33-30-13.1. Furnishing claims experience to policyholders.

As used in this Code section, the term “insurer” means an accident and sickness insurer, fraternal benefit society, health care corporation, provider sponsored health care corporation, health maintenance organization, or any similar entity.#

1. (1)

   All insurers shall furnish, regardless of the rating methodology used, claims experience to group policyholders within 30 days of any policyholder’s request unless such information has been furnished to the group policyholder within the preceding six months. Such claims experience shall be furnished for all groups of 20 or more covered employees, members, or enrollees, not including dependents, and shall include, but shall not be limited to:#

   1. (A)

      Earned premiums separated by policy year for at least the last two policy years, if applicable;#

   2. (B)

      Total paid claims and total incurred claims, inclusive of any high amount or pooled claims, including both capitated and noncapitated expenses set forth in the same manner as premiums; and#

   3. (C)

      Any amounts in excess of the individual pooling or stop-loss point applicable to the group.#

2. (2)

   Insurers that utilize provider contracting methods including financial devices such as global fee arrangements to cover all medical expenses or other methods used to calculate premiums may make application to the Commissioner for approval of the use of an alternative form of claims experience reporting. The insurer must still provide Georgia experience on a group-specific basis or on such other reasonable basis as the Commissioner may approve for such insurer, in advance, based upon a submission of an explanation and supporting documentation. Any insurer that received approval for an alternative form of group claims experience reporting to policyholders shall be required to seek the Commissioner’s advance approval of a proposed response letter to group policyholders who request experience reporting. Such letter should describe the insurer’s reasons for seeking an alternative reporting process and describe the alternative form of reporting approved by the Commissioner.#

3. (3)

   Insurers may charge a reasonable fee for providing this information to group policyholders. The schedule or amount of fees to be charged group policyholders for providing this information shall be filed by each insurer with the Commissioner.#

4. (4)

   In providing claims experience to group policyholders under this Code section, insurers shall adhere to all state and federal laws regarding disclosure of protected health or personal information.#