Georgia Administrative Code

(1) This Regulation shall apply to any life insurance policy or annuity contract or service or advice related thereto, wherein an "advertisement," as that term is hereinbefore defined, is used or is intended for presentation, distribution or dissemination in this State when such …

(1) Advertisements shall be truthful and not misleading in fact or by implication. The form and content of an advertisement of a policy shall be sufficiently accurate, complete and clear so as to avoid deception or the capacity or tendency to mislead or deceive. Whether an advert…

(1) The information required to be disclosed by this Regulation shall not be minimized, rendered obscure, or presented in an ambiguous fashion or intermingled with the text of the advertisement so as to confuse or mislead. (2) No advertisement shall omit material information or u…

(1) The name of the insurer shall be clearly identified and prominently displayed, and if any specific individual policy is advertised it shall be identified either by form number or other appropriate description. An advertisement shall not use a trade name, an insurance group de…

(1) An advertisement which is intended or not intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond such limits. (2) An advertisement may state that an insurer is licensed in the state which the advert…

An advertisement shall not contain statements, pictures, comparative financial ratios, or illustrations which are false or misleading, in fact or by implication, with respect to the assets, liabilities, insurance in force, corporate structure, financial condition, age or relative…

(1) No insurer, agent or counselor shall in connection with the consultation, service or advertisement of a policy: (a) State, represent or imply that a prospective policyholder or certificateholder will receive the right to benefits which are not a part of the policy itself, or …

(1) Each insurer shall maintain at its home or principal office a complete file containing a specimen copy of every printed, published, or prepared advertisement of its individual policies and specimen copies of typical printed, published, or prepared advertisements of its blanke…

It is not intended that these rules conflict with or supersede any rules currently in force or subsequently adopted in this State governing specific aspects of the sale or replacement of life insurance including, but not limited to, rules dealing with life insurance cost comparis…

If any Section or portion of a Section of this Regulation or the applicability thereof to any person or circumstances is held invalid by a court of competent jurisdiction, the remainder of the rules or the applicability of such provision to other persons or circumstances, shall n…

Any insurer, or agent, counselor, representative, officer or employee of such insurer, failing to comply with the requirements of this Regulation shall be subject to such penalties as may be appropriate under the Insurance Laws of this State.

(1) Pursuant to O.C.G.A. Section 33-24-59.27(c)(4) the Commissioner is responsible for promulgating rules and regulations which include definitions for the following terms: a) Risk adjusted hospital readmission rates; b) Absolute hospital readmission rates; c) Admission volume; d…

These Rules shall apply to the applicants for certification as independent review organizations, and all attendant procedures thereto; any and all independent review organizations certified by the State Health Planning Agency, or its successor Agency, the Department of Insurance,…

(1) "Act" means O.C.G.A. § 33-20A-30et seq., which shall be known and cited as the "Patient's Right to Independent Review Act." (2) "Adverse Outcome" means a decision issued by a managed care entity to an eligible enrollee after the grievance procedure provided for in O.C.G.A. § …

(1) Certification of Independent Review Organizations. (a) All Independent Review Organizations specified in O.C.G.A. § 33-20A-31(4) must obtain certification by the Department. The Department shall deem as certified any applicant for certification that meets standards developed …

(1) An eligible enrollee shall be entitled to appeal to an independent review organization when: (a) The eligible enrollee has received notice of an adverse outcome pursuant to a grievance procedure or the managed care entity has not complied with the requirements of Code Section…

(1) In the event that the outcome of the grievance procedure under Code Section 33-20A-5 is adverse to the eligible enrollee, the managed care entity shall include with the written notice of the outcome of the grievance procedure a statement specifying that any request for indepe…

(1) Within three working days of receipt of notice from the Department of assignment of the request for independent review, the managed care entity shall submit to that organization the following: (a) Any information submitted to the managed care entity by the eligible enrollee o…

(1) The expert reviewer of the independent review organization shall make a determination as to whether a treatment is experimental based upon the following criteria: (a) Whether such treatment has been approved by the federal Food and Drug Administration; or (b) Whether medical …

(1) An independent review organization shall have appropriate personnel reasonably available by telephone, in accordance with Eastern Standard or Eastern Daylight time, whichever is applicable, at least forty (40) hours per week during normal business hours, to discuss eligible e…

(1) An independent review organization, and all agents, contractors, and employees thereof, shall preserve the confidentiality of individual medical records and personal information to the extent required by law and by the doctor-patient relationship. (2) An independent review or…

(1) Complaints to the Department. Within a reasonable time period, upon receipt of a written complaint alleging a violation of these Rules or the Act by an independent review organization from an eligible enrollee's health care provider, a person acting on behalf of the eligible …

(1) The Department is authorized to make examinations concerning the quality, availability, accessibility, and performance of independent review services as often as is deemed necessary. (2) A representative of the Department is authorized to visit the administrative offices or a…

(1) If the Department believes that any person conducting independent review is in violation of the Act, or these Rules, the Department shall notify the independent review organization of the alleged violation and may compel the production of any and all documents or other inform…

(1) Any reviews which involve either a Medical Doctor or a Doctor of Osteopathy will be tier-one reviews with a flat fee of $ 1,500. (2) All other type of reviews shall be tier-two reviews with a flat fee of $ 1,000. (3) The fees referenced above shall be the flat rate for the ap…

(1) The Department shall assign each request for Independent Review to an Independent Review Organization. The Department shall reject any duplicate request which has previously been assigned. (2) Independent Review Organizations shall be added to the list from which assignments …

This Subject is promulgated by the Commissioner of Insurance pursuant to the authority set forth in O.C.G.A. §§ 33-1-23; 33-2-9; 33-23-44; 50-13-21.

The purpose of this Subject is to do establish the rules necessary to implement, establish, administer, and operate Georgia Access, a state-based health exchange to facilitate the purchase and sale of qualified health plans to eligible individuals and qualified employers.

(1) "Advanced Premium Tax Credit" or "APTC" means payment of the tax credit authorized by 26 U.S.C. § 36B and otherwise defined as "advanced payment of the premium tax credits" in 45 C.F.R. § 155.20, which are provided on an advance basis to an eligible individual enrolled in a q…

(1) Certification. Georgia Access is authorized to certify issuers seeking QHP or SADP certification of plan(s) to be offered on Georgia Access, regardless of licensure type. Georgia Access will publish certification criteria and guidelines annually. (2) Georgia Access shall publ…

Pursuant to O.C.G.A. § 33-1-23, the Commissioner is authorized to impose fees on Issuers offering QHPs. Failure to timely remit fees may result in the assessment of penalties. (1) Annual User Fee. To support the functions of Georgia Access, issuers offering QHPs must remit a user…

(1) Open Enrollment Period. (a) Georgia Access will establish the annual open enrollment period and shall provide a minimum of one hundred twenty (120) days advance public notice prior to its first day. (b) Georgia Access shall comply with federal requirements with respect to the…

Any issuer, representative, officer, or employee of such issuer failing to comply with the requirements of the Subject shall be subject to such penalties and other enforcement actions as may be appropriate under the insurance laws of this State.

If any provision of this Subject or the application thereof to any person or circumstance is for any reason held to be invalid by a court of competent jurisdiction, the remainder of the Subject or the applicability of such provision to other persons or circumstances shall not be …

(1) Authorization. Georgia Access is authorized to establish a Small Business Health Options Program, which shall be a small-group health insurance exchange that provides a marketplace for small businesses to purchase health coverage for their employees. (2) Certification. Georgi…

Georgia Access shall publish all requirements for consumer applications in the Policy Manual. Eligible individuals who have opted into an automatically renewing plan shall have their plans renewed in the manner provided by Georgia Access in the Policy Manual.

(1) Consumers who meet all of the following requirements shall be Eligible Individuals: (a) The consumer is a U.S. Citizen, national, or a non-citizen deemed lawfully present within the United States; (b) The consumer is not incarcerated, other than incarceration pending the disp…

(1) Applicants and Enrollees shall have the right to appeal the following: (a) Adverse determinations of eligibility for enrollment in a QHP or SADP; (b) Any determination of eligibility for or the amount of advanced premium tax credit payments or level of cost-sharing reduction.…

Issuers may terminate enrollment in a QHP or SADP only for the reasons and in the manner provided by Georgia Access in the Policy Manual.

This regulation is made and promulgated by the Commissioner of Insurance, pursuant to the authority set forth in O.C.G.A. 33-46-20.1.

To establish annual reporting requirements for insurers participating in a program that permits the selective reduction of prior authorization obligations.

(1) "Health insurer" or "insurer" means an accident and sickness insurer, care management organization, healthcare corporation, health maintenance organization provider sponsored healthcare corporation, or any similar entity regulated by the Commissioner. (2) "Program" means a pr…

By July 1, 2026, and annually thereafter on or before January 1 of each calendar year, each insurer that utilizes prior authorization requirements shall submit to the Commissioner a filing concerning their respective program. Such filing shall include: (1) A full narrative descri…

Any insurer which violates or fails to comply with any provision of Chapter 46 of Title 33 of the Official Code of Georgia Annotated and this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance will be subject to fines and penalties applicable to licen…

If any provisions of this Regulation or the application thereof to any person or circumstance is held invalid by a court of competent jurisdiction, the remainder of the Regulation or the applicability of such provision to other persons or circumstances shall not be affected.

This Regulation is made and promulgated by the undersigned Insurance Commissioner pursuant to the authority set forth in Section 33-2-9 of the Insurance Laws of this State, and especially Chapter 33-6 of the Georgia Insurance Code.

The purpose of this Regulation is: 1. To implement the Insurance Laws of the State of Georgia with respect to advertising and sale of Accident and Sickness Insurance in this State, as defined in Section 33-7-2 of the Georgia Insurance Laws, and included in Section 33-7-3. 2. To p…