§ 33-30-15 - Continuation of similar coverage; preexisting conditions; procedures and guidelines - Georgia Statutes

O.C.G.A. 33-30-15 (2010)
33-30-15. Continuation of similar coverage; preexisting conditions; procedures and guidelines

(a) As used in this Code section, the term:

(1) "Affiliation period" means a period, used by health maintenance organizations in lieu of a preexisting condition exclusion clause, beginning on the enrollment date, which must expire before health insurance coverage provided by a health maintenance organization becomes effective. The health maintenance organization is not required to provide health care benefits during such period, nor is it authorized to charge premiums over such a period.

(2) "Creditable coverage" under another health benefit plan means medical expense coverage with no greater than a 90 day gap in coverage under any of the following:

(A) Medicare or Medicaid;

(B) An employer based accident and sickness insurance or health benefit arrangement;

(C) An individual accident and sickness insurance policy, including coverage issued by a health maintenance organization, nonprofit hospital or nonprofit medical service corporation, health care corporation, or fraternal benefit society;

(D) A spouse's benefits or coverage under medicare or Medicaid or an employer based health insurance or health benefit arrangement;

(E) A conversion policy;

(F) A franchise policy issued on an individual basis to a member of a true association as defined in subsection (b) of Code Section 33-30-1;

(G) A health plan formed pursuant to 10 U.S.C. Chapter 55;

(H) A health plan provided through the Indian Health Service or a tribal organization program or both;

(I) A state health benefits risk pool;

(J) A health plan formed pursuant to 5 U.S.C. Chapter 89;

(K) A public health plan; or

(L) A Peace Corps Act health benefit plan.

(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, or any similar entity and any self-insured health care 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.

(4) "Newly eligible group member" means a Georgia domiciled group member or the dependent of a currently enrolled Georgia domiciled group member who has creditable coverage and who first becomes eligible to elect coverage under a group sponsored comprehensive major medical or hospitalization plan. A newly eligible group member also includes:

(A) During a special enrollment period, existing group members and existing dependents of existing group members who declined coverage when first offered because of the existence of other creditable coverage, if all the following conditions are met:

(i) The group member or group member's dependent had creditable coverage at such time when the group coverage was first offered;

(ii) The group member stated in writing that such creditable coverage was the reason for declining enrollment in group coverage, if such statement is required by the policyholder;

(iii) The coverage of the group member or group member's dependent was under COBRA and has been exhausted or the creditable coverage was terminated as a result of loss of eligibility for the creditable coverage or policyholder contributions toward such creditable coverage were terminated; and

(iv) The group member requests such enrollment not later than 31 days after the date of exhaustion or termination of the creditable coverage; or

(B) In the case of marriage, if the group member requests such enrollment not later than 31 days following the date of marriage or the date dependent coverage is first made available, whichever is later, coverage of the spouse shall commence not later than the first day of the first month beginning after the date the completed request for enrollment is received.

(b) Notwithstanding any other provision of this title which might be construed to the contrary, on and after July 1, 1998, all group basic hospital or medical expense, major medical, or comprehensive medical expense coverages which are issued, delivered, issued for delivery, or renewed in this state shall provide the following:

(1) Subject to compliance with the provisions of subsections (c) and (d) of this Code section, any newly eligible group member, subscriber, enrollee, or dependent who has had creditable coverage under another health benefit plan within the previous 90 days shall be eligible for coverage immediately upon completion of any policyholder imposed waiting period; and

(2) Once such creditable coverage terminates, including termination of such creditable coverage after any period of continuation of coverage required under Code Section 33-24-21.1 or the provisions of Title X of the Omnibus Budget Reconciliation Act of 1986, the insurer must offer a conversion policy to the eligible group member, subscriber, enrollee, or dependent.

(c) Notwithstanding any provisions of this Code section which might be construed to the contrary, such coverages may include a limitation for preexisting conditions not to exceed 12 months for group members who enroll when newly eligible and 18 months for group members who enroll late following the effective date of coverage; provided, however, that:

(1) Such coverages shall waive any time period applicable to the preexisting condition exclusion or limitation for the period of time an individual was previously covered by creditable coverage; or

(2) Such coverages shall waive any time period applicable to the preexisting condition exclusion or limitation in accordance with an insurer's election of an alternative method pursuant to Section 701(c)(3)(B) of the Employee Retirement Income Security Act of 1974.

(d) The preexisting condition limitation described in subsection (c) of this Code section shall not apply to pregnancies.

(e) The preexisting condition limitation described in subsection (c) of this Code section shall not apply to newborn children or newly adopted children where such children are added to the plan by the insured no later than 31 days following the date of birth or the date placed for adoption under order of the court of jurisdiction.

(f) In case of a group health plan offered by a health maintenance organization, an affiliation period may be offered in place of the preexisting condition limitation described in subsection (c) of this Code section, provided that the affiliation period:

(1) Is applied uniformly without regard to any health status related factors;

(2) Does not exceed:

(A) Two months for newly eligible group members and dependents; or

(B) Three months for group members who enroll late; and

(3) Runs concurrently with any policyholder imposed waiting period under the plan.

(g) The Commissioner shall promulgate appropriate procedures and guidelines by rules and regulations to implement the provisions of this Code section after notification and review of such regulations by the appropriate standing committees of the House of Representatives and Senate in accordance with the requirements of applicable law. The Commissioner may allow in such regulations methods other than that described in subsection (f) of this Code section for health maintenance organizations to address adverse selection, as authorized by the Employee Retirement Income Security Act of 1974, Section 701(g)(3).