Rule 120-2-20-.03 - Unlawful Agreements between Insurers and Providers(1) An agreement between an insurer and a provider shall not include a most favored nation clause or an upper limit trigger clause.(2) Definitions: (a) "Most favored nation clause" means any clause or combination of clauses in an agreement between an insurer and a provider that: 1. Prohibits, or grants the insurer an option to prohibit, a provider from contracting with another party to provide health care services at a lower rate than the payment or reimbursement rate specified in the contract;2. Requires, or grants the insurer an option to require, a provider to accept a lower payment or reimbursement rate if the provider agrees to provide health care services to another party at a lower rate than the payment or reimbursement rate specified in the contract;3. Requires, or grants a contracting insurer an option to terminate or renegotiate an existing contract in the event the provider agrees to provide health care services to any other party at a lower rate; or4. Requires a provider to disclose, to the insurer or its designee, the provider's contractual payment or reimbursement rates with other parties.(b) "Upper limit trigger clause" means any clause or combination of clauses in an agreement between an insurer (the "first insurer") and a provider that requires the provider to cease accepting as patients individuals covered by an agreement with another insurer, or non-covered patients, if the provider elects to limit, or cease, accepting patients covered by the agreement between the first insurer and the provider. As used in this Regulation, the term "upper limit trigger clause" only refers to a clause or combination of clauses contained within an agreement between an insurer and a provider where the provider is a primary care physician and is compensated by the insurer on a capitated basis.(3) The Commissioner shall follow the procedure set forth in O.C.G.A. § 33-6-13(d)whenever there is a violation of this regulation.(4) For the purposes of this regulation, "provider" means any physician, hospital, or other person who is licensed or otherwise authorized in this state to furnish health care services.(5) For the purposes of this regulation, "health care services" means any services included in the furnishing to any individual of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury.Ga. Comp. R. & Regs. R. 120-2-20-.03
O.C.G.A. Secs. 33-2-9, 33-6-13, 33-6-36.
Original Rule entitled "Severability" adopted as ER. 120-2-20-0.19-.03 adopted. F. and eff. Feb. 20, 2006, the date of adoption.Amended: ER. 120-2-20-0.21-.03 adopted. F. June 13, 2006; eff. June 20, 2006, as specified by the Agency.Amended: Permanent Rule adopted. F. Sept. 22, 2006; eff. Oct. 12, 2006.Repealed: New Rule entitled "Unlawful Agreements between Insurers and Providers" adopted. F. Feb. 10, 2012; eff. Mar. 1, 2012.Note: Correction of non-substantive typographical error, "Amended: F. Feb. 10, 2012; eff. Mar. 1, 2012." changed to "Repealed: New Rule entitled "Unlawful Agreements between Insurers and Providers" adopted. F. Feb. 10, 2012; eff. Mar. 1, 2012." as published in the Official Compilation, Rules and Regulations of the State of Georgia (March 1, 2012 (Rev)). Eff. Oct. 21, 2015.Amended: F. Oct. 1, 2015; eff. Oct. 21, 2015.