§ 33-30-12 - Standards and requirements for rating of small groups under accident and sickness insurance; exemptions - Georgia Statutes

O.C.G.A. 33-30-12 (2010)
33-30-12. Standards and requirements for rating of small groups under accident and sickness insurance; exemptions

(a) As used in this Code section, the term "small group" means a group or subgroup of at least two and no more than 50 employees, members, or enrollees.

(b) Except as otherwise provided in this Code section, the claims experience produced by small groups covered under accident and sickness insurance for each insurer shall be fully pooled for rating purposes. Except to the extent that the claims experience of an individual small group affects the overall experience of the small group pool, the claims experience produced by any individual small group of each insurer shall not be used in any manner for rating purposes or solely as a reason for termination of any individual group.

(c) Each insurer's small group pool shall consist of each insurer's total claims experience produced by all small groups in this state, regardless of the marketing mechanism or distribution system utilized in the sale of the group insurance. The pool shall include the experience generated under any medical expense insurance coverage offered under separate group contracts; contracts issued to trusts, multiple employer trusts, or association groups or trusts; or any other group-type coverage. The experience produced under multiple employer trusts or arrangements through contracts issued in this state or provided by solicitation and sale to Georgia residents through an out-of-state multiple employer trust or arrangement for all the Georgia small groups shall be fully pooled for rating purposes. Multiple employer trusts or arrangements shall include any group or group-type coverage issued to a trust or association or to any other group policyholder where such group or group-type contract provides coverage, primarily or incidentally, for sole proprietors, employers, or both.

(d) Notwithstanding the requirements of subsection (b) of this Code section, age, sex, size, area, industry, occupational and avocational factors, and any other factors deemed relevant by the Commissioner may be considered in the initial and renewal rating of each small group. Durations since issue and tier factors may not be considered. Substandard rating in accordance with recognized underwriting practices may be applied only when the employee, member, enrollee, or dependent enters the small group for the first time but shall not be used for renewal rating purposes. Any substandard rating may only be applied across the entire group such that similarly situated employees are charged the same rate. For the purposes of this Code section, an individual who qualifies as a "newly eligible employee," as defined in paragraph (4) of subsection (a) of Code Section 33-30-15, shall not be specified as entering the small group for the first time. Notwithstanding subsection (b) of this Code section, the total initial or renewal premium calculated for any individual small group may deviate from the pool rate by not more than plus or minus 25 percent based upon individual small group experience factors. The direct premium result of select or substandard underwriting practices shall not be considered a deviation from the pool rate.

(e) This Code section shall not apply to:

(1) Policies issued to an employer in another state which provides coverage for employees of this state employed by such employer policyholder;

(2) Policies issued to true associations, as defined in subsection (b) of Code Section 33-30-1;

(3) A policy negotiated in connection with a collective bargaining agreement; or

(4) Limited benefit insurance policies. For the purposes of this Code section, the term "limited benefit insurance" means accident and sickness insurance designed, advertised, and marketed to supplement major medical insurance. The term "limited benefit insurance" includes accident only, CHAMPUS supplement, dental, disability income, fixed indemnity, long-term care, medicare supplement, specified disease, vision, and any other accident and sickness insurance other than basic hospital expense, basic medical-surgical expense, or major medical insurance.

(f) The Commissioner is authorized to exempt insurers from one or more provisions of this Code section upon satisfactory demonstration that such exemption will not result in rates which are unreasonable, inequitable, or unfair under the circumstances and would not conflict with the requirements of the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191.