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| Georgia General Assembly |
HB169.html
01 LC 21 6463S
The Senate Insurance and
Labor Committee offered the following substitute to HB
169:
A BILL TO BE
ENTITLED
AN ACT
To provide for a short title and legislative findings; to
amend Title 33 of the Official Code of Georgia Annotated, relating to insurance,
so as to define certain terms; to provide standards and procedures for
verification of benefits and precertifications relating to managed health
benefit plans; to provide for liability and personnel; to provide for
applicability; to include among unfair insurance practices certain practices of
insurers and managed care entities with regard to health benefit plans; to
expressly provide that the amount of a penalty for violation of provisions
relating to the timely payment of health benefits shall not apply toward any cap
on benefits payable; to repeal conflicting laws; and for other
purposes.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF
GEORGIA:
SECTION 1.
This Act shall be known as and may be cited as the
"Consumers´ Health Insurance Protection Act."
SECTION 2.
The General Assembly finds that the enactment of the
"Consumers´ Health Insurance Protection Act" is needed
to:
(1) Ensure that consumers receive benefits under
health benefit plans fairly and equitably and in a manner based on reasonable
expectations between consumers and their health benefit plans and health care
providers;
(2) Maximize accountability and the
consumer´s ability to comply with health benefit plan requirements;
and
(3) Reduce unanticipated financial burdens upon
consumers under such health benefit plans.
SECTION 3.
Title 33 of the Official Code of Georgia Annotated, relating
to insurance, is amended by striking in its entirety Code Section 33-20A-3,
relating to definitions, and inserting in lieu thereof the
following:
"33-20A-3.
As
used in this article, the term:
(1) 'Commissioner'
means the Commissioner of Insurance.
(2) 'Emergency
services' or 'emergency care' means those health care services that are provided
for a condition of recent onset and sufficient severity, including but not
limited to severe pain, that would lead a prudent layperson, possessing an
average knowledge of medicine and health, to believe that his or her condition,
sickness, or injury is of such a nature that failure to obtain immediate medical
care could result in:
(A) Placing the patient´s
health in serious jeopardy;
(B) Serious impairment to
bodily functions; or
(C) Serious dysfunction of any
bodily organ or part.
(2.1)(3)
'Enrollee' means an individual who has elected to contract for or participate in
a managed care plan for that individual or for that individual and that
individual´s eligible dependents.
(4)
'Facility' means a hospital, ambulatory surgical treatment center, birthing
center, diagnostic and treatment center, or similar institution for examination,
diagnosis, treatment, surgery, or maternity care but does not include
physicians´ or dentists´ private offices and treatment rooms in which
such physicians or dentists primarily see, consult with, and treat
patients.
(5) 'Health benefit plan' has the
same meaning as provided in Code Section
33-24-59.5.
(3)(6) 'Health
care provider' or 'provider' means any physician, dentist, podiatrist,
pharmacist, optometrist, psychologist, clinical social worker, advance practice
nurse, registered optician, licensed professional counselor, physical therapist,
marriage and family therapist, chiropractor, athletic trainer qualified pursuant
to paragraph (1) or (2) of subsection (a) of Code Section 43-5-8, occupational
therapist, speech language pathologist, audiologist, dietitian, or
physician´s
assistant.
(4)(7) 'Limited
utilization incentive plan' means any compensation arrangement between the plan
and a health care provider or provider group that has the effect of reducing or
limiting services to
patients.
(5)(8) 'Managed
care contractor' means a person who:
(A)
Establishes, operates, or maintains a network of participating providers;
(B) Conducts or arranges for utilization review
activities; and
(C) Contracts with an insurance
company, a hospital or medical service plan, an employer, an employee
organization, or any other entity providing coverage for health care services to
operate a managed care
plan.
(6)(9) 'Managed care
entity' includes an insurance company, hospital or medical service plan,
hospital, health care provider network, physician hospital organization, health
care provider, health maintenance organization, health care corporation,
employer or employee organization, or managed care contractor that offers a
managed care plan.
(7)(10)
'Managed care plan' means a major medical, hospitalization, or dental plan that
provides for the financing and delivery of health care services to persons
enrolled in such plan through:
(A) Arrangements with
selected providers to furnish health care services;
(B) Explicit standards for the selection of
participating providers; and
(C) Cost savings for
persons enrolled in the plan to use the participating providers and procedures
provided for by the plan; provided, however, that the term 'managed care plan'
does not apply to Chapter 9 of Title 34, relating to workers´
compensation.
(8)(11) 'Out of
network' or 'point of service' refers to health care items or services provided
to an enrollee by providers who do not belong to the provider network in the
managed care plan.
(8.1)(12)
'Patient' means a person who seeks or receives health care services under a
managed care plan.
(13) 'Precertification' means a
determination made by an insurer or agent thereof prior to an enrollee´s
receiving health care services that such services are a medical necessity, as
defined in Code Section
33-20A-31.
(9)(14)
'Qualified managed care plan' means a managed care plan that the Commissioner
certifies as meeting the requirements of this
article.
(15) 'Verification of benefits' means a
determination by an insurer or agent thereof of whether given health care
services are a covered benefit under the enrollee´s health benefit plan
without a determination as to whether the services are a medical necessity for
an enrollee under the
plan."
SECTION 4.
Said title is further amended by inserting immediately
following Code Section 33-20A-7 a new Code section to read as
follows:
"33-20A-7.1.
(a)
The provisions of this chapter shall apply to any managed care plan offered
pursuant to Article 1 of Chapter 18 of Title 45 and to any managed care plan
offered by any managed care entity.
(b) When an enrollee, a provider, or a facility requests
verification of benefits from a managed care plan, such managed care plan shall
advise the caller in a nonrecorded statement that:
(1)
Such verification is only a determination of whether given health care services
are a covered benefit under the health benefit plan and is not a guarantee of
payment for those services; and
(2) If the health care
services so verified are a covered benefit, whether precertification is required
and the phone number to request precertification.
(c)
When an enrollee, provider, or facility obtains precertification for any covered
health care service, the managed care plan is liable for such services at the
reimbursement level provided under the health benefit plan for such services
unless the enrollee is no longer covered under the plan at the time the services
are received by the enrollee.
(d) Any managed care
plan which requires precertification shall have personnel available 24 hours a
day, seven days a week, to provide such precertifications by
telephone.
(e) This Code section shall apply only to
health benefit plan contracts issued, delivered, issued for delivery, or renewed
in this state on or after July 1,
2001."
SECTION 5.
Said title is further amended by inserting between
paragraphs (12) and (13) of Code Section 33-6-5, relating to unfair insurance
practices, the
following:
"(12.1)
No insurer or managed care entity subject to licensing by the Commissioner shall
violate any provision of Chapter 20A of Title
33;"
SECTION 6.
Said title is further amended by striking subsection (c) of
Code Section 33-24-59.5, relating to timely payment of health benefits,
notification of failure to pay, and penalty for violation, and inserting in
lieu thereof the
following:
"(c)
Each insurer shall pay to the insured or other person claiming payments under
the health benefit plan interest equal to 18 percent per annum on the proceeds
or benefits due under the terms of such plan for failure to comply with
subsection (b) of this Code section. No amount of any such interest penalty
shall be applied toward any cap on benefits payable to the insured or other
person claiming payments under the health benefit
plan."
SECTION 7.
All laws and parts of laws in conflict with this Act are
repealed.