09 LC 33
2723ER
Senate
Bill 92
By:
Senators Hill of the 32nd, Johnson of the 1st, Thomas of the 54th, Rogers of the
21st, Murphy of the 27th and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 49 of the Official Code of Georgia Annotated, relating to social
services, so as to convert Medicaid and the PeachCare for Kids Program funds to
premium assistance to allow low-income families to participate in private sector
health insurance plans; to provide for definitions; to provide for an amended
state plan for Medicaid and PeachCare; to designate qualified health benefit
plans; to provide for enrollment in a qualified health benefit plan; to provide
for premium assistance; to provide for premiums and cost sharing; to provide for
an individual incentive program; to provide for health opportunity accounts; to
provide for related matters; to provide for an effective date; to repeal
conflicting laws; and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Title
49 of the Official Code of Georgia Annotated, relating to social services, is
amended by adding a new chapter to read as follows:
"CHAPTER
11
49-11-1.
As
used in this chapter, the term:
(1)
'Commissioner' means the commissioner of community health.
(2)
'Department' means the Department of Community Health.
(3)
'Full benefit eligible individual' means an individual who meets the criteria
established in Section 1937(a)(2)(C)(i) of the Social Security Act (42 U.S.C.
Section 1396u-7).
(4)
'Insurer' means any person or organization subject to the authority of the
Commissioner of Insurance that offers or issues one or more health benefit plans
or insurance in the State of Georgia, and includes an insurer, a hospital and
medical services corporation, a fraternal benefit society, a health maintenance
organization, and a multiple employer welfare arrangement.
(5)
'Medicaid state plan' means the state plan for medical assistance adopted and
administered by the department pursuant to Code Section 49-4-142.
(6)
'PeachCare state plan' means the state plan for the State Children̓s Health
Insurance Program, known as the PeachCare for Kids Program, adopted and
administered by the department pursuant to Code Section 49-5-273.
(7)
'Qualified health benefit plan' means any health benefit plan that is determined
by the commissioner, in accordance with the provisions of Code Section 49-11-3,
to meet the criteria of being either a benchmark benefit plan or a benchmark
equivalent benefit plan as provided for in 42 U.S.C. Section 1396u-7 or 42
U.S.C. Section 1397cc.
(8)
'Self-funded health benefit plan' means a health benefit plan, not subject to
regulation by the State of Georgia or any other state, that is paid in whole or
in part by the employer from its own assets or from a funded welfare benefit
plan, provided that such plan does not shift any risk or liability for benefit
payments to an insurer, other than through reinsurance or stop-loss
coverage.
49-11-2.
(a)
The commissioner shall amend the Medicaid state plan:
(1)
To adopt each of the benchmark benefit plans permitted under Section 1937(b)(1)
of the Social Security Act (42 U.S.C. Section 1396u-7);
(2)
To adopt the benchmark equivalent benefit plan permitted under Section
1937(b)(2) of the Social Security Act (42 U.S.C. Section 1396u-7);
and
(3)
To provide that in calculating the actuarial value of any benchmark equivalent
plan, in accordance with the provisions of Section 1937(b)(3) of the Social
Security Act (42 U.S.C. Section 1396u-7), the actuary shall apply the maximum
cost sharing allowable under Sections 1916 and 1916A of the Social Security Act
(42 U.S.C. Section 1396o-1).
(b)
The commissioner shall amend the PeachCare state plan to:
(1)
To adopt each of the benchmark benefit plans permitted under Section 2103(a)(2)
of the Social Security Act (42 U.S.C. Section 1397cc);
(2)
To adopt the benchmark equivalent benefit permitted under Section 2103(a)(1) of
the Social Security Act (42 U.S.C. Section 1397cc); and
(3)
To provide that in calculating the actuarial value of any benchmark equivalent
plan, in accordance with the provisions of Section 1937(b)(3) of the Social
Security Act (42 U.S.C. Section 1396u-7), the actuary shall apply the maximum
cost sharing allowable under Section 1916 and Section 1916A of the Social
Security Act (42 U.S.C. Section 1396o-1).
49-11-3.
(a)
The commissioner, in consultation with the Commissioner of Insurance, shall
determine, from among all the health benefit plans offered or issued in the
State of Georgia by insurers, which plans meet the criteria of being either a
benchmark benefit plan or a benchmark equivalent benefit plan, and shall certify
all such plans as qualified health benefit plans for purposes of Code Section
49-11-4.
(b)
The commissioner shall establish procedures for determining, in cases where one
or more eligible individuals are also eligible to enroll in a self-funded health
benefit plan, whether the plan meets the criteria of being either a benchmark
benefit plan or a benchmark equivalent benefit plan, and shall certify all such
plans that meet the criteria as qualified health benefit plans for purposes of
Code Section 49-11-4.
49-11-4.
(a)
The commissioner shall require all full benefit eligible individuals to enroll
in a qualified health benefit plan.
(b)
In the case of a household or family where more than one individual is eligible
for benefits under either Medicaid or the PeachCare for Kids Program, whenever
possible, the commissioner shall enroll all full benefit eligible individuals in
the family or household in the same qualified health benefit plan.
(c)
Individuals who are exempt from mandatory enrollment under the provisions of
Section 1937(a)(2)(C)(ii) of the Social Security Act (42 U.S.C. Section
1396u-7), may elect to opt out of enrollment in a qualified health benefit plan
at any time.
49-11-5.
(a)
The commissioner shall pay, on behalf of eligible individuals, the applicable
individual or family premiums to entities that provide or sponsor qualified
health benefit plans, including plans that are:
(1)
Commercial health plans;
(2)
Managed care organizations; or
(3)
Employer sponsored health insurance plans.
(b)
For reasons of administrative ease and program integrity, the commissioner may
direct that premium assistance payments be made to one or more of the
following:
(1)
Eligible individuals;
(2)
Insurers that issue qualified health benefit plans;
(3)
Plan administrators of qualified self-funded health benefit plans;
and
(4)
One or more administrative agents designated by the commissioner.
49-11-6.
(a)
The commissioner shall calculate the maximum allowable cost sharing for an
eligible individual based on the individual̓s family or household gross
income, including all earned and unearned income.
(b)
Income and expense disregards applied in determining program eligibility shall
not be applied in determining the maximum allowable cost sharing under
subsection (a) of this Code section.
(c)
In cases where an eligible individual enrolled in a qualified health benefit
plan incurs cost sharing during a plan year in excess of the maximum allowable
cost sharing, the commissioner shall pay to the plan or plan sponsor, on behalf
of the individual, any cost sharing incurred by the individual under the terms
of the plan that is in excess of the maximum allowable amount.
49-11-7.
(a)
The commissioner shall establish an incentive program in which cost-sharing
obligations may be reduced for individuals that participate in initiatives to
improve health outcomes and lower health care costs.
(b)
Incentive program activities may include, but are not limited to, appropriate
immunizations, appropriate and cost-effective prescription drug utilization,
self-management of chronic health conditions, and participation in quality
improvement initiatives.
49-11-8.
The
department shall establish a program of Health Opportunity Accounts as provided
for in Section 1938 of the Social Security Act and shall amend the Medicaid
state plan in conformance with Section 1938 of the Social Security
Act."
SECTION
2.
This
Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.