Health Insurance; Recovery Rights of State for Payments Made Under Medicaid; Rights of Children to Coverage; Requirements for Insurers Under Orders to Provide Coverage

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  5. General Provisions
  6. Health Insurance; Recovery Rights of State for Payments Made Under Medicaid; Rights of Children to Coverage; Requirements for Insurers Under Orders to Provide Coverage

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  1. Any health insurer under this title, including a group health plan, as defined in Section 607(1) of the federal Employee Retirement Income Security Act of 1974, is prohibited from considering the availability or eligibility for medical assistance in this or any other state under 42 U.S.C. 1396(a), Section 1902 of the Social Security Act, herein referred to as Medicaid, when considering eligibility for coverage or making payments under its plan for eligible enrollees, subscribers, policyholders, or certificate holders.
  2. To the extent that payment for covered expenses has been made under the state Medicaid program for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services.
  3. An insurer shall not deny enrollment of a child under the health plan of the child's parent on the ground that the child was born out of wedlock, is not claimed as a dependent on the parent's federal income tax return, or does not reside with the parent or in the insurer's service area.
  4. Where a child has health coverage under this title through an insurer of a noncustodial parent, the insurer shall:
    1. Provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;
    2. Permit the custodial parent or the provider, with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent; and
    3. Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the provider, or the state Medicaid agency.
  5. Where a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage, the insurer shall be required:
    1. To permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;
    2. If the parent is enrolled but fails to make application to obtain coverage for the child, to enroll the child under the family coverage upon application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering 42 U.S.C. Sections 651 through 669, the child support enforcement program; and
    3. Not to disenroll or eliminate coverage of any child unless the insurer is provided satisfactory written evidence that:
      1. The court or administrative order is no longer in effect; or
      2. The child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment.
  6. An insurer may not impose requirements on a state agency which has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer that are different from requirements applicable to an agent or assignee of any other individual so covered.
  7. In any case in which a group health insurance plan provides coverage for dependent children of participants or beneficiaries, the plan shall provide benefits to dependent children placed with participants or beneficiaries for adoption under the same terms and conditions as apply to the natural, dependent children of the participants and beneficiaries, irrespective of whether the adoption has become final.
  8. A group health plan may not restrict coverage under the plan for any dependent child adopted by a participant or beneficiary, or placed with a participant or beneficiary for adoption, solely on the basis of a preexisting condition of the child at the time that the child would otherwise become eligible for coverage under the plan, if the adoption or placement for adoption occurs while the participant or beneficiary is eligible for coverage under the plan.

(Code 1981, §33-24-55, enacted by Ga. L. 1994, p. 1728, § 5.)

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- For note on the 1994 enactment of this Code section, see 11 Ga. St. U.L. Rev. 171 (1994).


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