Point-of-Service Option for Persons Offered Health Care Coverage Through Health Maintenance Organization

  1. Law
  2. Georgia Code
  3. Insurance
  4. Health Maintenance Organizations
  5. Point-of-Service Option for Persons Offered Health Care Coverage Through Health Maintenance Organization

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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 with as few mandates from government and business as possible. It is also the intent to allow these choices with no additional cost to any business in this state. With these intentions, and the recognition of necessary governmental involvement through various laws, the General Assembly enacts this Code section.
  2. As used in this Code section, the term:
    1. "Employer" means an employer, association, or other private group arrangement.
    2. "Enrollee" means any person entitled to receive health care services or reimbursement for such services pursuant to a contract with a health maintenance organization, whether the contract is with the person entitled to receive those services or reimbursement or the contract is with an employer of which such person is an employee or member.
    3. "Point-of-service option" means a delivery system that permits an enrollee of a health maintenance organization to receive services outside the provider panel of the health maintenance organization under the terms and conditions of the enrollee's contract with the health maintenance organization.
    4. "Provider" means a provider or a group of providers designated to provide health care services to the health maintenance organization's enrollees, as provider is defined in Code Section 33-21-1.
    5. "Provider panel" means those providers with which a health maintenance organization contracts to provide health care services to the health maintenance organization's enrollees.
  3. If the only type of insurance that an employer offers to eligible employees or individuals is health benefit plan coverage through a health maintenance organization, then the health maintenance organization with which such employer contracts to provide such coverage shall offer or make arrangements for the offering of a point-of-service option to such employer for the employer's eligible employees or individuals, and each such eligible employee or individual shall have the right to accept or reject such option.
  4. An employer may require an employee or individual who accepts the point-of-service option to be responsible for the payment of a premium over the amount of the premium for the coverage offered by the health maintenance organization or by an arrangement with another entity in conjunction with the health maintenance organization either directly to the health maintenance organization or other entity or by payroll deduction.
  5. A health maintenance organization may impose different cost-sharing provisions for the point-of-service option based on whether the service is provided through the provider panel of the health maintenance organization or outside the provider panel of the health maintenance organization.
  6. This Code section shall not apply to the Department of Community Health with regard to any and all health benefits that the department may provide pursuant to Article 7 of Chapter 4 of Title 49, the "Georgia Medical Assistance Act of 1977," nor shall this Code section apply to Chapter 9 of Title 34, relating to workers' compensation.
  7. An employer may charge an employee or individual who accepts the point-of-service option a reasonable administrative fee for costs associated with the employer's reasonable administration of the point-of-service option.

(Code 1981, §33-21-29, enacted by Ga. L. 1996, p. 705, § 8; Ga. L. 1999, p. 296, § 24.)

Law reviews.

- For review of 1996 department and commissioner of insurance legislation, see 13 Ga. St. U.L. Rev. 183 (1996).

CHAPTER 21A MEDICAID CARE MANAGEMENT ORGANIZATIONS

Sec.

  • 33-21A-1. Short title.
  • 33-21A-2. Definitions.
  • 33-21A-3. Certificate of authority required; setting of rates; authority of commissioners.
  • 33-21A-4. Reimbursement for emergency health care services.
  • 33-21A-5. Requirements relating to critical access hospitals.
  • 33-21A-6. Coverage for newborn infants until discharged from inpatient care.
  • 33-21A-7. Bundling of provider complaints and appeals.
  • 33-21A-8. Participation by dentists.
  • 33-21A-9. Submission and payment of claims.
  • 33-21A-10. New and renewal agreements with care management organizations and health care providers.
  • 33-21A-11. Hospital statistical and reimbursement reports from care management organizations; penalty.
  • 33-21A-12. Federal law, rule and regulations control.


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