Emergency services requirements; restrictive formulary requirements

Every health benefits plan of every health maintenance organization shall include provisions that: (1) In the event a patient seeks emergency services and if necessary in the opinion of the health care provider responsible for the patient’s emergency care and treatment and warranted by his or her evaluation, such emergency provider may initiate necessary intervention necessary to stabilize the condition of the patient without seeking or receiving prospective authorization by the health maintenance organization or health benefits plan. If in the opinion of the emergency health care provider a patient’s condition has stabilized and the emergency health care provider certifies that the patient can be transported to another facility without suffering detrimental consequences or aggravating the patient’s condition, the patient may be relocated to another facility which will provide continued care and treatment as necessary; and (2) When a health maintenance organization uses a restrictive formulary for prescription drugs, such use shall include a written procedure whereby patients can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when: (A) The formulary’s equivalent has been ineffective in the treatment of the patient’s disease or condition; or (B) The formulary’s drug causes or is reasonably expected to cause adverse or harmful reactions in the patient. History. — Code 1981, § 33-21-18.1, enacted by Ga. L. 1996, p. 485, § 3. 33-21-19. Promulgation of rules and regulations for licensing of agents. The Commissioner of Insurance may, after notice and hearing, promulgate any reasonable rules and regulations which are necessary to provide for the licensing of agents. ‘‘Agent’’ means a person directly or indirectly associated with a health benefits plan who engages in solicitation or enrollment. 878 33-21-20.1 History. — Code 1933, § 56-3614, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1992, p. 6, § 33. 33-21-20. Conduct of hearings generally; participation in hearings by commissioner of community health; judicial review. (a) Except as otherwise provided in this chapter, all hearings and proceedings held under this chapter shall be conducted in accordance with Chapter 2 of this title and the Commissioner of Insurance shall have all the powers granted to him in Chapter 2 of this title. (b) The commissioner of community health, or his or her designated representative, shall be in attendance at the hearings and shall participate in the proceedings. The recommendation and findings of the commissioner of community health with respect to matters regarding health maintenance organizations under his or her jurisdiction relating to the quality of health care services provided in connection with any decision regarding denial, suspension, or revocation of a certificate of authority shall be conclusive and binding upon the Commissioner of Insurance. Health maintenance organizations meeting the requirements of subsection (b.1) of Code Section 33-21-3 shall not be subject to the jurisdiction of the commissioner of community health. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the Commissioner of Insurance shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization with a copy of the findings mailed to the commissioner of community health. The action of the Commissioner of Insurance and the recommendation and findings of the commissioner of community health shall be subject to review by the superior court having jurisdiction. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the Commissioner of Insurance in whole or in part. (c) Chapter 13 of Title 50, the ‘‘Georgia Administrative Procedure Act,’’ shall apply to proceedings under this Code section to the extent that they are not in conflict with subsections (a) and (b) of this Code section. History. — Code 1933, § 56-3620, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1992, p. 6, § 33; Ga. L. 2004, p. 493, § 6; Ga. L. 2009, p. 453, § 1-6/HB 228. 33-21-20.1. Regulation of HMOs by commissioner of community health. All health maintenance organizations meeting the requirements of subsection (b.1) of Code Section 33-21-3 shall not be subject to regula879 33-21-20.1 INSURANCE 33-21-22 tion by the commissioner of community health. Upon the Commissioner’s determination that a health maintenance organization no longer meets the requirements of subsection (b.1) of Code Section 33-21-3, the Commissioner shall immediately notify the commissioner of community health and such health maintenance organization shall be subject to regulation by the commissioner of community health until such time as it again meets the requirements of subsection (b.1) of Code Section 33-21-3 as determined by the Commissioner. History. — Code 1981, § 33-21-20.1, enacted by Ga. L. 2004, p. 493, § 7; Ga. L. 2009, p. 453, § 1-40/HB 228; Ga. L. 2019, p. 386, § 2/SB 133. The 2019 amendment, effective July 1, 2019, rewrote the first sentence, which formerly read: ‘‘On May 13, 2004, all health maintenance organizations meeting the requirements of subsection (b.1) of Code Section 33-21-3 shall not be subject to regulation by the commissioner of human resources (now known as the commissioner of community health for these purposes).’’, and, in the second sentence, substituted ‘‘Commissioner’s’’ for ‘‘Commissioner of Insurance’s’’ at the beginning, deleted a semicolon following ‘‘community health’’ in the middle, and deleted ‘‘of Insurance’’ following ‘‘Commissioner’’ at the end. 33-21-21. Authority of commissioner of community health to contract for making of recommendations required by chapter; acceptance of recommendations. The commissioner of community health, in carrying out his obligations under subsection (b) of Code Section 33-21-3, paragraph (4) of subsection (a) of Code Section 33-21-5, and subsection (b) of Code Section 33-21-17, may contract with qualified persons to make recommendations concerning the determinations required to be made by him. Such recommendations may be accepted in full or in part by the commissioner of community health. History. — Code 1933, § 56-3626, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 2009, p. 453, § 1-6/HB 228. 33-21-22. Applications, filings, and reports to be treated as public documents. All applications, filings, and reports required under this chapter shall be treated as public documents. History. — Code 1933, § 56-3624, enacted by Ga. L. 1979, p. 1148, § 1. 880 33-21-24 33-21-23. Confidentiality of medical information; claim of privileges by organizations.