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HB 159 - Insurance; certain claims; payment time limits

Graves, David B (125th)	Williams, Jeffrey L (83rd)	Bannister, Charles E (77th)
Jones, Vernon A (71st)	Tolbert, Scott (25th)	Hanner, Robert P (159th)

Status Summary	HC:	Ins	SC:	I&L	FR:	01/25/99	LA:	04/19/99	Signed by Governor

First Reader Summary

A BILL to amend Article 1 of Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to general provisions regarding insurance generally, so as to provide for time limits for payment of claims under certain health benefit plans and provide for sanctions; and for other purposes.

Code Sections - 33-24-59.4/ 33-24-59.5/ 33-29-22

HB 159                                             HB 159/AP 
 
      H. B. No. 159 (AS PASSED HOUSE AND SENATE) 
      By:  Representatives Graves of the 125th, Williams of the 
      83rd, Bannister of the 77th, Jones of the 71st, Tolbert of 
      the 25th and others 
 
                        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 for confidentiality 
  1- 3  of patients' medical information obtained by health insurers 
  1- 4  from pharmacies or pharmacists; to prohibit release of 
  1- 5  certain information to third parties without patient 
  1- 6  consent; to define a term; to provide a penalty for 
  1- 7  violations; to provide for time limits for payment of claims 
  1- 8  under certain health benefit plans and provide for 
  1- 9  sanctions; to change certain provisions relating to required 
  1-10  policy provisions for individual accident and sickness 
  1-11  insurance; to provide for notice prior to certain premium 
  1-12  increases; change certain provisions relating to required 
  1-13  provisions of group accident and sickness insurance 
  1-14  policies; to provide for applicability; to repeal 
  1-15  conflicting laws; and for other purposes. 
 
  1-16       BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA: 
 
  1-17                           SECTION 1. 
 
  1-18  Title 33 of the Official Code of Georgia Annotated, relating 
  1-19  to insurance, is amended by adding a new Code Section 
  1-20  33-24-59.4 to read as follows: 
 
  1-21    "33-24-59.4. 
 
  1-22    (a) As used in this Code section, the term 'insurer' means 
  1-23    an accident and sickness insurer, fraternal benefit 
  1-24    society, nonprofit hospital service corporation, nonprofit 
  1-25    medical service corporation, health care corporation, 
  1-26    health maintenance organization, provider sponsored health 
  1-27    care corporation, or the plan administrator of any health 
  1-28    benefit plan established pursuant to Article 1 of Chapter 
  1-29    18 of Title 45; and such term includes any entity which 
  1-30    administrates or processes claims on behalf of any of the 
  1-31    foregoing. 
 
  1-32    (b) Any medical information concerning a patient that was 
  1-33    obtained by or released to an insurer from a pharmacy or 
  1-34    pharmacist shall be confidential and privileged and may be 
 
 
                                 -1- 
 
 
 
  2- 1    released by such insurer to a third party for 
  2- 2    consideration only if such release is specifically 
  2- 3    authorized by such patient or a person otherwise 
  2- 4    authorized to act therefor.  Any insurer possessing 
  2- 5    patient medical information which was obtained from a 
  2- 6    pharmacy or pharmacist shall not release such information 
  2- 7    to any third party for consideration without the explicit 
  2- 8    written consent of the patient or a person otherwise 
  2- 9    authorized to act therefor, which consent was obtained 
  2-10    after written notice by the insurer to such patient or 
  2-11    person otherwise authorized to act therefor of the purpose 
  2-12    of such release, the party or parties to whom the 
  2-13    information will be released, and any consideration paid 
  2-14    or to be paid to the insurer for such information. 
 
  2-15    (c) The provisions of subsection (b) of this Code section 
  2-16    shall not prohibit the release of medical information by 
  2-17    an insurer to a third party for purposes of appropriate 
  2-18    medical research without notice to or the written consent 
  2-19    of a patient or person authorized to act therefor, 
  2-20    provided that such release does not provide any 
  2-21    information that identifies a patient, prescriber, 
  2-22    pharmacy, or pharmacist, including without limitation any 
  2-23    name, address, or telephone number of a patient, 
  2-24    prescriber, pharmacy, or pharmacist.  Information released 
  2-25    in accordance with the provisions of this subsection may 
  2-26    be used for appropriate medical research. 
 
  2-27    (d) Violation of this Code section by any insurer to which 
  2-28    any license or certificate of authority has been issued 
  2-29    under this title shall constitute an unfair trade practice 
  2-30    punishable under Article 1 of Chapter 6 of this title." 
 
  2-31                           SECTION 2. 
 
  2-32  Said title is further amended by adding a new Code Section 
  2-33  33-24-59.5 to read as follows: 
 
  2-34    "33-24-59.5. 
 
  2-35    (a) As used in this Code section, the term: 
 
  2-36      (1) 'Benefits' means the coverages provided by a health 
  2-37      benefit plan for financing or delivery of health care 
  2-38      goods or services; but such term does not include 
  2-39      capitated payment arrangements under managed care plans. 
 
  2-40      (2) 'Health benefit plan' means any hospital or medical 
  2-41      insurance policy or certificate, health care plan 
  2-42      contract or certificate, qualified higher deductible 
 
 
                                 -2- 
 
 
 
  3- 1      health plan, health maintenance organization subscriber 
  3- 2      contract, any health benefit plan established pursuant 
  3- 3      to Article 1 of Chapter 18 of Title 45, or any dental or 
  3- 4      vision care plan or policy, or managed care plan; but 
  3- 5      health benefit plan does not include policies issued in 
  3- 6      accordance with Chapter 31 of this title; disability 
  3- 7      income policies; or Chapter 9 of Title 34, relating to 
  3- 8      workers' compensation. 
 
  3- 9      (3) 'Insurer' means an accident and sickness insurer, 
  3-10      fraternal benefit society, nonprofit hospital service 
  3-11      corporation, nonprofit medical service corporation, 
  3-12      health care corporation, health maintenance 
  3-13      organization, provider sponsored health care 
  3-14      corporation, or any similar entity and any self-insured 
  3-15      health benefit plan not subject to the exclusive 
  3-16      jurisdiction of the federal Employee Retirement Income 
  3-17      Security Act of 1974, 29 U.S.C. Section 1001, et seq., 
  3-18      which entity provides for the financing or delivery of 
  3-19      health care services through a health benefit plan, or 
  3-20      the plan administrator of any health benefit plan 
  3-21      established pursuant to Article 1 of Chapter 18 of Title 
  3-22      45. 
 
  3-23      (b)(1) All benefits under a health benefit plan will be 
  3-24      payable by the insurer which is obligated to finance or 
  3-25      deliver health care services under that plan upon such 
  3-26      insurer's receipt of written proof of loss or claim for 
  3-27      payment for health care goods or services provided. The 
  3-28      insurer shall within 15 working days after such receipt 
  3-29      mail to the insured or other person claiming payments 
  3-30      under the plan payment for such benefits or a letter or 
  3-31      notice which states the reasons the insurer may have for 
  3-32      failing to pay the claim, either in whole or in part, 
  3-33      and which also gives the person so notified a written 
  3-34      itemization of any documents or other information needed 
  3-35      to process the claim or any portions thereof which are 
  3-36      not being paid.  Where the insurer disputes a portion of 
  3-37      the claim, any undisputed portion of the claim shall be 
  3-38      paid by the insurer in accordance with this chapter. 
  3-39      When all of the listed documents or other information 
  3-40      needed to process the claim have been received by the 
  3-41      insurer, the insurer shall then have 15 working days 
  3-42      within which to process and either mail payment for the 
  3-43      claim or a letter or notice denying it, in whole or in 
  3-44      part, giving the insured or other person claiming 
 
 
 
                                 -3- 
 
 
 
  4- 1      payments under the plan the insurer's reasons for such 
  4- 2      denial. 
 
  4- 3      (2) Receipt of any proof, claim, or documentation by an 
  4- 4      entity which administrates or processes claims on behalf 
  4- 5      of an insurer shall be deemed receipt of the same by the 
  4- 6      insurer for purposes of this Code section. 
 
  4- 7    (c) Each insurer shall pay to the insured or other person 
  4- 8    claiming payments under the health benefit plan interest 
  4- 9    equal to 18 percent per annum on the proceeds or benefits 
  4-10    due under the terms of such plan for failure to comply 
  4-11    with subsection (b) of this Code section." 
 
  4-12                           SECTION 3. 
 
  4-13  Said title is further amended by striking paragraph (8) of 
  4-14  subsection (b) of Code Section 33-29-3, relating to required 
  4-15  policy provisions for individual accident and sickness 
  4-16  insurance, and inserting in lieu thereof the following: 
 
  4-17      "(8) Time of payment of claims.  The policy shall 
  4-18      include a provision incorporating and restating the 
  4-19      substance of the provisions of  subsections (b) and (c) 
  4-20      of Code Section 33-24-59.5, relating to time limits for 
  4-21      payment of claims for benefits under health benefit 
  4-22      policies and sanctions for failure to pay timely.  
 
  4-23        (A) All benefits payable under the policy  other than 
  4-24        benefits for loss of time will be payable immediately 
  4-25        upon receipt of due written proof of such loss. 
  4-26        Should the insurer fail to pay the benefits payable 
  4-27        under its policy, other than benefits payable for loss 
  4-28        of time, upon receipt of due written proof of loss, 
  4-29        the insurer shall have 15 working days thereafter 
  4-30        within which to mail the insured or subscriber a 
  4-31        letter or notice which states the reasons the insurer 
  4-32        may have for failing to pay the claim, either in whole 
  4-33        or in part, and which also gives the insured or 
  4-34        subscriber a written itemization of any documents or 
  4-35        other information needed to process the claim or any 
  4-36        portions thereof which are not being paid.  When all 
  4-37        of the listed documents or other information needed to 
  4-38        process the claim have been received, the insurer 
  4-39        shall then have 15 working days within which to 
  4-40        process and either pay the claim or deny it, in whole 
  4-41        or in part, giving the insured the reasons the insurer 
  4-42        may have for denying such claim or any portion 
  4-43        thereof.  
 
 
                                 -4- 
 
 
 
  5- 1        (B) Subject If a policy provides benefits for loss of 
  5- 2        time, such policy shall also provide that, subject to 
  5- 3        proof of such loss, all accrued benefits payable under 
  5- 4        the policy for loss of time will be paid not later 
  5- 5        than at the expiration of each period of 30 days 
  5- 6        during the continuance of the period for which the 
  5- 7        insurer is liable and any balance remaining unpaid at 
  5- 8        the termination of such period will be paid 
  5- 9        immediately upon receipt of such proof.  
 
  5-10        (C) Each insurer admitted to transact accident and 
  5-11        sickness insurance in this state shall pay interest to 
  5-12        the insured equal to 18 percent per annum on the 
  5-13        proceeds or benefits due under the terms of the policy 
  5-14        for failure to comply with the requirements of 
  5-15        subparagraph (A) or (B) of this paragraph." 
 
  5-16                           SECTION 4. 
 
  5-17  Chapter 29 of Title 33 of the Official Code of Georgia 
  5-18  Annotated, relating to individual accident and sickness 
  5-19  insurance, is amended by adding at the end a new Code 
  5-20  section to read as follows: 
 
  5-21    "33-29-22. 
 
  5-22    Notice of any premium increase shall be mailed or 
  5-23    delivered to each holder of an individual accident and 
  5-24    sickness insurance policy not less than 60 days prior to 
  5-25    the effective date of such increase." 
 
  5-26                           SECTION 5. 
 
  5-27  Said title is further amended by striking paragraph (5) of 
  5-28  subsection (b) of Code Section 33-30-6, relating to required 
  5-29  provisions of group accident and sickness insurance 
  5-30  policies,  and inserting in lieu thereof the following: 
 
  5-31      "(5)(A) A provision incorporating and restating the 
  5-32      substance of the provisions of subsections (b) and (c) 
  5-33      of Code Section 33-24-59.5, relating to time limits for 
  5-34      payment of claims for benefits under health benefit 
  5-35      policies and sanctions for failure to pay timely that 
  5-36      all benefits payable under the policy other than 
  5-37      benefits for loss of time will be payable immediately 
  5-38      upon receipt of due written proof of such loss.  Should 
  5-39      the insurer fail to pay the benefits payable under the 
  5-40      policy, other than benefits for loss of time, upon 
  5-41      receipt of due written proof of loss, the insurer shall 
  5-42      have 15 working days thereafter within which to mail the 
 
 
                                 -5- 
 
 
 
  6- 1      insured or subscriber a letter or notice which states 
  6- 2      the reasons the insurer may have for failing to pay the 
  6- 3      claim, either in whole or in part, and which also gives 
  6- 4      the insured or subscriber a written itemization of any 
  6- 5      documents or other information needed to process the 
  6- 6      claim or any portions thereof which are not being paid. 
  6- 7      When all of the listed documents or other information 
  6- 8      needed to process the claim have been received, the 
  6- 9      insurer shall then have 15 working days within which to 
  6-10      process and either pay the claim or deny it, in whole or 
  6-11      in part, giving the insured the reasons the insurer may 
  6-12      have for denying such claim or any portion thereof.  
 
  6-13        (B) Subject If a policy provides benefits for loss of 
  6-14        time, such policy shall also provide that, subject to 
  6-15        proof of such loss, all accrued benefits payable under 
  6-16        the policy for loss of time will be paid not later 
  6-17        than at the expiration of each period of 30 days 
  6-18        during the continuance of the period for which the 
  6-19        insurer is liable and any balance remaining unpaid at 
  6-20        the termination of such period will be paid 
  6-21        immediately upon receipt of such proof.  
 
  6-22        (C) Each insurer admitted to transact accident and 
  6-23        sickness insurance in this state shall pay interest to 
  6-24        the insured equal to 18 percent per annum on the 
  6-25        proceeds or benefits due under the terms of the policy 
  6-26        for failure to comply with the requirements of 
  6-27        subparagraph (A) or (B) of this paragraph." 
 
  6-28                           SECTION 6. 
 
  6-29  Sections 2, 3, and 4 of this Act shall apply to plans, 
  6-30  policies, or contracts issued, delivered, issued for 
  6-31  delivery, or renewed on or after the date this Act becomes 
  6-32  effective. 
 
  6-33                           SECTION 7. 
 
  6-34  All laws and parts of laws in conflict with this Act are 
  6-35  repealed. 
 
 
 
 
 
 
 
 
 
 
                                 -6-