Ga. Comp. R. & Regs. R. 111-4-1-.10 - Plan Benefits
(1)
Creation of Benefit Schedule. The Board is authorized to establish
benefit schedules for Options to be included in a health benefit plan for
eligible persons as defined in Georgia law. Benefit schedules shall comply with
applicable state and federal law. Benefit schedules shall further the plan
design goals set forth by O.C.G.A. Sections
45-18-3;
20-2-883;
20-2-913: "to (1) Provide a
reasonable relationship between the hospital, surgical and medical benefits to
be included and the expected distribution of expenses of each such type to be
incurred by the covered employees and dependents; and (2) Include reasonable
controls, which may include deductible and reinsurance provisions applicable to
some or all of the benefits, to reduce unnecessary utilization of the various
hospital, surgical, and medical services to be provided and to provide
reasonable assurance of stability in the future years of the plan." Benefit
schedules for Options may include a different schedule for Medicare enrolled
Retirees and non-Medicare enrolled Retirees. Benefit schedules of Options shall
be considered in the calculation of Employer and Employee Contribution Rates.
The Regular Insurance Option benefit schedules shall be established upon
approval of the Employer and Employee Contribution Rates for such Options. The
Medicare Advantage Option benefit schedules shall be established upon approval
of the Employer and Employee Contribution Rates for such Options. The dates of
approval of Employer and Employee Contribution Rates shall be recorded in
official minutes of Board meetings. Medicare Advantage Options must be
developed and administered in the manner approved by the Centers for Medicare
and Medicaid Services. Accordingly, the following subsections apply only to
Regular Insurance Options.
(a) The
Administrator shall authorize the use of established procedures by the TPA to
terminate benefit payments if continuation of treatment in the mode being
billed is not medically necessary. The TPA's procedures must ensure that the
Member shall have the right to ask for a record review by medical
consultants.
(b) The Administrator
shall interpret the general schedules into specific benefit language for
inclusion in the Summary Plan Description and for use by the TPA in
adjudicating claim payments.
(c)
The Administrator shall incorporate specific benefit language to be used by the
TPA for review of utilization patterns and to implement claim cost containment
features, including but not limited to, medical review of excessive utilization
and audits of hospital or other claims.
(d) The Administrator shall be authorized to
require pre-authorization by the TPA of any new medical service before approval
for benefit payment. Generally, the service will not be considered for coverage
unless medical consultants/advisors substantiate through literature research
that clinical trials demonstrate the medical effectiveness of the service.
Other guidelines, such as those of the Federal Drug Administration of the
Centers for Medicare & Medicaid Services may also be used, at the
discretion of the Administrator, in the determination of coverage.
(e) The Administrator shall authorize the use
of established procedures by the TPA for obtaining additional medical
information from members and from providers of medical services and supplies,
in order to determine the amount and appropriateness of benefit
payments.
(f) The Administrator
shall establish procedures for permitting the Member to appeal an adverse
determination of eligibility for Coverage or of a benefit, service, or Claim.
These procedures shall be outlined in the Summary Plan Description to advise
the Member of the process to initiate an appeal. However, the Administrator has
delegated the final authority to the TPA for approval in accordance with the
schedule of Benefits and the interpretation thereof. The Administrator shall
have final authority for approval of al eligibility appeals.
(g) The Administrator may contract for or
employ professionals from any medical discipline to advise the Administrator on
continuing medical necessity, quality of medical care, or the level of fees
charged by the providers of medical care.
(h) The Administrator is authorized to
develop appropriate medical policy in conformity with the schedule of benefits
and these regulations so that new procedures will be included for coverage when
the new procedures are adopted as accepted medical practice and that medical
procedures which are excessively used without significantly improving the
treatment of an illness or injury are reviewed.
(2)
Exclusions. Plan benefits
shall exclude expenses incurred by or on account of an individual prior to the
effective date of coverage; expenses for services received for injury or
sickness due to war or any act of war, whether declared or undeclared, which
war or act of war shall have occurred after the effective date of this plan;
expenses for which the individual is not required to make payment; expenses to
the extent of benefits provided under any employer group plan other than this
plan of benefits in which the state participates in the cost thereof. In
addition, for all Regular Insurance Options, the Administrator shall publish in
the Summary Plan Description interpretative language showing the exclusions for
the following types of charges:
(a) Charges
for treatment for Pre-existing Conditions in excess of one thousand dollars
($1,000), to the extent this exclusion is permitted by federal law;
(b) Charges for treatment or supplies which
are determined to be not medically necessary;
(c) Charges for treatment before the
effective date of coverage or after coverage termination, except for Extended
Coverage benefits;
(d) Charges
other than Wellness/Preventive benefits, that are not specifically related to
the care and treatment of a sickness or an injury;
(e) Charges for treatment specifically for
dental or vision care;
(f) Charges
for treatment for experimental or investigative services or supplies;
(g) Charges that are considered educational
or treatment to restore learning capacity;
(h) Charges in connection with custodial
care, extended care facilities or a nursing home;
(i) Charges in connection with
rehabilitation, rehabilitation therapy, or restorative therapy when the
condition is no longer expected to improve significantly in a reasonable and
generally predictable period of time;
(j) Charges in connection with therapy for
learning disabilities;
(k) Charges
for prosthesis or equipment which are determined to be not medically
necessary.
(3)
Actions. In creating the SHBP, neither the Georgia General
Assembly nor the Board of Community Health has waived its sovereign immunity.
Thus no action either in law or in equity, can be brought or maintained against
the State of Georgia, the Board of Community Health, or any other department or
political subdivision of the State of Georgia to recover any money under this
Plan. In like fashion, no suit may be maintained against any officials or
Employees of these bodies if the ultimate financial responsibility would have
to be borne by public Funds from the General Treasury, the health benefit Funds
or elsewhere.
(a) The Board of Community
Health, however, does reserve the right to maintain any suits, either in its
own name, or through its officials, Employees, or agents, which it deems
necessary to the administration of the SHBP, including actions to recover money
from participants, beneficiaries, agents, Employees, officials, or any other
person.
(b) The Board of Community
Health reserves the right to modify its Benefits, Coverages, and eligibility
requirements at any time, subject only to reasonable advance notice to its
Members. When such a change is made, it will apply as of the effective date of
the modification to any and all charges which are incurred by Members from that
date forward, unless otherwise specified by the Board of Community
Health.
(c) The Administrator is
authorized to act as interpreter of the terms and conditions of the
Plan.
(4)
Non-duplication of Benefits and Subrogation. The Plan will not
duplicate payments for medical expenses made under third-party
personal-injury-protection contracts nor will it duplicate payments made as the
result of any litigation. The Plan will be subrogated to any right of recovery
that a Member has against a person or organization where medical expenses were
incurred as a result of injuries suffered because of alleged negligence or
misconduct. In any case where the primary plan provides for subrogation for
third-party liability and this Plan would be determined to be secondary,
benefits under this Plan shall be reduced to the amount that would have been
paid under the secondary provisions of this Plan.
(5)
Recovery of Benefit
Overpayments. The Administrator shall seek repayment for any benefits
paid to any individual, corporation, firm, or other entity who or which is not
qualified, in the opinion of the Administrator, to receive benefits from the
Plan. The Administrator shall establish procedures for collecting the
overpayments, duplicate payments, or wrong payee payments. The procedures may
include, but are not limited to, establishing installment payments, withholding
future benefit payment, or filing suit or garnishment.
Notes
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