Furnishing claims experience to policyholders

(a) As used in this Code section, the term ‘‘insurer’’ means an accident and sickness insurer, fraternal benefit society, health care corporation, provider sponsored health care corporation, health maintenance organization, or any similar entity. (b)(1) All insurers shall furnish, regardless of the rating methodology used, claims experience to group policyholders within 30 days of any policyholder’s request unless such information has been furnished to the group policyholder within the preceding six months. Such claims experience shall be furnished for all groups of 51 or more covered employees, members, or enrollees, not including dependents, and shall include, but shall not be limited to: (A) Earned premiums separated by policy year for at least the last two policy years, if applicable; (B) Total paid claims and total incurred claims, inclusive of any high amount or pooled claims, including both capitated and noncapitated expenses set forth in the same manner as premiums; and (C) Any amounts in excess of the individual pooling or stop-loss point applicable to the group. (2) Insurers that utilize provider contracting methods including financial devices such as global fee arrangements to cover all medical 562 33-30-13.1 GROUP ACCIDENT AND SICKNESS INSURANCE 33-30-14 expenses may make application to the Commissioner for approval of the use of an alternative form of claims experience reporting. The insurer must still provide Georgia experience on a group-specific basis or on such other reasonable basis as the Commissioner may approve for such insurer, in advance, based upon a submission of an explanation and supporting documentation. Any insurer that received approval for an alternative form of group claims experience reporting to policyholders shall be required to seek the Commissioner’s advance approval of a proposed response letter to group policyholders who request experience reporting. Such letter should describe the insurer’s reasons for seeking an alternative reporting process and describe the alternative form of reporting approved by the Commissioner. (3) Insurers may charge a reasonable fee for providing this information to group policyholders. The schedule or amount of fees to be charged group policyholders for providing this information shall be filed by each insurer with the Commissioner. (4) In providing claims experience to group policyholders under this Code section, insurers shall adhere to all state and federal laws regarding disclosure of protected health or personal information. History. — Code 1981, § 33-30-13.1, enacted by Ga. L. 2002, p. 8, § 4; Ga. L. 2017, p. 164, § 48/HB 127. 33-30-14. Insurance coverage for treatment of temporomandibular joint dysfunction or surgery for deformities of maxilla or mandible. (a) As used in this Code section, the term: (1) ‘‘Functional deformity’’ means a deformity of the bone or joint structure of the maxilla or mandible such that the normal character and essential function of such bone structure is impeded. (2) ‘‘Policy’’ means any major medical benefit plan, contract, or policy except the Georgia Basic Health Plan, a credit insurance policy, disability income policy, specified disease policy, hospital indemnity policy, limited accident policy, or other similarly limited accident and sickness policy. (3) ‘‘Temporomandibular joint’’ means the connection of the mandible and the temporal bone through the articular disc surrounded by the joint capsule and associated ligaments and tendons. (4) ‘‘Temporomandibular joint dysfunction’’ means congenital or developed anomalies of the temporomandibular joint. (b) No policy may be issued or issued for delivery in this state which: 563 33-30-15 (1) Excludes medically necessary surgical or nonsurgical treatment for the correction of temporomandibular joint dysfunction by physicians or dentists professionally qualified by training and experience; or (2) Excludes medically necessary surgery for the correction of functional deformities of the maxilla and mandible. (c) The provisions of this Code section shall not cover cosmetic or elective orthodontic or periodontic care or general dental care. (d)(1) The coverage under paragraph (1) of subsection (b) of this Code section may contain such types of exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions which apply to other benefits under the accident and sickness insurance benefit plan, policy, or contract. (2) Basic coverage for the nonsurgical treatment of temporomandibular joint dysfunction under paragraph (1) of subsection (b) of this Code section may be limited to history and examination; radiographs, which must be diagnostic for temporomandibular joint dysfunction; splint therapy with necessary adjustments, provided that removable appliances designed for orthodontic purposes would not be reimbursable under a major medical plan; and diagnostic or therapeutic masticatory muscle and temporomandibular joint injections. (e) Except as provided in paragraph (1) of subsection (c) of Code Section 33-30-23 for policies limited only to dental coverage, nothing contained in this Code section shall be deemed to prohibit the payment of different levels of benefits or from having differences in coinsurance percentages applicable to benefit levels for services provided by preferred and nonpreferred providers as otherwise authorized under the provisions of Article 2 of this chapter, relating to preferred provider arrangements. History. — Code 1981, § 33-30-14, enacted by Ga. L. 1994, p. 474, § 2.