Definitions

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  5. Definitions

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As used in this chapter, the term:

  1. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
  2. "Facility" means an institution providing physical, mental, or behavioral health care services or a healthcare setting, including, but not limited to, hospitals; licensed inpatient centers; ambulatory surgical centers; skilled nursing facilities; residential treatment centers; diagnostic, treatment, or rehabilitation centers; imaging centers; and rehabilitation and other therapeutic health settings.
  3. "Health benefit plan" means a policy, contract, certificate, or agreement entered into, offered by, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including a standalone dental plan.
  4. "Health benefit plan surprise bill rating" means the number of checkmarks and X-marks between zero and four that a health benefit plan's in-network hospital has earned based upon the number of qualified hospital based specialty group types with which such health benefit plan is contracted for the provision of healthcare services. Each checkmark indicates the presence of a in-network particular type of qualified hospital based specialty group. An X-mark indicates the absence of an in-network particular type of qualified hospital based specialty group. If a hospital does not provide one of the qualified hospital based specialties, the absence of that specialty shall be designated by a green N/A mark. Any color advertisement which includes a health benefit plan surprise bill rating shall use green checkmarks, red X-marks, and green N/A marks.
  5. "Healthcare professional" means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral healthcare services consistent with his or her scope of practice under state law.
  6. "Healthcare provider" or "provider" means a healthcare professional, pharmacy, or facility.
  7. "Healthcare services" means services for the diagnosis, prevention, treatment, cure, or relief of a physical, mental, or behavioral health condition, illness, injury, or disease, including mental health and substance abuse disorders.
  8. "Insurer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including an accident and sickness insurance company, a health maintenance organization, a healthcare plan, or any other entity providing a health insurance plan, a health benefit plan, or healthcare services.
  9. "Network" means the group or groups of participating healthcare providers providing services under a network plan.
  10. "Network plan" means a health benefit plan of an insurer that either requires a covered person to use healthcare providers managed by, owned by, under contract with, or employed by the insurer or that creates incentives, including financial incentives, for a covered person to use such healthcare providers.
  11. "Qualified hospital based specialty group" means a medical group of anesthesiologists, pathologists, radiologists, or emergency medicine physicians.
  12. "Standalone dental plan" means a plan of an insurer that provides coverage substantially all of which is for treatment of the mouth, including any organ or structure within the mouth, which is provided under a separate policy, certificate, or contract of insurance or is otherwise not an integral part of a group benefit plan.
  13. "Tiers" or "tiered network" means a network that identifies and groups some or all types of providers and facilities into specific groups to which different provider reimbursement, covered person cost sharing, or provider access requirements, or any combination thereof, apply for the same services.

(Code 1981, §33-20C-1, enacted by Ga. L. 2016, p. 149, § 1/SB 302; Ga. L. 2017, p. 164, § 11/HB 127; Ga. L. 2017, p. 774, § 33/HB 323; Ga. L. 2020, p. 228, § 2/HB 789.)

The 2020 amendment, effective November 1, 2020, substituted "healthcare" for "health care" throughout the Code section; added paragraph (4); redesignated former paragraphs (4) through (9) as present paragraphs (5) through (10), respectively; added paragraph (11); and redesignated former paragraphs (10) and (11) as present paragraphs (12) and (13), respectively.

Editor's notes.

- Ga. L. 2020, p. 228, § 1/HB 789, not codified by the General Assembly, provides that: "This Act shall be known and may be cited as the 'Surprise Bill Transparency Act.' "

Ga. L. 2020, p. 228 contains two sections numbered as "2". The language in the first Section 2 of the Act amended this Code section.


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