(a)This chapter shall apply to all insurers providing a healthcare plan that pays for the provision of healthcare services to covered persons.
(b)As used in this chapter, the term:
(1)"Balance bill" means the amount that a nonparticipating provider charges for services provided to a covered person. Such amount equals the difference between the amount paid or offered by the insurer and the amount of the nonparticipating provider's bill charge, but shall not include any amount for coinsurance, copayments, or deductibles due by the covered person.
(2)"Contracted amount" means the median in-network amount paid during the 2017 calendar year by an insurer for the emergency or nonemergency services provided by in-network providers engaged in the same or similar specialties and provided in the
Free access — add to your briefcase to read the full text and ask questions with AI
(a) This chapter shall apply to all insurers providing a healthcare plan that pays for the provision of healthcare services to covered persons. (b) As used in this chapter, the term: (1) "Balance bill" means the amount that a nonparticipating provider charges for services provided to a covered person. Such amount equals the difference between the amount paid or offered by the insurer and the amount of the nonparticipating provider's bill charge, but shall not include any amount for coinsurance, copayments, or deductibles due by the covered person. (2) "Contracted amount" means the median in-network amount paid during the 2017 calendar year by an insurer for the emergency or nonemergency services provided by in-network providers engaged in the same or similar specialties and provided in the same or nearest geographical area. Such amount shall be annually adjusted by the department for inflation which may be based on the Consumer Price Index, and shall not include Medicare or Medicaid rates. (3) "Covered person" means an individual who is insured under a healthcare plan. (4) "Emergency medical provider" means any physician licensed by the Georgia Composite Medical Board who provides emergency medical services and any other healthcare provider licensed or otherwise authorized in this state to render emergency medical services. (5) "Emergency medical services" means physical or mental health care services rendered for a medical or traumatic condition, sickness, or injury, including a mental health condition or substance use disorder, in which a person is exhibiting acute symptoms of sufficient severity, including, but not limited to, severe pain, regardless of the initial, interim, final, or other diagnoses that are given, 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. "Emergency medical services" includes medical services rendered after such person is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which such services are furnished, unless each of the conditions of subdivision (a)(3)(C)(ii)(II) of the federal Public Health Service Act, 42 U.S.C. Section 300gg-111 are met. (6) "Facility" means a hospital, an ambulatory surgical treatment center, birthing center, diagnostic and treatment center, hospice, or similar institution. (7) "Geographic area" means a specific portion of this state which shall consist of one or more zip codes as defined by the Commissioner pursuant to department rule and regulation. (8) "Healthcare plan" means any hospital or medical insurance policy or certificate, healthcare plan contract or certificate, qualified higher deductible health plan, health maintenance organization or other managed care subscriber contract, or state healthcare plan. This term shall not include limited benefit insurance policies or plans listed under paragraph (3) of Code Section 33-1-2 , air ambulance insurance, or policies issued in accordance with Chapter 21A or 31 of this title or Chapter 9 of Title 34, relating to workers' compensation, Part A, B, C, or D of Title XVIII of the Social Security Act (Medicare), or any plan or program not described in this paragraph over which the Commissioner does not have regulatory authority. Notwithstanding paragraph (3) of Code Section 33-1-2 and any other provision of this title, for purposes of this chapter this term shall include stand-alone dental insurance and stand-alone vision insurance. (9) "Healthcare provider" or "provider" means any physician, other individual, or facility other than a hospital licensed or otherwise authorized in this state to furnish healthcare services, including, but not limited to, any dentist, podiatrist, optometrist, psychologist, clinical social worker, advanced practice registered nurse, registered optician, licensed professional counselor, physical therapist, marriage and family therapist, chiropractor, athletic trainer qualified pursuant to Code Section 43-5-8 , occupational therapist, speech-language pathologist, audiologist, dietitian, or physician assistant. (10) "Healthcare services" means emergency or nonemergency medical services. (11) "Insurer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including those of an accident and sickness insurance company, a health maintenance organization, a healthcare plan, a managed care plan, or any other entity providing a health insurance plan, a health benefit plan, or healthcare services. (12) "Nonemergency medical services" means the examination or treatment of persons for the prevention of illness or the correction or treatment of any physical or mental condition resulting from an illness, injury, or other human physical problem which does not qualify as an emergency medical service and includes, but is not limited to: (A) Hospital services which include the general and usual care, services, supplies, and equipment furnished by hospitals; (B) Medical services which include the general and usual care and services rendered and administered by doctors of medicine, dentistry, optometry, and other providers; and (C) Other medical services which, by way of illustration only and without limiting the scope of this chapter, include the provision of appliances and supplies; nursing care by a registered nurse; institutional services, including the general and usual care, services, supplies, and equipment furnished by healthcare institutions and agencies or entities other than hospitals; physiotherapy; drugs and medications; therapeutic services and equipment, including oxygen and the rental of oxygen equipment; hospital beds; iron lungs; orthopedic services and appliances, including wheelchairs, trusses, braces, crutches, and prosthetic devices, including artificial limbs and eyes; and any other appliance, supply, or service related to healthcare which does not qualify as an emergency medical service. (13) "Out-of-network" refers to healthcare services provided to a covered person by providers or facilities who do not belong to the provider network in the healthcare plan. (14) "Nonparticipating provider" means a healthcare provider who has not entered into a contract with a healthcare plan for the delivery of medical services. (15) "Participating provider" means a healthcare provider that has entered into a contract with an insurer for the delivery of healthcare services to covered persons under a healthcare plan. (16) "Resolution organization" means a qualified, independent, third-party claim dispute resolution entity selected by and contracted with the department. (17) "State healthcare plan" means: (A) The state employees' health insurance plan established pursuant to Article 1 of Chapter 18 of Title 45; (B) The health insurance plan for public school teachers established pursuant to Subpart 2 of Part 6 of Article 17 of Chapter 2 of Title 20; (C) The health insurance plan for public school employees established pursuant to Subpart 3 of Part 6 of Article 17 of Chapter 2 of Title 20; and (D) The Regents Health Plan established pursuant to authority granted to the board pursuant to Code Sections 20-3-31 , 20-3-51 , and 31-2-4 . (18) "Surprise bill" means a bill resulting from an occurrence in which charges arise from a covered person receiving healthcare services from an out-of-network provider at an in-network facility.