23 LC 52 0206
S. B. 20
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Senate Bill 20
By: Senators Kirkpatrick of the 32nd, Watson of the 1st, Hufstetler of the 52nd, Tillery of
the 19th, Butler of the 55th and others
A BILL TO BE ENTITLED
AN ACT
To amend Chapter 20E of Title 33 of the Official Code of Georgia Annotated, the "Surprise
1
Billing Consumer Protection Act," so as to ensure consumer access to quality healthcare by2
setting adequacy standards for network plans offered by an insurer; to provide for a short3
title; to provide for definitions; to exempt ERISA plans and health maintenance4
organizations' health benefits plans; to establish standards for network plans; to provide that,5
under certain circumstances, an insurer shall cover healthcare services provided by a6
nonparticipating provider at an in-network level of benefits; to prohibit an insurer from7
denying preauthorization for healthcare services to be performed by a participating provider8
solely because the referral was made by a nonparticipating provider; to hold a covered person9
financially harmless when a network is inadequate for its contracted purposes; to hold a10
covered person financially responsible for healthcare services under certain circumstances;11
to establish an arbitration process between an insurer and a nonparticipating provider for12
payment of healthcare services; to require an insurer to make a minimum initial payment to13
a nonparticipating provider when a payment of healthcare services is disputed; to authorize14
the Commissioner to monitor and ensure compliance through multiple means; to provide for15
rules, regulations, and penalties; to amend Chapter 6 of Title 33 of the Official Code of16
Georgia Annotated, related to unfair trade practices, so as to make failure to comply with any17
insurer requirement in the Consumer Access to Contracted Healthcare (CATCH) Act an18
unfair claims settlement practice; to amend Chapter 20F of Title 33 of the Official Code of19 23 LC 52 0206
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Georgia Annotated, relating to self-funded healthcare plans, so as to permit a self-funded
20
healthcare plan to elect to participate in and be bound by the CATCH Act; to provide for21
conforming changes; to provide for an effective date and applicability; to repeal conflicting22
laws; and for other purposes.23
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:24
SECTION 1.25
Chapter 20E of Title 33 of the Official Code of Georgia Annotated, the "Surprise Billing26
Consumer Protection Act," is amended by designating Code Sections 33-20E-127
through 33-20E-23 as Article 1.28
SECTION 2.29
Said chapter is further amended by replacing "chapter" with "article" wherever the former30
term appears in:31
(1) Code Section 33-20E-1, relating to short title;32
(2) Code Section 33-20E-2, relating to application to insurers and definitions;33
(3) Code Section 33-20E-3, relating to exemption;34
(4) Code Section 33-20E-4, relating to payment for emergency medical services;35
(5) Code Section 33-20E-5, relating to payment for nonemergency medical services;36
(6) Code Section 33-20E-7, relating to surprise bill exclusion and requirements;37
(7) Code Section 33-20E-17, relating to referral of parties for violations;38
(8) Code Section 33-20E-18, relating to limitation on litigation when arbitration sought;39
(9) Code Section 33-20E-21, relating to exclusion from other statutory provisions; and40
(10) Code Section 33-20E-23, relating to financial responsibilities for ground ambulance41
transportation.42 23 LC 52 0206
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SECTION 3.
43
Said chapter is further amended by adding a new article to read as follows:44
"ARTICLE 2
45
33-20E-30.46
This article shall be known and may be cited as the 'Consumer Access to Contracted47
Healthcare (CATCH) Act.'48
33-20E-31.49
As used in this article, the term:50
(1) 'Accessible' means a participating provider in a healthcare plan's network is:51
(A) Accepting new patients;52
(B) Available within a reasonable travel distance and time or available within a53
reasonable time by means of medically appropriate telehealth, as determined by rules54
and regulations promulgated by the Commissioner; and55
(C) Able to make appointments for urgent healthcare services within two business56
days; for behavioral health services within ten business days; for routine, preventive,57
or nonurgent healthcare services by primary care providers within 15 business days; or58
for acute care hospital or specialty care services by specialists or subspecialists within59
30 business days; or60
(D) For a clinical laboratory or pharmacy, able to provide urgent laboratory or61
pharmacy services within 24 hours and routine or nonurgent laboratory or pharmacy62
services within seven business days.63
(2) 'Clinical laboratory' has the same meaning as provided in Code Section 31-22-1.64
(3) 'Covered benefit' means nonemergency healthcare services to which a covered person65
is entitled under the terms of a healthcare plan.66 23 LC 52 0206
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(4) 'Covered person' has the same meaning as provided in Code Section 33-20E-2.67
(5) 'Facility' has the same meaning as provided in Code Section 33-20E-2.68
(6) 'Healthcare plan' has the same meaning as provided in Code Section 33-20E-2.69
(7) 'Healthcare provider' or 'provider' has the same meaning as provided in Code70
Section 33-20E-2.71
(8) 'Insurer' has the same meaning as provided in Code Section 33-20E-2.72
(9) 'Network' means the group or groups of participating providers or facilities providing73
services under a healthcare plan offered by an insurer.74
(10) 'Network plan' means a healthcare plan that either requires a covered person to use,75
or creates incentives, including financial incentives, for a covered person to use,76
providers managed, owned, under contract with, or employed by the insurer.77
(11) 'Nonparticipating provider' has the same meaning as provided in Code78
Section 33-20E-2.79
(12) 'Participating provider' has the same meaning as provided in Code80
Section 33-20E-2.81
(13) 'Pharmacy' has the same meaning as provided in Code Section 26-4-5.82
(14) 'Primary care' means healthcare services that address the patient as a whole; are83
provided by a physician or nonphysician professional where permitted; and are for a84
range of common physical, mental, or behavioral health conditions. Primary care85
providers include family practice and general practice physicians, internists, obstetricians86
or gynecologists, and pediatricians.87
(15) 'Resolution organization' has the same meaning as provided in Code88
Section 33-20E-2.89
(16) 'Specialty care' means advanced medically necessary care and treatment of specific90
physical, mental, or behavioral health conditions, or those health conditions which may91
manifest in particular ages or subpopulations, that are provided by a specialist or92
subspecialist physician or nonphysician professional where permitted.93 23 LC 52 0206
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(17) 'Telehealth' has the same meaning as provided in Code Section 33-24-56.4.94
(18) 'Telemedicine' has the same meaning as provided in Code Section 33-24-56.4.95
33-20E-32.96
(a) Nothing in this article shall be applicable to a healthcare plan which is subject to the97
exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C.98
Section 1001, et seq., unless such plan elects to participate in and agrees to comply with99
the CATCH Act, as provided in Code Section 33-20F-2.100
(b) The requirements of this article shall not apply to a group model health maintenance101
organization that has an exclusive contract with a medical group practice to provide or102
arrange for the provision of substantially all healthcare services to enrollees in the103
healthcare plans of such organization.104
33-20E-33.105
(a)(1) An insurer providing a network plan shall contract with and maintain a network106
of providers in sufficient number and appropriate type, including primary care and107
specialty care, pharmacies, clinical laboratories, and facilities, throughout such plan's108
service area to ensure covered persons have access to the full scope of benefits and109
services covered under such plan.110
(2) An insurer providing coverage for mental health or substance use disorders as part111
of a network plan shall contract with and maintain a network of providers that specialize112
in mental health and substance use disorder services in sufficient number and appropriate113
type throughout such plan's service area to ensure covered persons have access to the full114
scope of mental health and substance use disorder benefits and services covered under115
such plan.116
(b) An insurer shall demonstrate that any network plan it provides offers:117
(1) An adequate number of accessible acute care hospital services;118 23 LC 52 0206
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(2) An adequate number of accessible primary care providers;119
(3) An adequate number of accessible specialty care providers, and, if the specialty care120
provider needed for a specific condition is not represented on the plan's list of121
participating specialty care providers, covered persons have access to nonparticipating122
healthcare providers;123
(4) Accessible specialty care services; and124
(5) Accessible clinical laboratories and pharmacies.125
(c) The Commissioner shall determine network adequacy in accordance with the126
requirements of this Code section and may further assess network adequacy using127
appropriate criteria, including, but not limited to:128
(1) Primary care provider to covered person ratios;129
(2) Provider to covered person ratios by specialty;130
(3) Geographic accessibility of providers;131
(4) Geographic variation and population dispersion;132
(5) Waiting times for an appointment with providers;133
(6) Hours of operation;134
(7) The ability of the network to meet the needs of covered persons;135
(8) Access to healthcare services through telehealth or telemedicine;136
(9) Other healthcare service delivery system options, such as mobile clinics, centers of137
excellence, and other ways of delivering care; and138
(10) The volume of technologically advanced and specialty care services available to139
serve the needs of covered persons requiring such services.140
(d)(1) An insurer shall monitor on an ongoing basis the ability, clinical capacity, and141
legal authority of its participating providers to furnish all contracted covered benefits to142
covered persons.143
(2) An insurer shall notify the Commissioner and all affected covered persons of any144
material change to any existing network within 30 business days after the change occurs145 23 LC 52 0206
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and shall immediately update its provider directory in compliance with Chapter 20C of146
this title.147
33-20E-34.148
(a) An insurer shall not deny preauthorization for healthcare services to be performed by149
a participating provider solely because the covered person's referral to such provider was150
made by a nonparticipating provider.151
(b) An insurer shall not:152
(1) Require prior authorization, medical review, or administrative clearance for a153
telehealth service that would not be required if such service were provided in person;154
(2) Require demonstration that it is necessary to provide a service to a covered person155
through telehealth;156
(3) Require a provider to be employed by another provider or agency in order to provide157
a telehealth service that would not be required if such service were provided in person;158
(4) Restrict or deny coverage of a telehealth service based solely on the communication159
technology or application used to deliver such service;160
(5) Require a provider to be part of a telehealth network;161
(6) Require a covered person to utilize telehealth or telemedicine in lieu of a162
nonparticipating provider accessible for in-person consultation or contact; or163
(7) Be required to pay a facility fee to a hospital for telehealth services unless the164
hospital is the originating site as defined in subsection (b) of Code Section 33-24-56.4.165
33-20E-35.166
(a) An insurer shall provide a covered person in a network plan a covered benefit at an167
in-network level of benefits, including an in-network level of cost-sharing, from a168
nonparticipating provider when such plan does not have a type of participating provider169 23 LC 52 0206
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available to provide the covered benefit or when such plan does not have an accessible170
participating provider to provide the covered benefit to the covered person.171
(b) Upon written notification from the covered person or his or her designee of the172
conditions described in subsection (a) of this Code section, the insurer shall have 72 hours173
to respond in writing designating an accessible participating provider. Otherwise, the174
insurer shall treat the healthcare services the covered person receives from a175
nonparticipating provider as if the services were provided by a participating provider,176
including counting the covered person's cost-sharing for such services toward the177
deductible and maximum out-of-pocket limit applicable to services obtained from178
participating providers under the plan.179
(c)(1) The insurer shall document all covered benefits obtained from a nonparticipating180
provider under this Code section and shall provide this information to the Commissioner181
upon request.182
(2) The insurer shall disclose to the Commissioner when more than 15 percent of claims183
for routine, preventive, and nonurgent covered benefits in a network plan for the184
preceding calendar year are provided by nonparticipating providers.185
(d) The process established in this Code section is not intended to be used by insurers as186
a substitute for establishing and maintaining a sufficient network in accordance with the187
provisions of this article nor is it intended to be used by covered persons to circumvent the188
use of covered benefits available through the network delivery system options.189
(e) Nothing in this Code section prevents a covered person from exercising the rights and190
remedies available under applicable state or federal law relating to internal and external191
claims grievance and appeals processes.192
(f) Nothing in this Code section shall reduce a covered person's responsibilities if such193
person chose to receive nonemergency healthcare services from a nonparticipating provider194
when an accessible participating provider was designated by an insurer in writing and was,195
in fact, accessible.196 23 LC 52 0206
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33-20E-36.197
(a) If a covered person receives healthcare services from a nonparticipating provider, such198
provider shall collect or bill no more than such person's deductible, coinsurance,199
copayment, or other cost-sharing amount as determined by such person's policy directly200
and such insurer shall directly pay such provider the greater of:201
(1) The verifiable contracted amount paid by all eligible insurers subject to the202
provisions of this article for the provision of the same or similar services as determined203
by the department;204
(2) The most recent verifiable amount agreed to by the insurer and the nonparticipating205
provider for the provision of the same services during such time as such provider was206
in-network with such insurer; or207
(3) Such higher amount as the insurer may deem appropriate given the complexity and208
circumstances of the services provided.209
Any amount that the insurer pays the nonparticipating provider under this subsection shall210
not be required to include any amount of coinsurance, copayment, or deductible owed by211
the covered person or already paid by such person.212
(b) If a nonparticipating provider concludes that payment received from an insurer213
pursuant to this Code section is not sufficient given the complexity and circumstances of214
the services provided, such provider may initiate a request for arbitration with the215
Commissioner. Such arbitration shall proceed in accordance with the arbitration216
proceedings provided in Code Sections 33-20E-9 through 33-20E-21.217
(c) No nonparticipating provider shall report to any credit reporting agency any covered218
person who receives a bill for healthcare services from such provider and does not pay such219
provider any copay, coinsurance, deductible, or other cost-sharing amount beyond what220
such covered person would pay if the nonparticipating provider had been a participating221
provider.222 23 LC 52 0206
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33-20E-37.223
(a) The Commissioner may use information provided by a covered person, a provider, an224
insurer, a resolution organization, an arbitrator, or any other source to determine225
compliance with this article.226
(b) The Commissioner is authorized to conduct a data call, market conduct examination,227
or compliance audit to determine compliance with this article, as authorized by Code228
Section 33-2-11, and the insurer subject to such data call, market conduct examination, or229
compliance audit shall pay all the actual expenses incurred, in accord with Code230
Section 33-2-15.231
(c)(1) When the Commissioner determines noncompliance with this article, the232
Commissioner shall notify the insurer in writing of the determination and shall set forth233
the reasons for the determination.234
(2) The Commissioner may set forth proposed revisions that will render compliance in235
the judgment of the Commissioner, may order that healthcare services provided by236
nonparticipating providers be covered at an in-network level of benefits, and may impose237
any administrative penalties authorized by this title.238
(d) Within 30 days of notification from the Commissioner, the insurer shall submit a239
response to the Commissioner that addresses all of the Commissioner's concerns.240
(e) Within 30 days of the submission of the response, the Commissioner shall determine241
whether such response is acceptable and shall notify the insurer in writing of the242
determination and shall set forth the reasons for the determination.243
(f) If the response is deemed unacceptable to the Commissioner, the insurer shall have the244
right to request a hearing in accord with Code Section 33-2-17.245
33-20E-38.246
(a) The Commissioner may impose a monetary penalty of up to $2,000.00 for each and247
every act in violation of this article, unless the insurer knew or reasonably should have248 23 LC 52 0206
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known of the violation, in which case the monetary penalty imposed may be up249
to $5,000.00 for each and every act in violation.250
(b) The Commissioner may take any action authorized, including, but not limited to,251
issuing an administrative order imposing monetary penalties, imposing a compliance plan,252
ordering the insurer to develop a compliance plan, or ordering the insurer to reprocess253
claims.254
33-20E-39.255
The Commissioner shall adopt rules and regulations to implement and administer this256
article."257
SECTION 4.258
Chapter 6 of Title 33 of the Official Code of Georgia Annotated, relating to unfair trade259
practices, is amended in Code Section 33-6-34, relating to unfair claims settlement practices,260
by revising paragraph (15) as follows:261
"(15) Failure to comply with any insurer requirement in Article 1 of Chapter 20E of262
Title 33, the 'Surprise Billing Consumer Protection Act,' or in Article 2 of said chapter,263
the 'Consumer Access to Contracted Healthcare (CATCH) Act' including the failure to264
pay a resolution organization as required under Code Section 33-20E-16; and "265
SECTION 5.266
Chapter 20F of Title 33 of the Official Code of Georgia Annotated, relating to self-funded267
healthcare plans, is amended in Code Section 33-20F-2, relating to election to participate in268
Surprise Billing Consumer Protection Act and notices, as follows:269
"33-20F-2.270
(a) Notwithstanding any provision of law in Chapter 20E of this title, the 'Surprise Billing271
Consumer Protection Act,' a A self-funded healthcare plan may elect on an annual basis to272 23 LC 52 0206
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participate in and be bound by such Act Article 1 of Chapter 20E of this title, the 'Surprise273
Billing Consumer Protection Act,' or by Article 2 of said chapter, the 'Consumer Access274
to Contracted Healthcare (CATCH) Act,' or both.275
(b) A self-funded healthcare plan that elects to participate in either the Surprise Billing276
Consumer Protection Act or the Consumer Access to Contracted Healthcare (CATCH) Act,277
or both, shall provide notice to the Commissioner of its election decision on a form278
prescribed by the Commissioner. The completed form shall include an attestation that the279
self-funded healthcare plan has elected to participate in and be bound by the Surprise280
Billing Consumer Protection Act and by the Consumer Access to Contracted Healthcare281
(CATCH) Act to the extent that insurers are similarly bound. Such form shall be posted282
on the Commissioner's website for use by self-funded healthcare plans choosing to opt in.283
(c) A self-funded healthcare plan may elect to initiate its participation on either January 1284
of any year or on the first day of the self-funded healthcare plan's plan year of any year.285
(d) On its election form, the plan must indicate whether it chooses to affirmatively renew286
its election on an annual basis or whether it should be presumed to have renewed on an287
annual basis until the Commissioner receives advance notice from the plan that it is288
terminating its election as of either December 31 of a calendar year or the last day of its289
plan year. Notices under this subsection shall be submitted to the Commissioner at least 30290
days in advance of the effective date of the election to initiate participation and 30 days in291
advance of the effective date of the termination of participation.292
(e) Self-funded healthcare plans opting in shall develop processes to address employee293
notifications or other responsibilities under ERISA that may arise from electing to294
participate in the Surprise Billing Consumer Protection Act and in the Consumer Access295
to Contracted Healthcare (CATCH) Act."296 23 LC 52 0206
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SECTION 6.
297
Said chapter is further amended by revising Code Section 33-20F-3, relating to website298
listing of participants, as follows:299
"33-20F-3.300
The department shall maintain on its website a list of all self-funded healthcare plans that301
have chosen to participate in and comply with the Surprise Billing Consumer Protection302
Act and with the Consumer Access to Contracted Healthcare (CATCH) Act
."303
SECTION 7.304
Said chapter is further amended by revising Code Section 33-20F-4, relating to applicability,305
as follows:306
"33-20F-4.307
Nothing in this chapter shall be applicable to healthcare plans which are subject to the308
exclusive jurisdiction of ERISA, unless such plan elects to participate in and agrees to309
comply with the Surprise Billing Consumer Protection Act or with the Consumer Access310
to Contracted Healthcare (CATCH) Act."311
SECTION 8.312
Said chapter is further amended by revising Code Section 33-20F-5, relating to removal from313
participation by Commissioner and hearing, as follows:314
"33-20F-5.315
Notwithstanding any provision of law in the Surprise Billing Consumer Protection Act, in316
In the event that a self-funded healthcare plan has chosen to participate in and comply with317
such Act the Surprise Billing Consumer Protection Act or with the Consumer Access to318
Contracted Healthcare (CATCH) Act, the Commissioner shall allow such participation.319
The Commissioner shall retain the authority, however, to remove or refuse to readmit such320
participant if the Commissioner determines that the self-funded healthcare plan is failing321 23 LC 52 0206
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or previously failed to comply with the Surprise Billing Consumer Protection Act such322
Acts. Any self-funded healthcare plan shall have the opportunity to request a hearing323
pursuant to Code Section 33-2-17 prior to the effective date of such removal or denial."324
SECTION 9.325
This Act shall become effective on January 1, 2024, and shall apply to all policies or326
contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.327
SECTION 10.328
All laws and parts of laws in conflict with this Act are repealed.329