Legislative Consideration

Georgia HB 84 - Insurance; provide for consumer protections regarding health insurance

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Status: 1st Chamber

Issues: Network Adequacy

Summary for 1/29/2019 Version: The measure applies to both emergency and nonemergency services.

For nonemergency services, a health care provider, group practice of health care providers, diagnostic and treatment center or health center on behalf of health care providers must disclose to current or prospective patients in writing or through the Internet the health plans or hospitals the provider is affiliated with prior to the provision of nonemergency services. If the provider does not participate in a network of a patient or prospective patient's health plan, the provider must inform, upon request, the patient of the estimated amount that will be billed to the patient.

Physicians must provide a patient or prospective patient the name, practice name, mailing address and phone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services. Furthermore, physicians must, for a patient's scheduled hospital admission or scheduled outpatient hospital service for nonemergency services, provide information as how to determine the health care plans the physician participates in.

Insurers must provide information to enrollees that they may obtain a referral to a health care provider outside of the health maintenance organization's (HMO) network or panel when the HMO does not have a geographically accessible or appropriately trained provider in-network. Additionally, insurers must annually update a listing on the HMO's website which includes by specialty, the name, address and telephone number of all participating providers, including facilities, and in the case of physician, board certification, languages spoken. The listing must be on the HMO's website and updated within 15 days of the addition or termination of a provider from the HMO's network.

For out-of-network (OON) coverage - HMOs must provide an enrollee with a clear description of the methodology used for reimbursement of OON services, the amount the HMO will reimburse for as a percentage of the usual and customary for OON services and examples of anticipated out-of-pocket costs for frequently billed OON health services. Information must also be provided to a current or prospective enrollee of an estimated anticipated out-of-pocket cost for OON services in a geographic area or zip code. Furthermore, insurers must disclose whether a provider scheduled to provide health services in-network and disclose, for OON coverage, the approximate dollar amount the insurer will pay for OON health services. Information disclosed to an enrollee is not binding on the insurer.

Hospitals are required to establish, update and make public a list of the hospital's standard charges for items and services provided by the hospital, including for diagnosis-related groups (DRGs).

Outlook: This measure has been introduced for the 2019 Legislative Session. This measure is eligible for referral to a committee.