2022 Georgia Code
Title 33 - Insurance
Chapter 20A - Managed Health Care Plans
Article 1 - Patient Protection
§ 33-20A-3. Definitions

As used in this article, the term:

1. “Emergency services” or “emergency care” means those physical or mental health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, regardless of the initial, interim, final, or other diagnoses that are given, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:
   1. Placing the patient’s health in serious jeopardy;
   2. Serious impairment to bodily functions; or
   3. Serious dysfunction of any bodily organ or part.
2. “Enrollee” means an individual who has elected to contract for or participate in a managed care plan for that individual or for that individual and that individual’s eligible dependents.
3. “Facility” means a hospital, ambulatory surgical treatment center, birthing center, diagnostic and treatment center, hospice, or similar institution for examination, diagnosis, treatment, surgery, or maternity care but does not include physicians’ or dentists’ private offices and treatment rooms in which such physicians or dentists primarily see, consult with, and treat patients.
4. “Health benefit plan” has the same meaning as provided in Code Section 33-24-59.5.
5. “Health care provider” or “provider” means any physician, dentist, podiatrist, pharmacist, optometrist, psychologist, clinical social worker, advanced practice nurse, registered optician, licensed professional counselor, physical therapist, marriage and family therapist, chiropractor, athletic trainer qualified pursuant to Code Section 43-5-8, occupational therapist, speech language pathologist, audiologist, dietitian, or physician assistant.
6. “Home health care provider” means any provider or agency that provides health care services in a patient’s home including the supply of durable medical equipment for use in a patient’s home.
7. “Limited utilization incentive plan” means any compensation arrangement between the plan and a health care provider or provider group that has the effect of reducing or limiting services to patients.
8. “Managed care contractor” means a person who:
   1. Establishes, operates, or maintains a network of participating providers;
   2. Conducts or arranges for utilization review activities; and
   3. Contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan.
9. “Managed care entity” includes an insurance company, hospital or medical service plan, hospital, health care provider network, physician hospital organization, health care provider, health maintenance organization, health care corporation, employer or employee organization, or managed care contractor that offers a managed care plan.
10. “Managed care plan” means a major medical, hospitalization, or dental plan that provides for the financing and delivery of health care services to persons enrolled in such plan through:
    1. Arrangements with selected providers to furnish health care services;
    2. Explicit standards for the selection of participating providers; and
    3. Cost savings for persons enrolled in the plan to use the participating providers and procedures provided for by the plan; provided, however, that the term “managed care plan” does not apply to Chapter 9 of Title 34, relating to workers’ compensation.
11. “Nonurgent procedure” means any nonemergency or elective care that can be scheduled at least 24 hours prior to the service without posing a significant threat to the patient’s health or well-being.
12. “Out of network” or “point of service” refers to health care items or services provided to an enrollee by providers who do not belong to the provider network in the managed care plan.
13. “Patient” means a person who seeks or receives health care services under a managed care plan.
14. “Precertification” or “preauthorization” means any written or oral determination made at any time by an insurer or any agent thereof that an enrollee’s receipt of health care services is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such services have been satisfied. “Agent” as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.
15. “Qualified managed care plan” means a managed care plan that the Commissioner certifies as meeting the requirements of this article.
16. “Verification of benefits” means any written or oral determination by an insurer or agent thereof of whether given health care services are a covered benefit under the enrollee’s health benefit plan without a determination of precertification or preauthorization as to such services. “Agent” as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.

History. Code 1981, § 33-20A-3 , enacted by Ga. L. 1996, p. 485, § 1; Ga. L. 1999, p. 327, § 1; Ga. L. 1999, p. 350, § 2; Ga. L. 2002, p. 441, § 4; Ga. L. 2009, p. 859, § 3/HB 509; Ga. L. 2012, p. 775, § 33/HB 942; Ga. L. 2013, p. 141, § 33/HB 79; Ga. L. 2019, p. 337, § 1-88/SB 132; Ga. L. 2022, p. 598, § 4/HB 1324.

The 2019 amendment, effective July 1, 2019, deleted former paragraph (1), which read: “ ‘Commissioner’ means the Commissioner of Insurance.” and redesignated former paragraphs (2) through (17) as present paragraphs (1) through (16), respectively.

The 2022 amendment, effective July 1, 2022, inserted “physical or mental” and “regardless of the initial, interim, final, or other diagnoses that are given,” in the introductory language of paragraph (1).

Code Commission notes.

Pursuant to Code Section 28-9-5, in 1996, “refers” was substituted for “refer” in paragraph (8) (now paragraph (12)).

Pursuant to Code Section 28-9-5, in 2002, “Nonurgent” was substituted for “Non-urgent” in paragraph (12) (now paragraph (11)).

Editor’s notes.

Ga. L. 2002, p. 441, § 1, not codified by the General Assembly, provides that: “This Act shall be known and may be cited as the ‘Consumers’ Health Insurance Protection Act.’ ”

Ga. L. 2002, p. 441, § 11, not codified by the General Assembly, provides that: “This Act shall apply only to health benefit plan contracts issued, delivered, issued for delivery, or renewed in this state on or after October 1, 2002; provided, however, that Section 8 of this Act shall apply to all claims relating to health care services provided on or after July 1, 2002. Any carrier, plan, network, panel, or agent thereof conducting a post-payment audit or imposing a retroactive denial on any claim initially submitted prior to July 1, 2002, shall, no later than June 30, 2003, provide written notice to the claimant of the intent to conduct such an audit or impose such a retroactive denial of any such claim or part thereof, including the specific reason for the audit or denial and shall complete the audit or retroactive denial and provide notice to the claimant of any payment or refund due prior to January 1, 2004.” The reference to Section 8 of the Act apparently should be to Section 9 of the Act, which enacted Article 3 of this chapter.

Ga. L. 2022, p. 598, § 1/HB 1324, not codified by the General Assembly, provides: “The General Assembly finds that: (1) This state recognizes a ‘prudent layperson’ standard with regard to the need for emergency care;

“(2) Insurance companies operating in this state are required to adhere to that standard;

“(3) Patients in this state have had emergency medical claims denied due to insurers’ failure to adhere to the prudent layperson standard as intended;

“(4) The federal court system has recognized that this standard is not intended to look to the diagnosis that a patient receives. Rather, the only relevant considerations are the patient’s symptoms and whether a prudent layperson would think that emergency medical attention is necessary based on those symptoms;

“(5) This legislative body has intended and continues to intend that the prudent layperson standard be applied in the same manner;

“(6) In order to better protect Georgians seeking emergency care, legislation is needed not to change the meaning but to clarify the intended application of the prudent layperson standard in this state; and

“(7) Nothing in this Act is intended to be applicable to healthcare plans which are subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq.”

Law reviews.

For note on the 2002 amendment of this Code section, see 19 Ga. St. U.L. Rev. 220 (2002).