10 LC
37 1078S
The
Senate Insurance and Labor Committee offered the following substitute to HB
412:
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 contracting entities; to prohibit access to a provider's
health care services and contractual discounts by certain contracting entities
under certain circumstances; to provide certain requirements for contracting
entities; to provide for the rights and responsibilities of third parties; to
prohibit unauthorized access to provider network contracts; to provide for
enforcement; to provide for an effective date and applicability; 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)
'Contracting entity' means any person or entity that enters into direct
contracts with providers for the delivery of health care services in the
ordinary course of business.
(3)
'Control' and 'under common control with' mean possession, directly or
indirectly, of the power to direct or cause the direction of the management and
policies of an entity through the ownership of 50 percent or more of the voting
securities of the entity.
(4)
'Covered individual' means an individual who is covered under a health insurance
plan.
(5)
'Department' means the Department of Insurance.
(6)
'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.
(7)
'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; 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.
(8)
'Provider' means an individual licensed pursuant to Chapter 9, 10A, 11, 26, 30,
or 34 of Title 43 or Chapter 4 of Title 26, an institution as defined in Chapter
7 of Title 31, 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.
(9)
'Provider network contract' means a contract between a contracting entity 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.
(10)
'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.
33-20C-2.
(a)
This chapter shall not apply to provider network contracts for services provided
to Medicaid, medicare, the state employees' health insurance plan authorized
under Article 1 of Chapter 18 of Title 45, or State Children's Health Insurance
Program (SCHIP) beneficiaries.
(b)
This chapter shall not apply in circumstances where access to the provider
network contract is granted to an affiliate entity under common control with or
under the same brand licensee program as the contracting entity. Contracting
entities shall, however, make the list of such affiliate entities available on a
website or by other means. The affiliate entities shall have the same rights and
responsibilities under the provider network contracts as the contracting
entities.
(c)
This chapter shall not apply to a contract between a contracting entity and a
discount medical plan organization.
(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 a pharmacy benefits manager.
33-20C-3.
(a)
Any person who commences business as a contracting entity shall register with
the Commissioner within 90 days of commencing business in this state unless such
person is licensed by the Commissioner as an insurer. Effective July 1, 2010,
each person not licensed by the Commissioner as a contracting entity shall be
required to register with the Commissioner within 90 days following July 1,
2010.
(b)
Registration shall consist of the submission of the following
information:
(1)
The official name of the contracting entity, including any d/b/a designations
used in this state;
(2)
The mailing address and main telephone number for the contracting entity's main
headquarters; and
(3)
The name and telephone number of the contracting entity's 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.
33-20C-4.
(a)
A contracting entity shall not grant access to a provider's health care services
and contractual discounts pursuant to a provider network contract
unless:
(1)
The provider network contract specifically states that the contracting entity
may enter into an agreement with a third party allowing the third party to
obtain the contracting entity's rights and responsibilities under the provider
network contract as if the third party were the contracting entity;
(2)
The third party has a contractual right to access the contractual rates or
discounts in the provider network contract, and such third parties shall
reimburse the provider in accordance with the rates established in the provider
network contract; and
(3)
The third party accessing the provider network contract is contractually
obligated to comply with all applicable terms, limitations, and conditions of
the provider network contract.
(b)
A contracting entity that grants access to a provider's health care services and
contractual discounts pursuant to a provider network contract
shall:
(1)
Identify and provide to the provider, at the time a provider network contract is
entered into with a provider, a written or electronic list of all third parties
known at the time of contracting to which the contracting entity has or will
grant access to the provider's health care services and contractual discounts
pursuant to a provider network contract;
(2)
Maintain an Internet website or other readily available mechanism, such as a
toll-free telephone number, through which a provider may obtain a listing,
updated at least every 90 days, of the third parties to which the contracting
entity or another third party has executed contracts to grant access to such
provider's health care services and contractual discounts pursuant to a provider
network contract;
(3)
Provide the third party who contracts with the contracting entity to gain access
to the provider network contract with sufficient information regarding the
provider network contract to enable the third party to comply with all
applicable terms, limitations, and conditions of the standard provider network
contract;
(4)
Require that the third party who contracts with the contracting entity to gain
access to the provider network contract identify the source of the contractual
discount taken by the third party on each remittance advice (RA) or explanation
of payment (EOP) form furnished to a health care provider when such discount is
pursuant to the contracting entity's provider network contract; and
(5)
Notify the third party that contracts with the contracting entity to gain access
to the provider network contract of the termination of the provider network
contract no later than 30 days after receipt of notice of the termination of the
provider network contract; and require those that are by contract eligible to
claim the right to access a provider's discounted rate to cease claiming
entitlement to those rates or other contracted rights or obligations for
services rendered after termination of the provider network contract. The
notice required under this paragraph may be provided through any reasonable
means, including, but not limited to written notice, electronic communication,
or an update to an electronic data base or other provider listing.
(c)
Subject to any applicable continuity of care requirements, agreements, or
contractual provisions:
(1)
A third party's right to access a provider's health care services and
contractual discounts pursuant to a provider network contract shall terminate on
the date the provider network contract is terminated;
(2)
In accordance with the provider network contract, claims for health care
services performed after the termination date of the provider network contract
shall not be eligible for processing and payment; and
(3)
Claims for health care services performed before the termination date of the
provider network contract, but processed after the termination date, shall be
eligible for processing and payment in accordance with the provider network
contract.
(d)
All information made available to a provider in accordance with the requirements
of this chapter shall be confidential and shall not be disclosed to any person
or entity not involved in the provider's practice or the administration thereof
without the prior written consent of the contracting entity.
(e)
Nothing contained in this chapter shall be construed to prohibit a contracting
entity from requiring the provider to execute a reasonable confidentiality
agreement to ensure that confidential or proprietary information disclosed by
the contracting entity is not used for any purpose other than the provider's
direct practice management or billing activities.
33-20C-5.
(a)
A third party, having itself been granted access to a provider's health care
services and contractual discounts pursuant to a provider network contract, that
subsequently grants access to another third party shall be obligated to comply
with the rights and responsibilities imposed on contracting entities under Code
Sections 33-20C-4 and 33-20C-6.
(b)
A third party that enters into a contract with another third party to access a
provider's health care services and contractual discounts pursuant to a provider
network contract shall be obligated to comply with the rights and
responsibilities imposed on third parties under this Code section.
(c)(1)
A third party shall provide to the contracting entity the location of an
Internet website, or identify another readily available mechanism such as a
toll-free telephone number, which the contracting entity will make available to
the providers under the provider network contract accessed through the
contracting entity. The website or other readily available mechanism shall
identify the name of the person or entity to which the third party subsequently
grants access to the provider's health care services and contractual discounts
pursuant to the provider network contract.
(2)
The website shall allow the providers under the contracting entity's provider
network contract access to the information referenced in paragraph (1) of this
subsection and shall be updated on a routine basis as additional persons or
entities are granted access. The website shall be updated every 90 days to
reflect all current persons and entities with access. Upon request, a
contracting entity shall make updated access information available to a provider
by telephone or through direct notification.
33-20C-6.
(a)
It shall be an unfair trade practice for the purposes of Article 1 of Chapter 6
of this title to knowingly access or utilize a provider's contractual discount
pursuant to a provider network contract without a contractual relationship with
the provider, contracting entity, or third party, as specified in this
chapter.
(b)
A provider may refuse the discount taken on a remittance advice (RA) or
explanation of payment (EOP) if the discount is taken without a contractual
basis or in violation of paragraph (2) of subsection (b) of Code Section
33-20C-4 and subsection (c) of Code Section 33-20C-5 concerning the services
referenced on the RA or EOP.
(c)
A contracting entity shall not lease, rent, or otherwise grant to a third party
access to a provider network contract unless the third party accessing the
health care contract is:
(1)
A payor or third party administrator or another entity that administers or
processes claims on behalf of the payor;
(2)
A preferred provider organization or preferred provider network, including a
physician organization or physician-hospital organization; or
(3)
An entity engaged in the electronic claims transport between the contracting
entity and the payor that does not provide access to the provider's services and
discount to any other third party.
33-20C-7.
A
violation of this chapter shall be an unfair trade practice under Article 1 of
Chapter 6 of this title and shall be subject to the same enforcement as provided
in such article."
SECTION
2.
This
Act shall become effective on July 1, 2010, and shall apply to provider network
contracts entered into or materially amended on or after such date.
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.