Health Insurance in Georgia

Health Insurance in Georgia helps residents pay for medical care and coverage for unexpected medical illnesses or injuries. The Office of Insurance and Safety Fire Commissioner (OCI) regulates Georgia's health insurers and health insurance activities.

Premiums for a health insurance plan in Georgia are determined by several factors, including age, the location where the insured lives, the nature of the plan (family or individual), and drug usage. The premium charged by health insurers and scope of coverage also depends on whether the health policy is sponsored privately, by an employer, or subsidized by the government.

To understand your health coverage costs breakdown in Georgia, you need to understand the following key features of a health insurance policy:

1. Deductible - The amount an insured pays before their health coverage kicks in

2. Copayment - A fixed amount paid for a covered health care service after making deductible payment

3. Coinsurance - The percentage of the total costs of a covered health care service paid after paying deductible. For example, a health insurance policy with 10% coinsurance means you pay 10% of the total costs, while the insurer will pay for the remaining 90%

4. Out-of-pocket limit - The maximum non-refundable amount you will need to pay for a medical service covered by your health insurer

How Does Health Insurance Work in Georgia?

According to the National Association of Insurance Commissioners (NAIC), in 2020 more than $3.1 billion worth of direct premiums were written to health insurers in Georgia, while the claim payouts amounted for $2.5 billion (≈80%). The health insurance industry is a thriving industry and a vital aspect of Georgia's residents' lives. In Georgia, there are five major health insurance options:

1. Through your employer

2. Via the federal health insurance marketplace

3. Short-term health insurance

4. Fixed Hospital Indemnity

5. Medicare

6. Medicaid

While these health insurance options are quite accessible, it is always best to procure health insurance through a licensed health insurance broker or agent. Health insurance agents in Georgia are vital as they:

1. Help you review your application and ensure you apply for only relevant health coverage

2. Understand the health insurance landscape and know where to get the best deals and discounts for your intended policy

3. Aid the claims process to ensure smooth payments of outstanding claims

How Does Group Insurance Work in Georgia?

Group health insurance coverage is a type of health coverage for groups of people. The group will enjoy the same health benefits regardless of their social standing within the group and as stipulated in the group’s policy contract. Group insurance in Georgia covers the group members, their families, and other eligible dependents. Group health coverage is broadly offered in two ways:

• Formal group offerings: A formal group health offering is a policy offered by employer-employee groups within the state. Businesses and professional organizations are classified as formal groups and can offer health insurance to their employees

• Informal group offerings: An informal group health policy offering is offered by unions, societies, cultural organizations, and other informal groups. Informal group organizations purchase a policy on behalf of their group members

In Georgia, health insurers offer group health insurance under these four categories:

• Small business group plans: Insurers offer this group of health insurance plans to employers with between 2 to 50 employees.

• Large group plans: Health insurers offer this form of group health insurance plan to employers with 51 or more employees on the payroll

• National employers group insurance: This group insurance package is offered to national employers operating within Georgia

• Customized group insurance plans: Health insurers allow policyholders to design health insurance policies jointly, provided the offered coverage falls under the scope of the insurer

Organizations seeking group health insurance in Georgia should speak to Georgia-licensed health insurance agents and brokers, who specialize in group coverage.

How Does Individual Health Insurance Work in Georgia?

Individual health insurance in Georgia works similarly to how other insurance policies work in the state, except that they are procured on an individual basis. Individual health insurance plans are typically purchased from the federal health insurance marketplace or through independent agents, instead of getting coverage from an employer or government-run insurance programs like Medicare or the Georgia State Health Benefit Plan (SHBP). Insured individuals pay premiums based on the health coverage they want and how much they can afford.

In Georgia, the Individual Affordable Care Act (ACA)-compliant (Obamacare) insurance has ten basic coverages:

1. Outpatient hospital care and ambulance services

2. Emergency services

3. Hospitalization services and health care

4. Pregnancy, maternity, and newborn care

5. Mental health and substance abuse services

6. Prescription drug coverage

7. Rehabilitative services and related devices

8. Laboratory services

9. Wellness services and chronic disease management services

10. Oral and eye for pediatric patients and other pediatric services

Some other coverages provided by the Individual ACA/Obamacare in Georgia include preventive services screenings, vaccinations, and other condition-related counseling.

Individual ACA/Obamacare plans sold on the marketplace are set in four tiers:

1. Bronze Plan - In this plan, on average, within the state, the policyholder pays 40% while the health insurance company pays the remaining 60%

2. Silver Plan - In the silver plan offering, the policyholder pays 30% on average while the health insurer will pay the remaining 70%

3. Gold Plan - Gold plans, on average, allow the policyholder to pay 20% while the health insurer pays the remaining 80%

4. Platinum Plan - The platinum plan allows policyholders to pay 10%, while the health insurance company pays the remaining 90%

As the percentage paid by the health insurance company increases, so does the amount paid by the policyholder in the form of premiums and deductibles. As such, you can adjust your deductible, coinsurance, and copay to levels suitable to your health care needs and per your financial capacity. Plans often vary depending on the county you reside in. The average non-subsidised price for individual ACA-compliant insurance plans for an adult in Georgia on a silver plan is $590 - $620 per month. A family can pay up to $1,900 monthly.

The main feature of the individual health marketplace in Georgia is the possibility to apply for financial help through the government subsidies based on the insured’s level of income. If the insured earns less than the 200% of the Federal Poverty Level (FPL), such low-income residents can receive discounted health insurance. Persons who do not qualify for the subsidies can save money by opting for plans with significantly higher deductibles.

According to the Affordable Care Act, persons with any pre-existing medical conditions are covered; which means that health insurers cannot deny any insurance application based on pre-existing health conditions.

In Georgia, there are counties where adults under the age of 30 can get a catastrophic level health plan with significantly lower premiums and higher deductible than the bronze plan but less health coverage. The average cost of a catastrophic insurance plan for a 21-year-old in the state is $160-$170 monthly, compared to approximately $350-$370 for the platinum plan.

You can purchase ACA-compliant plans to be treated by a variety of health organizations:

• HMO: Health Maintenance Organization

• POS: Point of Service

• PPO: Preferred Provider Organization

• EPO: Exclusive Provider Organization

HMOs typically have the most affordable rates. However, they tend to have fewer hospital partners and healthcare providers. PPOs are more flexible and have a larger network of healthcare providers but charge a higher premium than other organizations.

What are Alternative Health Plans in Georgia?

Alternative health plans in Georgia are usually non-ACA compliant insurance plans for people who do not regularly need health services or individuals who need short-term health insurance coverage. Alternative health plans are meant to offer low cost coverage and are usually best for people without severe pre-existing conditions or requiring frequent health prescriptions.

Some healthcare providers refer to alternative health plans as supplemental health insurance. They offer these plans to boost an existing health insurance plan or provide coverage for health services required by insureds but not offered by other insurers. Examples of alternative/supplemental health insurance plans in Georgia are:

1. Accident Insurance: This insurance offers coverage for unexpected out-of-pocket costs resulting from accidents covered in a health insurance policy contract. Accident insurance offers cash reimbursements for medical and recovery expenses regardless of other insurance policies you may have. The cash benefits are paid after the accident insurer considers adjustments and other discounts paid by your primary health insurance for services rendered in the aftermath of your accident. Aside from the medical and recovery expenses reimbursement, the cash benefits of accident insurance include housekeeping assistance, childcare, and transportation to and from hospital appointments

2. Critical Illness Insurance: Critical illness insurance offers coverage for illnesses requiring high deductibles and other added expenses that can quickly drain your finances when diagnosed with a critical illness. It offers lump sum payments on critical illnesses covered by the health insurance policy. Critical illness insurance primarily caters to deductibles for living expenses after being diagnosed with a critical illness and other out-of-pocket costs, including prescriptions and other necessary treatments

3. Hospital Recovery Insurance: Hospital recovery insurance is a policy that allows you to focus on recovery instead of bothering about your finances while you are ill. You can purchase hospital recovery insurance regardless of your current health insurance policy. Hospital recovery insurance can be instrumental in covering wages lost while recovering, the fees associated with rehabilitative services, medical deductibles, and other copays

4. Short-term medical (STM) Limited Duration Insurance: Short-Term Limited Duration Health Insurance is often referred to as gap coverage policies, short term health, or Short-term medical insurance (STM) in Georgia. They are policies that are meant to serve as a bridge to prevent a policy lapse. You can buy STM insurance policies for a maximum of 364 days, three consecutive times. The premiums charged by insurers for STM plans are typically less than other plans like the ACA/Obamacare.

5. Fixed Hospital Indemnity: Fixed hospital indemnity in Georgia primarily offers cash reimbursements for medical events like visits to emergency rooms but not major coverage. This form of insurance is only to be used as supplemental coverage to cover out-of-pocket costs arising from a comprehensive health insurance package. Below are some key characteristics of fixed hospital indemnity coverage in Georgia:

   1. Applications can happen all year long: Unlike the ACA/Obamacare insurance with an open enrollment period, you can apply at any time you wish.

   2. Direct payments to the policyholder: Insurers that offer fixed hospital indemnity pay claims directly to the policyholder instead of the hospital or medical service provider.

   3. Guaranteed issuance of coverage: Generally, no health examination is required before the insurer issues coverage to a policyholder.

Below is an overview of what is typically covered and not covered by fixed hospital indemnity insurance in Georgia:

Other forms of alternative health insurance plans in Georgia include:

• Limited benefit plans

• Subscription plans

• Association plans

• Direct primary care

When deciding on alternative health insurance coverage, always consult with knowledgeable and licensed health insurance agents in Georgia.

SHORT-TERM LIMITED-DURATION HEALTH INSURANCE

Short-term limited-duration health insurance (STM) plans offer affordable health coverage. Ideally, they serve as a way to bridge the health insurance gap until the Georgia enrollment window opens on the federal health insurance exchange. The bridge offered by short-term insurance plans can last up to 364 days. STM plans in Georgia are helpful if you miss the registration window for an ACA plan, if you suddenly lose your health insurance benefit from your employer or parent, or if you retire and have to wait to enroll for Medicare benefits. STM insurance in Georgia is sometimes referred to as gap coverage since it is the best means of getting coverage until the ACA enrollment period opens. In addition, STM plans in Georgia no longer attract a tax penalty; residents with a gap in health insurance are encouraged to explore short term health insurance policies.

In Georgia, you can purchase an STM plan for up to 364 days and concurrently for up to 36 months; you have to reapply in each policy window. However, insurers reserve the right to reject your insurance application. Short term health plans typically provide only basic coverage and are very limited in scope; so make sure to speak with a licensed health insurance agent before purchasing an STM plan, to understand if it suits your needs. Health coverages typically exempted from STM plans in Georgia include:

1. Maternity care

2. Provision of prescription drugs

3. Mental health services

4. Coverage for major pre-existing conditions

Considering the health coverage exempted in STM plans in Georgia, it is easy to determine that the premiums will be far less compared to other state health insurance plans. With STM plans, when the time comes for a renewal, coverage for new conditions will not be considered as pre-existing conditions during an underwriting period for a new STM policy. To avoid this scenario, STM insurers sell pre-existing (pre-ex) waivers, ensuring that your insurer will always cover certain conditions in your STM insurance policy. (NOTE: If you are planning to purchase a short term health plan, make sure to understand exactly the type of coverage that you will be getting. This will help you avoid not having the coverage in the moment of need, especially in an emergency situation. To get complete details, contact a knowledgeable and experienced health insurance agent who can answer all your questions as they pertain to your specific needs and coverage types).

The table below compares Short term health plans and ACA (Obamacare) plans in Georgia:

LIMITED BENEFIT HEALTH PLANS

Limited benefit health plans are available in Georgia and are offered by health insurance companies in the state. The Georgia Consumer Choice Benefits Health Insurance Plan Act allows insurers to provide limited benefit health insurance policies without all of the required state-mandated benefits. This means that, with a limited benefit health plan, you can enjoy coverage based on what you can afford and what you need per time. This coverage is best suited for individuals on a budget or with financial challenges. Speak to a knowledgeable Georgia-licensed health insurance agent before purchasing a limited benefit health insurance.

SUBSCRIPTION HEALTH PLANS

Subscription healthcare plans are health policies that allow you to pay a flat installment fee on a fixed basis as stipulated in the policy agreement. Typically, health insurers in Georgia offer a monthly, quarterly, or annual payment plan for subscription health plans. The three major subscription healthcare plans are:

1. Membership medicine

2. Concierge medicine

3. Direct primary care

Concierge medicine differs from Direct Primary Care (DPC) because DPCs do not accept insurance. Hence you will have to work out a financial plan with the care provider. Concierge medicine accepts insurance payments for laboratory works, x-rays, and prescription drugs. DPCs are typically less expensive than concierge medicine plans. Membership Medicine offers Georgians access to clinical services for a monthly stipulated fee.

DISCOUNT HEALTH PLANS

Medical discount plans provide just that - discounts on medical care. They are far less expensive than health insurance plans because they do not provide protection offered by health insurance. With that in mind, such plans provide a way for Georgians without active health insurance policies to get at least some discounts on frequently very expensive medical services.

ASSOCIATION HEALTH PLANS (AHPs)

Association Health Plans (AHPs) in Georgia is a form of group health insurance where multiple employers jointly offer medical benefits. These plans allow self-employed individuals and freelancers to access health insurance plans like any other employees of large organizations. When self-employed persons connect or join forces with other employers, they will qualify as a large group in Georgia and can access the following benefits:

1. Less expensive health plans with lower administrative costs

2. Contribute to the design process of insurance policies and include coverage that can be considered best practices among large businesses

3. Negotiate better rates

4. Allowance for self-insurance with far lower administrative costs and a means to avoid health insurance tax

DIRECT PRIMARY CARE

Direct Primary Care (DPC) is similar to having a family doctor. It is an alternative healthcare payment system where Georgians can pay a fixed membership fee to access healthcare from physicians and institutions of their choosing. DPC also allows no fee-for-service payments and no third-party billing systems. DPC plans in Georgia cost as low as $70 per month.

TELEHEALTH and TELEMEDICINE

Telemedicine and Telehealth allow the insured to gain access to healthcare providers through the use of virtual visits. Typically, the patient makes a phone or video call to the doctor and all communication is kept to this “not in person” method.

In Georgia, telehealth and telemedicine can be offered by out-of-state physicians.

Check with your agent or the insurer, to find out if your current plan offers the convenience of telehealth.

HOSPITAL AT HOME

In recent years, some hospitals in Georgia started participating in the Hospital at Home program, which allows some qualifying patients to remain at home while receiving treatments. If qualified, regular health insurance plans cover it the same way as if the patient was at the hospital. (ask your treating physician if your condition qualifies you for the Hospital at Home program)

Commercial Health Insurance

Commercial health insurance in Georgia refers to employer-sponsored health insurance. In Georgia, getting your insurance policy through an employer is a common practice. As of 2020, more than 4.9 million Georgians had health insurance coverage from employers within the state. It is also important to note that since commercial health insurance in Georgia is ACA compliant, The Affordable Care Act (ACA) requires your employer to provide insurance if they employ more than 50 employees.

In 2021 small businesses accounted for 99.6 % of all businesses in Georgia, while employing around 43% (1.7 million) of all Georgians. Even though frequently with less than 50 employees, a large portion of these small businesses choose to offer group health insurance coverage to their staff.

Group Employer-Sponsored Health Insurance

Group Employer-Sponsored health insurance is any health insurance, the premiums for which are pre-negotiated and/or paid in part or in full by the employer.

Georgia Disability Income Insurance

Disability income insurance is a type of insurance that provides partial income protection in case if the insured suffers an injury on or off the job, and as a result cannot work. This type of insurance is most-frequently offered through mid-size and large organizations. If your employer does not offer disability income insurance at a group rate, you can research individual options online by yourself or by discussing your needs with a state-licensed health insurance agent.

Georgia Workers’ Compensation Insurance

Georgia state laws require employers with more than three full-time employees to provide workers' compensation insurance. Worker's compensation insurance offers medical, rehabilitative, and income benefits if you get injured while performing your work. Worker's compensation insurance can provide your named beneficiaries with continued payments if you die as a result of a work-related injury.

How Does Health Insurance for Seniors Work in Georgia?

According to the United State Census Bureau, 14% of Georgia’s population is older than 65. Some health insurance plans for this seniors in Georgia are:

1. Medicare

2. Medicaid

3. Medigap

4. Long-term Care Insurance

MEDICARE

Medicare is a federal health insurance program available to Georgians older than 65. There are over 1.8 million Georgians registered in the Medicare program. Medicare in Georgia has four major parts: A, B, C, and D. It offers coverage for medical expenses like hospital visits, prescription drugs, hospice care, and preventive services, among others.

To be eligible for Medicare in Georgia, you need to meet the following requirements:

1. You must be over 65

2. You are under 65, but are:

   1. Permanently disabled or

   2. Receiving disability benefits from social security or the railroad retirement board

3. You are a patient with end-stage renal disease (ERSD)

4. You are a patient with ALS (Amyotrophic Lateral Sclerosis), also called Lou Gehrig’s disease

5. Permanently disabled students are typically eligible for Medicare services regardless of age

You can register for Medicare three months before you turn 65. Medicare has a limited time for eligible persons to sign up; this is referred to as the Initial Enrollment Period (IEP). In Georgia, the IEP ends three months after one's 65th birthday. If you miss the IEP, there is a General Enrollment Period (GEP) for eligible residents to register for Medicare. The GEP is between January 1st and March 31st every year. However, you will have to pay the penalty, and the coverage will not be effective until July 1st.

The parts of Medicare are:

1. Original Medicare: There are two major original medicare plans in Georgia:

   1. Part A: This plan covers hospitalization costs

   2. Part B: The B part provides coverage offered by Part A medicare and, in addition, offers coverage for doctor's visits, laboratory tests, and medical equipment

2. Part C: This plan is also called the Medicare Advantage Plan. It is sold by private insurance companies and sells the Part A and Part B plans as a single policy. Most Medicare Advantage plans in Georgia include coverage for prescription drugs, dental, hearing, and vision coverage

3. Part D: The part D plan adds prescription drug coverage as a stand-alone policy to cover out-of-pocket costs like deductibles and copays

You can apply for Medicare in Georgia by contacting social security or a licensed health insurance agent to help you with the application process.

MEDICAID

Medicaid services in Georgia are offered under a government-sponsored health insurance program aimed at assisting low-income earners. The program provides free or low-cost health care coverage for low-income workers or persons with disabilities. In 2022, more than 2 million Georgia residents were receiving Medicaid benefits. To qualify for Medicaid, the resident of Georgia must be earning an income less than 138% of the consensus Federal Poverty Level (FPL). In 2022, if your income was less than $16,753, in Georgia you were eligible for the Medicaid program. A family of four with total earnings of less than $34,638 also qualified for Medicaid. Eligible Georgia residents can apply for Medicaid by using the Medicaid online application portal.

You are encouraged to use the services of a licensed health insurance agent when signing up for Medicaid plans. The agent will help determine your coverage eligibility and ease the application process.

As an additional resource for Georgia’s underinsured or uninsured residents, there are non-profit clinics referred to as Community Health Centers.

MEDIGAP

Medigap (Medicare Part D) is offered as supplemental Original Medicare health insurance coverage in Georgia. The policy aids in covering some bills that you are responsible for when enrolled in the Original Medicare plan - the Parts A and B combined policy. Original Medicare still leaves you with financial responsibilities such as copayments, coinsurance, and deductibles. The Medigap plan helps you pay for those additional expenses. Once your Original Medicare coverage pays for your healthcare, the Medigap policy will provide financial coverage for the remaining unpaid bills. In 2022, approximately 1.4 million Georgia residents were enrolled in Medigap.

LONG-TERM CARE (LTC) INSURANCE

Long-term care (LTC) insurance offers coverage for nursing-home care, home-health care, and adult day care costs for persons over 65 or persons with chronic medical conditions or disabilities requiring constant supervision. Long term care in Georgia can be purchased from private insurers or (if qualified) through Georgia's Long Term Care Partnership with Medicaid.

Discuss your long term care needs with a Georgia-licensed health insurance agent.

What are Additional or Stand-Alone Health Insurance Options in Georgia?

Additional or Stand-Alone health insurance coverage is a supplementary health insurance option and it is available in Georgia. These options include:

1. Short Term Health

2. Medigap Plan G

3. Medigap Plan N

4. Hospital Indemnity Insurance

5. Critical Illness insurance

6. Disability income insurance

7. Dental insurance

8. Vision plans

9. Hearing insurance

10. Cancer treatment insurance

What Health Insurance Rights Do I Have in Georgia?

As a consumer, you have rights and privileges as you purchase health insurance policies in Georgia. Some of these rights include:

1. A right to appeal the claims decision of your insurer

2. The right to a fair assessment by a health insurer

3. A right for continuity of care for chronic illness for up to 60 days

4. A timely payout of claims

5. Insurers must disclose all aspects of your insurance policy before signing the policy contract

Additionally, you can file complaints about a health insurer by completing an online complaint form provided by the OCI. Alternatively, you can print the complaint form, fill it, and mail the form to:

Georgia Department of Insurance

2 Martin Luther King Jr. Drive

Suite 716 West Tower

Atlanta, GA 30334

Before filing a complaint about an insurer, confirm that the OCI has regulatory jurisdiction over the insurer. In Georgia, the OCI does not have regulatory jurisdiction over the following health insurers:

• Self-insured employers - Federal laws exempt self-insured employers from state regulation. This exemption also affects health and welfare benefit plans offered by unions

• Federal employee’s health and life insurance

• Medicare Health Maintenance Organizations (HMOs)

• Military insurers

• Medicare

• Medicaid

• State of Georgia Employee’s Health Plan

• University of Georgia insurance systems

• Health insurance policies bought outside of Georgia. HMO policies purchased in other states might be subject to regulation depending on reciprocity laws between Georgia and the other jurisdiction. Speak with a licensed health insurance broker to confirm before making complaints

If you suspect insurance fraud, you can complain to the Commissioner of Insurance and Safety Fire Criminal Investigations Division (OCI-CID) by calling the toll-free line (800) 656-2298.

Discuss your health insurance needs with a knowledgeable Georgia-licensed health insurance agent.