Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-33 - HEALTH MAINTENANCE ORGANIZATIONS
Rule 120-2-33-.06 - Termination of Coverage or Service

(1) No HMO may cancel or refuse to renew the coverage of an enrollee for any reason which is not related to nonpayment of premium except as provided by the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-67.

(2) No HMO may cease offering a service or terminate a service within a contract period, unless approved arrangements equitable to enrollees are made providing for a rate adjustment or substitution of an equivalent service, and prior approval of the Commissioner is obtained.

(3) When an HMO terminates all or a portion of an enrollee's coverage, or the enrollee, access must be provided to the complaint system set forth in Rule 120-2-33-.09. No such termination shall be effective until the enrollee, if he so desires, and in accordance with the Act and Rule 120-2-33-.09, has exhausted the complaint system.

(4) Notwithstanding paragraphs (5) and (6), an HMO offering a point of service policy form may not terminate coverage under that policy form for a group or individual because no member of that group lives, resides, or works in the approved service area, or, in the case of individual policy coverage, the insured no longer lives, resides, or works in the approved service area.

(5) The HMO shall not terminate the coverage of an enrollee under a group contract or group policy because the enrollee moves out of the approved service area, provided the enrollee continues to be an eligible enrollee of the insured group and agrees in writing to return to the approved service area for covered medical care.

(6) The HMO shall not terminate the coverage of an enrollee under an individual contract because the enrollee moves out of the approved service area, provided the enrollee agrees in writing to return to the approved service area for covered medical care.