Accident and health insurance plans are regulated by both state and federal law. The 2010 Patient Protection and Affordable Care Act (ACA) made sweeping changes to the health insurance industry and imposed a number of requirements intended to control cost and expand the availability and quality of health insurance to consumers.
An insurance company in the United States must be licensed by the state in which it issues coverage. It is possible for an insurer to issue coverage in one state that covers members that live in another. The Georgia Office of Insurance and Fire Safety Commissioner is responsible for the licensing of companies to transact business in Georgia and for ensuring that those companies remain solvent and comply with all the requirements of Georgia laws and regulations. There are separate licensure requirements for certain types of health insurance, such as Health Maintenance Organizations (HMO) and Provider Sponsored Health Care Plans (PSHCP), and there may be other differences in legal requirements, as well.
The majority of health insurance offered in the United States today is considered “managed care.” The term managed care generally means a system for financing and, sometimes delivery, of health care that is intended to control cost, utilization and quality of care. For plans licensed in Georgia, there are a number of state regulations that address the way they can do business, including the time within which they plan must pay claims, late payment interest and rules related to authorizations for services and appeals. There are many types of managed care plans although the distinction between types has become more and more blurred over the past few years.