SB 479 - Insurance - provide for Patient Protection Act
Georgia Senate - 1995/1996 Sessions
SB 479 - Insurance - provide for Patient Protection Act
Page Numbers - 1/ 2/ 3/ 4/ 5/ 6/ 7/ 8/ 9/ 10/ 11/ 12
1. Stokes 43rd 2. Oliver 42nd 3. Walker 22nd
Senate Comm: I&L / House Comm: /
Senate Vote: Yeas Nays
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Senate Action House
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1/9/96 Read 1st time
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Code Sections amended: 33-56-1, 33-56-2, 33-56-3, 33-56-4, 33-56-5, 33-56-6,
33-56-7, 33-56-8, 33-56-9, 33-56-10, 33-56-11, 33-23-12, 33-56-13, 33-56-14,
33-56-15
SB 479 LC 19 2738
A BILL TO BE ENTITLED
AN ACT
1- 1 To amend Title 33 of the Official Code of Georgia Annotated,
1- 2 relating to insurance, so as to provide fairness and choice
1- 3 to patients and providers under managed care health benefit
1- 4 plans; to provide a short title; to provide definitions; to
1- 5 provide for enrollee information; to provide for the
1- 6 adoption of rules by the Commissioner of Insurance; to
1- 7 provide for network configuration; to provide for hospital
1- 8 participation; to provide for financial incentive programs;
1- 9 to provide for participating providers; to provide for
1-10 emergency care service; to provide for prior authorization
1-11 procedures; to provide for a point-of-service plan; to
1-12 provide that no private cause of action is created; to
1-13 provide for an annual performance report; to prohibit
1-14 retaliation; to provide for applicability; to provide for
1-15 related matters; to repeal conflicting laws; and for other
1-16 purposes.
1-17 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION 1.
1-18 Title 33 of the Official Code of Georgia Annotated, relating
1-19 to insurance, is amended by adding at the end thereof a new
1-20 Chapter 56 to read as follows:
"CHAPTER 56
1-21 33-56-1. (Index)
1-22 This chapter shall be known and may be cited as the
1-23 'Patient Protection Act.'
1-24 33-56-2. (Index)
1-25 As used in this chapter, the term:
1-26 (1) 'Dentist' means a person licensed to practice
1-27 dentistry under Title 43.
1-28 (2) 'Emergency care services' means medical services
1-29 provided for an emergency medical condition.
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LC 19 2738
2- 1 (3) 'Emergency medical condition' means:
2- 2 (A) A medical condition manifesting itself by acute
2- 3 symptons of sufficient severity, including severe
2- 4 pain, so that the absence of immediate medical
2- 5 attention could reasonably be expected to result in:
2- 6 (i) Placing the health of the individual or, if the
2- 7 individual is a pregnant woman, the health of the
2- 8 woman or her unborn child, in serious jeopardy;
2- 9 (ii) Serious impairment to a bodily function; or
2-10 (iii) Serious dysfunction of an organ or part of the
2-11 body; or
2-12 (B) With respect to a pregnant woman who is having
2-13 contractions:
2-14 (i) Inadequate time to effect a safe transfer to
2-15 another hospital before delivery; or
2-16 (ii) That transfer to another hospital may pose a
2-17 threat to the health or safety of the woman or the
2-18 unborn child.
2-19 (4)(A) 'Managed care plan' or 'plan' means a plan
2-20 operated by a managed care entity that provides for
2-21 the financing and delivery of health care or dental
2-22 services to persons enrolled in the plan through:
2-23 (i) Arrangements with selected providers to furnish
2-24 health care services;
2-25 (ii) Explicit standards for the selection of
2-26 participating providers;
2-27 (iii) Organizational arrangements for ongoing
2-28 quality assurance, utilization review, and dispute
2-29 resolution; or
2-30 (iv) Differential coverage or payments or financial
2-31 incentives for a person enrolled in the plan to use
2-32 the participating providers and procedures provided
2-33 by the plan.
2-34 (B) The term 'managed care plan' or 'plan' does not
2-35 include accident only, specified disease, individual
2-36 hospital indemnity, credit, dental only, vision only,
2-37 medicare supplement or medicare select, long-term
2-38 care, disability income, CHAMPUS supplement, or
2-39 workers' compensation insurance, insurance coverage
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LC 19 2738
3- 1 issued as a supplement to liability insurance or other
3- 2 similar insurance, or automobile medical payment
3- 3 insurance.
3- 4 (5) 'Physician' means a person licensed as a physician
3- 5 under Title 43.
3- 6 (6) 'Point-of-service plan' means a plan provided
3- 7 through a contractual arrangement under which indemnity
3- 8 benefits for the cost of health care services, other
3- 9 than emergency care services, are provided by an insurer
3-10 or group hospital service corporation in conjunction
3-11 with corresponding benefits arranged or provided by a
3-12 health maintenance organization, including a single
3-13 service health maintenance organization. An individual
3-14 may choose to obtain benefits or services under either
3-15 the indemnity plan or the health maintenance
3-16 organization plan in accordance with specific provisions
3-17 of a point-of-service contract.
3-18 (7) 'Prospective enrollee' means an individual eligible
3-19 for enrollment in a managed care plan offered by that
3-20 individual's employer.
3-21 (8) 'Provider' means a physician, dentist, podiatrist,
3-22 pharmacist, optometrist, psychologist, clinical social
3-23 worker, advanced nurse practitioner, registered
3-24 optician, licensed professional counselor, physical
3-25 therapist, and chiropractor.
3-26 33-56-3. (Index)
3-27 The Commissioner may adopt rules regarding standards
3-28 ensuring compliance with this chapter by managed care
3-29 entities that conduct business in this state. The
3-30 Commissioner may appoint an advisory committee to assist
3-31 in the implementation of this chapter.
3-32 33-56-4. (Index)
3-33 (a) A managed care entity shall provide a prospective
3-34 enrollee a written plan description of the terms and
3-35 conditions of the plan. The written plan description must
3-36 be in a readable and understandable format and must
3-37 include:
3-38 (1) Coverage provisions;
3-39 (2) Benefits, including prescription drug coverage, both
3-40 generic and brand name;
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LC 19 2738
4- 1 (3) Any exclusions by category of service, provider,
4- 2 and, if applicable, by specific service or types of
4- 3 drugs;
4- 4 (4) Any prior authorization, including procedures for
4- 5 and limitations or restrictions on referrals to
4- 6 providers other than primary care physicians or
4- 7 dentists, or other review requirements, including
4- 8 preauthorization review, concurrent review, postservice
4- 9 review, and postpayment review;
4-10 (5) An explanation of enrollee financial responsibility
4-11 for payment for coinsurance or other noncovered or
4-12 out-of-plan services;
4-13 (6) A disclosure to prospective enrollees that includes
4-14 the following language:
4-15 'YOUR RIGHTS UNDER GEORGIA LAW
4-16 You have the right to information about the plan,
4-17 including how the plan operates, what general types of
4-18 financial arrangements exist between providers and the
4-19 plan, names and locations of provides, the numbers of
4-20 enrollees and providers in the plan, the percentage of
4-21 premiums allocated for medical care, administrative
4-22 costs, and profit, and an explanation of the benefits
4-23 to which participants are entitled under the terms of
4-24 the plan.';
4-25 and
4-26 (7) A phone number and address for the prospective
4-27 enrollee to obtain additional information concerning the
4-28 items described by paragraph (6) of this subsection.
4-29 (b) The managed care entity may provide the information
4-30 under paragraph 6 of subsection (a) of this Code section
4-31 regarding the percentage of premiums allocated for medical
4-32 care, administrative costs, and profit by providing the
4-33 information in the entity's annual financial statement
4-34 most recently submitted to the department.
4-35 (c) The managed care entity shall demonstrate that each
4-36 covered enrollee has adequate access through the entity's
4-37 provider network to all items and services contained in
4-38 the package of benefits for which coverage is provided,
4-39 including access to at least one cancer care provider
4-40 certified as a comprehensive cancer center by the National
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LC 19 2738
5- 1 Cancer Institute. The access must be adequate considering
5- 2 the diverse needs of enrollees.
5- 3 (d) Nothing in subsection (c) of this Code section may be
5- 4 interpreted to mean that a comprehensive cancer center
5- 5 shall be the exclusive provider of cancer care services
5- 6 for the managed care plan.
5- 7 (e) Nothing in subsection (c) of this Code section may be
5- 8 interpreted to circumvent the managed care plan's normal
5- 9 referral and authorization processes.
5-10 (f) If the managed care plan uses a capitation method of
5-11 compensation, the plan must establish and follow
5-12 procedures that ensure that:
5-13 (1) Each plan application form includes a space in which
5-14 each enrollee selects a primary care physician or
5-15 dentist;
5-16 (2) Each enrollee who fails to select a primary care
5-17 physician or dentist and is assigned a physician or
5-18 dentist is notified of the name and location of that
5-19 physician or dentist; and
5-20 (3) A primary care physician or dentist to whom an
5-21 enrollee is assigned is physically located within a
5-22 reasonable travel distance, as established by rule
5-23 adopted by the Commissioner, from the residence or place
5-24 of employment of the enrollee.
5-25 33-56-5. (Index)
5-26 The managed care entity shall provide to the Commissioner,
5-27 for information, an explanation of the targeted physician,
5-28 dentist, and as appropriate, other provider network
5-29 configuration, including geographic distribution of
5-30 physicians and dentists by specialty, and other providers,
5-31 as appropriate. The information required by this Code
5-32 section shall be updated at least annually and:
5-33 (1) On establishment of a new managed care plan;
5-34 (2) On expansion of a service area; or
5-35 (3) When the network configuration targets are
5-36 significantly modified.
5-37 Nothing in this Code section shall require a particular
5-38 ratio for any type of provider. The information shall be
5-39 made available to the public by the Department of
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LC 19 2738
6- 1 Insurance on request. The department may charge a
6- 2 reasonable fee for providing the information.
6- 3 33-56-6. (Index)
6- 4 In the development of the plan's criteria for hospital
6- 5 participation, if a hospital is certified by the medicare
6- 6 program under Title XVIII of the Social Security Act, as
6- 7 amended, 42 U.S.C. Section 1395 et seq., or accredited by
6- 8 the Joint Commission on Accreditation of Health Care
6- 9 Organizations, the managed care plan shall accept such
6-10 certification or accreditation. This Code section shall
6-11 not prohibit a managed care plan from establishing
6-12 additional criteria for hospital participation.
6-13 33-56-7. (Index)
6-14 A managed care plan may not use a financial incentive
6-15 program that limits medically necessary and appropriate
6-16 services.
6-17 33-56-8. (Index)
6-18 (a) Each managed care plan shall establish a mechanism
6-19 under which physicians or dentists participating in the
6-20 plan provide consultation and advice on the plan's medical
6-21 or dental policy, including coverage of a new technology
6-22 and procedures, the development and use of a prescription
6-23 drug formulary, utilization review criteria and
6-24 procedures, quality and credentialing criteria, and
6-25 medical or dental management procedures. Other
6-26 participating providers shall be given an opportunity to
6-27 comment on the plan's policies affecting their services.
6-28 Each managed care plan on request shall make available and
6-29 disclose to providers the application process and
6-30 qualification requirements for participation in the plan.
6-31 The plan must give a provider not selected on initial
6-32 application each reason the initial application was
6-33 denied.
6-34 (b) Each physician or dentist under consideration for
6-35 inclusion in a managed care plan shall be reviewed by a
6-36 credentialing committee composed primarily of network
6-37 participating physicians or dentists selected by the
6-38 medical director of the managed care entity. If there are
6-39 no credentialed physicians or dentists in a newly created
6-40 plan, the committee shall be primarily composed of
6-41 physicians or dentists practicing in the same or similar
6-42 settings. Other providers may be credentialed, if
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LC 19 2738
7- 1 appropriate, as determined by the plan. When a provider,
7- 2 other than a physician or dentist, is credentialed by the
7- 3 plan, the credentialing committee shall include providers
7- 4 with the same license.
7- 5 (c) Credentialing of providers shall be based on
7- 6 identified standards developed after consultation with
7- 7 providers credentialed in the plan. If there are no
7- 8 credentialed providers in a newly created plan, the plan
7- 9 shall develop credentialing standards after consulting
7-10 with area providers. The managed care plan shall make the
7-11 credentialing standards available to applicants.
7-12 (d) If economic considerations are part of the decision to
7-13 select a provider or terminate a contract with a provider,
7-14 the plan shall use identified criteria which shall be
7-15 available to applicants and participating providers. If
7-16 the plan uses an economic profile of a provider, the plan
7-17 must adjust the profile to recognize the characteristics
7-18 of a provider's practice that may account for variations
7-19 from expected costs.
7-20 (e) A managed care plan that conducts or uses economic
7-21 profiling of providers within the plan shall make the
7-22 profile available to the provider profiled on a periodic
7-23 basis.
7-24 (f) Unless specifically required by this chapter, a
7-25 managed care plan is not required to disclose proprietary
7-26 information regarding marketplace strategies.
7-27 (g) A managed care plan may not exclude a provider solely
7-28 because of the anticipated characteristics of the patients
7-29 of that provider.
7-30 (h) Before terminating a contract with a provider, the
7-31 managed care plan shall provide a written explanation of
7-32 the reasons for termination, an opportunity for
7-33 discussion, and an opportunity to enter into and complete
7-34 a corrective action plan, if appropriate, as determined by
7-35 the plan. Except in cases in which there is imminent harm
7-36 to patient health or an action by a state medical, dental,
7-37 or other provider licensing board or other government
7-38 agency that effectively impairs the provider's ability to
7-39 practice medicine, dentistry, or another health care
7-40 profession or in cases of fraud or malfeasance, on request
7-41 and before the effective date of the termination, the
7-42 provider is entitled to a review of the plan's proposed
7-43 action by a plan advisory panel. For a physician or a
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LC 19 2738
8- 1 dentist, the plan advisory panel must be primarily
8- 2 composed of the physician's or dentist's peers. If the
8- 3 review involves another type of provider, the plan
8- 4 advisory panel must include providers with the same
8- 5 license. The review may include a review of the
8- 6 appropriateness and requirements of a corrective action
8- 7 plan. The decision of the advisory panel must be
8- 8 considered but is not binding on the plan.
8- 9 (i) If the action that is under consideration is of a type
8-10 that must be reported to the National Practitioner Data
8-11 Bank or a state medical or dental board under federal or
8-12 state law, the physician's or dentist's procedural rights
8-13 must meet the standards set forth in the federal Health
8-14 Care Quality Improvement Act of 1986, 42 U.S.C. Section
8-15 11101 et seq.
8-16 (j) A communication relating to the subject matter
8-17 provided for under subsection (a) or (h) of this Code
8-18 section may not be the basis for a cause of action for
8-19 libel or slander except for disclosures or communications
8-20 with parties other than the plan or provider.
8-21 (k) The managed care plan shall establish reasonable
8-22 procedures for assuring a transition of enrollees of the
8-23 plan to new providers.
8-24 (l) If a contract with a provider is terminated by a
8-25 managed care plan, the plan shall reimburse the provider
8-26 the reasonable cost for copies of medical or dental
8-27 records that are furnished to another provider at the
8-28 patient's request. If a provider terminates the contract
8-29 with the plan, the provider shall bear the reasonable cost
8-30 of providing copies of medical or dental records that are
8-31 furnished to another provider at the patient's request.
8-32 (m) This chapter does not prohibit a managed care plan
8-33 from rejecting an application from a provider based on the
8-34 determination that the plan has sufficient qualified
8-35 providers.
8-36 (n) A managed care plan may charge to a provider, other
8-37 than a physician or dentist:
8-38 (1) A reasonable application fee to cover the cost of
8-39 processing applications and informing the provider of
8-40 selection or nonselection under the plan;
8-41 (2) A reasonable credentialing fee to cover the cost of
8-42 the credentialing process; and
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LC 19 2738
9- 1 (3) A reasonable fee for providing to a provider a copy
9- 2 of credentialing standards, identified criteria for
9- 3 selection, and economic profiles requested by the
9- 4 provider.
9- 5 (o) For purposes of this Code section, the term 'managed
9- 6 care plan' does not include:
9- 7 (1) A group mode health maintenance organization that is
9- 8 a state certified health maintenance organization that
9- 9 provides the majority of its professional services
9-10 through a single group medical practice which educates
9-11 medical students or resident physicians through a
9-12 contract with the medical school component of a Georgia
9-13 state supported college or university accredited by the
9-14 Accrediting Council on Graduate Medical Education or the
9-15 American Osteopathic Association; or
9-16 (2) A state certified health maintenance organization
9-17 that implements all credentialing, quality assurance,
9-18 utilization review, and peer review policies through a
9-19 physician network board of directors composed
9-20 exclusively of persons actively engaged in the practice
9-21 of medicine as defined by the State Board of Medical
9-22 Examiners and educates medical students or resident
9-23 physicians through a contract with the medical school
9-24 component of a Georgia state supported college or
9-25 university accredited by the Accrediting Council on
9-26 Graduate Medical Education or the American Osteopathic
9-27 Association.
9-28 (p) Subsections (a), (c), (d), (e), (g), (h), (l), and (m)
9-29 of this Code section apply to hospitals, hospices, and
9-30 home health agencies.
9-31 33-56-9. (Index)
9-32 A managed care plan shall:
9-33 (1) Cover emergency care services provided to covered
9-34 individuals, without regard to whether the provider
9-35 furnishing the services has a contractual or other
9-36 arrangement with the entity to provide items or services
9-37 to covered individuals, including the treatment and
9-38 stabilization of an emergency medical condition;
9-39 (2) Provide that the prior authorization requirement for
9-40 medically necessary services provided or originating in
9-41 a hospital emergency department following treatment or
9-42 stabilization of an emergency medical condition is
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LC 19 2738
10- 1 approved unless denied in the time appropriate to the
10- 2 circumstances relating to the delivery of the services
10- 3 and the condition of the patient, as determined by the
10- 4 treating provider and communicated to the plan; and
10- 5 (3) Cover any medical screening examination to determine
10- 6 whether an emergency medical condition exists or any
10- 7 other evaluation required by state or federal law to be
10- 8 provided in the emergency department of a hospital.
10- 9 33-56-10. (Index)
10-10 A plan for which prior authorization is a condition to
10-11 coverage of a service must ensure that enrollees are
10-12 required to sign medical and dental information release
10-13 consent forms on enrollment.
10-14 33-56-11. (Index)
10-15 (a) When a health maintenance organization offers a
10-16 point-of-service plan in its service area and is the only
10-17 entity providing services under a health benefit plan, it
10-18 must offer to all eligible enrollees the opportunity to
10-19 obtain coverage for out-of-network services through the
10-20 point-of-service plan as defined by subsection (b) of this
10-21 Code section at the time of enrollment and at least
10-22 annually.
10-23 (b) The premium for the point-of-service plan shall be
10-24 based on the actuarial value of that coverage.
10-25 (c) Any additional costs for the point-of-service plan are
10-26 the responsibility of the enrollee, and the employer may
10-27 impose a reasonable administrative cost for providing the
10-28 point-of-service option.
10-29 (d) When 5 percent or less of the group's eligible
10-30 employees elect to purchase the point-of-service option,
10-31 the plan is not required to offer the point-of-service
10-32 option during subsequent open enrollment periods.
10-33 33-23-12. (Index)
10-34 This chapter and rules adopted under this chapter do not:
10-35 (1) Provide a private cause of action for damages or
10-36 create a standard of care, obligation, or duty that
10-37 provides a basis for a private cause of action for
10-38 damages; or
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LC 19 2738
11- 1 (2) Abrogate a statutory or common law cause of action,
11- 2 administrative remedy, or defense otherwise available
11- 3 and existing before July 1, 1996.
11- 4 33-56-13. (Index)
11- 5 (a) The Commissioner shall issue an annual report to
11- 6 consumers on the performance of managed care entities.
11- 7 (b) The Commissioner shall have access to:
11- 8 (1) Information provided under Code Section 33-56-5;
11- 9 (2) Information contained in complaints relating to
11-10 managed care entities made to the Insurance Department
11-11 or to the Department of Human Resources, provided that
11-12 the Commissioner shall maintain as confidential any
11-13 information in the complaint that relates to a patient
11-14 or that is made confidential by another law; and
11-15 (3) Any statistical information relating to utilization,
11-16 quality assurance, and complaints that a health
11-17 maintenance organization is required to maintain under
11-18 rules adopted by the Commissioner or the Department of
11-19 Human Resources.
11-20 (c) The Commissioner shall provide a copy of the report to
11-21 a person on request on payment of a reasonable fee. The
11-22 Commissioner shall set the fee in the amount necessary to
11-23 defray the cost of producing the report.
11-24 33-56-14. (Index)
11-25 A managed care plan may not take any retaliatory actions,
11-26 including cancellation or refusal to renew a policy,
11-27 against an employer or enrollee solely because the
11-28 enrollee has filed complaints with the plan or appealed a
11-29 decision of the plan.
11-30 33-56-15. (Index)
11-31 (a) Except as otherwise provided by law, all provisions of
11-32 this title or other applicable general law which are not
11-33 in conflict with this chapter shall apply to managed care
11-34 entities and other persons subject to this chapter.
11-35 (b) Solicitation of enrollees by a managed care entity
11-36 granted a certificate of authority or its representatives
11-37 shall not be construed to violate any provision of law
11-38 relating to solicitation or advertising by health
11-39 professionals.
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LC 19 2738
12- 1 (c) Any managed care entity authorized under this chapter
12- 2 shall not be deemed to be practicing medicine and shall be
12- 3 exempt from the provisions of Chaper 34 of Title 43,
12- 4 relating to the practice of medicine."
SECTION 2.
12- 5 All laws and parts of laws in conflict with this Act are
12- 6 repealed.
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Office of the Secretary of the Senate
Frank Eldridge, Jr., Secretary of the Senate
Last Updated on 01/02/97