SB 276: Recovery of Medical Assistance from Third Party; certain provisions to comply with federal law; revise

Georgia law already requires insurers, managed care companies, pharmacy benefit managers, and other third-party payers to cooperate with the Department of Community Health when the state seeks to recover Medicaid costs from someone else's insurance. This bill updates that law (O.C.G.A. § 49-4-148) to match federal requirements. It bars these payers from denying payment for a healthcare item or service solely because the department did not get prior authorization before providing it. It also adds a new requirement that payers respond to a department inquiry about the status of a claim within 60 days of receiving it. Other existing duties, like accepting assignment of payment rights and providing quarterly eligibility data, remain in place. The changes to paragraphs about prior authorization and timely response only apply to health plans issued or renewed on or after April 28, 2001.

• Prohibits third-party payers from refusing to pay a healthcare claim solely because the item or service was not previously authorized.
• Requires third-party payers to respond to a Department of Community Health inquiry about a claim's status within 60 days of receiving it.
• Clarifies that the department's own payment for a healthcare item or service counts as the third-party payer's authorization for that service.
• Renumbers and reorganizes existing payer obligations, such as quarterly data reporting and accepting assignment of payment rights, without changing their substance.
• Keeps the three-year window for the state to submit claims and the six-year window to enforce claim rights unchanged.

Health insurers, managed care organizations, pharmacy benefit managers, and other entities legally responsible for paying healthcare claims are affected, since they must follow the new prior-authorization and response-time rules. The Department of Community Health and Georgia Medicaid recipients are also affected because the changes govern how the state recovers medical costs from these third parties.

Insurers and similar payers would no longer be able to reject Medicaid-related claims purely over a missing prior authorization, and would face a firm 60-day deadline to respond to state inquiries. This could speed up the state's recovery of Medicaid payments from private insurance and reduce disputes over authorization technicalities.

• Section 1 revises O.C.G.A. § 49-4-148(b) to update terminology from 'health care' to 'healthcare' throughout the section.
• Paragraph (2) is amended so payers must accept the department's payment as the authorization for a service and cannot refuse payment solely for lack of prior authorization.
• A new paragraph (3) requires payers to respond to a department inquiry about a claim's status within 60 days of receiving it.
• The renumbered paragraphs (4) through (7) preserve existing requirements on timely claims payment, quarterly data reporting, accepting payment assignments, and not denying claims solely over submission timing or format.
• The prior-authorization and response-time requirements apply only to health benefit plans issued, delivered, or renewed on or after April 28, 2001.
• Section 2 repeals all conflicting laws.

1. 2025-05-14Effective Date 2025-07-01
2. 2025-05-14Act 297
3. 2025-05-14Senate Date Signed by Governor (Senado)
4. 2025-04-07Senate Sent to Governor (Senado)
5. 2025-03-18House Passed/Adopted (Cámara de Representantes)
6. 2025-03-18House Third Readers (Cámara de Representantes)
7. 2025-03-13House Committee Favorably Reported (Cámara de Representantes)
8. 2025-03-11House Second Readers (Cámara de Representantes)

• Drew Echols (R, SD-049)Patrocinador principal
• Brian Strickland (R, SD-042)
• Bo Hatchett (R, SD-050)
• Chuck Hufstetler (R, SD-052)
• Blake Tillery (R, SD-019)
• Ben Watson (R, SD-001)
• Timothy Bearden (R, SD-030)
• John Kennedy (R, SD-018)
• Kay Kirkpatrick (R, SD-032)
• Shawn Still (R, SD-048)
• Matthew Gambill (R, HD-015)

1. AprobadaVotación: Senado6 de marzo de 2025

   54 a favor, 1 en contra (0 sin votar, 1 ausentes)

   Passage: Senate Vote #166

2. AprobadaVotación: Cámara de Representantes18 de marzo de 2025

   168 a favor, 2 en contra (5 sin votar, 5 ausentes)

   Passage: House Vote #284

• Medicaid
• health insurance
• prior authorization
• third-party liability
• healthcare claims