Rules and Regulations of the State of Georgia
 

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<xmp>.</xmp> <form name="form1" method="post" action="120-2-98?urlRedirected=yes&amp;data=admin&amp;lookingfor=120-2-98" id="form1"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwUKLTY5ODkwOTM2Nw8WAh4Ec3BhbQIHFgJmD2QWAgIFDw8WAh4EVGV4dAUFNCArIDNkZGRFpqWfZUh/3IV/EkelxZj3uP9BxQ==" /> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="EEBB6393" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEWCALj25HXCQLniKOhBALV5cpNAoa5iIEFAoznisYGAsrv5u0MAsrv4u0MAsrv3u0MxguD4BHYQPvoSmZtlA3C98ITTrU=" /> <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." 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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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The federal regulations adopted by HHS at 45 C.F.R. Part 154 set forth criteria for an effective rate review program and provide that, on and after September 1, 2011, HHS will defer to a State review of certain health insurance rate filings only if that State has been deemed to have an effective rate review program. HHS will assert the authority to review certain health insurance rate filings in States without an effective rate review program. Georgia has been deemed to be an effective rate review State subject to the adoption of the federal rate review criteria on or before September 1, 2011. This Emergency Regulation Chapter is necessary to preserve the Commissioner of Insurance's ability to review certain health insurance rates and preserve the public welfare as contemplated 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=33-9-1&amp;title=33#33-9-1(a)" target="_newtab">33-9-1(a)</a> and other applicable provisions of Title 33 cited herein.</P> <P>This regulation is issued pursuant to the authority vested in the Commissioner under Chapters 2 and 9 of Title 33 and O.C.G.A. §§ <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-21-13&amp;title=33#" target="_newtab">33-21-13</a>, <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-21-18&amp;title=33#" target="_newtab">33-21-18</a>, and <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-21-28&amp;title=33#" target="_newtab">33-21-28</a>.</P> <h2><a href="/GAC/120-2-98-.02" name="120-2-98-.02" title="120-2-98-.02">Rule 120-2-98-.02 Definitions</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="120-2-98-.02(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "CMS" means the Centers for Medicare &amp; Medicaid Services.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.02(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Health benefit plan" has the same meaning as O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-59.5&amp;title=33#33-24-59.5(2)" target="_newtab">33-24-59.5(2)</a>as that term is modified by the provisions 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=33-1-2&amp;title=33#" target="_newtab">33-1-2</a>(1.1) but does not include coverage offered by a person not subject to the jurisdiction of the Commissioner 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=33-1-14&amp;title=33#" target="_newtab">33-1-14</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="120-2-98-.02(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Individual market" means the market for health benefit plans where the health benefit plan is issued directly to a natural person and not through coverage under a group, blanket or franchise health benefit 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="120-2-98-.02(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Rate increase" means any increase of the rates for a health benefit plan offered in the individual or small 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="120-2-98-.02(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Rate increase subject to review" means a rate increase that meets the criteria set forth in <a title="120-2-98-.03" href="120-2-98-.03">120-2-98-.03</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="120-2-98-.02(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Secretary" means the Secretary of the Department of Health and Human Services.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.02(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Small group market" means the market within which small group coverage is sold as that term is 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>.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.02(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Unreasonable rate increase" means a rate increase subject to review that violates applicable laws, regulations, and rules.</td> </tr> </table> <h2><a href="/GAC/120-2-98-.03" name="120-2-98-.03" title="120-2-98-.03">Rule 120-2-98-.03 Rate Increases Subject to Review</a></h2> <P>Only rate increases for health benefit plans that are equal to or exceed 10% are subject to review under this regulation. The methodology for determining the amount of a rate increase prescribed in <a href="https://links.casemakerlegal.com/states/us/books/Code_of_Federal_Regulations/browse?ci=25&amp;id=gasos&amp;codesec=154.200&amp;title=45#" target="_newtab">45 C.F.R. § 154.200</a> shall be used to determine whether a rate increase is equal to or exceeds 10%.</P> <h2><a href="/GAC/120-2-98-.04" name="120-2-98-.04" title="120-2-98-.04">Rule 120-2-98-.04 Rate Filing Requirements</a></h2> <P>In addition to other materials that are otherwise required to be filed, each insurer is required to file the following material for a rate increase subject to review:</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="120-2-98-.04(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The preliminary justification required by <a href="https://links.casemakerlegal.com/states/us/books/Code_of_Federal_Regulations/browse?ci=25&amp;id=gasos&amp;codesec=154.215&amp;title=45#154.215(b)" target="_newtab">45 C.F.R. § 154.215(b)</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="120-2-98-.04(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The documentary support for all assumptions used by the insurer to develop the proposed rate increase, including historical data underlying the assumptions;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.04(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The documentary support demonstrating the insurer's consideration of the applicable factors set forth in <a title="120-2-98-.05" href="120-2-98-.05">120-2-98-.05</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="120-2-98-.04(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any documentation requested by the Department to the extent that such documentation is pertinent to the filing under review.</td> </tr> </table> <h2><a href="/GAC/120-2-98-.05" name="120-2-98-.05" title="120-2-98-.05">Rule 120-2-98-.05 Standards of Review</a></h2> <P>In addition to standards or criteria of review that are otherwise applicable to a rate increase subject to review under this regulation, the following standards will apply to the review of rates to the extent applicable to the filing under review:</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="120-2-98-.05(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of medical trend changes by major service categories;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of utilization changes by major service categories;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of cost-sharing changes by major service categories;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of benefit changes;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of changes in enrollee risk profile;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of any overestimate or underestimate of medical trend for prior year periods related to the rate increase;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of changes in reserve needs;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(8)">(8)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of changes in administrative costs related to programs that improve health care quality;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(9)">(9)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of changes in other administrative costs;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(10)">(10)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The impact of changes in applicable taxes, licensing or regulatory fees;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-98-.05(11)">(11)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Medical loss ratio; 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="120-2-98-.05(12)">(12)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The health insurance issuer's capital and surplus.</td> </tr> </table> <h2><a href="/GAC/120-2-98-.06" name="120-2-98-.06" title="120-2-98-.06">Rule 120-2-98-.06 Access of Public to Rate Increase Process</a></h2> <P>The preliminary justification of a proposed rate increase subject to review, filed pursuant to <a title="120-2-98-.04(1)" href="120-2-98-.04#120-2-98-.04(1)">120-2-98-.04(1)</a>, will be published to the Department of Insurance website within five (5) business days of receipt. In addition the Department will accept public comments on any proposed rate increase.</P> <h2><a href="/GAC/120-2-98-.07" name="120-2-98-.07" title="120-2-98-.07">Rule 120-2-98-.07 Reporting Final Determination to CMS</a></h2> <P>The Department will report its final determination of whether a rate increase subject to review is unreasonable in accordance with <a href="https://links.casemakerlegal.com/states/us/books/Code_of_Federal_Regulations/browse?ci=25&amp;id=gasos&amp;codesec=154.210&amp;title=45#154.210(b)(2)" target="_newtab">45 C.F.R. § 154.210(b)(2)</a>.</P> <h2><a href="/GAC/120-2-98-.08" name="120-2-98-.08" title="120-2-98-.08">Rule 120-2-98-.08 Rate Filing Guidance</a></h2> <P>The Commissioner shall issue guidance for electronic filing of rates subject to this regulation via bulletins. All rate filings subject to this regulation must be filed in accordance with the relevant bulletin.</P> <h2><a href="/GAC/120-2-98-.09" name="120-2-98-.09" title="120-2-98-.09">Rule 120-2-98-.09 Applicability of Other Regulations</a></h2> <P>These regulations apply in addition to other applicable regulations.</P> <h2><a href="/GAC/120-2-98-.10" name="120-2-98-.10" title="120-2-98-.10">Rule 120-2-98-.10 Severability</a></h2> <P>If any provision of these sections or the application thereof to any person or circumstance is held invalid for any reason, the invalidity shall not affect the other provisions or any other application of these sections which can be given effect without the invalid provisions or application. To this end all provisions of these sections are declared to be severable.</P> </div> </div> </HTML> </div> <div id="toc" class="sidebar noprint"> <ul id="toc-children" class="children"><li><a href="/GAC/120-2-98-.01" name="120-2-98-.01" title="120-2-98-.01">Rule 120-2-98-.01 Purpose and Authority</a></li><li><a href="/GAC/120-2-98-.02" name="120-2-98-.02" title="120-2-98-.02">Rule 120-2-98-.02 Definitions</a></li><li><a href="/GAC/120-2-98-.03" name="120-2-98-.03" title="120-2-98-.03">Rule 120-2-98-.03 Rate Increases Subject to Review</a></li><li><a href="/GAC/120-2-98-.04" name="120-2-98-.04" title="120-2-98-.04">Rule 120-2-98-.04 Rate Filing Requirements</a></li><li><a href="/GAC/120-2-98-.05" name="120-2-98-.05" title="120-2-98-.05">Rule 120-2-98-.05 Standards of Review</a></li><li><a href="/GAC/120-2-98-.06" name="120-2-98-.06" title="120-2-98-.06">Rule 120-2-98-.06 Access of Public to Rate Increase Process</a></li><li><a href="/GAC/120-2-98-.07" name="120-2-98-.07" title="120-2-98-.07">Rule 120-2-98-.07 Reporting Final Determination to CMS</a></li><li><a href="/GAC/120-2-98-.08" name="120-2-98-.08" title="120-2-98-.08">Rule 120-2-98-.08 Rate Filing Guidance</a></li><li><a href="/GAC/120-2-98-.09" name="120-2-98-.09" title="120-2-98-.09">Rule 120-2-98-.09 Applicability of Other Regulations</a></li><li><a href="/GAC/120-2-98-.10" name="120-2-98-.10" title="120-2-98-.10">Rule 120-2-98-.10 Severability</a></li></ul> </div> </div> <!--content ends here--> <div id="footer" class="noprint"><span class="footer">Copyright &copy; 2019 Lawriter LLC - All rights reserved.</span>| <a href="mailto:support@casemakerlegal.com?subject=Rules and Regulations of the State of Georgia">Email Us</a> | 844-838-0769 | <a href="http://livechat.casemakerlegal.com/client.php?locale=en" target="_blank" onclick="if(navigator.userAgent.toLowerCase().indexOf('opera') != -1 && window.event.preventDefault)window.event.preventDefault();this.newWindow = window.open('http://livechat.casemakerlegal.com/client.php?locale=en&url='+escape(document.location.href)+'&referrer='+escape(document.referrer), 'webim','toolbar=0,scrollbars=0,location=0,status=1,menubar=0,width=640,height=480,resizable=1');this.newWindow.focus();this.newWindow.opener=window;return false;">Live Chat</a> </div> </div> </body> </html>