Subject 120-2-75 REGULATION OF PROVIDER SPONSORED HEALTH CARE CORPORATIONS
The intent of this Regulation is to set forth those requirements for provider sponsored health care corporations which are established in accordance with the provisions of Chapter 20 of Title 33 of the Official Code of Georgia Annotated for the purpose of providing medical services to citizens of this State. This Regulation is intended to protect the interests of the enrolled public and to ensure the fiscal stability of such organizations.
Unless otherwise provided, terms referenced in this Regulation are used as defined in O.C.G.A. §§ 33-1-2 and 33-20-3. Other terms are used in accordance with the Georgia Insurance Code and the Rules and Regulations of the Office of Commissioner of Insurance.
|(a)||"Basic Rates" is defined as rates for various categories of individuals that are calculated by or certified by a qualified actuary using reasonable assumptions as to expected medical expenses, administrative expenses and margins for contingencies;|
|(b)||"Commissioner" is defined as the Commissioner of Insurance;|
|(c)||"Enrollee" is defined as an individual who has been enrolled in a health care plan;|
|(d)||"Provider sponsored health care corporation" ("PSHCC") is defined as a corporation formed pursuant to O.C.G.A. § 33-20-5 and which provides medical services to enrollees or subscribers;|
|(e)||"Subscriber" is defined as a person to whom a subscriber's certificate is issued by a health care corporation;|
|(f)||"Subscriber's Certificate" is defined as the certificate issued to a subscriber which sets forth the kinds and extent of the health care services which may be all or part of the total health care services used by or provided to a subscriber for which the corporation is liable to make total or partial payment.|
A provider sponsored health care corporation may be established by providers for the purpose of providing health care services to enrollees or subscribers in this State under the provisions of Chapter 20 of Title 33 of the Official Code of Georgia Annotated. Such entity may be a licensed hospital, physician or other provider sponsored entity as the Commissioner may consider. Pursuant to O.C.G.A. §§ 33-1-2 and 33-20-32, provider sponsored health care corporations are insurers and are subject to all provisions of Title 33 which are not in conflict with Chapter 20 of Title 33.
|(1)|| Each provider sponsored health care
corporation shall obtain a certificate of authority from the Commissioner prior
to establishing, maintaining and operating a health care plan in this State. In
addition to the documents and information set forth in O.C.G.A. § 33-20-8, each provider sponsored
health care corporation must also accompany its application for a certificate
of authority with the following documents and information:
|(2)||Within one hundred eighty (180) days of receipt of the completed application and a fee of $600.00, the Commissioner shall issue a certificate of authority; deny said application; or provide a written description of deficiencies in the application to the applicant.|
|(3)|| Before a certificate
of authority can be issued, the Commissioner must be satisfied that:
|(4)||The burden of proving compliance with the requirements necessary for issuance of a certificate of authority shall be and remain on the applicant at all times.|
|(1)|| Subscriber Surplus Requirements.
|(2)||Reinsurance Requirements. In order to further protect against insolvency and protect the subscribers of provider sponsored health care corporations, each provider sponsored health care corporation shall obtain and thereafter maintain an aggregate excess reinsurance policy that is acceptable to the Commissioner. Such policy must be procured from a company licensed and authorized to transact business in this State and must have a retention amount that is commensurate with the financial strength of the provider sponsored health care corporation.|
|(3)||Assets and Investments. In determining the financial condition of provider sponsored health care corporations, admitted assets will be limited to those assets described in O.C.G.A. § 33-10-1. Pursuant to O.C.G.A. § 33-20-22, provider sponsored health care corporations shall invest their funds in the same manner as domestic life insurers pursuant to O.C.G.A. § 33-11-1et seq.|
|(4)||Liabilities. Every provider sponsored health care corporation shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium or subscription fees and reserves for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which the health care corporation is or may be liable, and to provide for the expense of adjustment or settlement of such claims.|
|(5)|| Hold Harmless.
|(6)||Continuation of Benefits. Each provider sponsored health care corporation shall have a plan satisfactory to the Commissioner for handling insolvency which guarantees the continuation of benefits to enrollees or subscribers who are confined on the date of insolvency in an inpatient facility until the earlier of their discharge or expiration of benefits.|
Any provider sponsored health care corporation issued a license shall file annual and quarterly financial statements using forms prescribed by the Commissioner pursuant to O.C.G.A. § 33-20-24. The annual financial report is due March 1 each year and the quarterly statements are due 45 days after the end of each calendar quarter. The Commissioner may also require additional financial reports as are required of other insurers including but not limited to an annual audit from a certified public accountant.
|(1)||An agent representing a provider sponsored health care corporation must comply with all of the requirements for a life, accident and sickness agent in O.C.G.A. § 33-23-1et seq. and have a current license and certificate of authority to represent the health care corporation.|
|(2)||The provider sponsored health care corporation must comply with the provisions of O.C.G.A. § 33-23-26 with regard to obtaining a certificate of authority for each agent representing the provider sponsored health care corporation as required by O.C.G.A. § 33-23-26(d), filing a certified listing of agents whose certificates of authority are to be renewed along with the appropriate fees, and maintaining a list of authorized agents as required in O.C.G.A. § 33-23-26(d).|
|(3)||All provider sponsored health care corporation agents shall act in a fiduciary capacity in regard to monies collected or held by such agent.|
Any provider sponsored health care corporation which is part of an insurance company holding system must make all required filings and disclosures mandated by Chapter 13 of Title 33.
Any changes to the name, address, legal structure, provider contracts, rates, services area(s), enrollee contracts, composition and identity of directors and principal officers must be filed with the Commissioner at least thirty (30) days prior to the intended effective date of the change.
Any person failing to comply with the requirements of this Regulation Chapter shall be subject to penalties and other enforcement action as may be appropriate under the insurance laws of the State of Georgia as well as any other applicable Georgia law.
If any provision of this Regulation Chapter or the application thereof to any person or 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 or circumstances shall not be affected.