2018 Georgia Code
Title 31 - Health
Chapter 2 - Department of Community Health
§ 31-2-12. Pilot program to provide coverage for bariatric surgical procedures for treatment of obesity and related conditions; definitions; eligibility; requirements; evaluation report on two-year pilot program
(a) As used in this Code section, the term "state health insurance plan" means:
(1) The state employees' health insurance plan established pursuant to Article 1 of Chapter 18 of Title 45;
(2) The health insurance plan for public school teachers established pursuant to Subpart 2 of Part 6 of Article 17 of Chapter 2 of Title 20; and
(3) The health insurance plan for public school employees established pursuant to Subpart 3 of Part 6 of Article 17 of Chapter 2 of Title 20.
(b) Beginning January 1, 2016, the department shall conduct a two-year pilot program to provide coverage for the treatment and management of obesity and related conditions under a state health insurance plan. The pilot program will provide benefits for medically necessary bariatric procedures for participants selected for inclusion in the pilot program.
(c) Participation in the pilot program shall be limited to no more than 75 individuals per year, to be selected in a manner determined by the department. Any person who has elected coverage under a state health insurance plan shall be eligible to be selected to participate in the pilot program in accordance with criteria established by the department which shall include, but not be limited to:
(1) Participation in a state health insurance plan for at least 12 months;
(2) Completion of a health risk assessment through a state health insurance plan;
(3) A body mass index of:
(A) Greater than 40; or
(B) Greater than 35 with one or more co-morbidities such as diabetes, hypertension, gastro-esophageal reflux disease, sleep apnea, or asthma;
(4) Consent to provide personal and medical information to a state health insurance plan;
(5) Non-tobacco user;
(6) No other primary group health coverage or primary coverage with Medicare; and
(7) Must have been covered under a state health insurance plan for two years immediately prior to the pilot program and must express an intent to continue coverage under such state health insurance plan for two years following the approved surgical procedure date.
(d) Eligible individuals must apply to participate in the pilot program. The individual and his or her physician shall complete and submit an obesity treatment program application to the department no later than February 1 for each year of the pilot program. The department's contracted health insurance carrier shall review the criteria contained in subsection (c) of this Code section to determine qualified applicants for the pilot program.
(e) The selected participants shall be eligible to receive a multi-disciplinary health evaluation at a facility located within the State of Georgia which is designated by the American Society for Metabolic and Bariatric Surgery as a Bariatric Surgery Center of Excellence. The bariatric surgical procedures covered in the pilot program are:
(1) Gastric band;
(2) Laparoscopic sleeve gastrectomy; and
(3) Rouen-Y gastric bypass.
The participants shall use the department's contracted health insurance carrier to enroll in a case management program and to receive prior authorization for a surgical procedure provided pursuant to the pilot program. The health insurance carrier shall provide case management and patient follow-up services. Benefits for a bariatric surgical procedure under the pilot program shall be provided only when the surgical procedure is performed at a Center of Excellence within the State of Georgia.
(f) All health care services provided pursuant to the pilot program shall be subject to the health insurance carrier's plan of benefits and policy provisions. Complications that arise after the discharge date are subject to the health insurance carrier's plan of benefits and policy provisions.
(g) Participants must agree to comply with any and all terms and conditions of the pilot program including, but not limited to, participation and reporting requirements. Participation requirements shall include a 12 month postsurgery case management program. Each participant must also agree to comply with any and all requests by the department for postsurgical medical and productivity information, and such agreement shall survive his or her participation in a state health insurance plan.
(h) A panel shall review the results and outcomes of the pilot program beginning six months after program initiation and shall conduct subsequent reviews every six months for the remainder of the pilot program. The panel shall be composed of the following members, appointed by the Governor:
(1) A representative of a state health insurance plan;
(2) A representative of the state contracted health insurance carrier or carriers providing coverage under the pilot program; and
(3) At least two physicians who carry a certification by the American Society for Metabolic and Bariatric Surgery.
(i) The department shall provide a final report by December 15 of the last year of the pilot program to the chairpersons of the House Committee on Health and Human Services, the Senate Health and Human Services Committee, the House Committee on Appropriations, and the Senate Appropriations Committee. The report shall include, at a minimum:
(1) Whether patients in the pilot have experienced:
(A) A reduction in body mass index, and if so, the average amount of reduction; or
(B) The reduction or elimination of co-morbidities, and if so, which co-morbidities were reduced or eliminated;
(2) The total number of individuals who applied to participate in the pilot program;
(3) The total number of participants who enrolled in the pilot program;
(4) The average cost of each procedure conducted under the pilot program, including gastric band, laparoscopic sleeve gastrectomy, and Rouen-Y gastric bypass;
(5) The total cost of each participant's annual health care costs prior to the surgical procedure and for each of the subsequent post-procedure years for the three years following the surgical procedure; and
(6) The percentage of participants still employed by the state 12 months following the surgical procedure and 24 months following the surgical procedure, respectively.
(j) This Code section shall stand repealed on December 31, 2018.
