Rule 120-2-96-.03 - Special Provisions for Preferred Provider Organization Products Under O.C.G.A. Section 33-51-5, O.C.GA. Section 33-51-6 and This Rule(1) Preferred Provider Organization ("PPO") products offered under O.C.G.A. Section 33-51-5may contain greater percentage differentials between preferred and non-preferred providers than the 30% percentage differential limitations under Rule 120-2-44-.04(5). Notwithstanding O.C.G.A. Section 33-51-5 and Rule 120-2-96-.03(1), plans may not have a coinsurance percentage applicable to benefit levels for services provided by non-preferred providers that is less than 60% of the benefit levels under the policy for such services. This means the maximum coinsurance percentage which may be required by insurers for the enrollee's responsibility for non-preferred provider benefits under PPO products remains at a maximum of 40%.(2) O.C.G.A. Section 33-51-6confirms the continuation of the historical requirement under Georgia Law that within PPO coverage, non-preferred dental and/or non-preferred pharmaceutical providers be reimbursed by insurers at the same level as preferred dental or pharmaceutical providers as stated in O.C.G.A. Section 33-30-23 and O.C.G.A. Section 33-51-6.Ga. Comp. R. & Regs. R. 120-2-96-.03
O.C.G.A. Secs. 33-2-9, 33-51-3.
Original Rule entitled "Special Provisions for Preferred Provider Organization Products Under O.C.G.A. Section 33-51-5, O.C.G.A. Section 33-51-6 and This Rule" adopted. F. Oct. 20, 2009; eff. Nov. 9, 2009.