§ 33-20e-25 — Monitoring of providers for accessibility; notification of noncompliance; responding to notification; requesting hearing

(a) (1) An insurer shall monitor on an ongoing basis the ability, clinical capacity, and legal authority of its participating providers to furnish all contracted covered benefits to all covered persons under a network plan. (2) Beginning January 1, 2025, and annually thereafter, in a manner and format as determined by the Commissioner, an insurer shall report to the Commissioner such quantitative data as necessary to demonstrate compliance with Code Section 33-20E-24 . (b) The Commissioner is authorized to conduct a data call, market conduct examination, or compliance audit to determine compliance with the provisions in Code Section 33-20E-24 , as authorized by Code Section 33-2-11 , and the insurer subject to such data call, market conduct examination, or compliance audit shall pay all the actual expenses incurred, in accord with Code Section 33-2-15 . (c) (1) When the Commissioner determines noncompliance with the provisions in Code Section 33-20E-24 , the Commissioner shall notify the insurer of the determination and shall set forth the reasons for the determination. Prior to such determination, the Commissioner shall consider factors that might hinder an insurer's compliance, including, but not limited to, the availability of providers, the willingness of nonparticipating providers to enter into reasonable network contract agreements with an insurer, and good faith efforts by an insurer to enter into network contract agreements with such nonparticipating providers. (2) The Commissioner may set forth proposed remedies that will render compliance in the judgment of the Commissioner, may order that healthcare services provided by nonparticipating providers be covered at an in-network level of benefits, and may impose any administrative penalties authorized by this title. (d) Within 30 days of notification from the Commissioner, the insurer shall submit a response to the Commissioner that addresses all of the Commissioner's concerns. (e) Within 30 days of the submission of the response, the Commissioner shall determine whether such response is acceptable and shall notify the insurer of the determination and shall set forth the reasons for the determination. (f) If the response is deemed unacceptable to the Commissioner, the insurer shall have the right to request a hearing in accord with Code Section 33-2-17 .

Legislative History

Added by 2023 Ga. Laws 242,§ 2, eff. 1/1/2024, app. to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after 1/1/2024.