10 LC
37 1098S
The
House Committee on Insurance offers the following substitute to SB
50:
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 33 of the Official Code of Georgia Annotated, relating to insurance,
so as to provide definitions; to provide for applicability; to provide for the
registration of certain rental preferred provider networks; to provide for
enforcement; to specify that a private cause of action is not created; to
provide an effective date; to repeal conflicting laws; and for other
purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by adding a new chapter to read as follows:
"CHAPTER
20C
33-20C-1.
As
used in this chapter, the term:
(1)
'Commissioner' means the Commissioner of Insurance.
(2)
'Department' means the Department of Insurance.
(3)
'Health care services' means the examination or treatment of persons for the
prevention of illness or the correction or treatment of any physical or mental
condition resulting from illness, injury, or other human physical problem and
includes, but is not limited to:
(A)
Hospital services which include the general and usual care, services, supplies,
and equipment furnished by hospitals;
(B)
Medical services which include the general and usual services and care rendered
and administered by doctors of medicine, doctors of dental surgery, and doctors
of podiatry; and
(C)
Other health care services which include appliances and supplies; nursing care
by a registered nurse or a licensed practical nurse; care furnished by such
other licensed practitioners as may be expressly approved by the board of
directors from time to time; institutional services, including the general and
usual care, services, supplies, and equipment furnished by health care
institutions and agencies or entities other than hospitals; physiotherapy;
ambulance services; drugs and medications; therapeutic services and equipment,
including oxygen and the rental of oxygen equipment; hospital beds; iron lungs;
orthopedic services and appliances, including wheelchairs, trusses, braces,
crutches, and prosthetic devices, including artificial limbs and eyes; and any
other appliance, supply, or service related to health care.
(4)
'Health insurance plan' means any hospital and medical expense incurred policy,
nonprofit health care service plan contract, health maintenance organization
subscriber contract, or any other health care plan or arrangement that pays for
or furnishes medical or health care services, whether by insurance or otherwise.
The term shall not include any of the following: coverage only for accident or
disability income insurance; coverage issued as a supplement to liability
insurance; liability insurance, including general liability insurance and
automobile liability insurance; automobile medical payment insurance; insured or
self-insured workers' compensation insurance; credit-only insurance; coverage
for on-site medical clinics; coverage similar to the foregoing as specified in
federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits
for medical care are secondary or incidental to other insurance benefits;
benefits for long-term care, nursing home care, home health care, or community
based care; specified disease or illness coverage, hospital indemnity or other
fixed indemnity insurance, or such other similar, limited benefits as are
specified in regulations; medicare supplemental health insurance as defined
under Section 1882(g)(1) of the federal Social Security Act; coverage
supplemental to the coverage provided under Chapter 55 of Title 10 of the United
States Code; or other similar limited benefit supplemental
coverages.
(5)
'Provider' means an individual licensed pursuant to Chapter 9, 11, 26, 30, or 34
of Title 43 or Chapter 4 of Title 26, a physician organization, or a physician
hospital organization that is acting exclusively as an administrator on behalf
of a provider to facilitate the provider's participation in health care
contracts. The term shall not include a physician organization or physician
hospital organization that leases or rents the physician organization's or
physician hospital organization's network to a third party.
(6)
'Provider network contract' means a contract between a rental preferred provider
network and a provider specifying the rights and responsibilities of the
contracting entity and provider for the delivery of and payment for health care
services to covered individuals.
(7)
'Rental preferred provider network' means a preferred provider network that
contracts with an insurer or other payor or with another preferred provider
network to grant access to the terms and conditions of its contract with medical
physicians. Such contracts are often referred to as 'renting' or 'leasing' the
network. The term 'rental preferred provider network' does not refer to a
proprietary network of a licensed insurer or to arrangements providing for
access to the proprietary network of a licensed insurer by affiliates of the
licensed insurer or by entities receiving administrative services from the
licensed insurer or its affiliates.
(8)
'Third party' means an organization that enters into a contract with a
contracting entity or with another third party to gain access to a provider
network contract. 'Third party' shall not include the contracting entity's
subsidiaries and affiliates. 'Third party' shall also not include any
self-funded, employer sponsored health insurance plan regulated under the
Employee Retirement Income Security Act of 1974, as codified and amended at 29
U.S.C. 1001, et seq.
33-20C-2.
(a)
This chapter shall not apply to provider network contracts for services provided
to Medicaid, medicare, or State Children's Health Insurance Program (SCHIP)
beneficiaries.
(b)
This chapter shall not apply to employers, church plans, or government plans
receiving administrative services from a rental preferred provider network or
its affiliates, or pharmacy benefits managers.
(c)
This chapter shall not apply in circumstances where access to the provider
network contract is granted to an entity operating under the same brand licensee
program as the contracting entity.
(d)
This chapter shall not apply to the provision of any medical services for
injuries covered by workers' compensation.
(e)
This chapter shall not apply to health insurance plans.
33-20C-3.
(a)
Any person who commences business as a rental preferred provider network shall
register with the Commissioner within 30 days of commencing business in this
state unless such person is licensed by the Commissioner as an insurer. Each
rental preferred provider network not licensed by the Commissioner on July 1,
2010, shall be required to register with the Commissioner within 90 days
following July 1, 2010, and shall be placed on an approved list maintained by
the Commissioner.
(b)
Registration shall consist of the submission of the following
information:
(1)
The official name of the rental preferred provider network, including any d/b/a
designations used in this state;
(2)
The mailing address and main telephone number for the rental preferred provider
network's main headquarters; and
(3)
The name and telephone number of the rental preferred provider network
representative who shall serve as the primary contact with the
department.
(c)
The information required by this Code section shall be submitted in written or
electronic format, as prescribed by the Commissioner by rule or
regulation.
(d)
The Commissioner may, pursuant to rule or regulation, collect a reasonable fee
for the purpose of administering the registration process.
(e)
The Commissioner shall maintain an approved list of rental preferred provider
networks.
33-20C-5.
It
shall be grounds for the Commissioner to remove a rental preferred provider
network from the approved list and thereby revoke the registration of such
rental preferred provider network if the Commissioner finds that the entity
has:
(1)
Knowingly accessed or utilized a provider's contractual discount pursuant to a
provider network contract without a contractual relationship with the provider,
rental preferred provider network, or third party; or
(2)
Leased, rented, or otherwise granted to a third party access to a provider
network contract unless the third party accessing the health care contract
is:
(A)
A payor or third party administrator or another entity that administers or
processes claims on behalf of the payor;
(B)
A preferred provider organization or preferred provider network, including a
physician organization or physician-hospital organization; or
(C)
An entity engaged in the electronic claims transport between the preferred
provider network and the payor that does not provide access to the provider's
services and discount to any other third
party."
SECTION
2.
This
Act shall become effective on July 1, 2010.
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.