Ga. Comp. R. & Regs. R. 120-2-33-.08 - Rates and Forms
(1) Basic rates along with the method of
computation of charges for enrollee coverage or any amendments thereto to be
used in conjunction with any health benefits plan must be filed with and
approved by the Commissioner prior to use.
(2) The Commissioner shall approve or
disapprove any basic rate or method of computation of charges, or change
thereto, as provided in O.C.G.A. Section
33-21-13.
(3) Such basic rates and methods of
computation of charges shall be established in accordance with actuarial
principles for various categories of enrollees, provided that charges
applicable to an enrollee shall not be individually determined based on the
status of health.
(4) Basic rates
and charges shall not be excessive, inadequate, or unfairly
discriminatory.
(5) A certification
by a qualified actuary to the appropriateness of the basic rates, based on
reasonable assumptions, shall accompany the filing, along with adequate
supporting information. Supporting information shall include a detailed
description, as applicable, but not necessarily limited to the following:
(a) projected and actual hospital utilization
in days per thousand members per year;
(b) projected and actual hospital costs
attributable to those hospitals specifically utilized by the HMO through
contract or otherwise;
(c)
projected and actual utilization of physician services, expressed in terms of
numbers of visits per member per year;
(d) projected and actual costs of physician
services, expressed in terms of cost per visit;
(e) projected and actual costs of emergency
and out of area services of non-HMO providers, differentiated as to hospital
and medical service components;
(f)
identification, justification and derivation of any trend or protection
factors; and
(g) identification and
justification for any reserve or surplus contribution factor included within
its charges.
(6) The HMO
shall submit to the Commissioner every contract, policy, certificate or
evidence of coverage, rider, endorsement, application or outline of coverage
for approval prior to use in this State.
(7) Each form shall have the corporate name
and address of the HMO as on file with the Commissioner. Any name or title of
the policy shall be printed in a size of type smaller than that used for the
name of the HMO. All material shall be printed in accordance with the standards
set forth in O.C.G.A. Section
33-29-2.
(8) Each form shall be clearly worded with
all limitations, exclusions and exceptions printed in the same size of type
used to describe the benefits and grouped together under appropriate captions
and bold face type.
(9) An enrollee
under an individual contract may, if not satisfied for any reason, return the
contract or other evidence of coverage within ten (10) days of receipt and
receive a full refund of any payment made. This right may not be exercised if
the enrollee utilizes the services of the HMO within the ten (10) day period
unless the enrollee pays the reasonable cost of said services.
(10) Each group contract or group policy
shall contain a provision that the policyholder is entitled to a grace period
of not less than thirty-one (31) days for the payment of any premium due except
the first, during which grace period the coverage shall continue in force,
unless the policyholder shall have given the insurer notice of discontinuance
thirty (30) days in advance of the date of discontinuance and in accordance
with the terms of the policy. The policy may provide that the policyholder may
be liable to the HMO for payment of a pro rate premium for the time the
coverage was in force during such grace period.
(11) Individual contract or policies shall be
subject to O.C.G.A. Section
33-29-3(b)(3).
Notes
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