d. EPO / Any Willing Provider


(DRAFT 12-9-2012)


33-30-40. Short title.



This article shall be known and may be cited as the "Exclusive Provider Arrangements Act."  




33-30-41. Legislative intent.

It is the intent of the General Assembly to encourage health care cost containment while preserving quality of care by allowing health care insurers to enter into exclusive provider arrangements and by establishing minimum standards for exclusive provider arrangements and the health benefit plans associated with those arrangements.  



33-30-42. Definitions.


 As used in this article, the term:  


(1) "Emergency services" or "emergency care" means those health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:  


(A) Placing the patient's health in serious jeopardy;  


(B) Serious impairment to bodily functions; or  


(C) Serious dysfunction of any bodily organ or part.  


(2) "Health benefit plan" means the health insurance policy or subscriber agreement between the covered person or the policyholder and the health care insurer which defines the covered services and benefit levels available.  


(3) "Health care insurer" means an insurer, a fraternal benefit society, a health care plan, a nonprofit medical service corporation, nonprofit hospital service corporation, or a health maintenance organization authorized to sell accident and sickness insurance policies, subscriber certificates, or other contracts of insurance by whatever name called under this title.  


(4) "Health care provider" means any person duly licensed or legally authorized to provide health care services.  


(5) "Health care services" means services rendered or products sold by a health care provider within the scope of the provider's license or legal authorization. The term includes, but is not limited to, hospital, medical, surgical, dental, vision, chiropractic, psychological, and pharmaceutical services or products.  


(6) "Exclusive provider" means a health care provider or group of providers who have contracted to provide specified covered services.  


(7) "Exclusive provider arrangement" means a contract between or on behalf of the health care insurer and an exclusive provider which complies with all the requirements of this article.  



33-30-43. Standards; payments or reimbursement for noncontracting provider of covered services; filing requirements for unlicensed entities; provision for payment solely to provider.



(a)  Notwithstanding any provisions of law to the contrary, any health care insurer may enter into exclusive provider arrangements as provided in this article. Such arrangements shall:  


    (1) Establish the amount and manner of payment to the exclusive provider;  


     (2)(A) Include mechanisms which are designed to minimize the cost of the health benefit plan such as the review or control of utilization of health care services.  


        ( B) Include procedures for determining whether health care services rendered are medically necessary;  


    (3) Provide to covered persons eligible to receive health care services under that arrangement a statement of benefits under the arrangement and, at least every 60 days, an updated listing of physicians who are exclusive providers under the arrangement, which statement and listing may be made available by mail or by publication on an Internet service site made available by the health care insurer at no cost to such covered persons; and  


    (4) Require that the covered person, or that person's agent, parent, or guardian if the covered person is a minor, be permitted to appeal to a physician agent or employee of the health care insurer any decision to deny coverage for health care services recommended by a physician.  


(b)  Such arrangements shall not:  


    (1) Unfairly deny health benefits for medically necessary covered services;  



    (2) Have an adverse effect on the availability or the quality of services; and  


    (3) Be a result of a negotiation with a primary care physician to become a exclusive provider unless that physician shall be furnished, beginning on and after July 1, 2012, with a schedule showing common office based fees payable for services under that arrangement.  


  (c)  Any other provision of law to the contrary notwithstanding, if a covered person provides in writing to a health care provider, whether the health care provider is an exclusive provider or not, that payment for health care services shall be made solely to the health care provider and be sent directly to the health care provider by the health care insurer, and the health care provider certifies to same upon filing a claim for the delivery of health care services, the health care insurer shall make payment solely to the health care provider and shall send said payment directly to the health care provider. This subsection shall not be construed to extend coverages or to require payment for services not otherwise covered.  



33-30-44. Health benefit plans may require covered persons to use exclusive providers; minimum requirements.


Health care insurers may issue health benefit plans which require covered persons to use the health care services of exclusive providers. Such policies or subscriber certificates shall contain at least the following provisions:  


(a) (1) A provision that if a covered person receives emergency care for services specified in the exclusive provider arrangement and cannot reasonably reach an exclusive provider, that emergency care rendered during the course of the emergency will be paid for in accordance with the terms of the health benefit plan, at benefit levels at least equal to those applicable to treatment by exclusive providers for emergency care in an amount based on the usual, customary, and reasonable[TS1]  charges in the area where the treatment is provided; and  



    (2)  For purposes of this Code section, when a request for emergency care is made through the emergency 9-1-1 system on behalf of a covered person and the ambulance service licensed under Chapter 11 of Title 31 that was dispatched in response to the request is not an exclusive provider, for purposes of payment under paragraph (1) of this Code section, it shall be presumed that the covered person could not reasonably reach an exclusive provider.  



33-30-45. Right to become an exclusive provider

 (a) Every health care provider that provides health care services which are covered under any health benefit plan offered by a health care insurer shall have the right to become an exclusive provider subject to compliance with the following:

    (1) The health care provider satisfies any reasonable standards prescribed by the health care insurer;


    (2) The health care provider must be appropriately licensed and in good standing; and


    (3) The health care provider must accept the same terms and conditions as are imposed on exclusive providers that provide similar services and have similar qualifications.   


(b) Health care insurers shall not be required to admit health care providers as exclusive providers in geographical areas where the health care insurer is not accredited to operate.   


(c)  Health care insurers may not use standards that discriminate against health care providers on the basis of religion, race, color, national origin, age, sex, or marital or corporate status. 


A health care insurer that offers or delivers health care plans in Georgia using exclusive provider arrangements shall establish and maintain a provider network that assures both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility, and continuity of service.  Before offering or delivering a health care plan that utilizes exclusive provider arraignments the health care insure shall:


33-30-47. Applicability of Title 33 and related rules and regulations to health care insurers.


Health care insurers as defined in this article shall be subject to and shall be required to comply with all other applicable provisions of this title and rules and regulations promulgated pursuant to this title.  



33-30-48. Promulgation of rules and regulations.


The Commissioner shall promulgate all rules and regulations necessary or appropriate to the administration and enforcement of this article.  


 [TS1]I have a few comment about the use of UCR for out-of-network provider compensation.   

 [TS2]This could use some work; the idea is that more than one type of provider might be able to provide the same health service.  The qualifications and thus comparable "exclusive provider" would be different.  this should be built into the language. 

 [TS3]I will try to come up with something that we can work with over the weekend.