Legislative Intent; Consumer Choice Option; Provisions; Increased Expenses; Covered Benefits; Forms

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  6. Legislative Intent; Consumer Choice Option; Provisions; Increased Expenses; Covered Benefits; Forms

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  1. It is the intent of the General Assembly to allow citizens to have the right to choose their own health care providers and hospitals with as few mandates from government and business as possible. It is also the intent to allow these choices with minimal additional cost to any business or consumer in this state.
  2. As used in this Code section, the term "consumer choice option" means a plan for health care delivery which grants enrollees a right to receive covered services outside of any plan provider panel and under the terms and conditions of the plan.
  3. Except for managed care plans offering a consumer choice option under subparagraph (d)(2)(C) of this Code section, every managed care plan offered by a managed care entity shall offer a separate consumer choice option to enrollees at least annually with the following provisions:
    1. Every enrollee of a managed care plan shall have the right to nominate one or more out of network health care providers or hospitals for use by that enrollee and that enrollee's eligible dependents, if:
      1. Such health care provider or hospital is located within and licensed by the state;
      2. Such health care provider or hospital agrees to accept reimbursement from both the plan and the enrollee at the rates and on the terms and conditions applicable to similarly situated participating providers and hospitals. The reimbursement rates for the plan may be proportionally reduced from those paid to participating providers if the cost-sharing provisions in paragraph (3) of subsection (d) of this Code section are utilized in the consumer choice option;
      3. Such health care provider or hospital agrees to adhere to the managed care plan's quality assurance requirements and to provide the plan with necessary medical information related to such care; and
      4. Such health care provider or hospital meets all other reasonable criteria as required by the managed care plan of in network providers and hospitals; and
    2. Each nominated health care provider or hospital which meets the requirements of subparagraphs (A), (B), (C), and (D) of paragraph (1) of this subsection shall be reimbursed by the plan, subject to the agreement in subparagraph (B) of paragraph (1) of this subsection, as though it belonged to the managed care plan's provider network. Such reimbursement shall be full and final payment for the health care services provided to the enrollee and no health care provider or hospital shall bill the enrollee for any portion of a payment exclusive of the requirements of subparagraph (B) of paragraph (1) of this subsection.
    1. An enrollee who selects the consumer choice option shall be responsible for any increases in premiums and cost sharing associated with the option; provided, however, that any differential in cost sharing as provided in paragraph (3) of this subsection shall only apply when the enrollee goes out of network.
    2. Any increases in premiums for the consumer choice option shall be limited as follows:
      1. For health benefit plans offered by health maintenance organizations under Chapter 21 of this title, the managed care entity may offer both of the following options, but must offer either:
        1. The actuarial basis of the option taking into account administrative and other costs associated with the exercise of this option or a 17.5 percent increase in premium over the plan without the option, whichever is less; or
        2. The actuarial basis of the option with cost sharing as provided under paragraph (3) of this subsection taking into account administrative and other costs associated with the exercise of this option or a 15 percent increase in premium over the plan without the option and with cost sharing as provided under paragraph (3) of this subsection, whichever is less;
      2. For all other managed care plans under this chapter, the managed care entity may offer both of the following options, but must offer either:
        1. The actuarial basis of the option taking into account administrative and other costs associated with the exercise of this option or a 10 percent increase in premium over the plan without the option, whichever is less; or
        2. The actuarial basis of the option with cost sharing as provided under paragraph (3) of this subsection taking into account administrative and other costs associated with the exercise of this option or a 7.5 percent increase in premium over the plan without the option and with cost sharing as provided under paragraph (3) of this subsection, whichever is less;
      3. Notwithstanding subparagraph (B) of this paragraph, for all other managed care plans under this chapter, a health benefit plan may offer at no additional premiums or cost sharing a preferred provider organization network plan under Article 2 of Chapter 30 of this title, which plan contains standards for participating providers and hospitals which:
        1. Meets the requirements of subparagraphs (A), (C), and (D) of paragraph (1) of subsection (c) of this Code section; and
        2. Includes only health care providers and hospitals which agree to accept the reimbursement from both the plan and the enrollee at the rates and on the terms and conditions applicable to similarly situated participating providers and hospitals and under any cost-sharing conditions required of other similarly situated preferred providers, which reimbursement shall be accepted as full and final payment for the covered health care services provided to the enrollee and no preferred provider shall bill the enrollee for any portion of a payment exclusive of the requirements of this subparagraph.

        Managed care plans offering the preferred provider organization network plan under this subparagraph shall not place capacity limits on the number or classes of providers authorized to be preferred providers except where the services regularly performed by a particular class of providers are not covered services within the scope of the health benefit plan or plans offered by the managed care plan pursuant to Article 2 of Chapter 30 of this title. This subparagraph shall not supersede any other requirement of this title regarding the coverage of a certain class or classes of providers.

    3. Except as provided in subparagraph (C) of paragraph (2) of this subsection for a consumer choice option without cost sharing, any increases in cost sharing for the consumer choice option, as compared to in network cost sharing, shall be limited as follows:
      1. If deductibles are used in network, any deductibles in the consumer choice option shall not exceed a 20 percent difference between in and out of network; provided, however, that deductibles cannot be accumulated separately between in network and out of network;
      2. If copayments are used in network, any copayments in the consumer choice option shall not exceed a 20 percent difference between in and out of network;
      3. In all cases, any coinsurance in the consumer choice option shall not exceed 10 percentage points difference between in and out of network; and
      4. In all cases, the maximum differential for out-of-pocket expenditures of the consumer choice option shall not exceed 20 percent as compared to in network; provided, however, that out-of-pocket expenditures cannot be accumulated separately between in network and out of network. Further, all cost sharing that is counted toward the out-of-pocket limit for the consumer choice option shall be the same as that counted toward the in network plan.
    4. After 12 months of full implementation, the pricing of the consumer choice option may be reevaluated to consider actual costs incurred and the experience of the standard plan without the option as compared to the consumer choice option. Based on an independent actuarial evaluation of such actual costs incurred and experience, managed care entities may apply for a waiver of the cost provisions of paragraphs (2) and (3) of this subsection to the Insurance Commissioner's office.
  5. The consumer choice option shall have substantially the same covered benefits as the managed care plan without the option.
  6. For an enrollee who chooses the consumer choice option, the managed care entity shall provide such enrollee with a form to be completed by the enrollee nominated health care provider or hospital. This form shall indicate such health care provider's or hospital's agreement to accept reimbursement as provided in subparagraph (c)(1)(B) of this Code section and such health care provider's or hospital's agreement to adhere to the quality assurance requirements and other reasonable criteria of the plan as provided in subparagraphs (c)(1)(C) and (c)(1)(D) of this Code section. The form required by this subsection shall be one page, shall be signed and dated by the nominated health care provider or hospital, and shall be mailed to the managed care entity at the address indicated on the form. In a timely manner and upon receipt of such form from a nominated health care provider or hospital, the plan shall indicate acceptance of the health care provider or hospital and provide any necessary information to the health care provider or hospital including but not limited to a complete copy of the reimbursement terms, quality assurance requirements, and any other reasonable criteria required by the managed care plan of in network health care providers and hospitals. The plan may refuse to approve for reimbursement an enrollee nominated health care provider or hospital only upon a showing by clear and convincing evidence that the health care provider or hospital does not meet the requirements of paragraph (1) of subsection (c) of this Code section.

(Code 1981, §33-20A-9.1, enacted by Ga. L. 1999, p. 342, § 3; Ga. L. 2008, p. 1088, § 1/HB 1328; Ga. L. 2015, p. 1088, § 23/SB 148.)

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1999, in subsection (c), "; and" was substituted for a period, the formerly undesignated paragraph was designated as paragraph (2), and "paragraph (1) of this subsection" was substituted for "this paragraph" in three places in paragraph (2); in subsection (d), a semicolon was substituted for a comma in subdivision (d)(2)(A)(i), "toward" was substituted for "towards" in the last sentence of subparagraph (d)(3)(D), and, in the last sentence of paragraph (d)(4), "paragraphs" was substituted for "paragraph" and capitalization changes were made; and "The plan" was substituted for "A plan" in the last sentence in subsection (f).

Editor's notes.

- Ga. L. 1999, p. 342, § 7, not codified by the General Assembly, provides that: "This Act shall become effective on July 1, 1999, for purposes of preparing for implementation of the consumer choice option and shall be applicable to any contract, policy, or other agreement of a managed care plan or health maintenance organization if such contract, policy, or agreement provides for health care services or reimbursement therefor and is issued, issued for delivery, delivered, or renewed on or after January 1, 2000."

Law reviews.

- For note on 1999 enactment of this Code section, see 16 Ga. St. U.L. Rev. 163 (1999).


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