other requirements of law, no policy forms, except as stated in paragraph (3) of this Rule, shall be delivered or issued for delivery in this State on or after the dates such forms must be approved under this Rule, unless: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(4)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the text achieves a minimum score of forty on the Flesch reading ease test, or an equivalent score on any other comparable test as provided in paragraph (6) of this Rule;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(4)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> it is printed, except for specification pages, schedules and tables is not less than ten-point type, one-point leaded;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(4)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text of the policy or to any endorsements or riders; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(4)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> it contains a table of contents or an index of the principal sections of the policy, if the policy has more than 3,000 words printed on three or fewer pages of text, or if the policy has more than three pages regardless of the number of words.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> For the purpose of this Section, a Flesch reading ease test score shall be measured by the following method: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> For policy forms containing 10,000 words or less of text, the entire form shall be analyzed. For policy forms containing more than 10,000 words, the readability of two, 200 word samples per page may be analyzed instead of the entire form. The samples shall be separated by at least twenty printed lines.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The number of words and sentences in the text shall be counted and the total number of words divided by the total number of sentences. The figure obtained shall be multiplied by a factor of 1.015.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The total number of syllables shall be counted and divided by the total number of words. The figure obtained shall be multiplied by a factor of 84.6.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The sum of the figures computed under subparagraphs (5)(b) and (5)(c) above subtracted from 206.835 equals the Flesch reading ease score for the policy form.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> For purposes of subparagraphs (5)(b), (c) and (d) above, the following procedure shall be used: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(e)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> a contraction, hyphenated word, or numbers and letters when separated by spaces, shall be counted as one word;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(e)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> a unit of words ending with a period, semicolon, or colon, but excluding headlines and captions, shall be counted as a sentence; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(e)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> a syllable means a unit of spoken language consisting of one or more letters of a word as divided by an accepted dictionary. Where the dictionary shows two or more equally acceptable pronunciations of a word, the pronunciation containing fewer syllables may be used.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The term 'text' as used in this Rule shall include all printed matter except the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(f)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> the name and address of the insurer; the name, number or title of the policy; the table of contents or index; captions and subcaptions; specification pages, schedules or tables; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(5)(f)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> any policy language which is drafted to conform to the requirements of any federal law, regulation or agency interpretation; any policy language required by any collectively bargained agreement; and medical terminology; any words which are defined in the policy; and any policy language required by law or regulation; provided, however, the insurer identifies the language or terminology excepted by this subparagraph 2. and certifies, in writing, that the language or terminology is entitled to be excepted by the subparagraph 2.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any other reading test may be approved by the Commissioner for use as an alternative to the Flesch reading ease test if it is comparable in result(s) to the Flesch reading ease test.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Filings subject to this Rule shall be accompanied by a certificate signed by an officer of the insurer stating that is meets the minimum reading ease score on the test used or stating that the score is lower than the minimum required but should be approved in accordance with paragraph (10) of this Rule. To confirm the accuracy of any certification, the Commissioner may require the submission of further information to verify the certification in question.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> At the option of the insurer, riders, endorsements, applications, and any other forms made a part of the policy may be scored as separate forms or as part of the policy with which they may be used.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Nothing in this Rule shall be construed to negate any law of this State permitting the issuance of any policy form after it has been on file for the time period specified.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The Commissioner may authorize a lower score than the Flesch reading ease score required in subparagraph (4) (a) of this Rule whenever, in his sole discretion, he finds that a lower score: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(10)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> will provide a more accurate reflection of the readability of a policy form;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(10)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> is warranted by the nature of a particular policy or type or class of policy forms; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(10)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> is caused by certain policy language which is drafted to conform to the requirements of any State law, regulation or agency interpretation.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.09(11)">(11)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A policy form meeting the requirements of paragraph (4) or this Rule shall be approved notwithstanding the provisions of any other Laws which specify the content of policies, if the policy form provides the policyholders and claimants protection not less favorable than they would be entitled to under such laws.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.10" name="120-2-10-.10" title="120-2-10-.10">Rule 120-2-10-.10 Group Coverage Discontinuance and Replacement</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This Rule is applicable to all insurance policies, subscriber contracts, and any other insurance coverage by whatever name called issued in this State or provided through an out-of-state multiple employer trust or arrangement by an insurer on a group or group-type basis covering persons as employees of employers or as members of unions (or associations).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The term "group type basis" means a benefit plan, other than "salary budget" plans utilizing individual insurance policies or subscriber contracts, which meets the following conditions: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(2)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Coverage is provided through insurance policies or subscriber contracts to classes of employees or members defined in terms of conditions pertaining to employment or membership.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(2)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The coverage is not available to the general public and can be obtained and maintained only because of the covered person's membership in or in connection with the particular organization or group.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(2)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> There are arrangements for bulk payment of premiums or subscription charges to the insurer or non-profit service corporation.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(2)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> There is sponsorship of the plan by the employer, union (or association).</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The effective date of discontinuance for non-payment of premium or subscription charges: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If a policy or contract subject to these rules and regulations provides for automatic discontinuance of the policy or contract after a premium or subscription charge has remained unpaid through the grace period allowance for such payment, the carrier shall be liable for valid claims for covered losses incurred prior to the end of the grace period.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If the actions of the carrier after the end of the grace period indicate that it considers the policy or contract as continuing in force beyond the end of the grace period (such as, by continuing to recognize claims subsequently incurred), the carrier shall be liable for valid claims for losses beginning prior to the effective date of written notice of discontinuance to the policyholder or other entity responsible for making payments or submitting subscription charges to the carrier. The effective date of discontinuance shall not be prior to midnight at the end of the third scheduled work day after the date upon which the notice is delivered.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Requirements for notice of discontinuance for other than nonpayment of premiums: Any notice of discontinuance by the insurer shall be mailed or delivered not less than sixty (60) days prior to the effective date of cancellation. Such written notice of discontinuance given by the insurer may also advise, in any instance in which the plan involves employee contributions, that if the policyholder or other entity continues to collect contributions for the coverage beyond the date of discontinuance, the policyholder or other entity may be held solely liable for the benefits with respect to which the contributions have been collected. The notice of discontinuance required by this paragraph shall not be required where a policy is cancelled due to nonpayment of premium or subscription charges following the end of any required grace period.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Extension of Benefits. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Every group or other contract subject to these rules and regulations hereafter issued, or under which the level of benefits is hereafter altered, modified, or amended, must provide a reasonable provision for extension of benefits in the event of total disability at the date of discontinuance of the group policy or contract as required by the following paragraphs of this section.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In the case of a group life plan which contains a disability benefit extension of any type (e.g., premium waiver extension, extended death benefit in the event of total disability, or payment of income for a specified period during total disability) the discontinuance of the group policy shall not operate to terminate such extension.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In the case of a group plan providing benefits for loss of time from work or specific indemnity during hospital confinement, discontinuance of the policy during a disability shall have no effect on benefits payable for the disability or confinement.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In the case of hospital or medical expense coverages, a reasonable extension of benefits or accrued liability provision is required. Such a provision will be considered "reasonable" if it provides an extension of at least twelve months under "major medical" and "comprehensive medical" type coverages, and under other types of hospital or medical expense coverages provides either an extension of at least ninety days or an accrued liability for expenses incurred during a period of disability or during a period of at least ninety days starting with a specific event which occurred while coverage was in force (e.g., an accident).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(5)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any applicable extension of benefits or accrued liability shall be described in any policy or contract involved as well as in group insurance certificates. The benefits payable during any period of extension or accrued liability may be subject to the policy's or contract's regular benefit limits (e.g., benefits ceasing at exhaustion of a benefit period or of maximum benefits).</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The continuance of coverage in situations involving replacement of one carrier by another: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This section shall indicate the carrier responsible for liability in those instances in which one carrier's contract replaces a plan of similar benefits of another.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Liability of prior carrier. The prior carrier remains liable only to the extent of its accrued liabilities and extensions of benefits. The position of the prior carrier shall be the same whether the group policyholders or other entity secures replacement coverage from a new carrier, self insures, or foregoes the provision of coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The liability of succeeding carrier: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each person who is eligible for coverage in accordance with the succeeding carrier's plan of benefits (in respect of classes eligible and actively at work and non-confinement rules) shall be covered by that carrier's plan of benefits.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each person not covered under the succeeding carrier's plan of benefits in accordance with paragraph 1. above must nevertheless be covered by the succeeding carrier in accordance with the following rules if such individual was validly covered (including benefit extension) under the prior plan on the date of discontinuance and if such individual is a member of the class or classes of individuals eligible for coverage under the succeeding carrier's plan. Any reference in the following rules to an individual who was or was not totally disabled is a reference to the individual's status immediately prior to the date the succeeding carrier's coverage becomes effective. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The minimum level of benefits to he provided by a succeeding carrier shall be the applicable level of benefits of the prior carrier's plan reduced by any benefits payable by the prior plan.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Coverage must be provided by the succeeding carrier until at least the earliest of the following dates: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.(ii)(I)">(I)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the date the individual becomes eligible under the succeeding carrier's plan as described in paragraph 1. above.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.(ii)(II)">(II)</a></td> <td valign="top" style="text-align:left" class="leftalign"> for each type of coverage, the date the individual's coverage would terminate in accordance with the succeeding carrier's plan provisions applicable to individual termination of coverage (e.g., at termination of employment or ceasing to be an eligible dependent, as the case may be).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)2.(ii)(III)">(III)</a></td> <td valign="top" style="text-align:left" class="leftalign"> in the case of an individual who was totally disabled, and in the case of a type of coverage for which paragraph 5. of this Rule requires an extension of accrued liability, the end of any period of extension of accrued liability which is required of the prior carrier by paragraph (5) of this Rule or, if the prior carrier's policy or contract is not subject to that paragraph, would have been required of that carrier had its policy or contract been subject to paragraph 5. at the time the prior plan was discontinued and replaced by the succeeding carrier's plan.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> In the case of a preexisting conditions limitation included in the succeeding carrier's plan, the level of benefits applicable to preexisting conditions or persons becoming covered by the succeeding carrier's plan in accordance with this subparagraph during the period of time this limitation applies under the new plan shall be the lesser of: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)3.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the benefits of the new plan determined without application of the preexisting conditions limitation; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)3.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the benefits of the prior plan.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The succeeding carrier, in applying any deductibles or waiting periods in its plan, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits. In the case of deductible provisions, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible provisions of the prior carrier's plan during the ninety (90) days preceding the effective date of the succeeding carrier's plan, but only to the extent these expenses are recognized under the terms of the succeeding carrier's plan and are subject to similar deductible provision.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(c)5.">5.</a></td> <td valign="top" style="text-align:left" class="leftalign"> In any situation where a determination of the prior carrier's benefits is required by the succeeding carrier, at the succeeding carrier's request the prior carrier shall furnish a statement of the benefits available or pertinent information, sufficient to permit verification of the benefit determination or the determination itself by the succeeding carrier. For the purpose of this section, benefits of the prior plan will be determined in accordance with all of the definitions, conditions, and covered expense provisions of the prior plan rather than those of the succeeding plan. The benefit determination will be made as if coverage had not been replaced by the succeeding carrier.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Replacement, for the purposes of this Rule for groups or subgroups of fifty-one (51) or more insured employees, members or enrollees (not including dependents), includes, but is not limited to, any group or group-type replacement coverage which becomes effective within ninety (90) days of the date of discontinuance of a group policy or contract or within ninety (90) days of the date of discontinuance of an employer group insured under a group policy or contract covering multiple employer groups. Replacement, for the purposes of this Rule for groups or subgroups of fifty (50) or less insured employees, members or enrollees (not including dependents), shall be defined in Rule 120-2-10-.(1)(k). <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(d)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The succeeding carrier's plan may be effective on the date agreed upon by the policyholder and insurer for the period for which a premium is paid.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.10(6)(d)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The succeeding carrier shall not be liable for new conditions arising during the period of no coverage. Such conditions may be subject to the succeeding carrier's preexisting conditions limitation.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <h2><a href="/GAC/120-2-10-.11" name="120-2-10-.11" title="120-2-10-.11">Rule 120-2-10-.11 Group Health Insurance Conversion Privilege</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A group policy and any other group insurance coverage by whatever name called delivered or issued for delivery in this State or which covers Georgia residents through an out-of-state multiple employer trust or arrangement, by an insurer, nonprofit health care corporation or a Health Maintenance Organization (HMO) which provides hospital, surgical, or major medical coverage, or any combination of these coverages, on an expense incurred or service provided basis, but not a policy which provides benefits for specific diseases or for accidental injuries only shall provide that an insured employee, member, or enrollee whose insurance under the group policy has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class, and who has been continuously insured under the group policy (and under any group policy providing similar benefits which it replaces) for at least six (6) months immediately prior to termination, shall be entitled to have issued by the insurer an individual policy of health insurance (hereafter referred to as the `converted policy'). An employee, member, or enrollee shall not be entitled to have a converted policy issued if termination of the insurance under the group policy occurred because (i) the employee, member, or enrollee failed to pay any required contribution, (ii) any discontinued group coverage was immediately replaced by similar group coverage unless such person was declined coverage under the replacing group coverage, or (iii) an HMO enrollee's coverage was terminated in accordance with Rule <a title="120-2-33-.06" href="120-2-33-.06">120-2-33-.06</a> of the Rules and Regulations of the Georgia Insurance Department. Issuance of a converted policy shall be subject to the following conditions: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Time Limit: Evidence of Insurability. Written application for the converted policy shall be made and the first premium paid to the insurer not later than thirty-one (31) days after such termination. The converted policy shall be issued without evidence of insurability.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Effective Date of Coverage: Scope of Coverage. The effective date of the converted policy shall be the day following the termination of insurance under the group policy. The converted policy shall cover the employee, member or enrollee and any dependents who were covered by the group policy on the date of termination of insurance.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Optional Coverage. The insurer shall not be required to issue a converted policy under the plans specified herein to any person if such person is or could be covered by Medicare of the United States Social Security Act as added by the Social Security Amendments of 1965, or as later amended or superseded. Furthermore, except as required under subparagraph (c)3. below, the insurer shall not be required to issue a converted policy covering any person if: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(c)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> such person is covered for similar benefits by an insurer under another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or such person is eligible for similar benefits (whether or not covered therefore) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements or any state or federal law; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(c)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> the benefits provided or available under the sources referred to in subparagraph 1. above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards. The insurer's standards must bear some reasonable relationship to actual health care costs in the area in which the insured lives at the time of conversion and must be filed with the commissioner prior to their use in denying coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(1)(c)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notwithstanding subparagraphs 1. and 2. above, overinsurance shall not exist, for the purpose of issuing a conversion policy to any insured person, if no other coverage, including other group insurances on the person, fully covers preexisting conditions. When full coverage for preexisting conditions is provided under other similar coverage, then the insurer may nonrenew the conversion policy or the coverage of any person insured in accordance with subparagraph (14) of this Rule.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Benefits Offered. An insurer shall not be required to issue a converted policy which provides benefits in excess of those provided under the group policy from which conversion is made.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Preexisting Condition Provision. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy shall not exclude a preexisting condition not excluded by the group policy. The converted policy shall not exclude disease or physical condition of a particular employee, member, or enrollee by name or specific description.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(3)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy during the first policy year, may provide that the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual's insurance under the group policy remained in force and effect.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(3)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any period, not to exceed one year, under the converted policy during which preexisting conditions are excluded shall be reduced by the time period the employee, member or enrollee was insured under the group policy from which conversion was made.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Basic Hospitalization or Surgical Expense Coverage. Subject to the provisions and conditions of this Rule, if the group insurance policy from which conversion is made insured the employee, member, or enrollee for only basic hospitalization or surgical expense insurance, the employee, member, or enrollee shall have the option of obtaining a converted policy providing coverage on an expense incurred basis under any one of the plans meeting the following requirements: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(4)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Plan A - Semiprivate hospital daily room and board charges for a maximum duration of seventy (70) days; miscellaneous hospital expense benefits of a maximum amount of ten (10) times the semiprivate hospital daily room and board charges; and surgical operation expenses benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policy and providing a maximum benefit of Eight Hundred Dollars ($800); or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(4)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Plan B - seventy-five percent (75%) of the semiprivate hospital daily room and board charges for a maximum duration of seventy (70) days; miscellaneous hospital expense benefits of a maximum amount of ten (10) times the semiprivate hospital daily room and board charges payable; and surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of Six Hundred Dollars ($600); or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(4)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Plan C - fifty percent (50%) of the semiprivate hospital daily room and board charges for a maximum duration of seventy (70) days; miscellaneous hospital benefits for a maximum amount of ten (10) times the semiprivate hospital daily room and board charges payable; and surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of Four Hundred Dollars ($400).</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Major Medical Insurance Other Than HMO Contracts. Subject to the provisions and conditions of this Rule, if the group insurance policy from which conversion is made insures the employee, member or enrollee for major medical expense insurance, the employee, member, or enrollee shall be entitled to obtain a converted policy providing catastrophic or major medical coverage under a plan meeting all of the following minimum requirements: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A maximum benefit at least equal to either, at the option of the insurer, the benefits contained in subparagraphs 1. or 2. below: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(a)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The smaller of the following amounts: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(a)1.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The maximum benefit provided under the group policy.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(a)1.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A maximum payment of Two Hundred Fifty Thousand ($25,000) for each unrelated injury or sickness.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Payment of benefits at the rate of eight percent (80%) of covered medical expenses which are in excess of the deductible. Payment of benefits for outpatient treatment of mental illness, if provided in the converted policy, may be at a lesser rate but not less than fifty percent (50%).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A cash deductible for each benefit period shall be not less than the corresponding deductible in the group policy. If the maximum benefit is determined by subparagraph 2. above, the insurer may require that the deductible be satisfied during a period of not less than three (3) months if the deductible is Two Hundred Dollars ($200) or less, and not less than six (6) months if the deductible exceeds Two Hundred dollars ($200).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The benefit period shall be each calendar year when the maximum benefit is determined by subparagraph (a)1. above or twenty-four (24) months when the maximum benefit is determined by subparagraph (a)2. above.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(5)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The term "covered medical expenses," as used above, shall include the semiprivate room and board rate for the hospital in which the individual is confined and twice such amount for charges in an intensive care unit. Any surgical schedule shall be consistent with those customarily offered by the insurer under group or individual major medical health insurance policies.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The conversion privilege required by this Rule shall, if the group insurance policy insures the employee, member or enrollee for basic hospital or surgical expense insurance as well as major medical expense insurance, make available the plans of benefits as set forth in paragraphs (4) and (5) hereof under one policy. <P>The insurer may also, in addition to plans of benefits set forth in paragraphs (4) and (5) above, offer a policy of Comprehensive Medical Expense Benefits without first dollar coverage. Said policy shall conform to the requirements of paragraph (5) provided, however, that insurer electing to provide such a policy shall offer to all potential policyholders a low deductible option not to exceed One Hundred Dollars ($100), a high deductible option not to exceed Five Thousand Dollars ($5,000), and other deductible options between the high and low deductible options.</P> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> HMO contracts. Subject to the provisions and conditions of this rule, a terminated employee who was an enrollee under a group HMO contract shall have the option of obtaining an individual HMO contract with all of the same benefits as were provided in the group HMO contract or any lower option contract then being issued by the HMO as a conversion contract.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Alternate Plans. The insurer may, at its option, offer alternate plans for group health conversion in addition to those required by this Rule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Retirement Coverage. In the event coverage would be continued under the group policy on an employee following retirement prior to the time the employee is or could be covered by medicare, the employee may elect, in lieu of such continuation of group insurance, to have the same conversion rights as would apply had the insurance terminated at retirement by reason of termination of employment or membership.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Reduction of Coverage. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(10)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any converted policy may provide for a reduction of coverage on any person upon eligibility for coverage under Medicare of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded or under any other state or federal law.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(10)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No converted policy may provide for a reduction of coverage on any person upon that person's eligibility for coverage under the Medicaid program of the State of Georgia.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(10)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the benefits under the conversion policy shall be secondary to any group or blanket accident and sickness contract covering any person insured under the conversion contract.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)">(11)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Conversion Privilege Allowed. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Subject to the conditions set forth above, the conversion privilege shall be exercised at the insured's option at the time coverage terminates or at the end of any required period of continuation of coverage under the group policy and shall be available. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(a)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> to the surviving spouse, if any, of the employee, member, or enrollee with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(a)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> to the spouse of the employee, member, or enrollee upon termination of coverage of the spouse, while the employee, member, or enrollee remains insured under the group policy, by ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time, or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(a)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> to a child solely upon termination of the coverage by reason of ceasing to be a qualified family member under the group policy, or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(a)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> to the former spouse whose coverage under the group policy terminates by reason of an entry of a valid decree of divorce between the insured and spouse.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(11)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If the circumstances as related above in subparagraphs (a)1. or 4. occur, the spouse is entitled to have issued, in addition to the plans specified in this Rule without evidence of insurability, an individual or family policy then being issued by the insurer. Such individual or family policy must provide coverage most nearly similar to the coverage contained in the group policy or any other similar individual or family policy then being issued by the insurer but may contain lesser coverage if selected by the spouse.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(12)">(12)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Benefit Levels. This rule shall not require that benefits exceed those provided under the converting group plan or group contract.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(13)">(13)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Conversion Premium. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(13)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All premium rates and amended rates must be filed with the Commissioner of Insurance, and must provide for the payment of monthly premiums. Optional modes of premium payment maybe offered to the converting employee, member, or enrollee.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(13)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The initial premium for the converted policy for the first twelve (12) months and subsequent renewal premiums shall be determined in accordance with premium rates applicable to individually underwritten standard risks, to the age and class of risk of each person to be covered under the converted policy and to the type and amount of insurance provided. The experience under converted policies shall not be an acceptable basis for establishing rates for converted policies.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(13)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If an insurer experiences incurred losses for a period of two (2) years on conversion policies which have been in force for at least one (1) year, which exceed earned premiums by more than twenty percent (20%), the insurer may determine and file with the Commissioner of Insurance amended renewal rates for the subsequent year so that the amended rates shall produce a future projected loss ratio of not less than one hundred twenty percent (120%). This subparagraph shall not affect the initial twelve (12) month premium required under subparagraph (13)(b) above.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(13)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Conditions pertaining to health shall not be an acceptable basis for classification for the purposes of this Rule.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)">(14)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Information Requested by Insurer. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A converted policy may include a provision to allow the insurer to request information in advance of any premium due date of such policy of any person covered thereunder as to whether: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(a)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The insured is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(a)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The insured is covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(a)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any state or federal law.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy may provide that the insurer can refuse to renew the policy or the coverage of any person insured thereunder for the following reasons only: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Either the benefits provided under the sources referred to in subparagraphs (a)1. and 2. above for such person, or benefits provided or available under the sources referred to in subparagraph (a)3. above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards on file with the Georgia Insurance Department, or the converted policy-holder fails to provide the requested information;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligibility of the insured person for coverage under Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendements of 1965 or as later amended or superseded) or under any other state or federal law providing for benefits similar to those provided by the converted policy except that the conversion policy may not contain any provision purporting to exclude or reduce coverage provided an otherwise insurable person, solely for the reason that the person is eligible for or receiving medical assistance, as defined in the Georgia Medical Assistance Act of 1977.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(14)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any refusal to renew shall be without prejudice to any valid claim commending while the policy is in force.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(15)">(15)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Individual Conversion Policies. Insurers must provide for the issuance of individual conversion policies. Group conversion policies shall not be issued in lieu of individual conversion policies. The individual conversion policy is not exempt under Chapter 120-2-25 of the Rules and Regulations of the Georgia Insurance Department entitled "Exemption From Filing Certain Life and Health Forms." All individual conversion policies must be filed for approval in accordance with O.C.G.A. Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-9&amp;title=33#" target="_newtab">33-24-9</a>.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11(16)">(16)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notification. A notification of the conversion privilege shall be included in each certificate of coverage.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.11A" name="120-2-10-.11A" title="120-2-10-.11A">Rule 120-2-10-.11A Group Health Insurance Enhanced Conversion Privilege</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Definitions. For the purpose of this Rule, the following definitions shall apply: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Continuation Coverage" shall mean any coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) or continuation benefits under O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.1&amp;title=33#" target="_newtab">33-24-21.1</a> or § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.2&amp;title=33#" target="_newtab">33-24-21.2</a>.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Eligible Dependent" shall mean a dependent of a qualifying eligible individual, including a spouse, covered under the qualifying eligible individual's most recent group health insurance policy or contract, or continuation coverage thereof, who meets the requirements of paragraphs (g) 1. through 5. Eligible dependents shall include any dependents who would otherwise not qualify for coverage because they have less than 18 months previous creditable coverage, provided: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> They were born, adopted, or placed for adoption during coverage under the most recent group policy or continuation coverage of the qualifying eligible individual: and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> They were enrolled under such coverage within thirty-one (31) days of birth, adoption, or placement for adoption.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Group Pool Rate" shall mean the average base rate for employees, members, and enrollees, or dependents of such individuals, for all groups in the insurer's group pool in this state, determined over a period of twelve months and adjusted for benefit design but unadjusted for any demographic and experience factors relating to qualified eligible individuals in the enhanced conversion pool. In determining pool rates, the insurer must take into account all actual and anticipated experience data of the entire group pool itself (excluding the enhanced conversion pool) as well as other experience data of the insurer or data available generally, and must apply recognized actuarial practices as to credibility, trend factors, expense factors, and margins. Insurers shall use pool rates to determine premiums for all qualifying eligible individuals enrolling in enhanced conversion coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Managed Care Organization" shall mean an insurer which is a health maintenance organization or a provider-sponsored health care corporation.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Model Low Option" shall mean a minimum benefit option for use by insurers or managed care organizations for the purpose of offering a choice of coverage that is more limited in nature than the model standard option, but which constitutes creditable coverage. The model low option shall be associated with the policy form template prescribed in Form <I>GHBAS-1 </I>for managed care organizations, Form <I>GHIAS-2 </I>for coverage under a preferred provider arrangement, or Form <I>GHIAS-1 </I>for all other types of coverage, and with a schedule of benefits prescribed by Plan C in Form <I>GHBAS-S </I>for managed care organizations or by Plan A in Form <I>GHIAS-S </I>for all other types of coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Model Standard Option" shall mean a minimum benefit option for use by insurers or managed care organizations for the purpose of offering comprehensive coverage comparable to a standard option of coverage in the individual health insurance market in this state. The model standard option shall be associated with the policy form template prescribed in Form <I>GHBAS-1 </I>for managed care organizations, Form <I>GHIAS-2 </I>for coverage under a preferred provider arrangement, or Form <I>GHIAS-1 </I>for all other types of coverage, and with a schedule of benefits prescribed by Plan D in Form <I>GHBAS-S </I>for managed care organizations or by Plan B in Form <I>GHIAS-S </I>for all other types of coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)">(g)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Qualifying Eligible Individual" shall mean any Georgia domiciliary who meets all of the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> As of the date on which the individual seeks coverage under this section, the aggregate period of previous creditable coverage is 18 months or more;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The individual's most recent coverage was under a group plan, or continuation coverage thereof;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The individual's insurance under the group plan has been terminated for any reason, including discontinuance of the group plan in its entirety or with respect to an insured class, except for nonpayment of premium contribution pertaining to the qualifying eligible individual;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> With regard to such an individual's coverage under a group plan or continuation thereof, a qualifying event has occurred on or after October 30, 1997;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)5.">5.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The individual is not eligible for, nor has declined, any of the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)5.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Coverage under a group health insurance policy or contract, or other employer sponsored health benefit arrangement, including continuation coverage under COBRA or O.C.G.A. §§ <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.1&amp;title=33#" target="_newtab">33-24-21.1</a> or <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.2&amp;title=33#" target="_newtab">33-24-21.2</a>;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)5.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Medicare; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)5.(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The state plan under Medicaid or any successor program;</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)6.">6.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The individual is not enrolled in or covered under any other creditable health insurance coverage, including individual health insurance policies or blanket accident and sickness insurance pertaining to student health coverage; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)7.">7.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The individual is one of the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)7.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A current or former employee, member, or enrollee covered under the group health policy or contract and continuation thereof, if applicable;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)7.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The surviving spouse, if any, of a deceased covered employee, member, or enrollee, with or without dependents;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)7.(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The spouse, or a former spouse, with or without dependents, of a covered employee, member, or enrollee upon a qualifying event of the spouse while the employee, member, or enrollee remains insured under the group policy or continuation thereof, by ceasing to be a qualified family member under the group policy, such as a result of a valid decree of divorce; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(g)7.(iv)">(iv)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An otherwise eligible dependent upon reaching limiting age or otherwise losing dependent status under the group policy or continuation thereof, or under the enhanced conversion policy of another qualifying eligible individual.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(h)">(h)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Qualifying Event" shall mean loss of creditable coverage resulting from either: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(h)(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Exhaustion of continuation coverage to the maximum extent eligible under federal or state law; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(h)(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Termination of coverage under a group health insurance policy or contract, in the event such a qualifying eligible individual is not eligible for any continuation coverage. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(1)(h)(ii)(I)">(I)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Schedule of Benefits" shall mean the outline of benefit levels for a policy, including but not limited to the types of benefits covered and associated cost-sharing provisions.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Conversion Privilege. A group policy or any other group insurance coverage by whatever name called, delivered or issued for delivery in this State or which covers Georgia residents through an out-of-state multiple employer trust or arrangement, by an insurer (including a managed care organization) which provides creditable coverage for hospital, surgical or major medical benefits, or any combination of these benefits, on an expense incurred or service provided basis, but not a policy which provides limited benefits as defined in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.1&amp;title=33#33-24-21.1(i)" target="_newtab">33-24-21.1(i)</a>, shall provide that all qualifying eligible individuals and eligible dependents are entitled to have issued by the insurer a policy of health insurance (hereafter referred to as the "enhanced conversion policy").</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notification and Application. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Time Limit for Exercising Privilege. A substantially completed application for the converted policy shall be filed with, and the first premium paid to, the insurer not later than sixty-three (63) consecutive days after a qualifying event, or the date of notice of rights from the insurer following a qualifying event, whichever is later. An insurer is required to issue, either directly or through an administrator or group policyholder entrusted with the distribution of notices, a notice of conversion privileges under this Rule: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> With regard to qualifying eligible individuals or dependents exhausting continuation coverage, as soon as the insurer, administrator, or group policyholder receive payment for the final period of continuation coverage prior to exhaustion, but in no event later than fourteen (14) days after exhaustion of coverage;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> With regard to dependents covered under an enhanced conversion option and reaching limiting age, no later than fourteen (14) days after the last day of the month in which the dependent no longer becomes eligible for dependent coverage;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> With regard to qualifying eligible individuals or dependents not eligible for continuation, no later than fourteen (14) days from the date the insurer, administrator, or group policyholder obtains information as to the termination of coverage under the group policy;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)(iv)">(iv)</a></td> <td valign="top" style="text-align:left" class="leftalign"> By first class mail to the last known address of the qualifying eligible individual, available in records held by the insurer, administrator, or group policyholder; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(a)(v)">(v)</a></td> <td valign="top" style="text-align:left" class="leftalign"> With an application for coverage, information on the amount of the first premium payment required to effectuate coverage, as well as an explanation of the insured's enhanced conversion privilege.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notification of Individuals at Same Address. Issuance of notice to the last known address of a qualifying eligible individual shall satisfy the notice requirement for all qualifying eligible individuals and qualifying dependents last known to have resided at that address.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Responsibility for Notification. In all cases, the insurer is responsible for the timely offer of enhanced conversion policies, and compliance with the notification requirements of this Rule, whether or not there is a written agreement whereby a group policyholder or other administrator or third party assumes such responsibility. Nothing in this paragraph shall prevent an insurer from making a written agreement with a group policyholder or other administrator or third party for the administration or delivery of such notices. For the purposes of eliminating duplication of notices and assuring notification of qualifying eligible individuals, delivery of notice by either the insurer, an administrator, or the group policyholder in accordance with this Rule shall satisfy the requirement of this Rule paragraph.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Model Notice. Insurers may use the following model notice for an explanation of conversion privileges: <P><B>OFFICIAL NOTICE OF ENHANCED CONVERSION RIGHTS</B></P> <P>"Under Georgia law, you, and any qualifying dependents, are entitled to elect one of at least two benefit options provided by us. Enclosed with this notice you will find information on the benefit options available to you, as well as premium information. Upon exhaustion of continuation coverage (whether through COBRA or other extension of benefits under state law), loss of group coverage if ineligible for continuation, or loss of enhanced conversion policy coverage by reason of losing dependent status, you are eligible for these benefits. However, we must receive a completed application and an initial premium payment no later than sixty-three (63) consecutive days after the date of exhaustion or the date of this notice, whichever is later. You may enroll any dependent who was covered under continuation with you.</P> <P>If we do not receive a completed application from you within sixtythree (63) days of the date of this notice, or the date you lost coverage, whichever is later, you will have forfeited your privileges to this enhanced conversion product, and subsequently to any portability rights offered by state law.</P> <P>Upon submission of the completed application with premium payment, your coverage will become effective on the date continuation coverage was exhausted, or, if ineligible for continuation, the date group coverage was terminated.</P> <P>Your rights to an enhanced conversion policy guarantee you and any qualified dependents you may have comprehensive coverage without any pre-existing condition exclusions. Although you also have the right to seek individual health insurance coverage elsewhere, with this or another insurer, Georgia law does not guarantee you the same protections offered through this enhanced conversion product."</P> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Exception to Use of Model Notice and Application. An insurer may use a different notice, provided that the document is substantially similar to the model notice and is filed for approval by the Commissioner with the conversion policy form.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(3)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notice After Extention of Continuation. Upon exhaustion of extension, the provisions of this Rule shall apply with regard to timely notice and application. </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Extension Coverage in Lieu of Approved Enhanced Conversion Policies. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In General. In the event an insurer has not filed enhanced conversion policy forms for approval as required by this Rule, or has not obtained approval by the Commissioner for such filed policy forms, the insurer must provide all qualifying eligible individuals the opportunity for an extension of group or continuation coverage up until the last day of the month following the date enhanced conversion policies are approved by the Commissioner. All benefit and rating requirements under COBRA or state extension of benefits shall apply to such extension coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notification. The insurer must provide notice to all qualifying eligible individuals regarding the group plan or continuation extension in accordance with guidelines for notice of conversion privileges of this Rule. However, notice of extension privileges as permitted in this paragraph is not, in any case, required to be issued prior to January 1, 1998. Such notice must include the following information: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligibility criteria for both extension and enhanced conversion policies;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Premium requirements;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(b)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Assurances that benefits are continued as of January 1, 1998, or on the date of a qualifying event, whichever is later; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(b)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Transition procedures between extension and enhanced conversion policies.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Model Notice. Notice must include language that is identical or substantially similar to the disclosure below: <P>"Georgia law allows you to convert to other health insurance coverage offered by us when you exhaust continuation coverage to the maximum extent, or when you terminate employment and are ineligible for continuation benefits. Due to timing issues associated with recently enacted legislation, as of the date we issue this notice to you our enhanced conversion products are unavailable. However, we are providing you with an automatic extension of your group or continuation benefits, subject to timely payment of premium for upcoming benefit months and any past periods of coverage. If you should choose to renew your coverage through this extension, your extension will terminate on the last day of the month our enhanced conversion products are available. At that time, you will have the opportunity, within sixty-three (63) days of the notice of termination, to enroll yourself and any eligible dependents in an enhanced conversion product. You must renew coverage for any eligible dependents under this extension of continuation in order for them to be eligible for such enhanced conversion products.</P> <P>"The enclosed billing reflects extension coverage available to you, if you should choose to elect it. You will forfeit your rights to any extension of coverage described in this notice and any opportunity to purchase enhanced conversion policies later if you fail to elect and pay for this extension of group or continuation benefits within sixty-three (63) days of the date of this notice. If you have additional questions, you may call us at __________ or contact the Office of Commissioner of Insurance, John W. Oxendine, Consumer Services Division, at (404) 656-2070 or 1-800-656-2298."</P> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Alternate Extension Coverage. Nothing in this Rule shall prevent an insurer from offering any less comprehensive group plan, in addition to the group coverage which was terminated or continued, as a low option extension. However, in no case may an insurer refuse to extend a qualifying eligible individual's previous continuation or group coverage until approved enhanced conversion policies become available pursuant to this Rule. Election of low option extension coverage by an individual shall not preclude conversion privileges.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Effective Date of Coverage. Coverage under an extension or continuation of group coverage as required by this paragraph must become effective on the date of a qualifying event. However, insurers are not required to issue coverage under such extension for periods prior to January 1, 1998. Nothing in this paragraph shall prevent an insurer from offering extension coverage for periods prior to January 1, 1998.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(4)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Transition into Enhanced Coversion Coverage. Upon termination of extension coverage as permitted in this Rule, the insurer shall provide notice of enhanced conversion privileges to each qualified eligible individual covered under such extension. Such individuals shall have sixty-three (63) consecutive days from the date of such notice, or the date extension coverage is terminated, whichever is later, to elect an enhanced conversion option in accordance with this Rule.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Effective Date of Coverage; Scope of Coverage. Coverage under an enhanced conversion policy upon application and payment of premium must become effective on the date of a qualifying event, or, if applicable, on the date extension coverage is lost due to termination by the insurer. An insurer may require payment for any retroactive periods of coverage in order to effectuate coverage. The converted policy shall cover the employee, member or enrollee and any dependents who were covered by the group plan or continuation coverage on the date of termination of insurance.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligibility for Benefits. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Family Coverage. A qualifying eligible individual or a spouse or former spouse who is an eligible dependent shall have a choice of individual coverage or family coverage to include any or all eligible dependents.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Dependents not Eligible for Coverage. Qualifying eligible individuals may enroll dependents who are not eligible dependents for enhanced conversion options at the discretion of the insurer, or may enroll such dependents for coverage under any other coverage offered by the insurer pursuant to the terms of state law. Insurers must at least offer for such dependent coverage under all basic conversion options if the dependent would otherwise be eligible for such basic conversion options under the terms of state law, but may instead allow such dependents to be enrolled under the qualifying eligible individual's enhanced conversion coverage. Insurers are not required to comply with paragraph (6)(f)1. pertaining to coverage limitations on preexisting conditions with regard to such dependents enrolled in enhanced conversion policies; however, pre-existing condition exclusion limitations applicable to basic conversion coverage shall apply with regard to such dependents. The offer to cover such dependents under enhanced conversion coverage must be made consistently to all qualifying eligible individuals with such dependents.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Election on Behalf of Dependents. An election of conversion coverage by a qualifying eligible individual shall be deemed to be an election on behalf of any eligible dependents covered under the qualifying eligible individual's continuation coverage, unless the application indicates an election of the qualifying eligible individual otherwise, or this Rule provides otherwise. Election shall not be contingent on identical election of any other family member with regard to individual or family coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligibility Determinations. An insurer, or an administrator or group policyholder under written agreement with an insurer, is responsible for promptly determining the eligibility of individuals for enhanced conversion policies in accordance with state law and this Rule. The insurer may at any time request additional information from the individual, and must act promptly to make its determination after receipt of the requested information. The qualifying eligible individual must comply with an insurer's request for additional information and verification of eligibility to the fullest extent possible. However, the initial application date shall toll the sixty-three (63) day election period for the qualifying eligible individual and all other eligible individuals or dependents for whom coverage is elected, provided that eligibility is ultimatley confirmed and premium is paid. The insurer is subject to the provisions of the Rules and Regulations of the Office of Commissioner of Insurance Rule <a title="120-2-67-.12" href="120-2-67-.12">120-2-67-.12</a> with regard to accepting attestations and other evidence of coverage if a certification of creditable coverage is not available.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Network Provisions. With regard to coverage under a managed care plan issued by a managed care organization, if a qualifying eligible individual moves out of state prior to electing an enhanced conversion option, and the individual becomes eligible for coverage under another state alternative mechanism or the individual health insurance guaranteed availability provisions of the federal Health Insurance Portability and Accountability Act of 1996 as enforced in another state, the managed care organization may refuse to offer coverage under an enhanced conversion policy. If a qualifying eligible individual moves to a location outside the service area within this state, the managed care organization may require the qualified eligible individual to agree in writing to return to the service area to receive covered benefits as a condition of issuing the enhanced conversion policy.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Preexisting Conditions and Health Status. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(f)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy shall not exclude any preexisting condition or maintain any preexisting condition limitation.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(6)(f)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy may not take into account health status related factors, claims experience, or evidence of insurability with regard to eligibility for coverage or benefit choices.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Benefit Options. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Standard and Low Options. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> In General. Subject to the provisions and conditions of this Rule, a qualifying eligible individual and any eligible dependents shall be entitled to obtain an enhanced conversion policy providing health insurance coverage under a plan meeting all of the minimum requirements of the model standard option, or, at the option of the qualifying eligible individual, a less comprehensive plan meeting all of the minimum requirements of the model low option. Both standard and low options shall constitute creditable coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Filing Requirements. An insurer using a model standard and low option as enhanced conversion policies may comply with filing requirements by either: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)2.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer may file the forms for the model standard and low options using the appropriate policy form template specified in Form <I>GHBAS-1 </I>and schedule of benefits specified in Form <I>GHBAS-S </I>for managed care organizations, or Form <I>GHIAS-1 </I>and Form <I>GHIAS-S</I>, respectively, for all other insurers. Upon an insurer filing such templates and schedule of benefits with the Commissioner, the policy forms shall be deemed approved as of the date the filing is received provided they conform to the above mentioned form templates.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)2.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer may file a form with contractual language substantially similar to the model policy form templates for approval, and may provide benefits, benefit levels and cost-sharing schedules that are at least as comprehensive as those indicated in the model policy form templates and under Plans C and D in Form <I>GHBAS-S </I>for managed care organizations, or under Plans A and B in Form <I>GHIAS-S </I>for other insurers. Such filings must include a description which specifically outlines the variances in language between the model policy form template and the submitted form, and must demonstrate to the satisfaction of the Commissioner that the schedule of benefits is at least as comprehensive as that required by the appropriate standardized plan. Nothing in this Rule shall prevent an insurer from offering the same benefits and benefit levels provided by the insurer to groups under one or more group health insurance policies or contracts, provided that such benefit levels meet or exceed the schedule of benefits outlined in Plans A, B, or D, as appropriate.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Special Rules for Preferred Provider Arrangements. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)3.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer offering a group health insurance plan with a preferred provider arrangement may offer a standard and low option with preferred provider arrangements. The out-of-network benefit levels must be at least as comprehensive as the schedule of benefits prescribed in Form <I>GHIAS-S</I>, and the policy form must be substantially similar to Form <I>GHIAS-2</I>. Such policies may be filed as prescribed in subparagraph (2)(b) for insurers other than managed care organizations.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)3.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers may offer preferred provider arrangements with gatekeeper provisions only to qualifying eligible individuals who were subject to gatekeeper provisions under the prior group health insurance coverage or continuation thereof.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)3.(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers are not required to offer a standard and low option that does not contain preferred provider arrangements to qualifying eligible individuals who were subject to preferred provider arrangements under the prior group health insurance coverage or continuation thereof; however, an insurer may offer such options with preferred provider arrangements in addition to the standard and low options without preferred provider arrangements to individuals who were not subject to preferred provider arrangements under the prior group health insurance coverage or continuation thereof.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(a)3.(iv)">(iv)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Special Waiver from Use of Model Standard and Low Options. In the event an insurer's group health insurance policies or contracts, including any and all benefit riders typically offered to groups, contain benefit provisions that are, overall, substantially less comprehensive than the model standard option, the insurer may provide, as a standard option, the same benefits offered under the group health insurance policy or contract or continuation thereof. The insurer may then elect to use a low option with higher cost-sharing provisions than that included in the standard option, but not to exceed the highest cost-sharing provisions made available by the insurer to groups. If no higher cost-sharing provisions or lower benefit levels than what is part of the standard option are available to groups, then the insurer may submit for approval a low option with higher cost-sharing options than the standard option. The insurer must submit the policy forms and schedule of benefits for approval, and must demonstrate, to the satisfaction of the Commissioner, that the group health insurance policy or contract from which qualifying eligible individuals will convert is indeed substantially less comprehensive than the schedule of benefits for the model standard option. Examples include higher deductibles, coinsurance, or copayments, and a schedule of benefits less generous than the schedule included as part of the model standard option. An insurer obtaining such a waiver may offer standard and low options which are identical except for cost-sharing provisions.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Additional Options. Nothing in this Rule shall prohibit an insurer from offering additional options based on either group policies or contracts currently being issued or made available to groups, policies based on the model policy forms with different cost-sharing requirements or benefit levels, or individual policies or contracts actively marketed and issued by an insurer, provided that such additional options: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Are offered consistently to all qualified eligible individuals without regard to any health status related factor;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Are filed for approval; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(b)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Are otherwise subject to all the requirements of this Rule, including rating, eligibility, notice, and prohibitions on preexisting condition limitations.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Special Rule for Managed Care Organizations and Preferred Provider Arrangements. A managed care organization or insurer with a preferred provider arrangement must use the same network of providers for the conversion policies that it uses for group policies issued in Georgia. If such insurer offers different provider networks for different group policyholders, the conversion policies issued must include the specific network to which the qualified eligible individual had access under group or continuation coverage, or a choice of networks including the one to which the qualified eligible individual previously had access.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Choice After Election of Conversion Privilege. Any qualifying eligible individual covered under a converted policy shall have the option of switching from a standard option to a low option policy or any other additional option offered by the insurer under paragraph (7)(b) of this Rule after exercising the conversion privilege. The insurer shall also permit the privilege to switch from a low option policy to any other additional option offered by the insurer under paragraph (7)(b) of this Rule after an individual exercises the conversion privilege. The insurer may limit such choice to the following events: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(d)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Once a year within 31 days of the policy anniversary date, with coverage becoming effective on the policy anniversary date;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(d)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Upon notification of premium increase, with coverage becoming effective on the effective date of the premium increase; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(7)(d)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Within 31 days of divorce or marriage, with coverage becoming effective on the first day of the following calendar month.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Reduction of Coverage. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any converted policy may provide for a reduction or coordination of coverage on any person upon eligibility for coverage under Medicare.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No converted policy may provide for a reduction or coordination of coverage based upon a person's eligibility for coverage under the Medicaid program of the State of Georgia.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The benefits under the conversion policy shall be secondary to any group or blanket accident and sickness contract that constitutes creditable coverage and covers any person insured under the conversion contract. The converted policy shall not provide benefits in excess of the maximum benefit levels specified therein, when combined with any benefits payable or rendered through any such creditable coverage.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under continuation coverage after the termination of the individual's insurance thereunder.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer may request information in advance of any premium due date of the converted policy of any person covered thereunder only as to whether: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(e)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The insured is covered for similar benefits under any arrangement of coverage for individuals in a group , whether on an insured or uninsured basis; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(8)(e)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of Medicare.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Conversion Premium. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rate Guarantee and Modes. All premium rates must provide for the payment of monthly premiums. Optional modes of premium payment may be offered to the converting employee, member, or enrollee. In any case, rates shall be developed for a one-year guaranteed rate for all enhanced conversion policy issues and renewals.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Prohibition. The enhanced conversion pool shall include the claims experience produced by all individuals insured by enhanced conversion policies. Experience in the enhanced conversion pool, whether actual or anticipated or both, shall be separate from the insurer's group pool and shall not be considered in the group pool rate or in the development of the base rate for enhanced conversion options.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rate Development. Insurers shall develop a base rate for the enhanced conversion policies based on the cost of providing such policies to a group comprised of standard risks in the insurer's group pool. Such rate may be derived by adjusting the group pool rate in accordance with the following steps to determine a base rate for the product: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(c)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> An age and sex distribution factor which represents the demographic mix of the group pool and accounts for variances in cost because of such distribution;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(c)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> A benefit adjustment factor, determined by developing a composite benefit factor for each group health insurance benefit option or all group health insurance benefits offered by the insurer in this state to compare the benefit values of the enhanced conversion policies to the average type of coverage issued by the insurer in the group market;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(c)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> A trend adjustment which reflects the anticipated cost of each option without taking into consideration the health status of individuals in the enhanced conversion pool; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(c)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Determination of a lowest possible base rate normalized in accordance with the age and sex factors provided in Form CONV-1.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Experience and Demographic Factors. The base rate may be further adjusted by: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(d)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> An experience adjustment factor determined for the enhanced conversion pool, not to exceed 150 percent of the group pool rate, and applied uniformly, consistently, and equitably to all enhanced conversion policies issued, and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(d)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Demographic factors for particular individuals or families based on age, sex, and family tiers provided in Form CONV-1 or as permitted in paragraph (9)(e), and area factors typically used by the insurer for group health insurance policies or contracts and disclosed to the Commissioner for approval.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Exception from Use of Standardized Factors. Only an insurer electing a special waiver as permitted in subparagraph (7)(a) 4. of this Rule may use the set of age and sex factors applied to all groups covered by the insurer for use with the approved converted policies. Such an insurer must use the base rate of the product as it is marketed and issued in the group market, and disclose such rate. If an insurer is using a model policy form or a derivative of one, it must use the factors specified in Form CONV-1.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Disclosure. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers must file premium rates and modes to be used for all enhanced conversion policies with the Commissioner for approval prior to use. Rating documentation must demonstrate the development of the group pool rate and each of the factors and adjustments in a step-by-step approach. Insurers must also submit a rate filing for approval by the Commissioner prior to any renewal rate change, change in methodology, or change in factor schedule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The insurer must disclose area factors, or all demographic factors if excepted under paragraph (9)(e), as part of its rate filing for approval and in every subsequent rate filing.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer must include in each rate filing an actuarial certification completed by a qualified actuary, attesting to the fact that: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)3.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The rates are developed using reasonable assumptions and in accordance with generally accepted actuarial principles and are not excessive nor unfair; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(9)(f)3.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The filing is in compliance with state law and Regulations.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Renewability. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(10)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In General. The converted policy may provide that the insurer may refuse to renew the policy or the coverage of any person insured thereunder only as permitted in the Rules and Regulations of the Office of Commissioner of Insurance Rule <a title="120-2-67-.10(b)(1),(2),(3), and (5)" href="120-2-67-.10#120-2-67-.10(b)(1),(2),(3), and (5)">120-2-67-.10(b)(1),(2),(3), and (5)</a>, with regard to renewability of individual health insurance policies or contracts.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(10)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Continuation of Benefits. Any refusal to renew shall be without prejudice to any valid claim commencing while the policy is in force.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(11)">(11)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Notification in Group Certificate of Coverage. A notification of the enhanced conversion privilege for qualifying eligible individuals, including all eligibility and application requirements, shall be included in each certificate of coverage under any group health insurance policy or contract.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.11A(12)">(12)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Substitution for Basic Conversion Option. An insurer may substitute coverage under this Rule for coverage under a basic conversion option as required by O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-21.1&amp;title=33#" target="_newtab">33-24-21.1</a> and Rule <a title="120-2-10-.11" href="120-2-10-.11">120-2-10-.11</a> for group members who terminate group coverage but are not qualifying eligible individuals.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.12" name="120-2-10-.12" title="120-2-10-.12">Rule 120-2-10-.12 Small Group Health Insurance Access and Pooling</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Definitions. The terms used in this Rule are defined as follows: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Anticipated Group Premium" shall mean the premium expected to be generated on each new and existing group over a period of the next twelve (12) months including only deviations permitted pursuant to subparagraphs (b), (d), (e) and (f) of paragraph (5) of this Rule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Anticipated Pool Premium" shall mean the total amount of premium expected to be generated on all new or existing groups over a period of the next twelve (12) months. The anticipated pool premium shall equal the sum of all anticipated group premiums for all small groups in an insurer's pool.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Dependent" shall mean any dependent of an employee, member, or enrollee, including children, adopted children, and non-custodial children, as permitted in O.C.G.A. §§ <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-28&amp;title=33#33-24-28(b)" target="_newtab">33-24-28(b)</a> and <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-4&amp;title=33#33-30-4(3) and (4)" target="_newtab">33-30-4(3) and (4)</a>, or a spouse, or other family member eligible for coverage under the terms of the group health insurance policy or contract because of that person's dependency on the employee, member, or enrollee.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Eligible employees, members or enrollees" shall mean persons who are actively employed with a small group and are eligible for coverage under the employment rules of the small group or who are otherwise, except for dependents, eligible for coverage under a group health insurance policy, without regard to claims experience or any health status related factor.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Existing Group" shall mean a small group that is insured by an insurer and part of that insurer's small group pool.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Group Health Insurance" shall mean any major medical insurance, medical expense coverage, hospital expense coverage, comprehensive health benefit plan, or managed health care plan issued by an insurer to small groups, other than a blanket accident and sickness policy, a health insurance policy written as part of workers' compensation equivalent coverage or supplemental to a liability policy, a credit insurance policy, or any limited benefit insurance policy as defined in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#33-30-12(e)(4)" target="_newtab">33-30-12(e)(4)</a>. Group health insurance shall include all types of policies, contracts, or certificates, as applicable, or other comparable group-type coverage as specified in Rule <a title="120-2-10-.10(2)" href="120-2-10-.10#120-2-10-.10(2)">120-2-10-.10(2)</a>, actively marketed or issued in this state to small groups, including the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(f)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Group health insurance policies or certificates issued pursuant to group insurance contracts;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(f)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Group health insurance policies issued or marketed to association groups or trusts, except bona fide associations as defined in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#33-30-1(b)" target="_newtab">33-30-1(b)</a> and as specified in subparagraph (10) of this Rule;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(f)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Group health insurance policies issued to multiple employer trusts established in or out of this state; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(f)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Except for policies excluded under O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#33-30-12(e)" target="_newtab">33-30-12(e)</a>, individual health insurance policies which provide as a minimum primary or basic medical or hospital expense benefits and are spon- sored in any manner by an employer or other group insurance policyholder.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(g)">(g)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Insured" shall mean any employee, member, enrollee, or dependent of an employee, member or enrollee insured under group health insurance issued to a small group.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(h)">(h)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "New Entrant" shall mean an eligible employee, member, enrollee or dependent not previously covered by the existing group insurance contract or policy and who is either a late enrollee or does not have previous creditable coverage as defined by O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-15&amp;title=33#33-30-15(a)(2)" target="_newtab">33-30-15(a)(2)</a>. <P>A New Entrant shall not include the following individuals:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(h)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> a "newly eligible employee" as defined by O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-15&amp;title=33#33-30-15(a)(4)" target="_newtab">33-30-15(a)(4)</a>;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(h)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> an insured covered under the group's prior group health insurance contract or policy, provided that such contract or policy constitutes previous creditable coverage; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(h)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> newborn children or newly adopted children enrolled as permitted in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-15&amp;title=33#33-30-15(e)" target="_newtab">33-30-15(e)</a> and Rule Chapter 120-2-67.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "New Group" shall mean a small group that is not currently insured by an insurer or any affiliated insurer.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(j)">(j)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Policyholder" shall mean, with respect to group health insurance coverage, the small group to which a group health insurance policy or contract is issued in accordance with O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#" target="_newtab">33-30-1</a>, including, but not limited to, an employer or employer groups issued certificates of coverage through a multiple employer trust.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(k)">(k)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Pool Rate" shall mean the average rate for employees, members, and enrollees, or dependents of such individuals, in all small groups within an insurer's small group health insurance pool, to be determined and used over a period of the next twelve months and adjusted for benefit design but unadjusted for factors specified in paragraph (5). In determining pool rates, the insurer must take into account all actual and anticipated experience data of the entire pool itself as well as other experience data of the insurer or data available generally, and must apply recognized actuarial practices as to credibility, trend factors, expense factors, and margins. Insurers shall use pool rates to determine premiums for new and existing groups.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(l)">(l)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Small Employer" shall mean any employer that employed an average of at least two but not more than 50 employees on business days during the preceding calendar year and that employs at least two employees on the first day of the rating period. All employers treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. Subsequent to the issuance of a health insurance policy or contract to a small employer and for the purpose of determining continued eligibility, the size of a small employer shall be determined annually. Except as otherwise specifically provided, provisions of this Act that apply to a small employer shall continue to apply at least until the final day of the rating period following the date the small employer no longer meets the requirements of this definition. In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether or not an employer is a small employer shall be based on the average number of employees that it is reasonably expected that the employer will employ on business days in the current calendar year. Each small employer shall be considered a small group.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(m)">(m)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Small Group" shall mean, as defined in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#33-30-12(a)" target="_newtab">33-30-12(a)</a>, a group which is a single employer, including a Small Employer, firm, corporation, partnership, sole proprietor, or other legitimate group as specified in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#33-30-1(a)" target="_newtab">33-30-1(a)</a>with at least two and no more than fifty (50) total eligible employees, members or enrollees (not including dependents) on the initial application date and on average during the calendar quarter preceding application. In determining the number of eligible employees, members, or enrollees, companies that are affiliated companies, are eligible to file a combined tax return for purposes of taxation by this state, or are subsidiaries of another company and covered under the parent company's group health insurance contract or policy, shall be considered one group. Subsequent to the issuance of a health insurance policy or contract to a small group and for the purpose of determining continued eligibility, the size of a small group shall be determined annually. Except as otherwise specifically provided, provisions of this Rule shall continue to apply at least until the renewal date following the date the small group no longer meets the requirements of this definition. Such small groups include sole proprietors or employer members of a trust or an association which does not meet the definition in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#33-30-1(b)" target="_newtab">33-30-1(b)</a>. For the purposes of applying this Rule, a small group shall be subject to this Rule if: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(m)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> the majority of insured employees, members, or enrollees in the group are employed or reside in this state; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(m)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> if no state contains a majority of the insured employees, members, or enrollees in a group, the primary business location of the employer is in this state. If an employer which constitutes a small group meets subparagraphs 1. or 2. of this definition, it shall not be considered to be an employer in another state as specified in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1.1&amp;title=33#" target="_newtab">33-30-1.1</a>.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(1)(n)">(n)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "True Association" shall mean an association which meets the requirements of O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#33-30-1(b)" target="_newtab">33-30-1(b)</a> and any applicable Rules and Regulations issued by the Commissioner.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each insurer shall maintain only one small group health insurance experience pool for all types of group health insurance insuring small groups in Georgia as defined in paragraph (l)(m) and subject to O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#" target="_newtab">33-30-12</a>, regardless of where the group health insurance policy or contract is issued. Each insurer's small group health insurance pool shall consist of each insurer's total claims experience produced by all small groups in this state, regardless of the marketing mechanism or distribution system utilized.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Prohibitions. The following practices by an insurer are prohibited with regard to small groups and the small group health insurance pool: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Durational rating which increases premiums for any small group based solely on the length of time the small group has been insured;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Except as permitted under O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#33-30-12(d)" target="_newtab">33-30-12(d)</a> and paragraph (5)(e), tier rating which increases rates directly related to the tier within which any one small group's claims experience falls;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Cancellation or termination of any small group or any insured individual in a small group, provided that insurers may refuse to re- new coverage only for those reasons permitted by the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-67;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Waivers for one or more preexisting conditions, except that insurers may use preexisting condition exclusions pursuant to O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-15&amp;title=33#" target="_newtab">33-30-15</a>;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Declination of any small employer for coverage, or refusal to offer to insure, make insurance available or make a quote or offer of coverage to any small employer, or engagement in practices directly or through agents or representatives which prevent, discourage, delay or impede the availability or marketing of group health insurance to any small employer, under all policies or contracts offered or actively made available by an insurer to small employers in the state or service area, except that an insurer may decline a small employer for coverage if any of the following applies: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> minimum participation or contribution rules are not satisfied by the small employer;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> with regard to policies offered only through a true association of employers, a small employer is not a member of the association;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> none of the eligible employees, members, or enrollees live, work, or reside in the service area of the network if the policy or contract is offered by a health maintenance organization or a provider- sponsored health care corporation;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> a health maintenance organization or provider-sponsored health care corporation has demonstrated, to the satisfaction of the Commissioner, and based on current documentary evidence, that it does not have the service capacity to adequately provide medical services to new small employers through network providers in a particular service area because of its obligations to existing groups in the service area, provided that: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)4.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> all declinations apply uniformly to all small employers in the service area without regard to claims experience or any health status- related factors; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)4.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the health maintenance organization or provider-sponsored health care corporation includes in such filing a certification from the President, Executive Director, or Chief Financial Officer which purports to claim such service capacity limits; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)4.(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the Commissioner has not determined that such a claim is not warranted within 90 days of filing documentary evidence.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)5.">5.</a></td> <td valign="top" style="text-align:left" class="leftalign"> an insurer has demonstrated, to the satisfaction of the Commissioner, and based on its most recent quarterly financial report, examination, or any other more current documentary evidence, that it does not have sufficient financial capacity to underwrite additional coverage under any and all policy forms available to small employers in the state, provided that: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)5.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> all declinations apply uniformly to all small employers in the state without regard to claims experience or any health status-related factors; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)5.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the insurer includes in such filing a certification from the President, Executive Director, or Chief Financial Officer which purports to claim such financial capacity limits; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(e)5.(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the Commissioner has not determined that such a claim is unwarranted within 90 days of filing documentary evidence.</td> </tr> </table> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Issuing coverage under any and all policies or contracts in the small employer market in the state (or a particular service area if applicable) after satisfactorily demonstrating to the Commissioner the conditions described in subparagraphs (e)4. or (e)5., unless at least 180 days have elapsed since the date coverage was declined and the Commissioner has approved such resumption of issue based on documentary evidence that conditions have changed.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(g)">(g)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Discriminatory rating practices which result in premium rate differentials for an individual employee, member, enrollee, or dependent of such employee, member, or enrollee, within a small group based solely on any health status-related factor or claims experience in relation to that individual in the small group, or premium rate differentials for classes of employees, members, or enrollees within a small group subdivided solely on the basis of any health status-related factor or claims experience. Rate adjustments for demographic underwriting factors, differences in benefit designs or network arrangements, premium differentials based on family or dependent coverage, or other rate differentials permitted by this Rule do not constitute discriminatory rating practices.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(3)(h)">(h)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Repealed.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligibility. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(4)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Eligible employees, members, or enrollees in a small group who apply when first eligible for coverage under group health insurance during the most recent continuing period of employment, and dependents of such employees, members, and enrollees who apply when first eligible for coverage, are deemed to be insurable and must be accepted for enrollment. No insurer may subdivide any small group for benefit eligibility under a group insurance policy or contract solely on the basis of any health status-related factor or claims experience.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(4)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer may establish, either as a provision applying to all small groups insured by the insurer, or at the option of a particular small group policyholder, terms of coverage which govern acceptance of late enrollees to a small group. Once established, such terms may not be changed within a contract period or the entire effective term of the policy for a small group policy or contract in such a way as to discriminate against late enrollees on the basis of health status. Such terms, and any changes thereto, must be disclosed within each policy and all certificates, and may only be changed either for all small groups insured by the insurer, or at the option of each small group policyholder.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rating. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rating Period and Rate Guarantee. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(a)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The initial or renewal rate for any small group shall be based on the pool rate adjusted for benefit design and the factors permitted by this Rule section. The rating period for any small group shall be not less than twelve (12) months. An insurer may not modify rates during this period except for any benefit alteration elected by a small group during this period or as otherwise permitted by this paragraph. The rates in effect at the beginning of the rating period, or on the effective date of any benefit alteration during such period, shall be used for adjusting small group premiums as a result of new or terminating employees, members, enrollees, or dependents. For small groups not rated on a composite basis, an insurer may further adjust small group rates for a newly eligible employee, New Entrant, or the dependent of either using only demographic underwriting factors as permitted by this Rule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(a)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> If a New Entrant enters an existing group at any time during the rating period other than on the small group's renewal date, and such a New Entrant elects coverage when first eligible, an insurer may impose a waiting period on such a New Entrant not to extend beyond the next renewal date, with coverage becoming effective for the New Entrant on the effective date of the next rating period. Imposition of such a waiting period must be applied consistently for all New Entrants, without regard to any health status-related factor, and any preexisting condition exclusion must run concurrently with the waiting period.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(a)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> If an insurer does not elect to choose the New Entrant waiting period, it must enroll a New Entrant under the terms of the group health insurance policy or contract during the rating period without assessing any substandard rating.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(a)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer electing the New Entrant waiting period must disclose this method within each policy and to all small group policyholders prior to use or issue. An insurer may require such a method for all small groups insured by it, or may elect to use it at the option of the small group policyholder.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Permitted Demographic Underwriting Factors. An insurer may set rates using pool rates adjusted for age, group size (provided that the group size factor may not vary by more than 15% from a base factor of 1.0), family size or composition, sex, area, industry, occupational, and avocational factors (including, but not limited to, tobacco usage). Demographic underwriting factors used by the insurer must be applied consistently with respect to all small groups in the insurer's pool, except that area factors may vary between policies or contracts with different network reimbursement provisions. These demographic underwriting factors may be adjusted: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> on a composite basis for any small group,</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> on a composite basis for all small groups in an insurer's pool, or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(b)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> on an individual, family, or other tier basis as used by the insurer for all insureds in any small group. <P>Methods 1. and 3. of adjusting demographic underwriting factors may both be used in an insurer's small group pool provided that group size is the only determining factor and such methods are applied consistently within the insurer's small group pool. An insurer may use the demographic underwriting factors in renewal rating of such a small group where changes in these underwriting factors have occurred.</P> </td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Use of Claims Experience under Previous Insurance Coverage Prohibited. Previous claims experience of a new group under any other group health insurance prior to its entry into a pool is deemed not to be credible and such previous claims experience may not be considered in the initial rating of any small group. This paragraph shall not be construed to prevent insurers from using the health status of individuals in the small group for the purposes of substandard rating or determining group experience factors at initial rating as permitted under this Rule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rate Changes Based on Trend. The pool rate change for the next twelve months shall be based on the experience trend for the entire pool and shall be applied uniformly to the current pool rate for each small group's upcoming rating period. Trend factors may vary during a small group's rating period or between small groups to account for changes to or differences in benefit design or network requirements only. Trend factors may not be based on the demographic characteristics, experience, or any health status-related factor of a small group or any insureds in a small group. Nothing in this paragraph shall prevent an insurer from applying the annual trend factor on a graduated basis in an equitable, consistent, and uniform manner to small groups according to the month, quarter, or semi-annual period in which a small group was issued its policy or contract.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Group Experience Factor. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(e)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Except as prohibited in subparagraph (c), the actual claims experience produced by a small group may be used to deviate the premium from the pool rate applicable for that group. The group experience factor must be applied uniformly, consistently, and equitably to the rates charged for all employees, members, enrollees, and dependents in the small group and may not exceed plus or minus twenty-five percent (25%) of the pool rate. The change in premium resulting directly from select or substandard ratings applied to any group following recognized underwriting practices and the provisions of this Rule shall not be considered a deviation from the pool rate only for the purposes of determining the group experience factor. A group experience factor may be adjusted upon renewal.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(e)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> The percent change in the group experience factor at renewal shall not exceed 15% from one rating period to the next.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Select and Substandard Ratings. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> General Application. Select and substandard ratings resulting from the health status of one or more New Entrants must only be applied to an existing group or new group as set forth in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-12&amp;title=33#33-30-12(d)" target="_newtab">33-30-12(d)</a> and this Rule.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Applicability of Substandard Ratings. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)2.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer may not, with regard to a new group or existing group, use substandard rating for, nor adjust any individual or group premium by way of a substandard rating as a result of the health status of anyone who is not a New Entrant as defined in this Rule. An insurer may not assess a substandard rate on any small group or small group member because of the health status of dependents with previous creditable coverage who enroll when first eligible or during special enrollment in accordance with O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-15&amp;title=33#33-30-15(a)(4)(A) and (e)" target="_newtab">33-30-15(a)(4)(A) and (e)</a>.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)2.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Substandard rating may only be determined and assessed as a result of the health status of New Entrants to an existing group or New Entrants in a new group, relative to what may be considered a standard health risk by the insurer using recognized underwriting practices. Substandard ratings assessed as the result of New Entrants to an existing group may be imposed only at the beginning of the first rating period after the New Entrant waiting period permitted in subparagraph (b)2.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)3.">3.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Compliant Methods of Applying Select and Substandard Rating. No insurer may bill or charge select or substandard rating adjustments allowed in this subparagraph to individual employees, members, enrollees, or dependents because of health status-related factors for which the adjustments are applied. Select or substandard rating assessed as a result of the health status of a New Entrant must be applied uniformly, consistently, and equitably to the rates charged for all employees, members, enrollees, and dependents in the small group. For example, select or substandard ratings may be assessed to all insureds in a small group on a composite basis as a uniform factor derived from the total select or substandard rating for all New Entrants insured through the small group; or, select or substandard ratings may be assessed as a lump-sum quantity divided equally among all insured employees, members, or enrollees.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)4.">4.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rating Parameters. Effective for all rating periods commencing on or after May 1st, 1998, and all subsequent rating periods, the differential resulting from applying select or substandard ratings as permitted in this subparagraph onto group premiums may not be greater than plus or minus twenty percent of the total premium for a small group determined using pool rates as adjusted for permitted demographic underwriting factors, group experience factors, and rate changes based on trend. The Commissioner may adjust these permitted select and substandard rating parameters at any time in the interest of ensuring affordable coverage and access in the small group health insurance market after such due notice and hearing as may be required by law. The effective date of any such adjustments shall be a reasonable period of time as determined by the Commissioner not to exceed one year after the date such adjustments have been promulgated by the Commissioner.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)5.">5.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Other Prohibitions on Assessing Substandard Ratings: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)5.(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers may not add, assess, use, or continue to use substandard ratings for an insured in replacing group health insurance where the replacing insurer is affiliated with the prior insurer, nor may an insurer add, assess, use, or continue to use substandard ratings when discontinuing a policy form and offering coverage under another policy form; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)5.(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers may not add, assess, or increase a substandard rating at any time other than during initial underwriting of a New Entrant to a new or existing group as permitted by this Rule.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(f)6.">6.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Removal. Insurers may remove substandard ratings at any time with a corresponding reduction in the group's premium. When an insured with a substandard rating leaves a small group, the insurer must remove the substandard rating from the small group premium within thirty (30) days of the date on which the insured is no longer eligible for coverage or continuation of coverage under the group.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(g)">(g)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Deviations Resulting From Rating Factors. In setting premiums to be charged each small group, insurers must determine upward and downward premium deviations from the pool rate resulting from application of each small group's demographic underwriting factors as specified in subparagraph (b), the group experience factor as specified in subparagraph (e), rate changes based on trend as specified in subparagraph (d), and select or substandard ratings permitted in subparagraph (f), in such a manner that the anticipated total of the upward deviations for all small groups in an insurer's pool is offset by the anticipated total of downward deviations. The total of all anticipated group premiums, which include all deviations resulting from factor adjustments described in this subparagraph (g), must equal the total anticipated pool premium.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(h)">(h)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Other Permissible Methodologies. Insurers may use a rating methodology which establishes a lowest possible base rate charged by an insurer for all small groups in lieu of a pool rate, and adjusts the rate upward for all factors permitted in this Rule, provided that: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(h)(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the group experience factor applied to the lowest possible base rate is no greater than 1.67;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(h)(ii)">(ii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the select and substandard rating is applied as permitted in subparagraph (f)4. and is limited to a factor no greater than 1.20 as applied to the small group's total premium based on the lowest possible base rate adjusted for demographic underwriting factors, group experience factors, and rate changes based on trend as permitted in this Rule;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(h)(iii)">(iii)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the midpoint of all rates for all small groups in an insurer's pool is equivalent to the pool rate which would be determined in accordance with this Rule, such that all anticipated rate deviations below the midpoint are offset by all anticipated rate deviations above the midpoint; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(h)(iv)">(iv)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the methodology otherwise complies with all the requirements of this Rule.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(5)(i)">(i)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The rating provisions of this Rule section shall apply to all rating periods commencing on or after November 1, 2002.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Documentation. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(6)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All insurers must determine pool rates annually or more frequently and document their rate and deviation determinations.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(6)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All insurers must disclose at the initial sale of a small group case the degree to which rates may vary within allowable +/-25% range around the pool rate.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(6)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All insurers must provide to each small group upon request at each rating period, the pool rate compared to the proposed rate for the small group to demonstrate where the rate for the small group lies in comparison to the pool rate, and shall be required to document to each small group the benefit design, demographic factors, group experience factor, select or substandard or other permitted adjustments from the pool rate and percentage change in the base pool rate, demographic and group experience factors since the pool rate utilized in the small group's previous rating period. In addition, reference must be made to legal and regulatory citations that relate to changes in rating factors. Each small group policy must contain a notice to the insured that this information is available upon request. If such information is requested, the insurer must respond to such request within ten (10) business days of the request for information.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(6)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Rating documentation shall be maintained at the insurer's home or principal office for a period of five years and insurers shall furnish this information to the Commissioner of Insurance or insurance department examiners upon request.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> On or before March 1 each year, an insurer writing small group health insurance in this State shall provide for the preceding calendar year a certification by a responsible officer of the insurer as follows: <P>"I (name of officer), hereby certify that the rates charged small groups in the State of Georgia by the (name of insurer) are in compliance with all the requirements of § <a title="120-2-10" href="120-2-10">120-2-10</a>-.12 of the Rules and Regulations of the Georgia Insurance Department.</P> <P>I further certify and affirm that my company will provide prior, written notice to the Commissioner and to each small group in my company's small group health insurance pool within the State of Georgia at least 180 days before my company withdraws from the small group health insurance market in Georgia. Such written notice to the Commissioner will include a report or other substantial documentation of the extent of coverage, including identification of policy forms, certificates, and the number of insureds covered at the time of any notice of proposed withdrawal from this small group market in Georgia. I understand and agree to submit such other documentation as the Commissioner may reasonably require at that time. Additionally, I further certify and affirm that my company will comply with all other provisions in the Official Code of Georgia, Annotated, or in the Rules and Regulations of the Georgia Insurance Department, pertaining to withdrawal or discontinuation of coverage in the small group market.</P> <P>(Date) ____________________________</P> <P>(Signature of Officer)" ___________________________________</P> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> One-life Groups. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(8)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers may issue small group health insurance policies or contracts actively marketed to small groups, or certificates from such policies or contracts, to sole proprietors or other employers with only one employee, member, or enrollee (not counting dependents). In order for such coverage to qualify as group coverage, it must meet all rating and eligibility requirements of this Rule except those applicable only to small employers. At such time as the one life group acquires one or more additional employees, members, or enrollees, the exceptions shall not apply. Such one-life groups shall include sole proprietors offered coverage under a group health insurance policy or contract issued through a trust or association which does not meet the definition of O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-30-1&amp;title=33#33-30-1(b)" target="_newtab">33-30-1(b)</a>, provided that such group health insurance policy or contract covers other small groups as defined by this Rule. One-life groups may also include other such arrangements as provided for in the Rules and Regulations of the Office of Commissioner of Insurance or at the discretion of the Commissioner.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(8)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All policies or certificates issued to one-life groups as permitted by this Rule shall comply with the requirements of O.C.G.A. Title 33, including Chapter 30.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(8)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All policies or certificates issued to one-life groups in this state on or before June 30, 1997, shall be deemed one-life groups and shall be subject to the provisions of this Rule, as well as all the requirements of O.C.G.A. Title 33, including Chapter 30.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(8)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers may not issue multiple one-life group policies or certificates to a single employer with more than one employee.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Minimum participation rules for small groups. <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Minimum participation rules for a particular group health insurance policy shall apply uniformly and consistently to all small groups.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer shall not require a minimum participation level for small groups greater than: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(b)1.">1.</a></td> <td valign="top" style="text-align:left" class="leftalign"> One hundred percent (100%) of eligible employees, members, or enrollees with three (3) or less employees; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(b)2.">2.</a></td> <td valign="top" style="text-align:left" class="leftalign"> Seventy-five percent (75%) of eligible employees, members, or enrollees with more than three (3) employees but not more than fifty (50) employees.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An insurer shall not modify such minimum participation rules applicable to a small group at any time after the small group has obtained coverage, except that an insurer may relax such rules prospectively upon notification to all existing groups, and must apply such relaxed rules to all new groups. Relaxation of such rules means that such rules are made more favorable to the insured than what is required in subparagraph (b).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(9)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> In applying minimum participation rules with respect to a small group as permitted in (b), an insurer may not count eligible employees, members, or enrollees who have other group health insurance coverage from an unaffiliated insurer as a spouse or dependent in determining whether the applicable minimum participation level is met.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.12(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Associations. Only the provisions of paragraph (3) shall apply to true associations.</td> </tr> </table> <h2><a href="/GAC/120-2-10-.13" name="120-2-10-.13" title="120-2-10-.13">Rule 120-2-10-.13 Severability Provision</a></h2> <P>If any section or portion of a section of this Regulation or the applicability thereof to any insurer, agent, counselor, broker, solicitor, or circumstances is held invalid by a court of competent jurisdiction, the remainder of the rules or the applicability of such provisions to other insurers, agents, counselors, brokers, solicitors or circumstances, shall not be affected thereby.</P> <h2><a href="/GAC/120-2-10-.14" name="120-2-10-.14" title="120-2-10-.14">Rule 120-2-10-.14 Penalties</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.14(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Violation of these regulations by an insurer or by an officer of an insurer shall be deemed grounds for revocation of the insurer's certificate of authority as provided in Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-3-17&amp;title=33#33-3-17(2)" target="_newtab">33-3-17(2)</a> of the Georgia Insurance Code, which shall be in addition to any other penalty provided by statute.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-10-.14(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Violation of these regulations by an agent, counselor, broker, solicitor or other representative of an insurer shall be deemed to be a fraudulent and dishonest practice, a material misrepresentation, an unfair method of competition and unfair and deceptive acts and practices in the business of insurance furnishing grounds for the revocation of his license.</td> </tr> </table> </div> </div> </HTML> </div> <div id="toc" class="sidebar noprint"> <ul id="toc-children" class="children"><li><a href="/GAC/120-2-10-.01" name="120-2-10-.01" title="120-2-10-.01">Rule 120-2-10-.01 Profit-Sharing Policies</a></li><li><a href="/GAC/120-2-10-.02" name="120-2-10-.02" title="120-2-10-.02">Rule 120-2-10-.02 Coupon Policies or Policies with Annual Pure Endowment Benefits</a></li><li><a href="/GAC/120-2-10-.03" name="120-2-10-.03" title="120-2-10-.03">Rule 120-2-10-.03 Medical or Surgical Policies-Outpatient Coverage</a></li><li><a href="/GAC/120-2-10-.04" name="120-2-10-.04" title="120-2-10-.04">Rule 120-2-10-.04 Misleading Terms Prohibited</a></li><li><a href="/GAC/120-2-10-.05" name="120-2-10-.05" title="120-2-10-.05">Rule 120-2-10-.05 Describing Premiums as "Deposits", "Savings", or "Investments"</a></li><li><a href="/GAC/120-2-10-.06" name="120-2-10-.06" title="120-2-10-.06">Rule 120-2-10-.06 Filing Requirements-Life and Health Forms</a></li><li><a href="/GAC/120-2-10-.07" name="120-2-10-.07" title="120-2-10-.07">Rule 120-2-10-.07 Agents, Payments for Furnishing Leads and Reference to Regulations</a></li><li><a href="/GAC/120-2-10-.08" name="120-2-10-.08" title="120-2-10-.08">Rule 120-2-10-.08 Participating Policies</a></li><li><a href="/GAC/120-2-10-.09" name="120-2-10-.09" title="120-2-10-.09">Rule 120-2-10-.09 Life, Annuities and Accident and Sickness Insurance Policy Language Simplification Standards</a></li><li><a href="/GAC/120-2-10-.10" name="120-2-10-.10" title="120-2-10-.10">Rule 120-2-10-.10 Group Coverage Discontinuance and Replacement</a></li><li><a href="/GAC/120-2-10-.11" name="120-2-10-.11" title="120-2-10-.11">Rule 120-2-10-.11 Group Health Insurance Conversion Privilege</a></li><li><a href="/GAC/120-2-10-.11A" name="120-2-10-.11A" title="120-2-10-.11A">Rule 120-2-10-.11A Group Health Insurance Enhanced Conversion Privilege</a></li><li><a href="/GAC/120-2-10-.12" name="120-2-10-.12" title="120-2-10-.12">Rule 120-2-10-.12 Small Group Health Insurance Access and Pooling</a></li><li><a href="/GAC/120-2-10-.13" name="120-2-10-.13" title="120-2-10-.13">Rule 120-2-10-.13 Severability Provision</a></li><li><a href="/GAC/120-2-10-.14" name="120-2-10-.14" title="120-2-10-.14">Rule 120-2-10-.14 Penalties</a></li></ul> </div> </div> <!--content ends here--> <div id="footer" class="noprint"><span class="footer">Copyright &copy; 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