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 120-2-44 - PREFERRED PROVIDER ARRANGEMENTS
Rule 120-2-44-.04 - Required Policy Provisions

(1) Preferred provider arrangements shall contain provisions for the continuous review of the utilization of services and facilities, and costs.

(2) Each individual policy or group preferred provider insurance 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 group or individual policyholder shall have given the health care 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 group or individual policyholder may be liable to the health care insurer for payment of a pro rata premium for the time the coverage was in force during such grace period.

(3) Any contract between a health care insurer and the various health care providers shall state that an insured shall be held harmless for provider utilization review decisions over which he has no control. In the absence of such hold harmless agreement, the agreement shall be deemed to be included therein.

(4) If the preferred provider insurance policy or health benefit plan defines a specific service area, the insurer shall not terminate the members coverage because an individual policyholder or group member moves out of the service area.

(5) Differentials in coinsurance percentages which are applicable to benefit levels for services provided by preferred and nonpreferred providers may not exceed thirty percentage points. The coinsurance percentage applicable to benefit levels for services provided by non-preferred providers may not be greater than forty percent (40) of the benefit levels under the policy for such services. Examples of acceptable coinsurance percentages payable by an insured for preferred and nonpreferred providers, respectively, are 0, 30; 5, 35; 10, 40; 20, 40; 30, 40.

(6) Individual preferred provider insurance policies, outlines of coverage or preferred provider insurance certificates shall contain a brief and prominent notice in boldface type reflecting the limitations of the preferred provider policy or health plan benefit. Such warning shall be placed on the face page of the policy, outline of coverage or certificate and refer to the differentials in coinsurance percentages payable by the insureds for preferred and nonpreferred provider services, service area requirements, and emergency care services.

(7) Preferred Provider Insurance policies or certificates shall fully disclose the limitations, differentials, penalties, incentives or other arrangements by which the insurer provides for a primary care physician or other health care provider, as defined by the insurance policy or certificate, to act as a gatekeeper, if any. A gatekeeper shall not be used to restrict access to services or non-preferred providers under the individual preferred provider policy or group preferred provider certificate.

(8) Preferred Provider Insurance policies or certificates shall fully disclose the use of discrete dollar copayments which apply to any covered health care benefits under the policy or certificate. Discrete dollar copayments may be imposed by an insurer in a Preferred Provider Insurance policy or certificate and need not be considered in the determination of percentage differential limitations described in O.C.G.A. Section 33-30-23. Such copayments, if applicable, shall be reasonable in relation to the covered benefits to which they apply, shall serve as an incentive rather than a barrier to access of appropriate care and shall not work so as to unfairly deny necessary health care services.