Current through Rules and Regulations filed through September 23, 2024
(1) For purposes of renewability, health plan purchasing cooperatives, members, and participating carriers shall be subject to Rule 120-2-67-.09 with regard to renewability and non-termination of coverage, and coverage under a health plan purchasing cooperative shall be considered coverage under a true association for such purposes. In particular:
(a) With respect to Rule 120-2-67-.09, the health plan purchasing cooperative shall be considered the policyholder;
(b) The written agreement or contract between the health plan purchasing cooperative and participating carriers shall specify the terms of renewal and shall define the date of renewal; and
(c) The health plan purchasing cooperative is responsible for assuring continuity and renewal of coverage for members under Rule 120-2-67-.09 in the event a participating insurer no longer participates in a health plan purchasing cooperative, and shall not exclude a member from coverage under any health benefit plan at any time.
(2) A member of a health plan purchasing cooperative may have its coverage under a health benefit plan nonrenewed, canceled, or terminated pursuant to the written agreement or contract between the health plan purchasing cooperative and a participating carrier, only if:
(a) The member has failed to pay premiums, contributions, membership or administrative fees, as applicable, in accordance with the terms of membership or the health benefit plan, including any timeliness requirements, subject to applicable State law;
(b) The member has performed an act or practice that constitutes fraud or intentional misrepresentation of material fact in applying for or procuring coverage under the terms of membership or the health benefit plan;
(c) The member has violated the applicable minimum contribution or participation rules as set by the health plan purchasing cooperative, provided that the health plan purchasing cooperative or participating carrier submits written notice to each affected member and provides such member sixty (60) days in which to bring the member into compliance prior to cancellation; or
(d) None of the member's employees or enrollees live, reside, or work in the service area of the provider network, only if the health benefit plan is issued by a health maintenance organization or a provider-sponsored health care corporation, unless there is at least one insured employee or enrollee who has agreed to return to the service area of a health maintenance organization in accordance with the Rule 120-2-33-.06(5).
(3) If a health plan purchasing cooperative, because of insolvency or nonrenewal, suspension, or revocation of its certificate of authority, fails to continue to make coverage available to member small employers through participating carriers, all participating carriers at the time of such failure shall, subject to guidelines established by the Commissioner for the assumption, rehabilitation, or liquidation of the particular health plan purchasing cooperative, or in any decision to revoke or suspend the certificate of authority, do one of the following:
(a) In the event of a health plan purchasing cooperative which allowed employer choice, continue covering and renewing each member as a policyholder pursuant to Rule 120-2-67-.09; or
(b) In the event of a health plan purchasing cooperative which allowed employee choice, not discontinue coverage until the renewal date that otherwise would have applied to the health plan purchasing cooperative or to each member, and then
(1) With regard to every small employer member, offer the option to purchase all group policies currently being offered to or renewed by small employers in this State;
(2) With regard to every large employer member, offer the option to purchase any other group policy from the carrier currently being offered to or renewed by a large employer in this State; or
(3) With regard to every individual member pursuant to O.C.G.A. §
33-30A-4(4), offer the option to purchase any other individual policy most similar to the group policy under which the individual was covered, or any other similar group policy currently being offered to or renewed by small employers in this State.
(4) With regard to compliance with subparagraph (3)(b), a participating carrier which is a health maintenance organization or provider- sponsored health care corporation shall not be required to offer coverage to a member without any employees who live, work, or reside in the service area of the carrier, or offer coverage to an individual member who does not live, work, or reside in the service area of the carrier.
(5) In the event the participating carrier completes its obligation to issue a health benefit plan under the terms of an agreement with a health plan purchasing cooperative which opts not to renew the agreement, the participating carrier shall:
(a) Provide notice of the decision at least 180 days prior to the nonrenewal of any health benefit plan (or the first nonrenewal of any member under such health benefit plan) to the members and enrollees;
(b) Not terminate coverage prior to the renewal date of the health benefit plan, or the renewal date of any member covered under the health benefit plan provided that such renewal date is at least 180 days after the date of notice stipulated in subparagraph (5)(a) of this Rule; and
(c) Be prohibited from writing new business through the health plan purchasing cooperative consistent with the Portability and Renewability requirements in the federal Health Insurance Portability and Accountability Act of 1996 and applicable laws and Rules and Regulations of the State of Georgia.
(5) Upon such time as notice is sent by a carrier in accordance with subparagraph (5)(a) of this Rule, the health plan purchasing cooperative shall make available through all other participating carriers any other coverage to affected members and enrollees to assure continuity of coverage within the health plan purchasing cooperative.
(6) Subject to paragraphs (3) and (4), no health plan purchasing cooperative shall have the unilateral authority to move the coverage of a member group to a new carrier.
(7) Any individual in this state, insured through a health benefit plan offered by a health plan purchasing cooperative and whose coverage under such plan terminates as a result of termination of employment or cessation of membership or the employer's membership in the health plan purchasing cooperative without replacement group coverage, regardless of the situs of the group policy, shall be entitled to continuation and conversion rights as required under O.C.G.A. §
33-24-21.1, Rules 120-2-10-.11 and 120-2-10-.11 A, and under the federal Consolidated Omnibus Budget Reconciliation Act of 1986.
(8) Where a health benefit plan is discontinued and replaced, the individual carriers shall be entitled to all takeover rights provided under Rule 120-2-10-.10.
O.C.G.A. Secs. 33-2-9, 33-30A-5, 33-30A-9.
