TITLE 33 INSURANCE

Section 21. Health Maintenance Organizations, 33-21-1 through 33-21-29.

ARTICLE 4 JOINT COMMITTEE TO STUDY PRESCRIPTION COSTS IN STATE FUNDED HEALTH CARE PLANS

33-21-3. Grounds and procedure for issuance or denial of certificate of authority; endorsement of change of address upon certificate of authority.

1. Upon receipt of an application for issuance of a certificate of authority, the Commissioner of Insurance shall forthwith transmit copies of such application and accompanying documents to the commissioner of community health; provided, however, that if the applicant meets the standards of subsection (b.1) of this Code section the Commissioner shall not be required to transmit the application and accompanying documents to the commissioner of community health.
2. The commissioner of community health shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished:
   1. Has demonstrated the willingness and potential ability to assure that such health care services will be provided in a manner to assure both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility, and continuity of service;
   2. Has arrangements, established in accordance with existing laws and regulations promulgated by the commissioner of community health, for an ongoing quality of health care assurance program concerning health care processes and outcomes;
   3. Has a procedure, established in accordance with regulations of the commissioner of community health, to develop, compile, evaluate, and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services, and such other matters as may be reasonably required by the commissioner of community health;
   4. Has arrangements, established in accordance with existing laws and regulations promulgated by the commissioner of community health, for coverage of out-of-area emergency services rendered to its enrollees; and
   5. Has arrangements to comply with the provisions of Code Section 33-20A-9.1, relating to nomination and reimbursement of providers which are not on that health maintenance organization's provider panel.
3. Within 90 days of receipt of the application for issuance of a certificate of authority, the commissioner of community health shall certify to the Commissioner of Insurance whether the proposed health maintenance organization meets the requirements of subsection (b) of this Code section. If the commissioner of community health certifies that the health maintenance organization does not meet the requirements, he or she shall specify in what respects it is deficient.
4. The Commissioner of Insurance shall issue or deny a certificate of authority to any person filing an application pursuant to Code Section 33-21-2 within 90 days of receipt of the certification from the commissioner of community health or upon the applicant's presentation of proof to the Commissioner of Insurance of its compliance with or accreditation by a national accreditation agency or organization. Issuance of a certificate of authority shall be granted upon payment of the application fees prescribed in Code Sections 33-8-1 and 33-8-3 if the Commissioner of Insurance is satisfied that the following conditions are met:
   1. The persons responsible for the conduct of the affairs of the applicant are competent and trustworthy, possess good reputations, and have had appropriate administrative experience, training, or education in health care delivery systems or allied professions;
   2. The commissioner of community health certifies, in accordance with subsection (a) of this Code section, that the health maintenance organization's proposed plan of operation meets the requirements of subsection (b) of this Code section or the Commissioner of Insurance has received proof of the health maintenance organization's compliance with or accreditation by a nationally recognized accreditation agency or organization;
   3. The health benefits plan constitutes an appropriate mechanism whereby the health maintenance organization will effectively provide or arrange for the provision of basic health care services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments;
   4. The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the Commissioner of Insurance may consider:
      1. The financial soundness of the health benefits plan's arrangements for health care services and the schedule or charges used in connection with providing health care services;
      2. The adequacy of working capital;
      3. Any agreement with an insurer, a government, or any other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the plan;
      4. Any agreement with providers for the provision of health care services; and
      5. Any deposit of cash or securities submitted in accordance with Code Section 33-21-10 as a guarantee that the obligations will be duly performed;
   5. The enrollees will be afforded an opportunity to participate in matters of policy and operation pursuant to Code Section 33-21-6;
   6. Nothing in the proposed method of operation, as shown by the information submitted pursuant to Code Section 33-21-2 or by independent investigation, is contrary to the public interest; and
   7. Any deficiencies, if applicable, certified by the commissioner of community health have been corrected.
5. Before any health maintenance organization changes its address, the certificate of authority shall be returned to the Commissioner of Insurance who shall endorse the certificate of authority indicating the change.

(b.1)An applicant that is compliant with or accredited by a nationally recognized accreditation agency or organization shall be deemed to be in compliance with subsection (b) of this Code section; and, upon submission of proof of compliance or accreditation to the Commissioner of Insurance, certification pursuant to subsection (c) of this Code section shall not be required. The Commissioner of Insurance shall be authorized to promulgate rules and regulations to determine which national accreditation agencies shall be used for purposes of this Code section.

(Code 1933, § 56-3603, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1986, p. 676, § 4; Ga. L. 1999, p. 342, § 4; Ga. L. 2004, p. 493, § 1; Ga. L. 2005, p. 60, § 33/HB 95; Ga. L. 2009, p. 453, § 1-6/HB 228.)