Georgia Health Insurance Laws & Frequently Asked Questions
Having your claims denied or not paid right away by an insurer is a frustrating issue that many insurance policyholders experience. According the Consumer Services Division of Georgia’s insurance department, claim payment issues are most frequently received questions they encounter. Why would a claim not get covered? There are several reasons, some of which point to benefit exclusions and limitations on your plan. Many plan members do not read the fine print on their plan and note which services are not covered, and this is the first place to check when a claim is denied. If your health plan should cover the service, the issue may be with the claims code, lack of documentation, or a mistake on the insurer or provider’s end.
When having an issue with claims, you first need to contact your insurer directly. You can speak with an agent from the health plan who will encourage you to reread your plan’s benefits, then address the issue if should have been covered. If they do not resolve the issue to your satisfaction, you may contact the Office of the Insurance and Safety Fire Commissioner Consumer Services and file an appeal. Once you provide them details of the situation, copies of your claims and other health insurance documents, they will be able to investigate your problem.
Question: Time Limits for Insurers to Pay Claims
My claim was given to my health plan a month ago and it has yet to be paid. What is the time frame for insurers to pay claims under state law?
15 workdays. Georgia law states that an insurer is required to pay, deny, or ask for more information within this amount of time. If they require more information, they have an additional 15 workdays to process payment after receiving the documents needed.
Question: Penalty for Late Payment
Is there a penalty for health plans who don’t pay claims on time? I provided all necessary documents several months ago and still received no response.
Yes, there is a penalty. The state law requires health plans to pay 18 percent per year on the amount of unpaid claim starting on the 16th workday until the date they pay the claim.
Question: Claim Auditing
The insurer paid my claim, yet the provider refunded the money saying it should not have been paid. Is this permissible?
Insurance companies are permitted to audit paid claims under the condition that the policyholder is informed of the refund or payment due. audit is made within 18 months of the time of service.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) eliminates the stress of losing health insurance when you have lost employment or reduced your hours at work. Since COBRA was signed in 1986, workers have been entitled to continuation of coverage for about 18 months after their employer stops paying for their insurance. Though somewhat of a protection, you are also forced to pay about double the premium you once paid, as you acquire your employer’s share of the costs. In order to determine your eligibility for COBRA or if you have any issues with your COBRA insurance, you can contact the U.S. Department of Labor at 866-444-3272.
COBRA only applies to those who work for companies with at least 20 workers, though in Georgia there is a continuation coverage law for employers with less than 20 employees. This works by continuing your most recent health plan for the remaining days of the month you lose insurance, then for three months afterward. To be eligible for continuation coverage, you must have been insured for at least 6 months.
Question: Creditable Coverage
Is Georgia Continuation coverage considered creditable coverage?
Yes, it is considered a group insurance plan, and therefore creditable coverage.
Question: Length of Plan
If I lose my job on the 16th of the month, for how long will the continuation plan cover me?
The continuation benefits will last throughout the entire month following the 16th, and for three more months afterward. Overall, you will have about 3 1/2 months of insurance under this plan.
Complaints & Regulation Of Insurance Companies
As a Georgia health plan member, you have the right to file a complaint against your insurer if they do not meet your needs or expectations. Contact the Consumer Services Division to make a complaint and the Office will try to resolve the issue or record the complaint for more consumers to be aware of.
In Georgia, the Office of the Insurance Commissioner follows state legislature under Title 33 of the Official Code of Georgia to regulates insurers and agents. When you file a complaint or submit an inquiry, your statement will be reviewed to decide whether the insurer and agent are in compliance with state laws, as well as the outlined terms of the insurance policy contract.
To be eligible for qualify for both plans, you are required to meet the following guidelines:
- Use COBRA if it is available until exhausted
- Live in Georgia for at least 6 months
- Have 18 months of creditable coverage
- Cannot qualify for any other plans
Question: Health Plan Status
How can I determine whether my health plan is fully insured or self-insured?
Speak to your employer or call the number on your insurance ID card. Either will be able to tell you whether your plan is issued in Georgia or self-insured.
Question: Out of Business Employer
I had COBRA coverage, but my former employer went out of business and their health plan therefore ended, as well. My COBRA coverage had only lasted 11 months so far, will this disqualify me from conversion?
No, you can still sign up for Conversion/Assignment. In such instances, you will not be penalized for losing COBRA. On the other hand, if you voluntarily cancel COBRA before it is full exhausted, Conversion/Assignment is not available to you.
Question: Certificate of Creditable Coverage
How to I obtain the Certificate of Creditable Coverage I was told I needed in order to be assigned? What is this document?
You are given a Certificate of Creditable Coverage once your coverage is complete, and outlines the dates you were insured through that plan and if you had any breaks in coverage. This should be available through the COBRA administrator, insurer, or employer. This should be sent to you right away after your coverage ends, yet if you do not, you may contact your plan, employer, or COBRA administrator and ask they send you a copy.
Coordination of Benefits Provision
Each health plan has a coordination of benefits rule that factors in or lowers the benefit amount if the policyholder also carries another, similar form of health insurance. Depending on several factors, including if the patient is an employee or dependent, birth date of the dependent’s parent, and wording of their policy’s Coordination of Benefits provision.
Question: Claim Balance Denial
My employer provides one of my insurance plans, and I also have coverage from my spouse’s group policy. My insurance covered 80 percent of the medical expenses, and when I submitted the other 20% of the claim to my spouse’s plan for coverage, they denied the claim. The reason I have two plans is to cover all possible costs. Is it possible for the secondary plan to refuse to pay the claim’s balance?
Georgia state insurance laws state that the secondary health plan only pays if the benefits under the secondary policy are greater than the benefits paid by your main policy. Conversely, if the secondary plan’s benefits are greater, the amount paid would only be the difference in the amount payable under the secondary rather than the amount paid by the primary policy. Essentially, if the secondary plan pays the same as or less than the primary policy, they are not obligated to pay anything.
Question: Dependent Coverage
If both parents work and have their own group health plans, which one will cover care for child dependents first?
In Georgia, insurers follow the “birthday rule” when dependents receive care, establishing the benefits of the parent with an earlier birthday in the year as the primary plan. However, if the parents share the same date of birth, the primary plan will be that which has been effective the longest.
Employer Health Plan Issues
Some workers are unhappy with the way their employer plan operates, including open enrollment, retirement benefits, eligibility, COBRA, and payroll deduction, among others. Know it is legal for group health plans to impose waiting periods of several months before your coverage is effective, as they spend that time determining eligibility. The employer dictates the guidelines for eligibility and waiting periods according to the guidelines set by the U.S. Department of Labor. A common question related to group coverage is related to when exactly an employer cancels health benefits, which is typically the same as the last day you worked. This also means your employer can continue taking premium deductions from your paycheck until your last check.
HIPAA (Health Insurance Portability and Accountability Act)
This federal law makes guaranteed renewability possible, therefore your insurer will offer to keep you covered for another year when your term is almost up. Additionally, HIPAA limits exclusions of coverage for individuals with health problems, an due to their health status under a group plan. This law makes health insurance to some employees available to availability of health coverage to certain employees and individuals and protects employees who lose group health coverage by providing access to an individual health policy.
Question: Pre-Existing Conditions
I currently have a job with coverage, and am thinking about switching to a new employer. However, I have a pre-existing condition and my wife is pregnant. If I get hired by a new employer, will their health plan cover my condition and her maternity care without a waiting period, or will she also be considered a pre-existing condition?
By federal and state law, pregnancy must not be considered a pre-existing condition by group or individual insurance plans. Your health problems will be covered as soon as your plan is effective as long as you had continuous, creditable coverage for a minimum of 12 months and you didn’t have a break in coverage longer than 63 days.
Question: HIPAA & Guaranteed Issue
According to the HIPAA law, which kinds of health insurance policies are guaranteed issue?
HIPAA-eligible health plans include health insurance plans on the small group market (businesses with 2 to 50 workers), individual conversion policies (available to those who have exhausted COBRA benefits), Georgia continuation and those who qualify to convert their group or COBRA plan to an individual health plan. You must apply for the individual plan within 63 days of your group or COBRA benefits ending in order to qualify, however.
Question: Cancellation of Plans
My health plan is guaranteed renewable under HIPAA, yet I received a notice that my coverage was being terminated. Is this legal?
No. Under the Patient Protection and Affordable Care Act, no health plan can cancel your coverage unless you have neglected to pay your premiums, committed fraud, or lied on your health plan application.
It is beneficial to purchase a health plan from an agent or insurer who is licensed in to sell policies in the state of Georgia, such as East Coast Health Insurance. Those who are not licensed are not obligated to file claims in a timely manner, and will likely not be worth your time. Licensing is a liability issue on the insurer, agent, or brokerage’s end which helps consumers know they are a trusted source and are authorized to sell plans for a specified Georgia insurer.
Question: Verifying an Insurer
Is there a way to determine whether a health plan or agent is licensed to operate in Georgia?
You can research the company online, or call the Insurance Commissioner’s Office at (404) 656-2070. The Consumer Services Division will connect you with an investigator to look up the insurer, find out if they are licensed, when they obtained their license to sell plans in Georgia, and which lines of business they provide in the state. The same process applies to insurance agents and brokers.
Question: Licensing Importance
What is the significance of purchasing a plan from a company with a Georgia insurance license?
In order to be licensed in the state of Georgia, insurers are required to meet specific capital and surplus guidelines qualifying them to pay claims quickly, and demonstrating an insurers’ capacity to pay claims in general. Additionally, if insurers licensed in Georgia go bankrupt, a plan member living in the state would have protection provided by the Georgia Life & Health Guaranty Association for up to $100,000. Insured Georgians who purchase coverage through an unlicensed company do not have access to payments under the Life & Health Guaranty Association.
Medically Necessary Services
Many health plans are required to cover medical necessary care, or services needed in the event of a particular injury or illness. The type of treatment provided and covered will be determined as the most relevant and successful method of care based on current medical procedures. However, your health plan, especially on the individual market, may not want to cover a service, regardless of whether it is medically necessary.
Question: Providers vs. Insurers
If my physician tells me this surgery is a medical necessity, and my health plan disagrees, what course of action can I take? Is the plan required to cover it?
Your specific health plan contract will determine whether a service is covered or not. Even if a doctor deems your care medically necessary, your insurer has the right to deny a claim if it is not a covered benefit.
As an elderly Georgia resident, you are entitled to coverage under the Medicare program. This is the national health insurance program for individuals age 65 and older, including various parts and plans. Medicare Supplement plans, or Medigap, in Georgia is regulated by Office of Commissioner of Insurance. Otherwise, your coverage is provided by the federal government or a private insurer. Private health insurers sell Medicare Advantage plans, which cover hospital and medical care, and also provide Medicare Supplement plans to provide coverage to individuals without and Advantage plan. Services not covered in Part A and B are covered by Medigap. In order to file a complaint or inquiry regarding a Medigap policy, contact the OCI.
Question: Choosing a Plan
Is one company more preferable than another? How can I select the right Medigap plan?
Each health insurer is required to offer ten standard Medigap Plans (Plans A through J), making a level playing field and no reason for one company to be particularly better. Plan A is also a requirement among all insurance companies providing Medicare Supplements in Georgia. Plans B through J are variably available based on which insurer you choose.
Question: Decline of Coverage
Does underwriting apply to Medicare Supplements, and can I get denied coverage?
When applying during open enrollment, the six month period beginning when you are enrolled in Medicare Part B and meet the age requirements (65 or older), you cannot be turned down for Medigap.
Question: Open Enrollment & Group Plans
If I’m still employed, is it necessary to enroll right away in Medicare Part B and begin my Medicare Supplement Open Enrollment Period if I am age 65 or older?
There is no rush to enroll in Medicare Part B if you are covered by an employer-sponsored plan or group coverage through a union. For the Medigap Open Enrollment Period to begin, you must apply for Part B and be 65 or older, but if you still have other coverage you should keep those benefits.
Question: Premium Rating Process
Why are premiums different across various insurers and how do plans determine rate increases?
Like buying an individual plan as a non-elderly person from a private insurer, rates increase based on company and plan-specific factors such as losses, company overhead, and amount of coverage the plan provides. Additionally, your zip code, gender, health status, tobacco use, and whether you are married or single are all permissible reasons for an insurer to increase your rates. After the health reform law is in place, the state will not allow discrimination for health conditions and gender, however.
Portability Laws in Georgia
HIPAA made it easier for health insurance policyholders to switch health plans without the consequence of a new pre-existing exclusion period. Under the Affordable Care Act, insurers are unable to issue any exclusion periods for pre-existing conditions, yet HIPAA paved the way by making plans portable. Typically exclusion periods last 12 months in Georgia, and by providing creditable coverage to help reduce or eliminate a new plan’s exclusion period. By having credit for your previous coverage, which requires no more than 63 days of a coverage gap for non-Georgia plans, and 90 days for plans issued in the state, you can receive care related to your condition sooner, if needed.
Question: Creditable Coverage & Exclusion Periods
I had coverage through a personal health plan for 8 months before I acquired my new job, which offers health insurance. I have changed plans and am currently covered under the employer-sponsored policy at the job. How long will my pre-existing exclusion period last?
With 8 months of creditable coverage behind you, your pre-existing exclusion period will cut that time in half to 4 months.
Question: Individual Portability
I currently have coverage through an individual health plan who has raised my rates by 50 percent over the past two years. I am familiar with the HIPAA laws concerning portability and thought that I could transfer to any individual policy as long as I had the appropriate amount of creditable coverage time. I applied with a company for an individual policy and was turned down. Can the company do that?
Portability only applies when you are changing from one group health insurance plan to another, or from group to individual. Within the individual market, the portability rule is nil when going between individual plans.
Self Funded Plans & Georgia Laws
Self-funded plans are employer-sponsored medical expense benefit plans provided to workers, not provided by a health insurance company. Rather than the health plan pay for your medical care, the employer pays for it personally. As this type of coverage never involves insurers, no insurance plan is involved or contracted with. Plan documents can be found through your employer, and these plans are not required to follow Georgia state insurance laws.
When my claims are being denied through a self-funded plan, where can I report this problem?
Self-insured plans are required to follow the laws of the U.S. Department of Labor as per ERISA, the Employee Retirement Income Security Act. The DOL can be contacted at (404) 302-3900 or (866) 444-3272. Additionally, you should first take up your issue with the employer, who is responsible for paying the claims to begin with. ERISA laws permit you, the employee, to appeal a claims denial from your employer.
If my claims are sent to a health insurer, does that imply my plan is not self-insured?
No. Insurance companies often manage self-funded plans as they are hired by employers to do so. Your Human Resources Manager should be able to provide more information.
State Employee Health Plans
The State Merit High Option and PPO plans are funded by the State of Georgia administered by the Georgia Department of Community Health. HMO plans offered by the state of Georgia are fully insured and regulated by the Office of Commissioner of Insurance, however, which means you can file complaints and appeals through their site.
Instructors in the state university system have self funded health plans, as well, and their plans are regulated by the Board of Regents of the University System of Georgia.
Usual Customary and Reasonable (UCR)
UCR is the amount paid for a healthcare service in a geographical region, determined by what providers typically charge for similar types of care nearby. Insurers use this method to decide this amount under an indemnity type health plan, for instance, when an insurer covers 80 percent and the policyholder pays the remaining 20 for covered care. Insurers arrive at the UCR rate by considering claim information and current medical fee levels in particular areas of Georgia. UCR can cause many questions to arise, yet the insurer is allowed liberties in applying these amounts.
A provider charged $3500 for a medical procedure and insurance company only paid $2000, claiming this is the UCR amount. Is this permitted by the state and am I required to pay the balance?
Yes, the insurer is allowed to do this, and you must pay the remaining fees. Healthcare expenses do not necessarily follow sensible patterns, and providers are able to charge by to their own fee schedule. To secure rate consistency and uniformity of coverage, UCR fees are established and serve as the maximum allowable charge for all insureds.
Is there any way to lower or eliminate the difference in the UCR allowed and the actual provider fee?
Your have the right to appeal to the insurer, asking they reevaluate the permitted UCR amount. Your health plan may be able to justify additional payments and may also contact the healthcare provider to reach a compromise amount.
Am I able to purchase a policy that does not pay according to UCR, so I can avoid paying the balance charged by the provider and permitted by the insurance company?
HMO and PPO health plans pay based on a previously decided fee reached in a contract between the insurer and their providers. Therefore, the provider charge will be paid by the insurer except for the deductible, coinsurance or copay owed by the insured.