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Subject 120-2-83 CONSUMER CHOICE OPTION

Rule 120-2-83-.01 Authority and Purpose

This Regulation Chapter is adopted and promulgated pursuant to the authority granted to the Commissioner of Insurance pursuant to O.C.G.A. §§ 33-2-9 and 33-20A-9.1. The purpose and intent of this Regulation Chapter is to provide for the implementation of the consumer choice option as defined in O.C.G.A. § 33-20A-9.1(b).

Rule 120-2-83-.02 Definitions

(a) For purposes of this Regulation Chapter and O.C.G.A. § 33- 20A-9.1:
(1) "Accepted provider" shall mean a provider that has been nominated by an enrollee and either accepted by a managed care entity which has chosen not to credential nominated providers or accepted by a managed care entity following credentialing in accordance with Rule 120-2-83-.05.
(2) "Deselected provider" shall mean a provider that has been nominated by an enrollee and provisionally accepted by the managed care entity, but later disapproved for reimbursement because the provider fails to meet one of the criteria for participation set forth in O.C.G.A. § 33-20A-9.1(c).
(3) "Enrollee" shall mean an enrollee of a managed care entity required to offer the consumer choice option pursuant to O.C.G.A. § 33- 20A-9.1(b).
(4) "Nominated provider" shall mean an out of network provider nominated by an enrollee.
(5) "Option" shall mean the consumer choice option as defined in O.C.G.A. § 33-20A-9.1(b).
(6) "Managed Care Entity" shall mean any entity identified pursuant to O.C.G.A. § 33-20A-3(6) and required to offer the option pursuant to O.C.G.A. § 33-20A-9.1(c).
(7) "Provider" shall mean a health care provider as defined in O.C.G.A. § 33-20A-3(3) or a hospital.
(8) "Provisionally accepted provider" shall mean a provider that has been nominated by an enrollee and provisionally accepted by the managed care entity upon receipt of the nominating form.
(9) "Rejected provider" shall mean a provider that has been nominated by an enrollee and disapproved because the provider fails to meet one of the criteria for participation set forth in O.C.G.A. § 33- 20A-9.1(c) by a managed care entity which has chosen not to credential nominated providers.
(10) "Similarly situated provider" shall mean an in network provider located in the same geographic area and providing the same or similar services as the nominated provider.

Rule 120-2-83-.03 Notification and Disclosure

(a) Notification of the option's availability and explanatory materials regarding the option shall be provided to enrollees at least annually at open enrollment, renewal, time of solicitation or by direct mail advertising, or upon request. Such information shall be provided to prospective enrollees upon request. Such information shall also be provided to newly eligible employees. Information shall include, but shall not be limited to:
(1) A one page form to be completed and signed by the enrollee and the nominated provider containing the enrollee's name, identification number, group number, address, date of birth, and telephone number. The form shall also include the provider's name, group name (if applicable), State of Georgia license number, tax identification number, address, identity of the hospital(s) where the provider has privileges, telephone number, and facsimile number;
(2) Pricing (including information that allows the enrollee to compare pricing with and without the option so that the enrollee may make an informed choice);
(3) The nomination process in accordance with Rule 120-2-83-.04; and
(4) The credentialing process in accordance with Rule 120-2-83-.05.
(b) Only the enrollee may elect the option on behalf of him/herself and his/her eligible dependents.
(c) The Commissioner may create a disclosure form for managed care entities to provide to each prospective enrollee or enrollee with the information required in paragraphs (a) and (b) of this Rule. Said form may be changed from time to time as the Commissioner deems necessary.
(d) Enrollees shall have the right to withdraw from the option in limited situations where their nominated provider is rejected, deselected or declines to participate, effective the first day of the month following written notice to the managed care entity. In the event of withdrawal, the managed care entity shall provide the enrollee with a commensurate decrease in premium for the remainder of the plan year. However, due to federal taxation consequences, the enrollee's right to withdraw shall not apply to cafeteria benefit plans qualified under § 125 of the Internal Revenue Code.

Rule 120-2-83-.04 Provider Nomination

(a) Managed care entities shall create, and make readily available to nominated providers, a nomination package which shall include, if applicable:
(1) Information regarding credentialing procedures pursuant to Rule 120-2-83-.05. This includes, but is not limited to, all forms required to be completed by the provider for the purpose of credentialing; and
(2) A compensation schedule specific to the nominated provider's area of practice.
(b) Managed care entities shall accept the nomination form referenced in Rule 120-2-83-.03(a) by any means that evidences the date and time of receipt.
(c) Submission of the nomination form by the enrollee shall not constitute acceptance of the nominated provider by the managed care entity.
(d) Within three (3) business days of receipt of the nomination form by the insurer, the managed care entity shall provide notice in writing, to the provider and the enrollee, of the provisional acceptance (in the case of managed care entities which will implement a credentialing process in accordance with Rule 120-2-83-.05 ), final acceptance (in the case of managed care entities which choose not to implement a credentialing process in accordance with Rule 120-2-83-.05 ), or the rejection of the nominated provider. In addition, the managed care entity shall make a good faith effort to provide the notice required by this paragraph by facsimile where practicable.
(e) For deselected or rejected providers, the notice referred to in paragraph (d) shall contain specific statutory, medical, professional or ethical reasons for deselection or rejection. The provider may not be re-nominated by the enrollee unless the nomination form contains materially different information as determined by the provider or the managed care entity.
(f) Nothing in this Rule shall be construed to limit the enrollee's right to emergency care as set forth in O.C.G.A. §§ 33-20A-3 and 33- 20A-9.
(g) Accepted or provisionally accepted providers and enrollees shall be required to adhere to generally accepted rules of the managed care entity.
(h) Accepted or provisionally accepted providers shall be reimbursed at the average contractual rate paid to similarly situated providers and such rates may differ from plan to plan offered by a managed care entity.
(i) If a nominated provider will not be providing services at a hospital within the managed care entity's network, the enrollee must submit an additional nomination form for the hospital where services will be provided. Managed care entities shall include information regarding this requirement with the material supplied pursuant to Rule 120-2-83-.03(a). Nothing in this Rule shall require a provider to perform services only at hospitals within the managed care entity's network. Pursuant to O.C.G.A. § 33-20A-9.1(c)(1)(d), out of network hospitals must meet all other reasonable criteria as required by the managed care plan of in network hospitals.
(j) Where a managed care entity provisionally accepts a nominated provider and then later deselects that provider based on the credentialing process in accordance with Rule 120-2-83-.05, the managed care entity is responsible for payment for covered services provided during the credentialing review period and before notice of the deselection of the nominated provider is received by the enrollee and the provider.
(k) Nothing in this Rule shall prohibit a managed care entity from implementing alternate measures which are more beneficial to the enrollee as agreed to by the enrollee and managed care entity, providing the minimum requirements of this Rule are met.

Rule 120-2-83-.05 Credentialing

(a) Nothing in this Regulation Chapter shall require managed care entities to credential as to nominated providers.
(b) As provided for in O.C.G.A. § 33-20A-9.1(c)(1)(C), managed care entities are permitted to implement credentialing procedures that meet minimum requirements set forth by recognized credentialing bodies.
(c) Within ninety (90) days of receipt of all necessary information as required by the managed care entity and provided with the nomination form in accordance with Rule 120-2-83-.04(a)(l), the managed care entity shall provide notice in writing, to the provider and the enrollee, of the credentialing decision.
(d) For deselected providers, this notice shall contain the specific statutory, medical, professional or ethical reasons for deselection.

Rule 120-2-83-.06 Form Filings; Examination Authority

(a) Rate and form filings for the option shall be deemed original filings.
(b) Managed care entities may seek approval of acceptable group master contract language which describes administrative procedures and limits changes to or withdrawals from the option election by an enrollee, consistent with Rule 120-2-83-.03(d).
(c) The requirements for offering the option pursuant to this Regulation Chapter shall be satisfied if a managed care entity meets all requirements set forth in O.C.G.A. § 33-20A-9.1(d)(2)(C). Compliance with this paragraph shall be applicable on a product and option specific basis, including different cost sharing levels.
(d) Nothing in this Regulation Chapter shall affect the Commissioner's examination authority pursuant to Title 33 of the Official Code of Georgia Annotated.

Rule 120-2-83-.07 Penalties

Any insurer, or any agent, counselor, representative, officer, or 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 120-2-83-.08 Severability

If any provision of this Regulation Chapter or the application of it to any person or circumstance is held invalid, such invalidity shall not affect the provisions or applications of the rules herein which can be given effect without the invalid portion. To that end, the provisions of this Rule are declared to be severable.