(Effective July 1, 2021) Right to Shop for Insurance Coverage; Disclosure of Pricing Information; Notice

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  6. (Effective July 1, 2021) Right to Shop for Insurance Coverage; Disclosure of Pricing Information; Notice

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  1. This Code section shall be known and may be cited as the "Georgia Right to Shop Act."
  2. As used in this Code section, the term:
    1. "Covered person" means an individual who is covered under a health benefit policy.
    2. "Emergency services" means those health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:
      1. Placing the patient's health in serious jeopardy;
      2. Serious impairment to bodily functions; or
      3. Serious dysfunction of any bodily organ or part.
    3. "Health benefit policy" or "policy" means any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, executed, or renewed in this state, including, but not limited to, those contracts executed by the state on behalf of state employees under Article 1 of Chapter 18 of Title 45, by an insurer.
    4. "Health care provider" or "provider" means any physician, dentist, podiatrist, pharmacist, optometrist, psychologist, clinical social worker, advanced practice nurse, registered optician, licensed professional counselor, physical therapist, marriage and family therapist, chiropractor, athletic trainer qualified pursuant to Code Section 43-5-8, occupational therapist, speech language pathologist, audiologist, dietitian, or physician assistant.
    5. "Health care service" means:
      1. Physical and occupational therapy services;
      2. Obstetrical and gynecological services;
      3. Radiology and imaging services;
      4. Laboratory services;
      5. Infusion therapy;
      6. Inpatient or outpatient surgical procedures;
      7. Outpatient nonsurgical diagnostic tests or procedures; and
      8. Any services designated by the Commissioner as shoppable by health care consumers.
    6. "Hierarchical Condition Category Methodology" means a coding system designed by the Centers for Medicare and Medicaid Services to estimate future health care costs for patients.
    7. "Insurer" means an accident and sickness insurer, fraternal benefit society, hospital service corporation, medical service corporation, health care corporation, health maintenance organization, preferred provider organization, provider sponsored heath care corporation, managed care entity, or any similar entity authorized to issue contracts under this title or to provide health benefit policies.
  3. Each insurer shall make available on its publicly accessible website an interactive mechanism whereby any member of the public may:
    1. For each health benefit policy offered, compare the payment amounts accepted by in-network providers from such insurer for the provision of a particular health care service within the previous year;
    2. For each health benefit policy offered, obtain an estimate of the average amount accepted by in-network providers from such insurer for the provision of a particular health care service within the previous year;
    3. For each health benefit policy offered, obtain an estimate of the out-of-pocket costs that such covered person would owe his or her provider following the provision of a particular health care service;
    4. Compare quality metrics applicable to in-network providers for major diagnostic categories with adjustments by risk and severity based upon the Hierarchical Condition Category Methodology or a nationally recognized health care quality reporting standard designated by the Commissioner. Metrics shall be based on reasonably universal and uniform data bases with sufficient claim volume. If applicable to the provider, quality metrics shall include, but not be limited to:
      1. Risk adjusted and absolute hospital readmission rates;
      2. Risk adjusted and absolute hospitalization rates;
      3. Admission volume;
      4. Utilization volume;
      5. Risk adjusted rates of adverse events; and
      6. Risk adjusted and absolute relative total cost of care.

        The Commissioner shall promulgate rules and regulations which define the following terms: risk adjusted hospital readmission rates, absolute hospital readmission rates, risk adjusted hospitalization rates, absolute hospitalization rates, admission volume, utilization volume, risk adjusted rates of adverse events, risk adjusted total cost of care, and absolute relative total cost of care. Such terms shall be defined in accordance with federal law or regulation or as otherwise determined necessary by the Commissioner; and

    5. Access any all-payer health claims data base which may be maintained by the department.
  4. An insurer shall provide notification on its website that the actual amount that a covered person will be responsible to pay following the receipt of a particular health care service may vary due to unforseen costs that arise during the provision of such service.
  5. Each estimate of out-of-pocket costs provided pursuant to paragraph (3) of subsection (c) of this Code section shall provide the following:
    1. The out-of-pocket costs a covered person may owe if he or she has exceeded his or her deductible; and
    2. The out-of-pocket costs a covered person may owe if he or she has not exceeded his or her deductible.
  6. An insurer may contract with a third party to satisfy part or all of the requirements of this Code section.
  7. Nothing in this Code section shall prohibit an insurer from charging a covered person cost sharing beyond that included in the estimate provided pursuant to paragraph (3) of subsection (c) of this Code section if such additional cost sharing resulted from the unforseen provision of additional health care services and the cost-sharing requirements of such unforseen health care services were disclosed in such covered person's policy or certificate of insurance.
  8. The requirements of this Code section, with the exception of paragraph (4) of subsection (c) of this Code section, shall not apply to any health maintenance organization health benefits plan as defined in paragraph (4) of Code Section 33-21-1.

(Code 1981, §33-24-59.27, enacted by Ga. L. 2020, p. 666, § 1/SB 303.)


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