Georgia Administrative Code

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions …

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after September 30, 2005 and with an effective date for coverage prior to June 1, 2010. No policy or certificate may be advertised, soli…

(1) An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic core benefits, as defined in Section of this regulation. (2) No groups, packages or combinations of Medicare supplement benefits o…

(1) (a) This section shall apply to Medicare Select policies and certificates as defined in this section. (b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. (2) For the purposes of this secti…

(1) An issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience, receipt of health…

(1) Guaranteed Issue (a) Eligible persons are those individuals described in Subsection (2) who seek to enroll under the policy during the period specified in Subsection (3), and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the…

(1) An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203) by: (a) Accepting a notice from a Medicare carrier on dually assigned claims submi…

(1) Loss Ratio Standards (a) 1. A Medicare Supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to …

(1) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed with and approved by the Commissioner in accordance with filing requirements and procedures prescribed by the Commis…

(1) An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200 percent of the commiss…

(1) General Rules. (a) Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. Such provision shall be appropriately captioned and shall …

(1) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, Medicare Advantage, Medicaid coverage or another health insurance policy or certificate in…

An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium to the Commissioner of Insurance of this state for review or approval by the Commissioner as provided in O.C.G.A. Section 33-…

(1) An issuer, directly or through its producers, shall: (a) Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate. (b) Establish marketing procedures to assure excessive insurance is not sold or issued…

(1) In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. (2) Any sale of a Medicare supplement policy or certificate that will…

(1) On or before March 1 of each year, an issuer shall report the following information for every individual resident of this State for which the issuer has in force more than one Medicare supplement policy or certificate: (a) Policy and certificate number, and (b) Date of issuan…

(1) If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare…

This Section applies to all policies with policy years beginning on or after this Regulation becomes effective. (1) An issuer of a Medicare supplement policy or certificate; (a) shall not deny or condition the issuance or effectiveness of the policy or certificate (including the …

If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby.

(1) This Regulation Chapter shall apply to licensed insurers, including, but not limited to, health maintenance organizations and health care corporations offering managed care plans in this State. (2) Insurers with approved or proposed policy contracts containing preferred provi…

Definitions under this Regulation Chapter shall have the meaning as set forth in the Georgia Insurance Code or the Rules and Regulations of the Office of Commissioner of Insurance, unless indicated below: (a) "Appeal" shall mean a formal request, either orally, or in writing or b…

(1) Managed care entities may make application for a managed care plan or plans to be certified under this Regulation Chapter by submitting Form GID PPA-1 with a filing fee of $500.00. (2) The Commissioner shall have ninety (90) days after receipt of the application in which to r…

(1) A managed care entity shall file supporting documentation for any substantial modification of its managed care plan or plans with the Commissioner. Such documentation shall describe changes in operations and update any previous filings made by the managed care entity for the …

(1) Managed care entities with annual and quarterly statement requirements which report premiums and claims, enrollment, utilization of services, numbers of contracting providers and numbers of complaints and grievances shall continue to capture and report this information on sta…

(1) As used in this section, the term "emergency services" or "emergency condition" shall have the same meaning as set forth in O.C.G.A. § 33-20A-3(2). (2) No managed care plan may require, as a condition of receiving emergency services, that a covered person seek prospective aut…

(1) All managed care entities offering managed care plans in this state shall have a utilization review program which complies with the requirements of Title 33, Chapter 46 and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58. Any managed care…

(1) A managed care entity shall disclose the quality assurance program in effect with documentation specified in Form GID PPA-1. (2) The managed care entity must demonstrate, to the satisfaction of the Commissioner, that its quality assurance program includes organizational arran…

A managed care entity shall demonstrate, as provided in Form GID PPA-1, that it has in place procedures designed to assure compliance with all applicable state and federal laws regarding the confidentiality of patient information and reporting requirements.

The Commissioner is authorized to examine insurers and other entities in matters related to managed care plans under the Patient Protection Act and this Regulation Chapter.

Any person failing to comply with the requirements of this Regulation Chapter shall be subject to such penalties as may be appropriate under the insurance laws of this State.

If any section or portion of a section of this rule or the applicability thereof to any person or circumstance is held invalid by a court, the remainder of the rule or the applicability of such portion to other persons or circumstances shall not be affected thereby.

This Regulation Chapter is issued pursuant to the authority vested in the Commissioner of Insurance by O.C.G.A. §§ 33-2-9 and 33-29A-1et seq.

The purpose of this Regulation Chapter is to implement O.C.G.A. § 33-29A-1et seq. and related provisions of the federal Health Insurance Portability and Accountability Act of 1996.

(1) For the purpose of this Regulation Chapter, the following definitions shall apply: (a) "Assignment System" shall mean the Georgia Health Insurance Assignment System (GHIAS) and the Georgia Health Benefits Assignment System (GHBAS) as established by O.C.G.A. § 33-29A-1et seq. …

(1) The standard benefit schedules developed by the Commissioner in accordance with O.C.G.A. § 33-29A-4 shall be designated as Plan A and Plan B respectively. The model policy form template for Plans A and B is designated as Form GHIAS-1, and schedule of benefits for Plans A and …

(1) The standard health benefit plans developed by the Commissioner in accordance with O.C.G.A. § 33-29A-5 shall be designated as Plan C and Plan D respectively. The model policy form template for Plans C and D are designated as Form GHBAS-1, and the schedule of benefits for Plan…

(1) A health insurer or managed care organization may offer, in addition to the standard policies or plans, other additional individual health insurance policies or plans approved by the Commissioner for use in this state. A health insurer or managed care organization may also of…

(1) Maximum premium rates are specified in Form GHIAS-R for Plans A and B, and in Form GHBAS-R for Plans C and D. All premium rates utilized by the health insurer or managed care organization for standard policies or plans must be filed for approval and shall include premium mode…

(1) Applications for coverage must be submitted to the Commissioner, or to a designated administrator appointed by the Commissioner, prior to assignment to a participating health insurer or managed care organization. Certificates of creditable coverage sufficient to establish sta…

(1) The Commissioner shall administer the GHIAS and the GHBAS or may designate an administrator to perform any specific tasks necessary for the administration of the GHIAS and the GHBAS. (2) The Commissioner may require that costs associated with administration of the GHIAS and t…

(1) Coverage issued through the assignment system shall cover the qualifying eligible individual and any eligible dependents if coverage for all such individuals is elected pursuant to application as provided for in this Regulation Chapter. (2) A qualifying eligible individual or…

All coverage issued through the assignment system, upon application and payment of premium, shall become effective on the date of a qualifying event. In no case shall a participating health insurer or managed care organization be required to make such coverage effective prior to …

A participating health insurer or managed care organization may require payment for any retroactive periods of coverage commencing with the date of a qualifying event as part of the initial premium in order to effectuate coverage. However, such initial premium shall not exceed th…

(1) All policies or plans issued through the assignment system shall not exclude any preexisting condition or maintain any preexisting condition limitation. (2) Health insurers or managed care organizations participating in the assignment system may not take into account health s…

(1) Any assignment system policy or plan may provide for a reduction or coordination of coverage on any person upon eligibility for coverage under Medicare. (2) No assignment system policy or plan may provide for a reduction or coordination of coverage based upon a person's eligi…

(1) All assignment system policies and plans must provide that the health insurer or managed care organization may refuse to renew the coverage of any person insured thereunder only as permitted in the Rules and Regulations of the Office of Commissioner of Insurance § with regard…

All insurers issuing accident and sickness insurance coverage in this state, managed care organizations, and third party administrators licensed by the Commissioner and engaged in the business of health insurance in this state may issue any notices or other information regarding …