Ga. Comp. R. & Regs. R. 120-2-106-.13 - Consumer Access to Contracted Healthcare (CATCH) Act Requirements

(1) The primary purposes of this Rule are to ensure compliance with the "Consumer Access to Contracted Health Act" or "CATCH Act" by assessing and ensuring adequacy and breadth of an insurer's provider network, ensuring insurers do not illegally deny pre-authorization of healthcare services, ensuring insurers comply with the CATCH Act requirements regarding telehealth services, and to allow for a variance or exception, if appropriate.

(2) For the purposes of this Rule only, the term "Insurer" does not include a "health maintenance organization," as defined in Chapter 21 of Title 33 of the Official Code of Georgia, possessing a valid certificate of authorization obtained in accordance with O.C.G.A. § 33-21-2.

(3) On March 1, 2025 and each following March 1, each Insurer subject to the CATCH Act shall provide a report to the Commissioner such quantitative data as necessary to demonstrate compliance with O.C.G.A. § 33-20E-24(the "CATCH Report").

(4) The CATCH Report must demonstrate the following:

(a) Insurer maintains a network of participating providers in sufficient number and appropriate type, including primary care and specialty care, pharmacies, clinical laboratories, and facilities, throughout such plan's service area to ensure covered persons have access to the full scope of benefits and services covered under such plan in accordance with the standards established by the Centers for Medicaid & Medicaid Services.

(b) Insurer maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay in accordance with the standards established by the Centers for Medicaid & Medicaid Services.

(c) Insurer has available participating providers within a reasonable time and distance to covered persons and accepting patients.

(d) Insurer maintains a network of participating providers that satisfy the meeting appointment wait time standards in accordance with the standards established by the Centers for Medicaid & Medicaid Services.

(e) Insurer did not engage in the prohibited actions set forth in O.C.G.A. § 33-20E-24 or O.C.G.A. § 33-20E-24 (e) and provides an attestation of the same.

(5) The Commissioner will monitor Insurers for ongoing compliance with this Regulation throughout the plan year. Compliance monitoring may be based on several data sources, including:

(a) Complaints data.

(b) Issuer self-reporting of problems.

(c) Issuer policies, procedures and operations.

(d) Network adequacy analysis using a data call, market conduct examination or compliance audit.

(6) An Insurer subject to a data call, market conduct examination, or compliance audit shall pay all actual expenses incurred, in accordance with O.C.G.A. § 33-2-15.

(7) If the Commissioner determines an Insurer is noncompliant with the provisions in O.C.G.A. § 33-20E-24, the Commissioner shall notify the insurer of the determination and set forth the reasons for the determination. The Commissioner may set forth proposed remedies that will render compliance in the judgment of the Commissioner.

(a) Within 30 days of notification from the Commissioner, the Insurer shall submit a response to the Commissioner that addresses all of the Commissioner's concerns.

(b) Within 30 days of the submission of the response, the Commissioner shall determine whether such response is acceptable and shall notify the insurer of the determination and shall set forth the reasons for the determination.

(c) If the response is deemed unacceptable to the Commissioner, the Insurer shall have the right to request a hearing in accordance with O.C.G.A. § 33-2-17.

(8) The Commissioner may grant an exception or variance to the requirements set forth in O.C.G.A. § 33-20E-24 in his or her sole discretion.

(9) Any insurer, or any agent, counselor, representative, officer, of employee of such insurer failing to comply with the requirements of this Regulation shall be subject to such penalties as may be appropriate under the insurance laws of this State for every act in violation of O.C.G.A. § 33-20E-24.

(10) If any provision of this Rule or the application thereof to any person or particular circumstance is held invalid by a court of competent jurisdiction, the remainder of the Regulation Chapter or the applicability of such provisions to other persons, insurers or circumstances shall not be affected thereby.

Notes

Ga. Comp. R. & Regs. R. 120-2-106-.13

O.C.G.A. §§ 33-2-9, 33-20E-12, 50-13-21.

Original Rule entitled "Consumer Access to Contracted Healthcare (CATCH) Act Requirements." F. Mar. 5, 2025; eff. Mar. 25, 2025.