Healthy Access Database

Georgia Information Directory

Employer-Based Health Insurance Coverage

Small Employer Groups

Definition
2-50 employees.

Requirements for Obtaining Coverage
Small employers must provide the DOL-4 Form listing all employees. In the cases of husband/wife sole proprietors, the carrier may ask for a business address and income tax returns that show IRA contributions for both spouses.

Guarantee Issue Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, all health insurance contracts for employer-groups of 2-50 employees must be issued on a guarantee-issue basis. All group insurance contracts must also be guarantee-renewable, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation or the employer has not complied with the terms of the health insurance contract.

Preexisting Condition Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, all group health insurance carriers can impose a 6-month look-back/12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage.

Underwriting Requirements
In the small group market in Georgia, private health insurance carriers can medically underwrite rates, and variations are allowed for up to + or - 25% of the pool rate for claims experience. An insurer may also make variations based on the demographic factors of age, group size, family size or composition, sex, area, industry, and occupational and advocational factors (including, but not limited to tobacco usage). The group size variation may not vary by more than + or - 15% of the base rate. Experienced based annual rate increases are limited to 15%, not inclusive of trend.

Creditable Coverage Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, credit for prior coverage is required as long as there is no more than a 63-day break in coverage.

Large Employer Groups

Definition
51 or more employees.

Issuance of Coverage
Large group health insurance contracts, unlike small group health insurance contracts, do not have to be offered on a guarantee-issue basis. Large group health insurance is medically underwritten at the time of purchase, with rates based on employee participation and prior claims experience. However, as per the federal Health Insurance Portability and Accountability Act of 1996, all group insurance contracts, including large group contracts, must be guarantee-renewable, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation or the employer has not complied with the terms of the health insurance contract.

Creditable Coverage Requirements
As per the federal Health Insurance Portability and Accountability Act of 1996, credit for prior coverage is required as long as there is no more than a 63-day break in coverage.

Continuation of Coverage Options

COBRA
Many organizations that employ more than 20 people and offer health benefits are required to allow employees and their dependents to temporarily continue their health insurance coverage for specified time periods and under specified conditions even after they would no longer be traditionally eligible for that coverage. The federal legislation that requires this is known as the Consolidate Omnibus Budget Reconciliation Act of 1985 (COBRA). This section explains people's rights under COBRA, which do not vary by state.

Qualifying Events

State Continuation and/or Individual Conversion Plans

Overview of State Continuation/Mini-COBRA Requirements
In Georgia, individuals who have employer-group coverage, but are part of a group of 2-19 employees (and thus ineligible for federal COBRA), can purchase continuation coverage through their employer group when their group health coverage is lost due to certain specific events. Coverage may be for up to three months, and to be eligible, the individual must have been part of the employer-group plan for at least 6 months prior to the loss of coverage. Individuals must also apply for this coverage before the group's next premium payment is due to be eligible, and they may be charged up to 102% of their individual premium for participation.

Conversion Plan Requirements
Individuals who are transferring out of a group plan have the option of selecting an individual conversion product.

HIPAA Group-to Individual Portability Coverage

Explanation
Individuals who have been in enrolled in a group health plan and decide to leave that group health plan and purchase individual market coverage have certain rights under the federal Health Insurance Portability and Accountability Act of 1996. States must provide at least one guarantee-issue option for those individuals to purchase individual market insurance, as long as that coverage is purchased within 63 days of disenrollment from the group plan. Individuals who have access to COBRA must first exhaust COBRA coverage before exercising their HIPAA rights, unless specified by the state. Individuals with less than 12 months of creditable coverage may be eligible for partial credit, based on the length of creditable coverage they do have available.

In Georgia, individuals exercising their federal group-to-individual portability rights provided by HIPAA can obtain guarantee-issue private individual health insurance coverage through either a conversion product, or through individual market carriers on an assignment basis.

Exhaustion of Other Coverage Requirements
Individuals must exhaust their COBRA benefits or similar state program benefits if available to them before exercising their HIPAA rights. Individuals also cannot currently be eligible for Medicare or Medicaid or covered under any other health insurance.

Creditable Coverage Requirements
Individuals must have at least 18 months of prior creditable coverage. The most recent prior coverage must have been group health insurance coverage offered by a health insurance issuer, group health plan, government plan or church plan. Individuals may not have had a prior coverage break of more than 63 days.

Other Requirements
Individuals must be Georgia residents.

Individual Health Insurance Coverage

Traditional Private Individual Health Insurance

Underwriting Requirements
Medical underwriting is allowed without restriction.

Rating Restrictions
There are no rate caps in the Georgia traditional private health insurance market.

Issuance of Coverage
Carriers are not required to guarantee-issue coverage, except to certain people who are exercising their HIPAA group-to-individual portability rights on an assignment basis. Elimination riders are permitted under certain circumstances, except for the HIPAA-eligible population.

Preexisting Condition Requirements
There is a 24-month exclusionary period limit for pre-existing conditions in the Georgia traditional individual health insurance market.

Creditable Coverage Requirements
Credit for prior coverage not required, except for individuals exercising their HIPAA group-to-individual portability rights, under certain circumstances.

Coverage for Medically Uninsurable Individuals

Guarantee Issue Requirements

General
Traditional individual market health insurance is not sold on a guarantee issue basis in Georgia.

HIPAA Group-to Individual Portability Coverage
In Georgia, individuals exercising their federal group-to-individual health insurance rights provided by the Health Insurance Portability and Accountability Act of 1996 can obtain guarantee-issue private individual health insurance coverage through either a conversion product, or through individual market carriers on an assignment basis.

Other State Options

Overview of State Alternative
Georgia does not currently have a mechanism in place to provide access to private market individual health insurance coverage to medically uninsurable individuals who do not either have access to group coverage or guarantee issue rights provided under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, legislation was passed during the 2005 session to mandate the development of a state commission to study the creation of a high-risk pool for the state of Georgia and report back on the feasibility by December 31, 2005.

Assistance for Obtaining Health Coverage

Medicaid

Income Requirements

Children
Children (ages 1-5)-133% of the Federal Poverty Level
Children (Ages 6-19)-100% of the Federal Poverty Level

Pregnant Women and Infants
Pregnant Women-200% of the Federal Poverty Level
Infants (ages 0-1)-200% of the Federal Poverty Level if the mother is enrolled in Medicaid at the time of birth. If not, infants with family incomes of 185% of the Federal poverty Level are eligible for coverage.

Parents
Non-Working Parents-32% of the Federal Poverty Level
Working Parents-58% of the Federal Poverty Level

Other Populations
Medically Needy Individual-44% of the Federal Poverty Level
Medically Needy Couple-39% of the Federal Poverty Level
Supplemental Security Income Recipients-74% of the Federal Poverty Level

Asset Requirements
Asset and resource requirements vary based on the Medicaid program for which an individual is applying. There are no asset or resource requirements for children or pregnant mothers.

Other Enrollment Requirements
Georgia resident, U.S. Citizen or lawful alien status, and meeting the age criteria of the Medicaid program for which the individual has applied.

Overview of Benefits and Covered Services
Ambulance Services
Ambulatory Surgical Services
Certified Registered Nurse Anesthetists
Childbirth Education Services
Children's Intervention Services
Community Based Alternatives
Diagnostic, Screening and Preventive Services (Health Departments)
Dental Services
Dialysis Services
Durable Medical Equipment Services
Family Planning Services
Georgia Better Health Care Health Check (Early and Periodic Screening, Diagnosis and Treatment)
Health Insurance Premium Purchase Program (HIPP)
Health Insurance Premiums (Medicare Part A and Part B)
Home Health Services
Hospice Services
Inpatient and Outpatient Hospital Services
Intermediate Care for the Mentally Retarded
Facility Services
Laboratory and Radiological Services
Medicare Crossovers
Mental Health Clinic Services
Non-Emergency Transportation Services
Nurse Midwifery Services
Nurse Practitioner Services
Nursing Facility Services
Oral Surgery Orthotic and Prosthetic Services
Pharmacy Services
Physician Services
Physician's Assistant Services
Podiatric Services
Pre-Admission Screening/Annual Resident Review
Pregnancy-Related Services
Psychological Services
Rural Health Clinic/Community Health Center Services
Vision Care Services

Cost Information
Medicaid premiums and co-payments vary by population and covered service in Georgia. Pregnant women, children under age 18, and hospital or nursing home patients who are expected to contribute most of their income to institutional care are exempt from cost-sharing requirements. In addition, all Medicaid beneficiaries are exempt from co-payments for emergency services and family planning services.

State Children's Health Insurance Program

Eligibility Requirements

Income Requirements
PeachCare for Kids provides comprehensive health care to Georgia children through the age of 18 who do not qualify for Medicaid, live in households with incomes at or below 235 percent of the federal poverty level, and meet the other eligibility requirements.

Other Eligibility Requirements
To participate, children must be:

U.S. citizens, certain qualified legal residents who have resided legally in the United States for at least 5 years, or refugees or asylees who reside in Georgia.
Age 18 and under (Eligible until 19th birthday).
Uninsured.

A child may be ineligible if:

He or she is eligible for Medicaid.
The child has access to health insurance through a parent's employment with the State of Georgia, even if the parent has not purchased the State coverage.

Children whose coverage is cancelled due to late or non-premium payment will be locked out of the PeachCare for Kids program for a period of three (3) months. For example, the premium payment for coverage in August is due July 1st. If it is not received on time, coverage will be cancelled effective August 1st and the child will not be eligible for reinstatement until November.

Crowd-Out Requirements
PeachCare for Kids was created to provide health care to uninsured children. For this reason, children must be uninsured for the six months prior to applying for PeachCare. There are exceptions for children who have lost coverage involuntarily (for example, if a child were covered through a parent's employer and the parent lost the job, or the employer dropped coverage for dependent children). The waiting period does not apply to families who had independently purchased private insurance outside of an employer group.

Overview of Benefits and Covered Services
PeachCare for Kids health benefits include:

Care from a doctor when your child is sick
Preventive services such as immunizations and regular check-ups
Specialist care
Dental care
Vision care, including vision screenings and eyeglasses Hospitalization
Emergency room services
Prescription medications
Mental health care

Integration with Employer-Based Coverage
There is currently no integration with a parent's potential employer-sponsored health insurance coverage at this time in Georgia.

Parental Benefits
PeachCare for Kids does not offer benefits for parents.

Cost Information
There is no cost for children under age 5. Currently, the cost per month for PeachCare for Kids coverage or children ages 6 an older ranges from $10 to $35 based on income for one child, with a family maximum of $70 for two or more children living in the same household.

Federal Health Care Tax Credit Program

Eligibility Requirements and Rights
This section provides detailed information about eligibility for the HCTC Program.

Purchasing Options

COBRA
Individuals can use federal Health Care Tax Credit funds to pay for COBRA continuation coverage, as long as the employer or former employer contributes less than 50% of the total health plan premium.

The COBRA Provisions only apply to federally mandated COBRA continuation coverage, which applies to employer-groups who employed 20 or employees in the prior year, and requires them to provide the option of temporarily continuing group coverage to individuals when their group health coverage is lost due to certain specific events. State continuation coverage mandates, which may apply to smaller group health plans may not necessarily be an approved mechanism to spend federal Health Care Tax Credit funds. Individuals also may not use Health Care Tax Credit funds to pay for employer-sponsored premiums if the employer is voluntarily providing some type of continuation benefit that is not the same as federally mandated COBRA.

Qualified Spouse's Plan
Individuals can use federal Health Care Tax Credit funds to pay for employer-sponsored health insurance they receive through their spouse's employer, provided that the employer pays no more than 50% of the total family premium (which includes any amount that the employer pays for the spouse's coverage).

Qualified Individual Health Insurance Coverage
Individuals can use federal Health Care Tax Credit funds to pay for private individual heath insurance coverage, provided that they were enrolled in such coverage for at least the last 30 days before they were separated from the job that makes them eligible for TAA benefits or for payments from the Pension Benefit Guarantee Corporation.

State-Elected Option(s)
At this time, there are no available state qualified plans in Georgia.