Ga. Comp. R. & Regs. R. 120-2-20-.03 - Unlawful Agreements between Insurers and Providers
(1) An agreement
between an insurer and a provider shall not include a most favored nation
clause or an upper limit trigger clause.
(2) Definitions:
(a) "Most favored nation clause" means any
clause or combination of clauses in an agreement between an insurer and a
provider that:
1. Prohibits, or grants the
insurer an option to prohibit, a provider from contracting with another party
to provide health care services at a lower rate than the payment or
reimbursement rate specified in the contract;
2. Requires, or grants the insurer an option
to require, a provider to accept a lower payment or reimbursement rate if the
provider agrees to provide health care services to another party at a lower
rate than the payment or reimbursement rate specified in the
contract;
3. Requires, or grants a
contracting insurer an option to terminate or renegotiate an existing contract
in the event the provider agrees to provide health care services to any other
party at a lower rate; or
4.
Requires a provider to disclose, to the insurer or its designee, the provider's
contractual payment or reimbursement rates with other parties.
(b) "Upper limit trigger clause"
means any clause or combination of clauses in an agreement between an insurer
(the "first insurer") and a provider that requires the provider to cease
accepting as patients individuals covered by an agreement with another insurer,
or non-covered patients, if the provider elects to limit, or cease, accepting
patients covered by the agreement between the first insurer and the provider.
As used in this Regulation, the term "upper limit trigger clause" only refers
to a clause or combination of clauses contained within an agreement between an
insurer and a provider where the provider is a primary care physician and is
compensated by the insurer on a capitated basis.
(3) The Commissioner shall follow the
procedure set forth in O.C.G.A. ยง
33-6-13(d)
whenever there is a violation of this
regulation.
(4) For the purposes of
this regulation, "provider" means any physician, hospital, or other person who
is licensed or otherwise authorized in this state to furnish health care
services.
(5) For the purposes of
this regulation, "health care services" means any services included in the
furnishing to any individual of medical or dental care or hospitalization or
incident to the furnishing of such care or hospitalization, as well as the
furnishing to any person of any and all other services for the purpose of
preventing, alleviating, curing, or healing human illness or injury.
Notes
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