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Subject 120-2-44 PREFERRED PROVIDER ARRANGEMENTS

Rule 120-2-44-.01 Authority

This Chapter is promulgated by the Commissioner of Insurance pursuant to the authority set forth in O.C.G.A §§ 33-30-27, 33-29-3.2, 33-29-3.4 and 33-2-9.

Rule 120-2-44-.02 Purpose

The purposes of this Chapter are:

(a) To regulate individual and group accident and sickness insurance plans, providing for differentials in benefit levels payable for preferred and non-preferred providers.
(b) To protect the interests of the enrolled public.
(c) To provide for disclosure of certain restrictions under individual and group insurance plans utilizing preferred provider arrangements.
(d) To define certain types of managed care principles and practices as they relate to current Preferred Provider Arrangements and individual or group accident and sickness contracts.

Rule 120-2-44-.03 Definitions

(1) "Co-pay" means a discrete, specified dollar amount an insured must pay for specified covered services at the time of service.
(2) "Preferred Benefits" means services and/or benefits due or payable when the insured seeks covered health care services from a Preferred Provider in accordance with policy provisions.
(3) "Preferred Provider Insurance Policy" means an individual accident and sickness insurance policy, group accident and sickness insurance master policy or certificate, by whatever name called, other than:
(a) disability income;
(b) specified disease;
(c) health insurance policy written as part of Workers' Compensation equivalent coverage; or
(d) a credit accident and sickness insurance policy which provides for differentials in the level of benefits because of preferred provider arrangements, or participation contracts between the insurer and health care providers through which insurers attempt to effect cost savings by employing financial and/or managed care principles in a health insurance policy or certificate.
(4) "Gatekeeper" means a primary care physician or other appropriate health care provider who is a preferred provider, as described in the preferred provider insurance policy or certificate, and who acts as a required initial point of contact for the insured and through whom covered health benefits may be required to be accessed or permission to seek covered care may be required by the insurer in order to receive preferred benefits.
(5) "Non-Preferred Benefits" means benefits payable on an indemnity basis when the insured seeks covered health care services from a non-preferred provider in accordance with policy provisions.
(6) Other terms used in this Chapter shall be defined to have the same meaning as the meaning ascribed to the particular terms by O.C.G.A. § 33-30-22 or by O.C.G.A. Title 33, whichever is applicable.

Rule 120-2-44-.04 Required Policy Provisions

(1) Preferred provider arrangements shall contain provisions for the continuous review of the utilization of services and facilities, and costs.
(2) Each individual policy or group preferred provider insurance policy shall contain a provision that the policyholder is entitled to a grace period of not less than thirty-one (31) days for the payment of any premium due except the first, during which grace period the coverage shall continue in force, unless the group or individual policyholder shall have given the health care insurer notice of discontinuance thirty (30) days in advance of the date of discontinuance and in accordance with the terms of the policy. The policy may provide that the group or individual policyholder may be liable to the health care insurer for payment of a pro rata premium for the time the coverage was in force during such grace period.
(3) Any contract between a health care insurer and the various health care providers shall state that an insured shall be held harmless for provider utilization review decisions over which he has no control. In the absence of such hold harmless agreement, the agreement shall be deemed to be included therein.
(4) If the preferred provider insurance policy or health benefit plan defines a specific service area, the insurer shall not terminate the members coverage because an individual policyholder or group member moves out of the service area.
(5) Differentials in coinsurance percentages which are applicable to benefit levels for services provided by preferred and nonpreferred providers may not exceed thirty percentage points. The coinsurance percentage applicable to benefit levels for services provided by non-preferred providers may not be greater than forty percent (40) of the benefit levels under the policy for such services. Examples of acceptable coinsurance percentages payable by an insured for preferred and nonpreferred providers, respectively, are 0, 30; 5, 35; 10, 40; 20, 40; 30, 40.
(6) Individual preferred provider insurance policies, outlines of coverage or preferred provider insurance certificates shall contain a brief and prominent notice in boldface type reflecting the limitations of the preferred provider policy or health plan benefit. Such warning shall be placed on the face page of the policy, outline of coverage or certificate and refer to the differentials in coinsurance percentages payable by the insureds for preferred and nonpreferred provider services, service area requirements, and emergency care services.
(7) Preferred Provider Insurance policies or certificates shall fully disclose the limitations, differentials, penalties, incentives or other arrangements by which the insurer provides for a primary care physician or other health care provider, as defined by the insurance policy or certificate, to act as a gatekeeper, if any. A gatekeeper shall not be used to restrict access to services or non-preferred providers under the individual preferred provider policy or group preferred provider certificate.
(8) Preferred Provider Insurance policies or certificates shall fully disclose the use of discrete dollar copayments which apply to any covered health care benefits under the policy or certificate. Discrete dollar copayments may be imposed by an insurer in a Preferred Provider Insurance policy or certificate and need not be considered in the determination of percentage differential limitations described in O.C.G.A. Section 33-30-23. Such copayments, if applicable, shall be reasonable in relation to the covered benefits to which they apply, shall serve as an incentive rather than a barrier to access of appropriate care and shall not work so as to unfairly deny necessary health care services.

Rule 120-2-44-.05 Prohibited Policy Provision

(1) In no event may a health care insurer deny at least non-preferred level of covered benefit reimbursement to an insured for services provided by a nonpreferred provider on the grounds that the insured was not referred to a preferred provider by a person acting on behalf of or under an agreement with the health care insurer.
(2) Preferred Provider Arrangements or Preferred provider insurance policies or certificates may not contain terms or conditions that would operate unreasonably to restrict the accessibility and availability of health care services for the insured.
(3) A health care insurer may not issue policies in this State containing preferred provider arrangements that provide no reimbursement for expenses of health care services rendered by a non-preferred provider.
(4) No health care plan utilizing a preferred provider arrangement shall be issued if the defined service area does not contain sufficient numbers of preferred providers to afford reasonable access to health care services by those persons covered under such plan.

Rule 120-2-44-.06 Rates and Forms

(1) In accordance with the Rules and Regulations of the Office of Commissioner of Insurance § 120-2-25-.06(1)(g), every group policy or contract, certificate, rider, endorsement, and application to be issued, delivered, or issued for delivery in this State in connection with a health plan having a preferred provider arrangement must be submitted for approval prior to use in this State. Following an initial approval of these forms for each insurer, subsequent, substantially similar group certificates and associated forms may be treated as exempt forms pursuant to the Rules and Regulations of the Office of Commissioner of Insurance § 120-2-25-.05(3), provided the insurer files a notice and schedule of benefit changes with the Commissioner of Insurance for informational purposes at least 30 days prior to the use of such forms.
(2) Basic rates and charges shall not be excessive, inadequate, or unfairly discriminatory. A certification by a qualified actuary to the appropriateness of the basic rates, based on reasonable assumptions as to expected medical expenses, administrative expenses, and margins for contingencies, shall accompany the filing along with supporting information.

Rule 120-2-44-.07 Allowable Arrangements

Only preferred provider arrangements and preferred provider insurance policies which contain payment plans for preferred providers and nonpreferred providers and insurance policy provisions conforming to the provisions of Article 2 of Chapter 30 of Title 33 or other applicable sections of Title 33 relative to individual preferred provider insurance plans of accident and sickness insurance within the Official Code of Georgia Annotated shall be permitted.

Rule 120-2-44-.08 Disclosure and Advertising Materials

(1) The health care insurer shall provide each insured individual or group member with a current preferred provider roster or directory of health care providers under contract to provide services at alternative rates under the health care benefit plan. The roster shall be updated annually, but may be updated more frequently at the insurer's option.
(a) Each preferred provider roster or directory shall contain tollfree telephone numbers so that individuals or groups may confirm current preferred provider status information.
(2) All advertising material used in the solicitation and sale of health benefit plans having preferred provider arrangements shall comply with the requirements of O.C.G.A. Title 33, Chapter 6, entitled "Unfair Trade Practices," and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-12, entitled "Advertising Accident and Sickness Insurance."
(3) Publications or advertisements of health benefit plans having preferred provider arrangements shall not refer to the quality or efficiency of the services of nonparticipating providers.

Rule 120-2-44-.09 Severability

If any provision of this Regulation Chapter or the application thereof to any person or particular circumstance is held invalid by a court of competent jurisdiction, the remainder of the Regulation Chapter or the applicability of such provisions to other persons, insurers or circumstances shall not be affected thereby.

Rule 120-2-44-.10 Failure to comply; Penalties

Any insurer, or any agent, counselor, representative, officer, of employee of such insurer failing to comply with the requirements of this Regulation Chapter shall be subject to such penalties as may be appropriate under the insurance laws of this State.

Rule 120-2-44-.11 Rental Preferred Provider Network Registration

(1) Any person required to register as a rental preferred provider network must submit the requisite forms in accordance with the instructions on the Commissioner's website.
(2) All registrations must be renewed on an annual basis by July 1st of each year per the instructions on the Commissioner's website.
(3) All registered persons must report any material changes to the information submitted on the registration documents within 30 days of such changes.