Ga. Comp. R. & Regs. R. 120-2-81-.04 - Georgia Health Insurance Assignment System
(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 B is
designated as Form GHIAS-S.
(2) A
health insurer who participates in the Georgia Health Insurance Assignment
System (GHIAS) must file policy forms necessary for providing the coverage
required by the GHIAS no later than thirty (30) days following either the
effective date of this Regulation Chapter, or the date of notice from the
Commissioner that the health insurer is subject to the provisions of O.C.G.A.
§
33-29A-1
et
seq., whichever is later. Coverage provided pursuant to assignment
by the GHIAS that is effective prior to the approval of the policy form shall
be subject to the requirements of this Regulation Chapter and shall be amended
pursuant to any modifications required by the Commissioner for approval of the
filing. Such coverage made effective prior to approval of filing shall not be
in violation if the policy form is filed within thirty (30) days as
required.
(3) Methods of Filing.
(a) A participating health insurer may file
policy forms prepared in accordance with Form GHIAS-1 and the schedule of
benefits in Form GHIAS-S . Such policy forms shall be deemed approved upon the
date the Commissioner receives the filing, provided they conform to the
template form; or
(b) A
participating health insurer may file policy forms with contractual language
substantially similar to the model policy form template for approval, but must
include the same benefits prescribed in the model policy form template and the
same schedule of benefits prescribed in Forms GHIAS-1 and GHIAS-S . Such
filings must include a description which specifically outlines the variances in
language between the model policy form template and the filed form. A policy
form filing with variances from the model policy form template prescribed in
Form GHIAS-1 may not contain any provisions which are less beneficial than the
relevant template provisions with regard to qualifying eligible individuals or
eligible dependents.
(4)
Special Rules for Preferred Provider Arrangements.
(a)
(a) A participating health insurer which
issues health insurance policies with preferred provider arrangements in this
state as approved by the Commissioner may offer standard policies with
preferred provider arrangements. The out-of-network benefit levels must be at
least as comprehensive as the schedule of benefits prescribed in Form GHIAS-S
for Plans A and B.
(b)
(b) Health insurers may offer preferred
provider arrangements with gatekeeper provisions if such provisions are
typically included in health insurance policies approved by the Commissioner
and issued by the health insurer in this state outside of the assignment
system.
(c)
(c) Policy forms including preferred provider
arrangements may be filed utilizing the model policy form template for
preferred provider arrangements described in Form GHIAS-2. Such policy forms
shall be deemed approved upon the date the Commissioner receives the filings,
provided they conform to the template form. Otherwise, the health insurer must
file for approval a policy form that is substantially similar to the preferred
provider model policy form template. The health insurer may submit a revised
schedule of benefits for approval which reflects in-network and out-of-network
benefit levels for Plans A and B.
(d)
(d) A policy form filing with variances from
the model policy form template prescribed in Form GHIAS-1 may not contain any
provisions which are less beneficial than the relevant template provisions with
regard to qualifying eligible individuals or eligible dependents.
(5) A health insurer shall file
with the Commissioner for approval any and all materials used to offer coverage
to a qualifying eligible individual and eligible dependents through the GHIAS.
These materials include enrollment forms, forms describing or soliciting an
election of benefit options, disclosures regarding coverage under standard and
optional policies, and any other documentation issued to qualifying eligible
individuals for enrollment in standard or optional policies offered by the
health insurer.
Notes
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