SB462: SB462 "Surprise Billing Consumer Protection Act"; insurance coverage for certain out-of-network ambulance transportation service; provide

LC 52 1122S The House Committee on Rules offers the following substitute to SB 462: A BILL TO BE ENTITLED AN ACT To amend Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to1 improve insurance policyholder protections by strengthening the regulation of excess profit2 in private passenger automobile insurance policies and healthcare plan coverage of ground3 ambulance transportation services; to provide for the collection of certain data annually from4 insurers writing private passe nger automobile insurance policie s; to provide for the5 Commissioner of Insurance to order the refund of any excess profit made by such insurers;6 to provide for calculations; to provide for notice and opportunity for hearing; to provide for7 cash refunds or credit refunds; to provide for certification; t o prohibit adjustments to8 commission, premium tax, or other tax payments; to provide for insurance coverage for9 certain out-of-network ambulance transportation service; to pro vide for the minimum10 allowable reimbursement rate for such service; to provide for m aximum amounts on11 copayments, coinsurance, or deductibles for such service; to pr ovide for definitions; to12 provide for rules and regulations; to provide for related matters; to provide for effective dates13 and applicability; to repeal conflicting laws; and for other purposes.14 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:15 - 1 - LC 52 1122S SECTION 1.16 Title 33 of the Official Code of Georgia Annotated, relating to insurance, is amended in17 Chapter 9, relating to regulation of rates, underwriting rules, and related organizations, by18 revising Code Section 33-9-41, which is reserved, as follows:19 "33-9-41.20 (a) As used in this Code section, the term:21 (1) 'Anticipated underwriting profit' means the expected, projected, or modeled net profit22 that an insurer anticipates making from providing insurance cov erage, exclusive of23 income from investments. Such term shall be calculated as the sum of the dollar amounts24 obtained by multiplying, for each rate filing of the insurer gr oup in effect during a25 five-year period, the earned premiums applicable to such rate filings by the percentage26 factor included in such rate filing for profit and contingencie s, such percentage factor27 having been determined with due recognition to investment income from funds generated28 by business in this state; provided, however, that separate cal culations shall not be29 necessary for consecutive filings containing the same percentag e factor for profits and30 contingencies.31 (2) 'Cash refund' means a refund issued to a policyholder or former policyholder by an32 insurer in a single payment of coins, currency, checks, drafts, or money orders.33 (3) 'Credit refund' means a refund issued to a policyholder by an insurer through34 application to a policy renewal premium for such policyholder.35 (4) 'Excess profit' means an underwriting gain for the five most recent calendar accident36 years combined which is greater than the anticipated underwriting profit plus 6 percent37 of earned premiums for such calendar accident years.38 (5) 'Final compilation year' means the final year in which data is reported in a five-year39 reporting period.40 (6) 'Private passenger automobile insurance' means insurance t hat covers the personal41 use of a private passenger automobile and its operating equipme nt; covers liability,42 - 2 - LC 52 1122S collision, comprehensive, personal injury protection or medical payments, or uninsured43 or underinsured motorist protection; or provides the mandatory minimum limits required44 under Chapter 34 of this title for the personal use of a privat e passenger automobile. 45 Such insurance may be written on a family automobile policy, st andard automobile46 policy, personal automobile policy, or similar private passenger automobile policy. Such47 term shall not include commercial automobile insurance or simil ar policies for48 commercial automobiles or commercial motor vehicles.49 (b) No later than July 1, 2028, and annually thereafter, any d omestic, foreign, or alien50 insurer that is authorized to write private passenger automobile insurance policies in this51 state shall file with the department on forms prescribed by the Commissioner data for52 private passenger automobile insurance in this state. Such data shall include both voluntary53 and joint underwriting association business and shall include the following:54 (1) Calendar year total limits earned premium;55 (2) Accident year incurred losses and loss adjustment expenses;56 (3) Administrative and selling expenses incurred in this state or allocated to this state for57 the calendar year;58 (4) Policyholder dividends incurred during the applicable calendar year;59 (5) A schedule of private passenger automobile loss and loss adjustment experience for60 each of the five most recent accident years. The incurred loss es and loss adjustment61 expenses shall be valued as of March 31 of the year following the close of the accident62 year, developed to an ultimate basis, and at four 12 month inte rvals thereafter, each63 developed to an ultimate basis, so that a total of five evaluations will be provided for each64 accident year; and65 (6) Any supplemental data the department needs for the determi nation of compliance66 with the provisions of this Code section.67 (c) The department shall review the data collected pursuant to subsection (b) of this Code68 section to determine if excess profit has been realized based o n a comparison of the69 - 3 - LC 52 1122S insurer's underwriting gain and anticipated underwriting profit. Each insurer's underwriting70 gain or loss for each calendar accident year shall be calculated as the sum of the accident71 year incurred losses and loss adjustment expenses as of March 3 1 of the following year,72 developed to an ultimate basis, plus the administrative and selling expenses incurred in the73 calendar year, plus policyholder dividends applicable to the calendar year, subtracted from74 the calendar year earned premium. Such underwriting gain or lo ss shall be compared to75 the anticipated underwriting profit for the five most recent ca lendar accident years to76 determine if excess profit has been realized.77 (d) Whenever the Commissioner has determined that an excess profit has been realized,78 the Commissioner shall issue an order for the insurer to return excess profit and otherwise79 c o m p l y w i t h t h e p r o v i s i o n s o f t h i s C o d e section . T h e o r d e r s h all contain or shall be80 accompanied by a notice of opportunity for hearing which clearl y explains that the81 opportunity must be requested within ten days of receipt of the order and notice. The order82 and notice shall be served in person by the Commissioner or his or her agent or by83 registered or certified mail or statutory overnight delivery, return receipt requested. The84 hearing shall be conducted in accordance with the provisions of Chapter 2 of this title.85 (e)(1) Excess profit shall be refunded unless an insurer demonstrates to the department86 that the refund of excess profit will render the insurer financially impaired or insolvent.87 (2) The insurer shall submit to the Commissioner a fair, pract icable, and88 nondiscriminatory plan to refund or credit to policyholders the realized excess profit as89 determined by the Commissioner within 30 days after receipt of the written notice90 provided for in subsection (d) of this Code section, or, if an insurer requests a hearing,91 within 30 days after the conclusion of such hearing. If the re fund or credit plan is not92 approved, the Commissioner shall issue a written notice to the insurer containing the93 reasons why it was not approved and specifications for correcti ons to the plan. Upon94 approval of the insurer's refund or credit plan, the Commission er shall issue an order95 - 4 - LC 52 1122S requiring the insurer to distribute the excess profit according to the approved plan in the96 form of:97 (A) A cash refund within 60 days of a final order on the refund of excess profit; or98 (B) A credit refund, which shall be applied to policy renewal premium notices that are99 forwarded to policyholders no more than 60 days after a final o rder on the refund of100 excess profit; provided, however, that, if a policyholder cancels the policy or allows the101 policy to terminate, the insurer shall make a cash refund no mo re than 60 days after102 termination of coverage.103 (f) An insurer shall immediately certify to the department when all cash refunds or credit104 refunds have been made. Any cash refund or credit refund made pursuant to this Code105 section shall be treated as a policyholder dividend applicable to the year in which it is106 incurred for purposes of reporting under this Code section for subsequent years.107 (g) The data in the required reports to the department obtaine d pursuant to this Code108 section and cash refunds or credit refunds to policyholders iss ued pursuant to this Code109 section may be rounded to the nearest dollar, provided that such rounding shall be applied110 consistently.111 (h) No insurer that makes any refund pursuant to this Code sec tion shall be allowed to112 adjust any payments of commissions, premium tax, or other tax due to such refund.113 (i) The Commissioner shall be authorized to promulgate rules and regulations necessary114 for the implementation and enforcement of this Code section. Reserved."115 SECTION 2.116 Said title is further amended in Chapter 20E, the "Surprise Billing Consumer Protection Act,"117 by revising Code Section 33-20E-23, relating to financial respo nsibilities for ground118 ambulance transportation, as follows:119 - 5 - LC 52 1122S "33-20E-23.120 Nothing in this chapter shall reduce a covered person's financial responsibilities with regard121 to ground ambulance transportation.122 (a) As used in this Code section, the term:123 (1) 'Ambulance provider' means an agency, including an agency of any political124 subdivision of this state, or a company which is operating under a valid license from the125 Emergency Health Section of the Department of Public Health and which provides126 emergency transport service; provided, however, that such term shall not include an air127 ambulance service as such term is defined in Code Section 31-11-2.128 (2) 'Clean claim' means a claim for reimbursement of service rendered by an ambulance129 provider that has no defect or impropriety, including any lack of required substantiating130 documentation, which would reasonably prevent timely payment for a claim.131 (3) 'Covered service' means emergency transport service which a covered person is132 entitled to receive under the terms of a healthcare plan.133 (4) 'Emergency transport service' means the provision of emerg ency transportation on134 the public streets and highways of this state by an ambulance p rovider for a wounded,135 injured, sick, invalid, or incapacitated human being to or from a place where medical or136 hospital care is furnished.137 (5) 'First responder' means any firefighter of a municipal, co unty, or volunteer fire138 department; paramedic as defined in Code Section 31-11-2; emerg ency medical139 technician as defined in Code Section 31-11-2; peace officer as defined in Code140 Section 35-8-2; or communications officer as defined in Code Section 37-12-1.141 (b) A healthcare plan shall consider emergency transport service as a covered service when142 such emergency transport service is requested by a first responder.143 (c)(1) The minimum allowable reimbursement rate under any healthcare plan other than144 a state healthcare plan for covered service to an out-of-network ambulance provider shall145 be the rate agreed to by contract with or through passage of an ordinance, resolution, rule,146 - 6 - LC 52 1122S or regulation by a county, municipality, special district, or a uthority for such service147 within the respective jurisdiction.148 (2) When no agreement on a minimum reimbursement rate exists a s set forth in149 paragraph (1) of this subsection, the minimum allowable reimbursement amount shall be150 the lesser of:151 (A) Three hundred and twenty-five percent of the reimbursement rate under the152 Medicare program, Part A or B of Title XVIII of the federal Soc ial Security Act, 42153 U.S.C. Section 1395, et seq., as amended, for ambulance services; or154 (B) The charges billed by the ambulance provider.155 (d) Any payment made to an ambulance provider pursuant to this Code section shall156 release a covered person from any further payment responsibilit y other than any157 copayment, coinsurance, or deductible owed by the covered person.158 (e) Any copayment, coinsurance, or deductible paid for covered service provided by an159 out-of-network ambulance provider shall not exceed the amount o f a copayment,160 coinsurance, or deductible amount owed for similar service prov ided by an ambulance161 provider that belongs to the provider network in a healthcare plan.162 (f) No later than 30 days after the receipt of a clean claim for covered service, an insurer163 shall remit payment for such service directly to the ambulance provider and shall not remit164 any payment to a covered person. When an insurer receives a cl aim that is not a clean165 claim, such insurer shall, within 30 days after receipt of such claim, send written notice to166 the ambulance provider making such claim that acknowledges the receipt of such claim and167 informs the ambulance provider that:168 (1) The insurer has declined to pay all or part of the claim, including the reasons for such169 denial; or170 (2) Additional information is necessary to make a determination regarding payment of171 all or part of the claim submitted, including the specific information required."172 - 7 - LC 52 1122S SECTION 3.173 (a) Except as provided in subsection (b) of this section, this Act shall become effective on174 July 1, 2026, and shall apply to all policies issued, delivered, issued for delivery, or renewed175 in this state on or after such date.176 (b) Section 2 of this Act shall become effective on January 1, 2027, and shall apply to all177 contracts entered into or renewed and all policies issued, deli vered, issued for delivery, or178 renewed in this state on or after such date.179 SECTION 4.180 All laws and parts of laws in conflict with this Act are repealed.181 - 8 -