Rule 120-2-106-.06 - Non-emergency Medical Services(1) If the provisions of 120-2-106.08 are met, an insurer that provides any benefits to covered persons with respect to non-emergency medical services shall pay for such services in the event that such services resulted in a surprise bill regardless of whether the healthcare provider furnishing non-emergency medical services is a participating provider with respect to non-emergency medical services.(2) In the event a covered person receives care in a facility that generates a surprise bill for non-emergency medical services from a non-participating medical provider, the non-participating provider shall collect or bill the covered person no more than such person's deductible, coinsurance, copayment, or other cost-sharing amount as determined by such person's policy. The insurer shall directly pay such provider the greater of: (a) The verifiable median contracted amount paid by all eligible insurers for similar services calculated by a vendor utilized and chosen by the Commissioner;(b) The most recent verifiable amount agreed to by the insurer and the non-participating emergency medical provider for the same services during which time the provider was in-network with the insurer; (if applicable)(c) A higher amount as the insurer may deem appropriate given the complexity and circumstances of the services provided. Any amount that the insurer pays the non-participating provider under this subsection shall not be required to include any amount of coinsurance, copayment, or deductible owed by the covered person or already paid by such person.
(3) Non-emergency medical services received from non-participating providers and/or facilities shall count toward the deductible and any maximum out of pocket policy provisions as if the services were obtained from a participating provider.(4) In cases of non-emergency medical services received from a non-participating facility, the facility shall bill the covered person no more than deductible, coinsurance, copayment, or other cost-sharing as determined by such person's policy.(5) All insurer payments made to providers pursuant to this Code section shall be in accord with Code Section 33-24-59.14. Such payments shall accompany notification to the provider from the insurer disclosing whether the healthcare plan is subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 202Sec. 1001, et seq.Ga. Comp. R. & Regs. R. 120-2-106-.06
O.C.G.A. §§ 33-2-9, 33-20E.
Original Rule entitled "Non-emergency Medical Services" adopted. F. Dec. 7, 2020; eff. Jan. 1, 2021, as specified by the Agency.