Rule 120-2-81-.08 - Individual Applications and Assignments(1) Applications for coverage must be submitted to the Commissioner, or to a designated administrator appointed by the Commissioner, prior to assignment to a participating health insurer or managed care organization. Certificates of creditable coverage sufficient to establish status as a qualified eligible individual shall be submitted with the application if available.(2) Qualifying eligible individuals must use application forms for assignment included in Form APP-ASSIGN . The Commissioner, or the Commissioner's designated administrator, shall furnish such applications to licensed insurance agents or to other individuals upon request.(3) An application form may be completed and submitted either by a licensed insurance agent or directly by the applicant. If the application for coverage in GHIAS or GHBAS using Form APP-ASSIGN is prepared and submitted by a licensed insurance agent, the participating health insurer or managed care organization to which the applicant is assigned and who issues a health insurance policy or benefit plan as a result of that assignment shall compensate that agent only for the procurement, preparation, and submission of such application at a commission rate of not less than 3 percent of the premiums received by the issuing health insurer or managed care organization for coverage issued to the applicant.(4) After initial review, the Commissioner, or the designated administrator, shall enter the application into either the GHIAS or the GHBAS as appears appropriate.(5) An applicant entered into the GHIAS will be assigned to a participating health insurer using a randomized assignment selection process established and maintained by the Commissioner, or an alternate method as deemed necessary by the Commissioner, that is based on the pro rata premium volume of individual health insurance business done in Georgia by each such health insurer. Assignments shall become final, and credited to the health insurer's share, upon final determination of eligibility and payment of the initial premium.(6) An applicant entered into the GHBAS will be assigned to a participating managed care organization using a randomized assignment selection process established and maintained by the Commissioner, or an alternate method as deemed necessary by the Commissioner, that is based on the pro rata premium volume of individual health benefits business done in Georgia by each such managed care organization. Assignments shall become final, and credited to the health insurer's share, upon final determination of eligibility and payment of the initial premium. If the applicant does not reside within a geographic area normally served by a participating managed care organization to which the applicant is initially assigned, the assignment selection process shall be repeated until a participating managed care organization is selected that serves the area in which the applicant resides. If no participating managed care organization serves the area in which the applicant resides, the applicant will be entered into the GHIAS and assigned to a participating health insurer.(7) The Commissioner or designated administrator shall notify the participating health insurer or managed care organization of an assignment and shall deliver the application to the assigned participating health insurer or managed care organization. The participating health insurer or managed care organization to which the applicant is assigned shall be responsible for verification of the information contained in the application and determining whether the applicant is an eligible individual. Upon determination that the applicant is an eligible individual, the participating health insurer or managed care organization to which the applicant is assigned shall, in writing, promptly offer the applicant a choice of the standard policies or plans (and optional policies or plans, if applicable). A participating health insurer or managed care organization shall make such determination and written offer no later than ten (10) business days after the health insurer or managed care organization is notified by the Commissioner of such assignment.(8) If the participating health insurer or managed care organization determines that the applicant is not an eligible individual, the determination, along with a detailed explanation for the decision, must be furnished to the applicant, and to the Commissioner or the designated administrator, no later than ten business (10) days after the health insurer or managed care organization is notified by the Commissioner of such assignment.(9) The written offer of coverage by a participating health insurer or managed care organization to an assigned applicant shall include copies of the appropriate schedule of benefits for each standard policy or plan as indicated on Form GHIAS-S or GHBAS-S, as well as a premium rate table for each policy or plan, as found in Forms GHIAS-R or GHBAS-R . The health insurer or managed care organization shall use the enrollment form prescribed in Form GHIAS-E or GHBAS-E for enrolling the applicant. The applicant must select the desired policy or plan and pay the initial premium within thirty (30) days of receiving such offer. Upon selection by the applicant and payment of the initial premium, the policy or plan shall be promptly issued and shall be made effective on the date specified by this Regulation Chapter.(10) Upon issuance of each health insurance policy or benefit plan, the participating health insurer or managed care organization shall notify the Commissioner, or the designated administrator, in writing and provide a copy of the completed enrollment form. Assignments will then be adjusted as policies are actually issued to assure that no participating health insurer or managed care organization issues coverage to a significantly disproportionate share of assigned applicants. Failure to promptly process applications, issue policies or benefit plans, and notify the Commissioner, could result in a disproportionate share of applicants being assigned to the participating health insurer or managed care organization. The participating health insurer or managed care organization shall promptly notify the Commissioner when it is determined that no policy or benefit plan will be purchased by the applicant.Ga. Comp. R. & Regs. R. 120-2-81-.08
O.C.G.A. Secs. 33-2-9, 33-29A-1, et seq.
ER. 120-2-81-0.8 adopted. F. Dec. 31, 1997; eff. Jan. 2, 1998, to remain in effect for a period of 120 days or until the effective date of a permanent Rule covering the same subject matter superseding the ER, is adopted, as specified by the Agency.Amended: Permanent Rule entitled "Eligibility for Benefits; Time Limit for Application" adopted. F. Apr. 29, 1998; eff. May 19, 1998.