Section 33-21-13. Evidence of coverage; filing and approval of basic rates and method of computation of coverage

   (a) Every enrollee residing in this state is entitled to evidence of coverage under a health benefits plan. The health maintenance organization shall issue the evidence of coverage.

(b) No evidence of coverage or amendment to the evidence of coverage shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the Commissioner.

(c) An evidence of coverage shall contain:

   (1) No provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in paragraphs (1) through (3) of subsection (a) of Code Section 33-21-26; and

   (2) No provisions or statements which are in violation of Code Section 33-24-23 or paragraph (9) of subsection (a) of Code Section 33-29-2; and

   (3) A disclosure to enrollees and prospective enrollees who inquire as individuals into the plan or plans offered by the health maintenance organization 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 under this paragraph shall be readable, understandable, and on a standardized form containing information regarding all of the following for each plan it offers:

      (A) 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;

      (B) 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 enrollee's being denied coverage or provision of a particular service;

      (C) 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;

      (D) 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);

      (E) 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;

      (F) Enrollee rights and responsibilities, including an explanation of the grievance process provided under Chapter 20A of this title;

      (G) An explanation of what constitutes an emergency situation and what constitutes emergency services, as defined in Chapter 20A of this title;

      (H) The existence of any limited utilization incentive plans as defined in Chapter 20A of this title;

      (I) 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;

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

      (K) A summary of any agreements or contracts between the health maintenance organization and any provider in the same manner and subject to the same conditions as required for summaries of managed care plan contracts and agreements under division (1)(A)(xiii) of Code Section 33-20A-5.

   (4) Any subsequent change may be evidenced in a separate document issued to the enrollee.

(d) A copy of the form of the evidence of coverage to be used in this state and any amendment thereto shall be subject to the filing and approval requirements of subsection (b) of this Code section unless it is subject to the jurisdiction of the Commissioner under the laws governing health insurance in which event the filing and approval provisions of such laws shall apply. To the extent, however, that the provisions do not apply to the requirements in subsection (c) of this Code section, the requirements in subsection (c) of this Code section shall be applicable.

(e) (1) Basic rates along with the method of computation of charges for enrollee coverage must be filed with and approved by the Commissioner prior to use.

   (2) The basic rates and the method of computation of specific rate charges shall be established in accordance with actuarial principles for various categories of enrollees, provided that charges applicable to an enrollee shall not be individually determined based on the status of his health. Basic rates and charges shall not be excessive, inadequate, or unfairly discriminatory. A certification by a qualified actuary to the appropriateness of the basic rates, based on reasonable assumptions as to expected medical expenses, administrative expenses, and margins for contingencies, shall accompany the filing along with adequate supporting information.

(f) The Commissioner shall, within a reasonable period, approve any form if the requirements of subsections (a) through (e) of this Code section are met. It shall be unlawful to issue the form until approved. If the Commissioner disapproves the filing, he shall notify the filer. The Commissioner shall specify the reasons for his disapproval in the notice. At the expiration of 90 days the form or basic rate or method of computation of charges so filed shall be deemed approved unless prior to such expiration the filing has been approved or disapproved by the Commissioner.

(g) The Commissioner may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this Code section.

Code 1933, § 56-3607, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1986, p. 676, § 8; Ga. L. 1988, p. 1760, § 1; Ga. L. 1996, p. 485, § 2; Ga. L. 1999, p. 342, § 5.