Georgia

SUMMARY

Georgia has been active in healthcare price transparency legislation. This legislative session, the legislature introduced HB 678 and SB 359, two bills aimed at providing consumer protection from surprise billing. Under House Bill 678, a consumer getting non-emergency services would receive information on whether the medical providers involved are in the patient’s insurance network, what the fees will be, and how much the patient’s policy will pay. A similar legislation was proposed in the 2017 session but ultimately died. Senate Bill 359 is similar to but broader than HB 678. The Senate version has provisions on payment for non-network medical services that the insurance industry opposes. In addition, in the 2017 legislative session, the legislature passed a legislation regulating pharmacy benefits managers (PBMs) to promote pharmaceutical price transparency.

Separately, we have our eye on provider markets in the state. Several Georgia rural hospitals have closed in the past four years, indicating a crisis of access for low-income and underserved residents in non-urban areas. In addition, on September 5, 2014, the FTC announced that it was withdrawing its acceptance of the consent agreement reached in the August 2013 settlement with the Hospital Authority of Albany-Dougherty County and Phoebe Putney Health System following a merger challenge by the FTC that had gone all the way to the U.S. Supreme Court.

 

LEGISLATION/REGULATION

Legislative Calendar

Georgia’s current regular legislative session runs from 1/8/2018 – late March 2018.

Recent Legislative Developments

Healthcare Transparency

2018 HB 678 RELATING TO DISCLOSURE REQUIREMENTS OF PROVIDERS, HOSPITALS, AND INSURERS: requiring an amendment to Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to provide for consumer protections regarding health insurance; to provide for definitions; to provide for disclosure requirements of providers, hospitals, and insurers; to provide for billing, reimbursement, and arbitration of certain services; to provide for related matters; to provide an effective date; to repeal conflicting laws; and for other purposes. Active — Passed in House, referred to Senate.
SB 359 RELATING TO CONSUMER COVERAGE AND PROTECTION FOR OUT-OF-NETWORK MEDICAL CARE ACT: to amend Title 33 of the O.C.G.A., relating to insurance, so as to establish standards for carriers and health care providers with regard to payment under a managed care plan in the provision of emergency medical care; to provide for applicability; to provide for related matters; to provide for a short title; to repeal conflicting laws; and for other purposes. Active – Passed in Senate, referred to House
HB 873 RELATING TO CONSUMER PROTECTIONS AND FREEDOM OF INFORMATION REGARDING PRESCRIPTION DRUGS: Requiring an amendment to Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to provide for consumer protections and freedom of information regarding prescription drug benefits; to provide for intent and applicability; to provide for definitions; to provide for requirements; to provide for an advisory committee; to provide for related matters; to provide for a short title; to provide for effective dates and applicability; to repeal conflicting laws; and for other purposes. Active – House Second Readers
2017 HB 276 & SB 103 Relating to the regulation and licensure of pharmacy benefits managers: authorizes the Commissioner of Insurance to promulgate rules and regulations to prohibit PBMs from requiring the use of mail-order pharmacies. Would ban the PBM practice that prohibits a pharmacist or pharmacy from providing an insured patient information regarding the amount of the patient’s prescription drug cost share and the clinical efficacy of a lower priced alternative drug if one is available. Neither pharmacy nor pharmacist shall be penalized for sharing information or for selling a more affordable alternative if one is available. Would prohibit PBMs charging or collecting from an insured a copayment that exceeds the total submitted charges by the network pharmacy for which the pharmacy is paid. Passed — Act 195.

 

Healthcare Cost

  • None identified.

 

Healthcare Markets

2018 HB 799 RELATING TO PATIENT PROTECTION UNDER MANAGED HEALTH CARE PLANS: requiring an amendment to Article 1 of Chapter 20A of Title 33 of the Official Code of Georgia Annotated, so as to provide certain requirements for out of network hospitals prior to providing post-stabilization care; to provide for definitions; to provide for contact with the patient’s health benefit plan or the plan’s contracted health care provider; to provide for transfer to an in network hospital; to provide for cost coverage associated with care and transfer; to provide for certain notice; to provide for related matters; to repeal conflicting laws; and for other purposes. Active — House Second Readers
SB 400 RELATING TO REPEAL OF CERTIFICATE OF NEED PROGRAM: to amend Title 31 of the Official Code of Georgia Annotated, relating to health, so as to repeal the Certificate of Need program; to amend other provisions in various titles of the Official Code of Georgia Annotated for purposes of conformity; to provide for legislative findings and intent; to amend Article 1 of Chapter 7 of Title 31 of the Official Code of Georgia Annotated, relating to regulation of hospitals and related institutions, so as to provide that certain requirements relating to charity and indigent care previously imposed as a condition for a certificate of need are imposed as a condition of licensure; to provide for related matters; to provide for effective dates; to repeal conflicting laws; and for other purposes. Active – Pending in Senate
SB 300 RELATING TO A PROGRAM OF PREMIUM ASSISTANCE: to amend Article 7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating to medical assistance generally, so as to provide for a program of premium assistance to enable eligible individuals to obtain health care coverage; to provide for definitions; to require personal responsibility premiums from eligible individuals; to provide for a compliance pool; to provide for any necessary state plan amendments or federal waivers; to provide for termination of the program under certain circumstances; to provide for the Legislative Oversight Committee for Health Care Premium Assistance; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes. Active – Pending in Senate
HR 915 RELATING TO TELEHEALTH: A resolution recognizing telehealth as an important tool to improving access to health care in Georgia; and for other purposes. Active – Pending in House


Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

 

Transparency in Healthcare

  • C.G.A. § 33-3-21 requires that every insurer file with a report with the Commissioner of Insurance of its affairs and operations annually, and any other periodic reports the Commissioner prescribes by regulation.

 

  • C.G.A. 33-20-23 all health care corporations must keep their books and records in accordance with the Commissioner’s requirements, and all books and records are subject to inspection.

 

  • C.G.A. 33-20-24 states that healthcare corporations must make periodic reports to the commissioner of insurance as necessary to protect policyholders and the public.

 

  • C.G.A 31-7-280 et seq. obligates health care facilities and providers to issue an annual report containing information regarding their financial condition and other public health data. The department is required to establish and operate a state-wide health care data system to collect the data pursuant to this chapter and disseminate it, incorporating also data from third-party payers.

 

  • C.G.A. 31-7-400 et seq. requires that entities must notify the Attorney General before acquiring a nonprofit hospital. The Attorney General will hold a hearing for the purpose of ensuring that the public’s interest is protected by way of a full disclosure of the purpose and terms of the transaction and by providing an opportunity for local public input.

 

Healthcare Contracting

  • C.G.A. 33-20a-6 prevents a managed care plan from using a financial incentive or disincentive program for ordering or providing less than medically necessary and appropriate care. Capitated payments are not prohibited, however.

 

Healthcare Markets

  • C.G.A. 31-6-40 implements a Certificate of Need (CON) program, which requires that a facility must obtain regulatory approval ensuring genuine community need before offering new or expanded health care services. A CON program can be anticompetitive by increasing the regulatory burden on new or smaller healthcare providers.

 

  • C.G.A. § 10-1-393 applies provisions of the state Fair Business Practices Act to contracts for healthcare services between a physician and an insurer in order to protect consumers and businesses from unfair or deceptive trade practices.

 

  • C.G.A. 33-6-3 et seq. prohibits unfair methods of competition and unfair or deceptive acts or practices in the business of insurance.

 

  • C.G.A. 33-20-20 health care corporations must submit a schedule of rates and plans for prior approval from the Commissioner of Insurance before they accept applications from subscribers in a nonprofit health care plan.

 

  • C.G.A. 33-20-21 requires that health care corporations must submit their payment rates rendered to providers of health care services to the Commissioner of Insurance, who must give prior approval on the basis of whether they are fair and reasonable.

 

  • C.G.A. 33-20-34 in order for a non-profit healthcare corporation to convert into a for-profit entity, they must submit a plan to the Commissioner of such conversion, who will approve the change in structure if it is in the “best interest of the company, its policyholders, and the general public.”

 

  • C.G.A. 33-57-3 et seq. creates a Consumer’s Insurance Advocate within the Governor’s Office of Consumer Affairs. The Advocate is a licensed attorney whose duties include reviewing rate information submitted to the Insurance Commissioner for the purposes of determining whether insurance rates are excessive, inadequate, or unfairly discriminatory.

 

FY 2018 BUDGET

Georgia’s budget is set for a fiscal year, starting on July 1 and continuing through the next June 30. Georgia enacted its FY 2018 Budget during the 2017 regular legislative session. To view Georgia’s FY 2018 Budget, click here.

 

LITIGATION/ENFORCEMENT

  • On September 5, 2014 the FTC announced that it was withdrawing its acceptance of the consent agreement reached in the August 2013 settlement with the Hospital Authority of Albany-Dougherty County and Phoebe Putney Health System following a merger challenge by the FTC that had gone all the way to the U.S. Supreme Court. In April 2011, the FTC challenged the acquisition as having anticompetitive effects and alleging that Phoebe had structured the deal to improperly take advantage of the state action doctrine. On June 27, 2011 the district court dismissed the FTC’s complaint, ruling that Phoebe Putney was immune from antitrust liability under the state action doctrine. The Eleventh Circuit affirmed. The Supreme Court reversed, ruling that the state of Georgia has no clearly articulated a policy that allows hospital authorities to make acquisitions that substantially lessen competition, after which the parties settled. Find the FTC case summary and related documents here.

 

KEY RESOURCES

Georgia State General Assembly

Georgia Office of the Attorney General