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-.08 - Rates and Forms

Universal Citation: GA Rules and Regs r 120-2-33-.08

Current through Rules and Regulations filed through March 20, 2024

(1) Basic rates along with the method of computation of charges for enrollee coverage or any amendments thereto to be used in conjunction with any health benefits plan must be filed with and approved by the Commissioner prior to use.

(2) The Commissioner shall approve or disapprove any basic rate or method of computation of charges, or change thereto, as provided in O.C.G.A. Section 33-21-13.

(3) Such basic rates and methods of computation of charges shall be established in accordance with actuarial principles for various categories of enrollees, provided that charges applicable to an enrollee shall not be individually determined based on the status of health.

(4) Basic rates and charges shall not be excessive, inadequate, or unfairly discriminatory.

(5) A certification by a qualified actuary to the appropriateness of the basic rates, based on reasonable assumptions, shall accompany the filing, along with adequate supporting information. Supporting information shall include a detailed description, as applicable, but not necessarily limited to the following:

(a) projected and actual hospital utilization in days per thousand members per year;

(b) projected and actual hospital costs attributable to those hospitals specifically utilized by the HMO through contract or otherwise;

(c) projected and actual utilization of physician services, expressed in terms of numbers of visits per member per year;

(d) projected and actual costs of physician services, expressed in terms of cost per visit;

(e) projected and actual costs of emergency and out of area services of non-HMO providers, differentiated as to hospital and medical service components;

(f) identification, justification and derivation of any trend or protection factors; and

(g) identification and justification for any reserve or surplus contribution factor included within its charges.

(6) The HMO shall submit to the Commissioner every contract, policy, certificate or evidence of coverage, rider, endorsement, application or outline of coverage for approval prior to use in this State.

(7) Each form shall have the corporate name and address of the HMO as on file with the Commissioner. Any name or title of the policy shall be printed in a size of type smaller than that used for the name of the HMO. All material shall be printed in accordance with the standards set forth in O.C.G.A. Section 33-29-2.

(8) Each form shall be clearly worded with all limitations, exclusions and exceptions printed in the same size of type used to describe the benefits and grouped together under appropriate captions and bold face type.

(9) An enrollee under an individual contract may, if not satisfied for any reason, return the contract or other evidence of coverage within ten (10) days of receipt and receive a full refund of any payment made. This right may not be exercised if the enrollee utilizes the services of the HMO within the ten (10) day period unless the enrollee pays the reasonable cost of said services.

(10) Each group contract or group policy shall contain a provision that the policyholder is entitled to a grace period of not less than thirty-one (31) days for the payment of any premium due except the first, during which grace period the coverage shall continue in force, unless the policyholder shall have given the insurer notice of discontinuance thirty (30) days in advance of the date of discontinuance and in accordance with the terms of the policy. The policy may provide that the policyholder may be liable to the HMO for payment of a pro rate premium for the time the coverage was in force during such grace period.

(11) Individual contract or policies shall be subject to O.C.G.A. Section 33-29-3(b)(3).

O.C.G.A. Secs. 33-2-9, Ch. 33-21.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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