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 120-2-75 - REGULATION OF PROVIDER SPONSORED HEALTH CARE CORPORATIONS
Rule 120-2-75-.05 - Participation in Fund

Universal Citation: GA Rules and Regs r 120-2-75-.05

Current through Rules and Regulations filed through September 23, 2024

(1) Each provider sponsored health care corporation shall obtain a certificate of authority from the Commissioner prior to establishing, maintaining and operating a health care plan in this State. In addition to the documents and information set forth in O.C.G.A. § 33-20-8, each provider sponsored health care corporation must also accompany its application for a certificate of authority with the following documents and information:

(a) A copy of the applicant's Charter or Articles of Incorporation, and all amendments thereto;

(b) A copy of the Applicant's Bylaws or other similar document regulating the conduct of the internal affairs of the applicant;

(c) A list of the names, addresses, official positions and biographical information of the persons who are to be responsible for the conduct of affairs and day-to-day operations of the applicant, including all members of the Board of Directors or the governing body or committee and the principal officers of the applicant and the names and addresses of each person entitled to cast five percent (5%) or more of the votes for selection of members of applicant's governing body;

(d) A copy of any contract form made or to be made between any provider, facility, class or providers and the applicant, and a copy of any contract made or to be made between the applicant and persons listed in subparagraph (c) above;

(e) A detailed description of the type of benefits to be furnished, including information concerning division of benefits into classes or kinds and reasons for division of benefits into classes and kinds;

(f) Every contract, policy, certificate or evidence of coverage, rider, endorsement, application or outline of coverage which it intends to use prior to use;

1. Basic rates and rating methodology accompanied by an actuarial certification, including assumptions upon which proposed levels and methods of reimbursement or other considerations for the health care services are based. The Actuarial Certification should state that the consideration for services is adequate, and makes provision for expected medical expenses, administrative expenses and margins for contingencies.

(g) Financial and other statements showing the applicant's assets, liabilities, sources of financial support, and sources of ability to cause health care services to be delivered to its enrollees, subscribers and covered dependents;

(h) A statement or map reasonably describing the counties or geographic area or areas to be served; listings of the providers by category and specialty within those counties or areas and such other detail as the Commissioner may reasonably require to ensure that services are available and accessible and to ensure continuity of service;

(i) A description of the internal grievance procedures to be utilized for the investigation and resolution of complaints and grievances by enrollees or subscribers and covered dependents;

(j) A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, and procedures for comprehensive evaluation of the quality of care rendered to enrollees, subscribers and covered dependents;

(k) A security deposit in the amount of at least $100,000.00 as required pursuant to O.C.G.A. § 33-3-8(b)(1);

(l) Form GID-3 Appointment of Attorney for Service of Process naming a natural person who is a resident of the State of Georgia, giving business and home address;

(m) A signed agreement stating that the provider sponsored health care corporation shall distribute certain information on a periodic basis to enrollees and subscribers regarding wellness services and preventive care offered by the provider sponsored health care corporation. Such information shall be submitted to the Office of Commissioner of Insurance for approval at least ninety (90) days before it is expected to be distributed to enrollees and subscribers.

(2) Within one hundred eighty (180) days of receipt of the completed application and a fee of $600.00, the Commissioner shall issue a certificate of authority; deny said application; or provide a written description of deficiencies in the application to the applicant.

(3) Before a certificate of authority can be issued, the Commissioner must be satisfied that:

(a) The persons responsible for the conduct of the affairs of the applicant are competent and trustworthy;

(b) The provider sponsored health care corporation has medical, administrative and financial capability to effectively provide the range of health care services as proposed in its application on a prepaid basis, except for copayments and/or deductibles; and

(c) The provider sponsored health care corporation is in compliance with the applicable provisions of the Georgia Insurance Code and the Rules and Regulations of the Georgia Insurance Department.

(4) The burden of proving compliance with the requirements necessary for issuance of a certificate of authority shall be and remain on the applicant at all times.

O.C.G.A. Secs. 33-2-9, 33-20-8.

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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