Bill Text: GA SB62 | 2009-2010 | Regular Session | Engrossed
Bill Title: Insurance; provide certain definitions; include plan administrators in prompt pay requirements; penalties
Spectrum: Partisan Bill (Republican 3-0)
Status: (Engrossed - Dead) 2009-02-19 - House Second Readers [SB62 Detail]
Download: Georgia-2009-SB62-Engrossed.html
09 SB62/FA/2
Senate
Bill 62
By:
Senators Hudgens of the 47th, Hawkins of the 49th and Butterworth of the 50th
AS
PASSED SENATE
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Title 33 of the Official Code of Georgia Annotated, relating to insurance,
so as to provide certain definitions; to include plan administrators in prompt
pay requirements; to provide for penalties; to provide for related matters; to
provide for an effective date; to repeal conflicting laws; and for other
purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Title
33 of the Official Code of Georgia Annotated, relating to insurance, is amended
by revising Code Section 33-23-100, relating to the definition of administrator,
as follows:
"33-23-100.
(a)
As used in this article, the term:
(1)
'Administrator' means any business entity that, directly or indirectly, collects
charges, fees, or premiums; adjusts or settles claims, including investigating
or examining claims or receiving, disbursing, handling, or otherwise being
responsible for claim funds;
and
or
provides underwriting or precertification and preauthorization of
hospitalizations or medical treatments for residents of this state for or on
behalf of any insurer, including business entities that act on behalf of
multiple
a single or
multiple employer self-insurance health
plans,
and
plan or
a self-insured
municipalities
municipality
or other political
subdivisions
subdivision.
Licensure is also required for administrators who act on behalf of self-insured
plans providing workers' compensation benefits pursuant to Chapter 9 of Title
34. For purposes of this article, each activity undertaken by the administrator
on behalf of an insurer or the client of the administrator is considered a
transaction and is subject to the provisions of this title.
(2)
'Business entity' means a corporation, association, partnership, sole
proprietorship, limited liability company, limited liability partnership, or
other legal entity.
(3)
'Standard financial quarter' means a three-month period ending on March 31, June
30, September 30, or December 31 of any calendar year.
(b)
Notwithstanding the provisions of subsection (a) of this Code section, the
following are exempt from licensure
as
so
long as such entities are acting directly through their officers and
employees:
(1)
An employer on behalf of its employees or the employees of one or more
subsidiary or affiliated corporations of such employer;
(2)
A union on behalf of its members;
(3)
An insurance company licensed in this state or its affiliate unless the
affiliate administrator is placing business with a nonaffiliate insurer not
licensed in this state;
(4)
An insurer which is not authorized to transact insurance in this state if such
insurer is administering a policy lawfully issued by it in and pursuant to the
laws of a state in which it is authorized to transact insurance;
(5)
A life or accident and sickness insurance agent or broker licensed in this state
whose activities are limited exclusively to the sale of insurance;
(6)
A creditor on behalf of its debtors with respect to insurance covering a debt
between the creditor and its debtors;
(7)
A trust established in conformity with 29 U.S.C. Section 186 and its trustees,
agents, and employees acting thereunder;
(8)
A trust exempt from taxation under Section 501(a) of the Internal Revenue Code
and its trustees and employees acting thereunder or a custodian and its agents
and employees acting pursuant to a custodian account which meets the
requirements of Section 401(f) of the Internal Revenue Code;
(9)
A bank, credit union, or other financial institution which is subject to
supervision or examination by federal or state banking authorities;
(10)
A credit card issuing company which advances for and collects premiums or
charges from its credit card holders who have authorized it to do so, provided
that such company does not adjust or settle claims;
(11)
A person who adjusts or settles claims in the normal course of his or her
practice or employment as an attorney and who does not collect charges or
premiums in connection with life or accident and sickness insurance coverage or
annuities;
(12)
A business
entity that acts solely as an administrator of one or more bona fide employee
benefit plans established by an employer or an employee organization, or both,
for whom the insurance laws of this state are preempted pursuant to the federal
Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et
seq.
An insurance
company licensed in this state or its affiliate if such insurance company or its
affiliate is solely administering limited benefit insurance. For the purpose of
this paragraph, the term 'limited benefit insurance' means accident or sickness
insurance designed, advertised, and marketed to supplement major medical
insurance, specifically: accident only, CHAMPUS supplement, disability income,
fixed indemnity, long-term care, or specified
disease; or
(13)
An association that administers workers' compensation claims solely on behalf of
its members.
(c)
A business entity claiming an exemption shall submit an exemption notice on a
form provided by the Commissioner. This form must be signed by an officer of
the company and submitted to the department by December 31 of the year prior to
the year for which an exemption is to be claimed. Such exemption notice shall
be updated in writing within 30 days if the basis for such exemption changes.
An
administrator claiming an exemption pursuant to paragraphs (3) and (4) of
subsection (b) of this Code section shall be subject to the provisions of Code
Sections 33-24-59.5 and 33-24-59.13.
(d)
Obtaining a license as an administrator does not exempt the applicant from other
licensing requirements under this title.
(e)
Obtaining a license as an administrator subjects the applicant to the provisions
of Code Sections 33-24-59.5 and 33-24-59.13.
(f)
An administrator shall be subject to Code Sections 33-24-59.5 and 33-24-59.13
unless the administrator provides sufficient evidence that the self-insured
health plan failed to properly fund the plan to allow the administrator to pay
any outside claim."
SECTION
2.
Said
title is further amended by revising Code Section 33-24-59.5, relating to timely
payment of health benefits, as follows:
"33-24-59.5.
(a)
As used in this Code section, the term:
(1)
'Benefits' means the coverages provided by a health benefit plan for financing
or delivery of health care goods or services; but such term does not include
capitated payment arrangements under managed care plans.
(2)
'Health benefit plan' means any hospital or medical insurance policy or
certificate, health care plan contract or certificate, qualified higher
deductible health plan, health maintenance organization subscriber contract, any
health benefit plan established pursuant to Article 1 of Chapter 18 of Title 45,
or any dental or vision care plan or policy, or managed care plan
or
self-insured plan; but health benefit plan
does not include policies issued in accordance with Chapter 31 of this title;
disability income policies; or Chapter 9 of Title 34, relating to workers'
compensation.
(3)
'Insurer' means an accident and sickness insurer, fraternal benefit society,
nonprofit hospital service corporation, nonprofit medical service corporation,
health care corporation, health maintenance organization, provider sponsored
health care corporation, or any similar entity and any self-insured health
benefit plan
not subject
to the exclusive jurisdiction of the federal Employee Retirement Income Security
Act of 1974, 29 U.S.C. Section 1001, et
seq., which entity provides for the
financing or delivery of health care services through a health benefit plan,
the plan
administrator of any health plan, or the
plan administrator of any health benefit plan established pursuant to Article 1
of Chapter 18 of Title 45
or any other
administrator as defined in paragraph (1) of subsection (a) of Code Section
33-23-100.
(b)(1)
All benefits under a health benefit plan will be payable by the insurer which is
obligated to finance or deliver health care services under that plan upon such
insurer's receipt of written
or
electronic proof of loss or claim for
payment for health care goods or services provided. The insurer shall within 15
working days
for electronic
claims or 30 calendar days for paper
claims after such receipt mail
or send
electronically to the insured or other
person claiming payments under the plan payment for such benefits or a letter or
electronic notice which states the reasons the insurer may have for failing to
pay the claim, either in whole or in part, and which also gives the person so
notified a written itemization of any documents or other information needed to
process the claim or any portions thereof which are not being paid. Where the
insurer disputes a portion of the claim, any undisputed portion of the claim
shall be paid by the insurer in accordance with this chapter. When all of the
listed documents or other information needed to process the claim has been
received by the insurer, the insurer shall then have 15 working days
for electronic
claims or 30 calendar days for paper
claims within which to process and either
mail payment for the claim or a letter or notice denying it, in whole or in
part, giving the insured or other person claiming payments under the plan the
insurer's reasons for such denial.
(2)
Receipt of any proof, claim, or documentation by an entity which administrates
or processes claims on behalf of an insurer shall be deemed receipt of the same
by the insurer for purposes of this Code section.
(c)
Each insurer shall pay to the insured or other person claiming payments under
the health benefit plan interest equal to
18
12
percent per annum on the proceeds or benefits due under the terms of such plan
for failure to comply with subsection (b) of this Code section.
(d)
An insurer may only be subject to an administrative penalty by the Commissioner
as authorized by the insurance laws of this state when such insurer processes
less than 95 percent of all claims in a standard financial quarter in compliance
with paragraph (1) of subsection (b) of this Code section. Such penalty shall
be assessed on data collected by the Commissioner.
(e)
This Code section shall be applicable when an insurer is adjudicating claims for
its fully insured business or its business as a third-party
administrator."
SECTION
3.
Said
title is further amended in Article 1 of Chapter 24, relating to general
provisions concerning insurance, by adding a new Code section to read as
follows:
"33-24-59.13.
(a)
As used in this Code section, the term:
(1)
'Administrator' shall have the same meaning as provided in Code Section
33-23-100.
(2)
'Benefits' shall have the same meaning as provided in Code Section
33-24-59.5.
(3)
'Facility' shall have the same meaning as provided in Code Section
33-20A-3.
(4)
'Health benefit plan' shall have the same meaning as provided in Code
Section 33-24-59.5.
(5)
'Health care provider' shall have the same meaning as provided in Code
Section 33-20A-3.
(6)
'Insurer' means an accident and sickness insurer, fraternal benefit society,
nonprofit hospital service corporation, nonprofit medical service corporation,
health care corporation, health maintenance organization, provider sponsored
health care corporation, or any similar entity, which entity provides for the
financing or delivery of health care services through a health benefit plan, the
plan administrator of any health plan, or the plan administrator of any health
benefit plan established pursuant to Article 1 of Chapter 18 of Title
45.
(b)(1)
All benefits under a health benefit plan will be payable by the insurer or
administrator which is obligated to finance or deliver health care services or
process claims under that plan upon such insurer's or administrator's receipt of
written or electronic proof of loss or claim for payment for health care goods
or services provided. The insurer or administrator shall within 15 working days
for electronic claims or 30 calendar days for paper claims after such receipt
mail or send electronically to the facility or health care provider claiming
payments under the plan payment for such benefits or a letter or notice which
states the reasons the insurer or administrator may have for failing to pay the
claim, either in whole or in part, and which also gives the facility or health
care provider so notified a written itemization of any documents or other
information needed to process the claim or any portions thereof which are not
being paid. Where the insurer or administrator disputes a portion of the claim,
any undisputed portion of the claim shall be paid by the insurer or
administrator in accordance with this chapter. When all of the listed documents
or other information needed to process the claim have been received by the
insurer or administrator, the insurer or administrator shall then have 15
working days for electronic claims or 30 calendar days for paper claims within
which to process and either mail payment for the claim or a letter or notice
denying it, in whole or in part, giving the facility or health care provider
claiming payments under the plan the insurer's or administrator's reasons for
such denial.
(2)
Receipt of any proof, claim, or documentation by an entity which administers or
processes claims on behalf of an insurer shall be deemed receipt of the same by
the insurer for purposes of this Code section.
(c)
Each insurer or administrator shall pay to the facility or health care provider
claiming payments under the health benefit plan interest equal to 12 percent per
annum on the proceeds or benefits due under the terms of such plan for failure
to comply with subsection (b) of this Code section.
(d)
An insurer or administrator may only be subject to an administrative penalty by
the Commissioner as authorized by the insurance laws of this state when such
insurer or administrator processes less than 95 percent of all claims in a
standard financial quarter in compliance with paragraph (1) of subsection (b) of
this Code section. Such penalty shall be assessed on data collected by the
Commissioner.
(e)
This Code section shall be applicable when an insurer is adjudicating claims for
its fully insured business or its business as a third-party
administrator."
SECTION
4.
This
Act shall become effective on January 1, 2011.
SECTION
5.
All
laws and parts of laws in conflict with this Act are repealed.