Rule 111-4-1-.10 - Plan Benefits(1)Creation of Benefit Schedule. The Board is authorized to establish benefit schedules for Options to be included in a health benefit plan for eligible persons as defined in Georgia law. Benefit schedules shall comply with applicable state and federal law. Benefit schedules shall further the plan design goals set forth by O.C.G.A. Sections 45-18-3; 20-2-883; 20-2-913: "to (1) Provide a reasonable relationship between the hospital, surgical and medical benefits to be included and the expected distribution of expenses of each such type to be incurred by the covered employees and dependents; and (2) Include reasonable controls, which may include deductible and reinsurance provisions applicable to some or all of the benefits, to reduce unnecessary utilization of the various hospital, surgical, and medical services to be provided and to provide reasonable assurance of stability in the future years of the plan." Benefit schedules for Options may include a different schedule for Medicare enrolled Retirees and non-Medicare enrolled Retirees. Benefit schedules of Options shall be considered in the calculation of Employer and Employee Contribution Rates. The Regular Insurance Option benefit schedules shall be established upon approval of the Employer and Employee Contribution Rates for such Options. The Medicare Advantage Option benefit schedules shall be established upon approval of the Employer and Employee Contribution Rates for such Options. The dates of approval of Employer and Employee Contribution Rates shall be recorded in official minutes of Board meetings. Medicare Advantage Options must be developed and administered in the manner approved by the Centers for Medicare and Medicaid Services. Accordingly, the following subsections apply only to Regular Insurance Options. (a) The Administrator shall authorize the use of established procedures by the TPA to terminate benefit payments if continuation of treatment in the mode being billed is not medically necessary. The TPA's procedures must ensure that the Member shall have the right to ask for a record review by medical consultants.(b) The Administrator shall interpret the general schedules into specific benefit language for inclusion in the Summary Plan Description and for use by the TPA in adjudicating claim payments.(c) The Administrator shall incorporate specific benefit language to be used by the TPA for review of utilization patterns and to implement claim cost containment features, including but not limited to, medical review of excessive utilization and audits of hospital or other claims.(d) The Administrator shall be authorized to require pre-authorization by the TPA of any new medical service before approval for benefit payment. Generally, the service will not be considered for coverage unless medical consultants/advisors substantiate through literature research that clinical trials demonstrate the medical effectiveness of the service. Other guidelines, such as those of the Federal Drug Administration of the Centers for Medicare & Medicaid Services may also be used, at the discretion of the Administrator, in the determination of coverage.(e) The Administrator shall authorize the use of established procedures by the TPA for obtaining additional medical information from members and from providers of medical services and supplies, in order to determine the amount and appropriateness of benefit payments.(f) The Administrator shall establish procedures for permitting the Member to appeal an adverse determination of eligibility for Coverage or of a benefit, service, or Claim. These procedures shall be outlined in the Summary Plan Description to advise the Member of the process to initiate an appeal. However, the Administrator has delegated the final authority to the TPA for approval in accordance with the schedule of Benefits and the interpretation thereof. The Administrator shall have final authority for approval of al eligibility appeals.(g) The Administrator may contract for or employ professionals from any medical discipline to advise the Administrator on continuing medical necessity, quality of medical care, or the level of fees charged by the providers of medical care.(h) The Administrator is authorized to develop appropriate medical policy in conformity with the schedule of benefits and these regulations so that new procedures will be included for coverage when the new procedures are adopted as accepted medical practice and that medical procedures which are excessively used without significantly improving the treatment of an illness or injury are reviewed.(2)Exclusions. Plan benefits shall exclude expenses incurred by or on account of an individual prior to the effective date of coverage; expenses for services received for injury or sickness due to war or any act of war, whether declared or undeclared, which war or act of war shall have occurred after the effective date of this plan; expenses for which the individual is not required to make payment; expenses to the extent of benefits provided under any employer group plan other than this plan of benefits in which the state participates in the cost thereof. In addition, for all Regular Insurance Options, the Administrator shall publish in the Summary Plan Description interpretative language showing the exclusions for the following types of charges:(a) Charges for treatment for Pre-existing Conditions in excess of one thousand dollars ($1,000), to the extent this exclusion is permitted by federal law;(b) Charges for treatment or supplies which are determined to be not medically necessary;(c) Charges for treatment before the effective date of coverage or after coverage termination, except for Extended Coverage benefits;(d) Charges other than Wellness/Preventive benefits, that are not specifically related to the care and treatment of a sickness or an injury;(e) Charges for treatment specifically for dental or vision care;(f) Charges for treatment for experimental or investigative services or supplies;(g) Charges that are considered educational or treatment to restore learning capacity;(h) Charges in connection with custodial care, extended care facilities or a nursing home;(i) Charges in connection with rehabilitation, rehabilitation therapy, or restorative therapy when the condition is no longer expected to improve significantly in a reasonable and generally predictable period of time;(j) Charges in connection with therapy for learning disabilities;(k) Charges for prosthesis or equipment which are determined to be not medically necessary.(3)Actions. In creating the SHBP, neither the Georgia General Assembly nor the Board of Community Health has waived its sovereign immunity. Thus no action either in law or in equity, can be brought or maintained against the State of Georgia, the Board of Community Health, or any other department or political subdivision of the State of Georgia to recover any money under this Plan. In like fashion, no suit may be maintained against any officials or Employees of these bodies if the ultimate financial responsibility would have to be borne by public Funds from the General Treasury, the health benefit Funds or elsewhere.(a) The Board of Community Health, however, does reserve the right to maintain any suits, either in its own name, or through its officials, Employees, or agents, which it deems necessary to the administration of the SHBP, including actions to recover money from participants, beneficiaries, agents, Employees, officials, or any other person.(b) The Board of Community Health reserves the right to modify its Benefits, Coverages, and eligibility requirements at any time, subject only to reasonable advance notice to its Members. When such a change is made, it will apply as of the effective date of the modification to any and all charges which are incurred by Members from that date forward, unless otherwise specified by the Board of Community Health.(c) The Administrator is authorized to act as interpreter of the terms and conditions of the Plan.(4)Non-duplication of Benefits and Subrogation. The Plan will not duplicate payments for medical expenses made under third-party personal-injury-protection contracts nor will it duplicate payments made as the result of any litigation. The Plan will be subrogated to any right of recovery that a Member has against a person or organization where medical expenses were incurred as a result of injuries suffered because of alleged negligence or misconduct. In any case where the primary plan provides for subrogation for third-party liability and this Plan would be determined to be secondary, benefits under this Plan shall be reduced to the amount that would have been paid under the secondary provisions of this Plan.(5)Recovery of Benefit Overpayments. The Administrator shall seek repayment for any benefits paid to any individual, corporation, firm, or other entity who or which is not qualified, in the opinion of the Administrator, to receive benefits from the Plan. The Administrator shall establish procedures for collecting the overpayments, duplicate payments, or wrong payee payments. The procedures may include, but are not limited to, establishing installment payments, withholding future benefit payment, or filing suit or garnishment.Ga. Comp. R. & Regs. R. 111-4-1-.10
O.C.G.A. Secs. 20-2-881 to 20-2-885, 20-2-887, 20-2-911 to 20-2-915, 45-18-1et seq., Health Insurance Portability and Accountability Act of 1996 (HIPAA), Social Security Act.
Original Rule entitled "Plan Benefits" adopted. F. Apr. 18, 2005; eff. May 8, 2005.Repealed: New Rule of same title adopted. F. Jan. 22, 2007; eff. Feb. 11, 2007.Amended: F. Sept. 28, 2007; eff. Oct. 18, 2007.Amended: F. Aug. 20, 2008; eff. Sept. 9, 2008.Repealed: New Rule of same title adopted. F. Apr. 14, 2010; eff. May 4, 2010.