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 120-2-79 - HEALTH PLAN PURCHASING COOPERATIVES
Rule 120-2-79-.16 - Additional Powers of and Restrictions on Purchasing Cooperative

(a) Set reasonable fees, which may vary by employer size, for membership in the health plan purchasing cooperative that will finance reasonable and necessary costs incurred in administering the health plan purchasing cooperative;

(b) Contract with independent third parties licensed by the Commissioner for any service necessary to carry out the powers and duties authorized or required by Title 33, Chapter 30A of the Official Code of Georgia and this Regulation Chapter;

(c) Contract with licensed insurance agents to market and service health benefit plans made available through the health plan purchasing cooperative to its members, provided that compensation for agents shall not vary based on the actual or expected experience or health status of the member or persons to which coverge is sold;

(d) Establish written standards to be met by participating carriers, including but not limited to benefit design, access, quality assurance, data collection, and cost, and accept or reject proposals from carriers for participation in the health plan purchasing cooperative based on such articulated standards, provided that carriers shall be responsible for determining the benefits, rates and underwriting criteria applicable to health benefit plans and for securing reinsurance, if any;

(e) Negotiate with participating carriers the administrative expense component of the premium rates charged for coverage offered through the health plan purchasing cooperative;

(f) Provide other services to members pursuant to O.C.G.A. § 33- 30A-2(b) provided that any insurance coverage offered by the health plan purchasing cooperative shall have complied with all applicable requirements of Title 33 of the Official Code of Georgia; and

(g) Establish written standards with participating carriers for the intake, processing, and resolution of member grievances pertaining to a health benefit plan and addressed or appealed to the health plan purchasing cooperative.

(a) Exclude from membership, or prevent continuation of membership for, a small employer who has met the conditions of membership established pursuant to O.C.G.A. § 33-30A-4(b)(1), agrees to pay and in fact does pay fees for membership and the premium for health benefit plan coverage through the health plan purchasing cooperative, and abides by the bylaws and rules of the health plan purchasing cooperative;

(b) The event that a health plan purchasing cooperative elects to accept other classes of membership pursuant to O.C.G.A. §33-30A- 4(3) or (4), exclude any employer or individual in such a class from membership, or prevent continuation of membership, in the health plan purchasing cooperative, provided that the employer or individual has met the conditions of membership established pursuant to O.C.G.A. § 33-30A-4(b)(1), agrees to pay fees for membership and the premium for health benefit plan coverage through the health plan purchasing cooperative, and abides by the bylaws and rules of the health plan purchasing cooperative;

(c) Exclude from coverage or decline for coverage an eligible employee or dependent of an eligible employee;

(d) Place any insurance coverage on behalf of a member with a carrier that is not authorized or approved by the Commissioner to do business in Georgia;

(e) Provide for any self-insurance or reinsurance of benefits provided to any member, or collection of members or eligible individuals, or any other arrangement covering health care expenses which is not through a health benefit plan from an insurer, health maintenance organization, or health care corporation holding an appropriate certificate of authority from the Commissioner;

(f) Charge a fee not directly related to the operation of the health plan purchasing cooperative;

(g) Engage in any unfair trade practice defined in Chapter 6 of Title 33 of the Official Code of Georgia;

(h) Fail to submit requested documentation to the Office of Commissioner of Insurance that pertains to this Regulation Chapter, or applicable provisions of the Official Code of Georgia, or any complaints or inquiries regarding the business practices of a health plan purchasing cooperative within a reasonable time frame as determined by the Commissioner; and

(i) Intentionally misrepresent or withhold any data or information that has been provided by the member and is pertinent to the lawful underwriting criteria of a health benefit plan, or intentionally misrepresent the terms or existence of any such health benefit plan in any way.