Online provider directories; printed directories by request; required content; accessibility
(1) An insurer shall post on its website a current and accurate electronic provider directory for each of its network plans with the information described in Code Section 33-20C-4. Such online provider directory shall be easily accessible in a standardized, downloadable, searchable, and machine readable format.
(2) In making the provider directory available online, the insurer shall ensure that the general public is able to view all of the current providers for a network plan through a clearly identifiable link or tab and without creating or accessing an account or entering a policy or contract number.
(3) The insurer shall update each network plan on the online provider directory no less than every 30 days.
(b) An insurer shall provide a print copy of a current provider directory, or a print copy of the requested directory information, with the information described in Code Section 33-20C-5 upon request by a covered person or a prospective covered person.
(c) For each network plan, an insurer shall include in plain language, in both the online and print directory, the following general information:
(1) A description of the criteria the insurer has used to build its provider network;
(2) If applicable, a description of the criteria the insurer has used to tier providers;
(3) If applicable, how the insurer designates the different provider tiers or levels, such as by name, symbols, or grouping, in the network and for each specific provider in the network, which tier each is placed in order for a covered person or a prospective covered person to be able to identify the provider tier; and
(4) If applicable, a notice that authorization or referral may be required to access some providers.
(d) The insurer shall make clear for both its online and print directories the provider directory that applies to each network plan by identifying the specific name of the network plan as marketed and issued in this state.
(e) The insurer shall make available through its online and print directories the source of the information required pursuant to Code Sections 33-20C-4 and 33-20C-5 pertaining to each health care provider and any limitations, if applicable.
(f) Provider directories, whether in electronic or print format, shall be accessible to individuals with disabilities and individuals with limited English proficiency as defined in 45 C.F.R. Section 92.201 and 45 C.F.R. Section 155.205(c).
(g)(1) When an insurer’s provider directory accessed through the insurer’s website includes a provider as a participating provider for a network plan at such time as a prospective covered person selects his or her health benefit plan during the designated open enrollment time frame, and subsequent to open enrollment in the succeeding plan year, the provider is no longer in-network for the covered person’s benefit plan, such
insurer shall, subject to the coverage terms of the health benefit plan, reimburse the provider at its most recent contracted in-network rates for a period ending 180 days after the date upon which the provider contract terminates or ending on the last day of the covered person’s coverage, whichever occurs sooner. The provider shall accept the insurer’s payment in full. Any amount paid to the provider by the insurer pursuant to this
subsection shall not be required to include any amount of coinsurance, copayment, or deductible owed by the covered person or already paid by such covered person.
(2) In the event of a public health emergency, including but not limited to a public health emergency as defined in Code Section 31-12-1.1, an insurer shall, for a period commencing on the effective date of the public health emergency and ending 150 days after the expiration of such public health emergency:
(A) Be prohibited from terminating a provider from the insurer’s network; and
(B) Reimburse a provider at its most recent contracted in-network rates.
(3) This subsection (g)(and with respect to (D) below, only subsection now (g)(1)) shall not apply if the:
(A) Provider becomes out-of-network due to suspension, expiration, or revocation of such provider’s license;
(B) Provider unilaterally terminates participation in the insurer’s network plan without cause;
(C) Insurer terminates the provider for cause for fraud, misrepresentation, or other actions constituting a termination for cause under such provider’s contract; or
(D) Insurer’s provider directory accessed through the insurer’s website accurately displayed any future date on which such provider would become out of network, days prior to the beginning of, and all during, the designated open enrollment time frame.
(4) The provisions of subsection (d) of Code Section 33-20C-3 shall not apply to the circumstances described in paragraph (1) of this subsection.
Section (g) above was added to 33-20C-2 in 2021 though the enactment of HB 454 (2021). See https://www.legis.ga.gov/legislation/59649