Section 33-20A-5. Standards for certification

   The Commissioner shall establish standards for the certification of qualified managed care plans that conduct business in this state. Such standards must include the following provisions:

   (1)  Disclosure to enrollees and prospective enrollees.

      (A) A managed care entity shall disclose to enrollees and prospective enrollees who inquire as individuals into a plan or plans offered by the managed care entity the information required by this paragraph. In the case of an employer negotiating for a health care plan or plans on behalf of his or her employees, sufficient copies of disclosure information shall be made available to employees upon request. Disclosure of information under this paragraph shall be readable, understandable, and on a standardized form containing information regarding all of the following for each plan it offers:

         (i) The health care services or other benefits under the plan offered as well as limitations on services, kinds of services, benefits, or kinds of benefits to be provided, which disclosure may also be published on an Internet service site made available by the managed care entity at no cost to such enrollees;

         (ii) Rules regarding copayments, prior authorization, or review requirements including, but not limited to, preauthorization review, concurrent review, postservice review, or postpayment review that could result in the patient's being denied coverage or provision of a particular service;

         (iii) Potential liability for cost sharing for out-of-network services, including, but not limited to, providers, drugs, and devices or surgical procedures that are not on a list or a formulary;

         (iv) The financial obligations of the enrollee, including premiums, deductibles, copayments, and maximum limits on out-of-pocket expenses for items and services (both in and out of network);

         (v) The number, mix, and distribution of participating providers. An enrollee or a prospective enrollee shall be entitled to a list of individual participating providers upon request, and the list of individual participating providers shall also be updated at least every 30 days and may be published on an Internet service site made available by the managed care entity at no cost to such enrollees;

         (vi) Enrollee rights and responsibilities, including an explanation of the grievance process provided under this article;

         (vii) An explanation of what constitutes an emergency situation and what constitutes emergency services;

         (viii) The existence of any limited utilization incentive plans;

         (ix) The existence of restrictive formularies or prior approval requirements for prescription drugs. An enrollee or a prospective enrollee shall be entitled, upon request, to a description of specific drug and therapeutic class restrictions;

         (x) The existence of limitations on choices of health care providers;

         (xi) A statement as to where and in what manner additional information is available;

         (xii) A statement that a summary of the number, nature, and outcome results of grievances filed in the previous three years shall be available for inspection. Copies of such summary shall be made available at reasonable costs; and

         (xiii) A summary of any agreements or contracts between the managed care plan and any health care provider or hospital as they pertain to the provisions of Code Sections 33-20A-6 and 33-20A-7. Such summary shall not be required to include financial agreements as to actual rates, reimbursements, charges, or fees negotiated by the managed care plan and any health care provider or hospital; provided, however, that such summary may include a disclosure of the category or type of compensation, whether capitation, fee for service, per diem, discounted charge, global reimbursement payment, or otherwise, paid by the managed care plan to each class of health care provider or hospital under contract with the managed care plan.

      (B) Such information shall be disclosed to each enrollee under this article at the time of enrollment and at least annually thereafter.

      (C) Any managed care plan licensed under Chapter 21 of this title is deemed to have met the certification requirements of this paragraph.

      (D) A managed care entity which negotiates with a primary care physician to become a health care provider under a managed care plan shall furnish that physician, beginning on and after January 1, 2001, with a schedule showing fees payable for common office based services provided by such physicians under the plan;

   (2)  Access to services. A managed care entity must demonstrate that its plan:

      (A) Makes benefits available and accessible to each enrollee electing the managed care plan in the defined service area with reasonable promptness and in a manner that promotes continuity in the provision of health care services, including continuity in the provision of health care services after termination of a physician's contract as provided in Code Section 33-20A-61;

      (B) When medically necessary provides health care services 24 hours a day and seven days a week;

      (C) Provides payment or reimbursement for emergency services and out-of-area services; and

      (D) Complies with the provisions of Code Section 33-20A-9.1 relating to nomination and reimbursement of out of network health care providers and hospitals; and

   (3)  Quality assurance program. A managed care plan shall comply with the following requirements:

      (A) A managed care plan must have arrangements, established in accordance with regulations of the Commissioner, for an ongoing quality assurance program for health care service it provides to such individuals; and

      (B) The quality assurance program shall:

         (i) Provide for a utilization review program which, in addition to the requirements of Chapter 46 of this title:

            (I) Stresses health outcomes;

            (II) Provides for the establishment of written protocols for utilization review, based on current standards of the relevant health care profession;

            (III) Provides review by physicians and appropriate health care providers of the process followed in the provision of such health care services;

            (IV) Monitors and evaluates high volume and high risk services and the care of acute and chronic conditions;

            (V) Evaluates the continuity and coordination of care that enrollees receive; and

            (VI) Has mechanisms to detect both underutilization and overutilization of services; and

         (ii) Establish a grievance procedure which provides the enrollee with a prompt and meaningful hearing on the issue of denial, in whole or in part, of a health care treatment or service or claim therefor. Such hearing shall be conducted by a panel of not less than three persons, at least one member of which shall be a physician other than the medical director of the plan and at least one member of which shall be a health care provider competent by reason of training and licensure in the treatment or procedure which has been denied. The enrollee shall be provided prompt notice in writing of the outcome of the grievance procedure. In the event the outcome of the grievance is favorable to the enrollee, appropriate relief shall be granted without delay. In the event the outcome is adverse to the enrollee, the notice shall include specific findings related to the care, the policies and procedures relied upon in making the determination, the physician's and provider's recommendations, including any recommendations for alternative procedures or services, and a description of the procedures, if any, for reconsideration of the adverse decision.

Code 1981, § 33-20A-5, enacted by Ga. L. 1996, p. 485, § 1; Ga. L. 1999, p. 342, § 1; Ga. L. 1999, p. 350, § 2; Ga. L. 2000, p. 802, § 1; Ga. L. 2002, p. 441, §§ 5, 8; Ga. L. 2005, p. 481, § 2/HB 291.