Ga. Comp. R. & Regs. R. 120-2-67-.07 - Alternative Method of Crediting Coverage

(a) Pursuant to O.C.G.A. § 33-30-15(c)(2), insurers offering group health insurance coverage may apply the preexisting condition exclusion crediting method described in this Rule within any category of benefits described in paragraph (b) and not based on coverage for any other benefits. Insurers may elect to use all or any of the categories in counting certain benefits within a category against a preexisting condition exclusion related to such benefits.

(b) The alternative method for counting creditable coverage may be used for the following categories of benefits:

(1) mental health;

(2) substance abuse treatment;

(3) prescription drugs;

(4) dental care; and

(5) vision care.

(c) All other benefits, and all associated conditions, not related to the categories of benefits outlined in paragraph (b) are subject to the preexisting condition exclusion and limitation provisions of Rule 120-2-67-.05.

(d) The time period applicable to a preexisting condition exclusion within a particular category under the new group health insurance plan shall be reduced by the amount of time any newly eligible insured was previously covered by creditable coverage, or a combination of creditable coverages, which included any level of benefits within that category maintained under such previous creditable coverage or coverages. A lapse of coverage for benefits within a category shall not be treated as a significant break in coverage if, during such a lapse, creditable coverage was maintained except for coverage in a category, or a break of 90 days or less occurred in which no creditable coverage was maintained.

(e) If an insured was covered for benefits within a particular category under prior creditable coverage, or a combination of coverages, for twelve (12) months, no preexisting condition exclusion period for benefits within that category shall be applicable to any preexisting condition under the new group health insurance benefit plan.

(f) An insurer may provide a maximum exclusion of less than twelve months for benefits within a category because of preexisting conditions related to that category of benefits.

(g) If an insurer uses the alternative method with a particular policy, the insurer must state prominently in any disclosure statement concerning the coverage, and to each employer at the time of the offer or sale of the coverage, that the insurer is using the alternative method, and include in such statements a description of the effect of using the alternative method. This applies separately to each type of coverage offered by the insurer.

(h) An insurer may require an eligible employee, group member, or enrollee to document previous creditable coverage within a category or categories and to cooperate in obtaining such documentation. An insurer may also request information on categories of benefits included in previous creditable coverage from any previous insurer, administrator, employer, or employer health benefit arrangement and solicit corroboration documentation for the purposes of crediting coverage under the alternative method.

(i) An insurer, upon the request of another insurer, administrator, employer, or employer health benefit arrangement providing coverage to a former insured, must promptly disclose specific information needed by the other insurer, administrator, employer, or employer health benefit arrangement in order to determine an insured's or former insured's previous creditable coverage with respect to any category or categories of benefits creditable coverage with respect to any category or categories of benefits permitted for consideration under the alternative method. An insurer furnishing this information may charge the reasonable cost of disclosing such information.

Notes

Ga. Comp. R. & Regs. R. 120-2-67-.07

O.C.G.A. Sec. 33-2-9, 33-30-15.

Original Rule entitled "Ratings" adopted. F. Feb. 29, 1996; eff. Mar. 20, 1996. Amended: ER 120-2-67-0.7 adopted. F. and eff. November 10, 1997, to remain in effect for 120 days or until the effective date of a permanent Rule covering the Same subject matter superseding this ER is adopted, as specified by the Agency. Repealed: Permanent Rule entitled "Alternative Method of Crediting Coverage" adopted. F. Feb. 17, 1998; eff. Mar. 9, 1998.