As Reported by the Senate Insurance, Commerce and Labor Committee 1
122nd General Assembly 4
Regular Session Sub. H. B. No. 361 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-TAVARES-BENDER-BOYD-BRADING-CAREY- 8
CLANCY-CORBIN-COUGHLIN-FORD-GARCIA-GERBERRY-HOTTINGER-KRUPINSKI- 9
LAWRENCE-MAIER-MILLER-MOTTLEY-O'BRIEN-OLMAN-OPFER-PADGETT-PERZ- 10
SALERNO-SAWYER-SCHULER-SCHURING-STAPLETON-TAYLOR-TERWILLEGER- 11
TIBERI-VESPER-WACHTMANN-WISE-ROMAN-METELSKY-LEWIS-NETZLEY- 12
HOUSEHOLDER-LOGAN-MASON-WINKLER-MYERS-OGG-BRITTON-WHALEN- 13
PATTON-CALLENDER-JERSE-MOTTL-REID-DAMSCHRODER-THOMAS- 14
HARRIS-BATEMAN-ROBERTS-AMSTUTZ-BEATTY-VERICH-WILSON- 15
WILLAMOWSKI-JONES-BUCHY-PRENTISS-WESTON- 16
SENATORS RAY-GILLMOR-SUHADOLNIK-WATTS 17
19
A B I L L
To amend sections 1751.02 to 1751.04, 1751.12, 21
1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 23
4121.121, 4123.01, 4123.25, 4123.35, and 4123.512
and to enact sections 1751.521, 1751.73 to 25
1751.75, 1751.77 to 1751.86, 1753.01, 1753.03 to 27
1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 28
1753.24, 1753.28, and 1753.30 of the Revised Code 29
to adopt the Physician-Health Plan Partnership 30
Act, to authorize the Administrator of Workers' 32
Compensation to transfer surplus computers and 33
computer equipment directly to an accredited
public school within Ohio, and to specify 35
circumstances under which a board of county
commissioners may be granted status as a 36
self-insuring employer for purposes of the
Workers' Compensation Law. 37
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 39
2
Section 1. That sections 1751.02, 1751.03, 1751.04, 41
1751.12, 1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 4121.121, 42
4123.01, 4123.25, 4123.35, and 4123.512 be amended and sections 43
1751.521, 1751.73, 1751.74, 1751.75, 1751.77, 1751.78, 1751.79, 44
1751.80, 1751.81, 1751.82, 1751.83, 1751.84, 1751.85, 1751.86, 45
1753.01, 1753.03, 1753.04, 1753.05, 1753.06, 1753.07, 1753.08, 47
1753.09, 1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 1753.24, 48
1753.28, and 1753.30 of the Revised Code be enacted to read as 50
follows:
Sec. 1751.02. (A) Notwithstanding any law in this state 59
to the contrary, any corporation, as defined in section 1751.01 61
of the Revised Code, may apply to the superintendent of insurance 63
for a certificate of authority to establish and operate a health 64
insuring corporation. If the corporation applying for a 65
certificate of authority is a foreign corporation domiciled in a 66
state without laws similar to those of this chapter, the 68
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 69
chapter.
(B) No person shall establish, operate, or perform the 72
services of a health insuring corporation in this state without 74
obtaining a certificate of authority under this chapter. 75
(C) Except as provided by division (D) of this section, no 78
political subdivision or department, office, or institution of 79
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 80
this state, shall establish, operate, or perform the services of 81
a health insuring corporation. Nothing in this section shall be 84
construed to preclude a board of county commissioners, a county 85
board of mental retardation and developmental disabilities, an 86
alcohol and drug addiction services board, a board of alcohol, 87
drug addiction, and mental health services, or a community mental 88
health board, or a public entity formed by or on behalf of any of 89
these boards, from using managed care techniques in carrying out 90
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the board's or public entity's duties pursuant to the 91
requirements of Chapters 307., 329., 340., and 5126. of the 93
Revised Code. However, no such board or public entity may 95
operate so as to compete in the private sector with health 96
insuring corporations holding certificates of authority under 97
this chapter.
(D) A corporation formed by or on behalf of a publicly 99
owned, operated, or funded hospital or health care facility may 100
apply to the superintendent for a certificate of authority under 102
division (A) of this section to establish and operate a health 103
insuring corporation.
(E) A health insuring corporation shall operate in this 106
state in compliance with this chapter AND CHAPTER 1753. OF THE 107
REVISED CODE, and with sections 3702.51 to 3702.62 of the Revised 109
Code, and shall operate in conformity with its filings with the 111
superintendent under this chapter, including filings made 112
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 113
the Revised Code. 115
(F) An insurer licensed under Title XXXIX of the Revised 119
Code need not obtain a certificate of authority as a health 120
insuring corporation to offer an open panel plan as long as the 121
providers and health care facilities participating in the open 122
panel plan receive their compensation directly from the insurer. 123
If the providers and health care facilities participating in the 124
open panel plan receive their compensation from any person other 125
than the insurer, or if the insurer offers a closed panel plan, 126
the insurer must obtain a certificate of authority as a health 127
insuring corporation.
(G) An intermediary organization need not obtain a 130
certificate of authority as a health insuring corporation, 131
regardless of the method of reimbursement to the intermediary 132
organization, as long as a health insuring corporation or a 134
self-insured employer maintains the ultimate responsibility to 135
assure delivery of all health care services required by the
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contract between the health insuring corporation and the 136
subscriber and the laws of this state or between the self-insured 137
employer and its employees. 138
Nothing in this section shall be construed to require any 140
health care facility, provider, health delivery network, or 141
intermediary organization that contracts with a health insuring 142
corporation or self-insured employer, regardless of the method of 144
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 145
certificate of authority as a health insuring corporation under 146
this chapter, unless otherwise provided, in the case of contracts 148
with a self-insured employer, by operation of the "Employee 149
Retirement Income Security Act of 1974," 88 Stat. 829, 29 154
U.S.C.A. 1001, as amended. 156
(H) Any health delivery network doing business in this 159
state that is not required to obtain a certificate of authority 160
under this chapter shall certify to the superintendent annually, 161
not later than the first day of July, and shall provide a 163
statement signed by the highest ranking official which includes 164
the following information:
(1) The health delivery network's full name and the 166
address of its principal place of business; 167
(2) A statement that the health delivery network is not 169
required to obtain a certificate of authority under this chapter 170
to conduct its business. 171
(I) The superintendent shall not issue a certificate of 174
authority to a health insuring corporation that is a provider 175
sponsored organization unless all health care plans to be offered 176
by the health insuring corporation provide basic health care 177
services. Substantially all of the physicians and hospitals with 178
ownership or control of the provider sponsored organization, as 179
defined in division (W) of section 1751.01 of the Revised Code, 182
shall also be participating providers for the provision of basic 183
health care services for health care plans offered by the 184
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provider sponsored organization. If a health insuring 185
corporation that is a provider sponsored organization offers 186
health care plans that do not provide basic health care services, 187
the health insuring corporation shall be deemed, for purposes of 188
section 1751.35 of the Revised Code, to have failed to 189
substantially comply with this chapter. 190
Except as specifically provided in this division and in 192
division (C) of section 1751.28 of the Revised Code, the 194
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 195
same manner that these provisions apply to all health insuring 196
corporations that are not provider sponsored organizations. 197
(J) Nothing in this section shall be construed to apply to 199
any multiple employer welfare arrangement operating pursuant to 200
Chapter 1739. of the Revised Code. 201
(K) Any person who violates division (B) of this section, 205
and any health delivery network that fails to comply with 206
division (H) of this section, is subject to the penalties set 207
forth in section 1751.45 of the Revised Code. 209
Sec. 1751.03. (A) Each application for a certificate of 219
authority under this chapter shall be verified by an officer or 220
authorized representative of the applicant, shall be in a format 221
prescribed by the superintendent of insurance, and shall set 222
forth or be accompanied by the following: 223
(1) A certified copy of the applicant's articles of 225
incorporation and all amendments to the articles of 226
incorporation; 227
(2) A copy of any regulations adopted for the government 229
of the corporation, any bylaws, and any similar documents, and a 230
copy of all amendments to these regulations, bylaws, and 231
documents. The corporate secretary shall certify that these 232
regulations, bylaws, documents, and amendments have been properly 234
adopted or approved.
(3) A list of the names, addresses, and official positions 237
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of the persons responsible for the conduct of the applicant, 238
including all members of the board, the principal officers, and 239
the person responsible for completing or filing financial 240
statements with the department of insurance, accompanied by a 241
completed original biographical affidavit and release of 242
information for each of these persons on forms acceptable to the 243
department;
(4) A full and complete disclosure of the extent and 245
nature of any contractual or other financial arrangement between 246
the applicant and any provider or a person listed in division 247
(A)(3) of this section, including, but not limited to, a full and 249
complete disclosure of the financial interest held by any such 250
provider or person in any health care facility, provider, or 251
insurer that has entered into a financial relationship with the 252
health insuring corporation; 253
(5) A description of the applicant, its facilities, and 255
its personnel, including, but not limited to, the location, hours 257
of operation, and telephone numbers of all contracted facilities; 258
(6) The applicant's projected annual enrollee population 260
over a three-year period; 261
(7) A clear and specific description of the health care 263
plan or plans to be used by the applicant, including a 264
description of the proposed providers, procedures for accessing 265
care, and the form of all proposed and existing contracts 266
relating to the administration, delivery, or financing of health 267
care services; 268
(8) A copy of each type of evidence of coverage and 270
identification card or similar document to be issued to 271
subscribers; 272
(9) A copy of each type of individual or group policy, 274
contract, or agreement to be used; 275
(10) The schedule of the proposed contractual periodic 277
prepayments or premium rates, or both, accompanied by appropriate 278
supporting data; 279
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(11) A financial plan which provides a three-year 281
projection of operating results, including the projected 282
expenses, income, and sources of working capital; 283
(12) The enrollee complaint procedure to be utilized as 285
required under section 1751.19 of the Revised Code; 288
(13) A description of the procedures and programs to be 290
implemented on an ongoing basis to assure the quality of health 291
care services delivered to enrollees, INCLUDING, IF APPLICABLE, A 292
DESCRIPTION OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE 294
REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE;
(14) A statement describing the geographic area or areas 296
to be served, by county; 297
(15) A copy of all solicitation documents; 299
(16) A balance sheet and other financial statements 301
showing the applicant's assets, liabilities, income, and other 302
sources of financial support; 303
(17) A description of the nature and extent of any 305
reinsurance program to be implemented, and a demonstration that 306
errors and omission insurance and, if appropriate, fidelity 307
insurance, will be in place upon the applicant's receipt of a 308
certificate of authority; 309
(18) Copies of all proposed or in force related-party or 311
intercompany agreements with an explanation of the financial 312
impact of these agreements on the applicant. If the applicant 313
intends to enter into a contract for managerial or administrative 315
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 316
description of the person to provide these services. The 318
description shall include that person's experience in managing or 319
administering health care plans, a copy of that person's most 320
recent audited financial statement, and a completed biographical 321
affidavit on a form acceptable to the superintendent for each of 322
that person's principal officers and board members and for any 323
additional employee to be directly involved in providing 324
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managerial or administrative services to the health insuring 325
corporation. If the person to provide managerial or 326
administrative services is affiliated with the health insuring 327
corporation, the contract must provide for payment for services 328
based on actual costs.
(19) A statement from the applicant's board that the 330
admitted assets of the applicant have not been and will not be 331
pledged or hypothecated; 332
(20) A statement from the applicant's board that the 334
applicant will submit monthly financial statements during the 335
first year of operations; 336
(21) The name and address of the applicant's Ohio 339
statutory agent for service of process, notice, or demand; 340
(22) Copies of all documents the applicant filed with the 342
secretary of state; 343
(23) The location of those books and records of the 345
applicant that must be maintained in Ohio; 346
(24) The applicant's federal identification number, 348
corporate address, and mailing address; 349
(25) An internal and external organizational chart; 352
(26) A list of the assets representing the initial net 354
worth of the applicant; 355
(27) If the applicant has a parent company, the parent 357
company's guaranty, on a form acceptable to the superintendent, 358
that the applicant will maintain Ohio's minimum net worth. If no 361
parent company exists, a statement regarding the availability of 362
future funds if needed.
(28) The names and addresses of the applicant's actuary 364
and external auditors; 365
(29) If the applicant is a foreign corporation, a copy of 367
the most recent financial statements filed with the insurance 368
regulatory agency in the applicant's state of domicile; 369
(30) If the applicant is a foreign corporation, a 371
statement from the insurance regulatory agency of the applicant's 372
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state of domicile stating that the regulatory agency has no 373
objection to the applicant applying for an Ohio license and that 374
the applicant is in good standing in the applicant's state of 375
domicile; 376
(31) Any other information that the superintendent may 378
require. 379
(B)(1) A health insuring corporation, unless otherwise 382
provided for in this chapter, shall file a timely notice with the 383
superintendent describing any change to the corporation's 384
articles of incorporation or regulations, or any major 385
modification to its operations as set out in the information 386
required by division (A) of this section that affects any of the 388
following:
(a) The solvency of the health insuring corporation; 391
(b) The health insuring corporation's continued provision 394
of services that it has contracted to provide; 395
(c) The manner in which the health insuring corporation 398
conducts its business.
(2) If the change or modification is to be the result of 400
an action to be taken by the health insuring corporation, the 401
notice shall be filed with the superintendent prior to the health 402
insuring corporation taking the action. The action shall be 404
deemed approved if the superintendent does not disapprove it 405
within sixty days of filing. 406
(C)(1) No health insuring corporation shall expand its 409
approved service area until a copy of the request for expansion, 410
accompanied by documentation of the network of providers, 411
enrollment projections, plan of operation, and any other changes 412
have been filed with the superintendent. 413
(2) Within ten calendar days after receipt of a complete 415
filing under division (C)(1) of this section, the superintendent 417
shall refer the appropriate jurisdictional issues to the director 418
of health pursuant to section 1751.04 of the Revised Code. 420
(3) Within seventy-five days after the superintendent's 422
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receipt of a complete filing under division (C)(1) of this 424
section, the superintendent shall determine whether the plan for 425
expansion is lawful, fair, and reasonable. The superintendent 426
may not make a determination until the superintendent has 427
received the director's certification of compliance, which the 428
director shall furnish within forty-five days after referral 429
under division (C)(2) of this section. The director shall not 431
certify that the requirements of section 1751.04 of the Revised 432
Code are not met, unless the applicant has been given an 434
opportunity for a hearing as provided in division (D) of section 436
1751.04 of the Revised Code. The forty-five-day and 437
seventy-five-day review periods provided for in division (C)(3) 439
of this section shall cease to run as of the date on which the 440
notice of the applicant's right to request a hearing is mailed 441
and shall remain suspended until the director issues a final 442
certification. 443
(4) If the superintendent has not approved or disapproved 445
all or a portion of a service area expansion within the 446
seventy-five-day period provided for in division (C)(3) of this 448
section, the filing shall be deemed approved. 449
(5) Disapproval of all or a portion of the filing shall be 452
effected by written notice, which shall state the grounds for the 453
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 454
Sec. 1751.04. (A) Upon the receipt by the superintendent 465
of insurance of a complete application for a certificate of 466
authority to establish or operate a health insuring corporation, 467
which application sets forth or is accompanied by the information 468
and documents required by division (A) of section 1751.03 of the 470
Revised Code, the superintendent shall transmit copies of the 472
application and accompanying documents to the director of health. 473
(B) The director shall review the application and 476
accompanying documents and make findings as to whether the 477
applicant for a certificate of authority has done all of the 478
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following with respect to any basic health care services and 479
supplemental health care services to be furnished: 480
(1) Demonstrated the willingness and potential ability to 482
ensure that all basic health care services and supplemental 483
health care services described in the evidence of coverage will 485
be provided to all its enrollees as promptly as is appropriate 486
and in a manner that assures continuity; 487
(2) Made effective arrangements to ensure that its 489
enrollees have reliable access to qualified providers in those 490
specialties that are generally available in the geographic area 491
or areas to be served by the applicant and that are necessary to 492
provide all basic health care services and supplemental health 493
care services described in the evidence of coverage; 495
(3) Made appropriate arrangements for the availability of 497
short-term health care services in emergencies within the 498
geographic area or areas to be served by the applicant, 499
twenty-four hours per day, seven days per week, and for the 500
provision of adequate coverage whenever an out-of-area emergency 501
arises; 502
(4) Made appropriate arrangements for an ongoing 504
evaluation and assurance of the quality of health care services 505
provided to enrollees, INCLUDING, IF APPLICABLE, THE DEVELOPMENT 506
OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE REQUIREMENTS OF 508
SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE, and the adequacy
of the personnel, facilities, and equipment by or through which 509
the services are rendered; 510
(5) Developed a procedure to gather and report statistics 512
relating to the cost and effectiveness of its operations, the 513
pattern of utilization of its services, and the quality, 514
availability, and accessibility of its services. 515
(C) Within ninety days of the director's receipt of the 517
application for issuance of a certificate of authority, the 519
director shall certify to the superintendent whether or not the 520
applicant meets the requirements of division (B) of this section 521
12
and sections 3702.51 to 3702.62 of the Revised Code. If the 522
director certifies that the applicant does not meet these 523
requirements, the director shall specify in what respects it is 524
deficient. However, the director shall not certify that the 525
requirements of this section are not met unless the applicant has 526
been given an opportunity for a hearing. 527
(D) If the applicant requests a hearing, the director 530
shall hold a hearing before certifying that the applicant does 531
not meet the requirements of this section. The hearing shall be 532
held in accordance with Chapter 119. of the Revised Code. 534
(E) The ninety-day review period provided for under 537
division (C) of this section shall cease to run as of the date on 539
which the notice of the applicant's right to request a hearing is 540
mailed and shall remain suspended until the director issues a 541
final certification order.
Sec. 1751.12. (A)(1) No contractual periodic prepayment 551
and no premium rate for nongroup and conversion policies for 552
health care services, or any amendment to them, may be used by 553
any health insuring corporation at any time until the contractual 554
periodic prepayment and premium rate, or amendment, have been 555
filed with the superintendent of insurance, and shall not be 556
effective until the expiration of sixty days after their filing 557
unless the superintendent sooner gives approval. The 558
superintendent shall disapprove the filing, if the superintendent 559
determines within the sixty-day period that the contractual 560
periodic prepayment or premium rate, or amendment, is not in 561
accordance with sound actuarial principles or is not reasonably 562
related to the applicable coverage and characteristics of the 563
applicable class of enrollees. The superintendent shall notify 564
the health insuring corporation of the disapproval, and it shall 565
thereafter be unlawful for the health insuring corporation to use 566
the contractual periodic prepayment or premium rate, or 567
amendment.
(2) No contractual periodic prepayment for group policies 570
13
for health care services shall be used until the contractual 571
periodic prepayment has been filed with the superintendent. The 572
superintendent may reject a filing made under division (A)(2) of 573
this section at any time, with at least thirty days' written 574
notice to a health insuring corporation, if the contractual 575
periodic prepayment is not in accordance with sound actuarial 577
principles or is not reasonably related to the applicable 578
coverage and characteristics of the applicable class of 579
enrollees.
(3) At any time, the superintendent, upon at least thirty 581
days' written notice to a health insuring corporation, may 582
withdraw the approval given under division (A)(1) of this 583
section, deemed or actual, of any contractual periodic prepayment 585
or premium rate, or amendment, based on information that either 586
of the following applies:
(a) The contractual periodic prepayment or premium rate, 589
or amendment, is not in accordance with sound actuarial 590
principles.
(b) The contractual periodic prepayment or premium rate, 593
or amendment, is not reasonably related to the applicable 594
coverage and characteristics of the applicable class of 595
enrollees.
(4) Any disapproval under division (A)(1) of this section, 597
any rejection of a filing made under division (A)(2) of this 599
section, or any withdrawal of approval under division (A)(3) of 600
this section, shall be effected by a written notice, which shall 601
state the specific basis for the disapproval, rejection, or 602
withdrawal and shall be issued in accordance with Chapter 119. of 603
the Revised Code. 604
(B) Notwithstanding division (A) of this section, a health 607
insuring corporation may use a contractual periodic prepayment or 608
premium rate for policies used for the coverage of beneficiaries 609
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 611
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 613
14
risk contract or medicare cost contract, or for policies used for 614
the coverage of beneficiaries enrolled in the federal employees 615
health benefits program pursuant to 5 U.S.C.A. 8905, or for 618
policies used for the coverage of beneficiaries enrolled in Title 619
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 621
U.S.C.A. 301, as amended, known as the medical assistance program 624
or medicaid, provided by the Ohio department of human services 625
under Chapter 5111. of the Revised Code, or for policies used for 626
the coverage of beneficiaries under any other federal health care 627
program regulated by a federal regulatory body, if both of the 628
following apply: 629
(1) The contractual periodic prepayment or premium rate 631
has been approved by the United States department of health and 632
human services, the United States office of personnel management, 634
or the Ohio department of human services.
(2) The contractual periodic prepayment or premium rate is 636
filed with the superintendent prior to use and is accompanied by 637
documentation of approval from the United States department of 639
health and human services, the United States office of personnel 641
management, or the Ohio department of human services. 643
(C) The administrative expense portion of all contractual 646
periodic prepayment or premium rate filings submitted to the 647
superintendent for review must reflect the actual cost of 648
administering the product. The superintendent may require that 649
the administrative expense portion of the filings be itemized and 650
supported.
(D)(1) Copayments and deductibles must be reasonable and 653
must not be a barrier to the necessary utilization of services by 654
enrollees.
(2) A health insuring corporation may not impose copayment 657
charges on basic health care services that exceed thirty per cent 658
of the total cost of providing any single covered health care 659
service, except for PHYSICIAN OFFICE VISITS, emergency health 660
services, and urgent care services. The total cost of providing 661
15
a health care service is the cost to the health insuring 662
corporation of providing the health care service to the enrollee 663
ITS ENROLLEES as reduced by any applicable provider discount. An 666
open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of 667
providing any single covered health care service. 668
(3) To ensure that copayments are not a barrier to the 670
utilization of basic health care services, a health insuring 671
corporation may not impose, in any contract year, on any 672
subscriber or enrollee, copayments that exceed two hundred per 673
cent of the total annual premium rate to the subscriber or 674
enrollees. This limitation of two hundred per cent does not 676
include any reasonable copayments that are not a barrier to the 677
necessary utilization of health care services by enrollees and 678
that are imposed on physician office visits, emergency health 679
services, urgent care services, supplemental health care 680
services, or specialty health care services.
(E) A health insuring corporation shall not impose 683
lifetime maximums on basic health care services. However, a 684
health insuring corporation may establish a benefit limit for 685
inpatient hospital services that are provided pursuant to a 686
policy, contract, certificate, or agreement for supplemental 687
health care services.
Sec. 1751.13. (A)(1)(a) A health insuring corporation 697
shall, either directly or indirectly, enter into contracts for 698
the provision of health care services with a sufficient number 699
and types of providers and health care facilities to ensure that 700
all covered health care services will be accessible to enrollees 701
from a contracted provider or health care facility. 702
(b) A HEALTH INSURING CORPORATION SHALL NOT REFUSE TO 705
CONTRACT WITH A PHYSICIAN FOR THE PROVISION OF HEALTH CARE
SERVICES OR REFUSE TO RECOGNIZE A PHYSICIAN AS A SPECIALIST ON 706
THE BASIS THAT THE PHYSICIAN ATTENDED AN EDUCATIONAL PROGRAM OR A 708
RESIDENCY PROGRAM APPROVED OR CERTIFIED BY THE AMERICAN 709
16
OSTEOPATHIC ASSOCIATION. A HEALTH INSURING CORPORATION SHALL NOT 710
REFUSE TO CONTRACT WITH A HEALTH CARE FACILITY FOR THE PROVISION 711
OF HEALTH CARE SERVICES ON THE BASIS THAT THE HEALTH CARE 712
FACILITY IS CERTIFIED OR ACCREDITED BY THE AMERICAN OSTEOPATHIC 714
ASSOCIATION OR THAT THE HEALTH CARE FACILITY IS AN OSTEOPATHIC 715
HOSPITAL AS DEFINED IN SECTION 3702.51 OF THE REVISED CODE. 718
(c) NOTHING IN DIVISION (A)(1)(b) OF THIS SECTION SHALL BE 722
CONSTRUED TO REQUIRE A HEALTH INSURING CORPORATION TO MAKE A 723
BENEFIT PAYMENT UNDER A CLOSED PANEL PLAN TO A PHYSICIAN OR 724
HEALTH CARE FACILITY WITH WHICH THE HEALTH INSURING CORPORATION 725
DOES NOT HAVE A CONTRACT, PROVIDED THAT NONE OF THE BASES SET 726
FORTH IN THAT DIVISION ARE USED AS A REASON FOR FAILING TO MAKE A 727
BENEFIT PAYMENT.
(2) When a health insuring corporation is unable to 729
provide a covered health care service from a contracted provider 730
or health care facility, the health insuring corporation must 731
provide that health care service from a noncontracted provider or 733
health care facility consistent with the terms of the enrollee's 734
policy, contract, certificate, or agreement. The health insuring 735
corporation shall either ensure that the health care service be 736
provided at no greater cost to the enrollee than if the enrollee 737
had obtained the health care service from a contracted provider 738
or health care facility, or make other arrangements acceptable to 739
the superintendent of insurance. 740
(3) Nothing in this section shall prohibit a health 742
insuring corporation from entering into contracts with 743
out-of-state providers or health care facilities that are 744
licensed, certified, accredited, or otherwise authorized in that 745
state. 746
(B)(1) A health insuring corporation shall, either 749
directly or indirectly, enter into contracts with all providers 750
and health care facilities through which health care services are 751
provided to its enrollees.
(2) A health insuring corporation, upon written request, 753
17
shall assist its contracted providers in finding stop-loss or 754
reinsurance carriers.
(C) A health insuring corporation shall file an annual 756
certificate with the superintendent certifying that all provider 757
contracts and contracts with health care facilities through which 758
health care services are being provided contain the following: 759
(1) A description of the method by which the provider or 761
health care facility will be notified of the specific health care 763
services for which the provider or health care facility will be 764
responsible, including any limitations or conditions on such 765
services;
(2) The specific hold harmless provision specifying 767
protection of enrollees set forth as follows: 768
"[Provider/Health Care Facility< agrees that in no event, 771
including but not limited to nonpayment by the health insuring 772
corporation, insolvency of the health insuring corporation, or 773
breach of this agreement, shall [Provider/Health Care Facility< 775
bill, charge, collect a deposit from, seek remuneration or 776
reimbursement from, or have any recourse against, a subscriber, 777
enrollee, person to whom health care services have been provided, 779
or person acting on behalf of the covered enrollee, for health 780
care services provided pursuant to this agreement. This does not 781
prohibit [Provider/Health Care Facility< from collecting 782
co-insurance, deductibles, or copayments as specifically provided 784
in the evidence of coverage, or fees for uncovered health care 785
services delivered on a fee-for-service basis to persons 786
referenced above, nor from any recourse against the health 787
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 789
facility to continue to provide covered health care services to 790
enrollees in the event of the health insuring corporation's 791
insolvency or discontinuance of operations. The provisions shall 793
require the provider or health care facility to continue to 794
provide covered health care services to enrollees as needed to 795
18
complete any medically necessary procedures commenced but 796
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. If an enrollee is 797
receiving necessary inpatient care at a hospital, the provisions 798
may limit the required provision of covered health care services 799
relating to that inpatient care in accordance with division 800
(D)(3) of section 1751.11 of the Revised Code, and may also limit 802
such required provision of covered health care services to the 803
period ending thirty days after the health insuring corporation's 804
insolvency or discontinuance of operations. 805
The provisions required by division (C)(3) of this section 808
shall not require any provider or health care facility to 809
continue to provide any covered health care service after the
occurrence of any of the following: 810
(a) The end of the thirty-day period following the entry 812
of a liquidation order under Chapter 3903. of the Revised Code; 814
(b) The end of the enrollee's period of coverage for a 816
contractual prepayment or premium; 817
(c) The enrollee obtains equivalent coverage with another 819
health insuring corporation or insurer, or the enrollee's 820
employer obtains such coverage for the enrollee; 821
(d) The enrollee or the enrollee's employer terminates 823
coverage under the contract; 824
(e) A liquidator effects a transfer of the health insuring 827
corporation's obligations under the contract under division 828
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 830
responsibilities of the health insuring corporation, and of the 831
contracted providers and health care facilities, with respect to 832
administrative policies and programs, including, but not limited 833
to, payments systems, utilization review, quality ASSURANCE, 834
assessment, and improvement programs, credentialing, 835
confidentiality requirements, and any applicable federal or state 836
programs; 837
19
(5) A provision regarding the availability and 839
confidentiality of those health records maintained by providers 840
and health care facilities to monitor and evaluate the quality of 842
care, to conduct evaluations and audits, and to determine on a 843
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 844
The provision shall include terms requiring the provider or 845
health care facility to make these health records available to 846
appropriate state and federal authorities involved in assessing 847
the quality of care or in investigating the grievances or 848
complaints of enrollees, and requiring the provider or health 849
care facility to comply with applicable state and federal laws 850
related to the confidentiality of medical or health records. 852
(6) A provision that states that contractual rights and 854
responsibilities may not be assigned or delegated by the provider 856
or health care facility without the prior written consent of the 857
health insuring corporation;
(7) A provision requiring the provider or health care 859
facility to maintain adequate professional liability and 860
malpractice insurance. The provision shall also require the 861
provider or health care facility to notify the health insuring 862
corporation not more than ten days after the provider's or health 864
care facility's receipt of notice of any reduction or
cancellation of such coverage. 865
(8) A provision requiring the provider or health care 867
facility to observe, protect, and promote the rights of enrollees 869
as patients;
(9) A provision requiring the provider or health care 871
facility to provide health care services without discrimination 872
on the basis of a patient's participation in the health care 873
plan, age, sex, ethnicity, religion, sexual preference, health 874
status, or disability, and without regard to the source of 875
payments made for health care services rendered to a patient. 876
This requirement shall not apply to circumstances when the 877
20
provider or health care facility appropriately does not render 878
services due to limitations arising from the provider's or health 880
care facility's lack of training, experience, or skill, or due to 881
licensing restrictions.
(10) A provision containing the specifics of any 883
obligation on the provider or health care facility to provide, or 885
to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week; 886
(11) A provision setting forth procedures for the 888
resolution of disputes arising out of the contract; 889
(12) A provision stating that the hold harmless provision 891
required by division (C)(2) of this section shall survive the 893
termination of the contract with respect to services covered and 894
provided under the contract during the time the contract was in 895
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 896
(13) A provision requiring those terms that are used in 898
the contract and that are defined by this chapter, be used in the 900
contract in a manner consistent with those definitions. 901
(D)(1) No health insuring corporation contract with a 904
provider or health care facility shall do either CONTAIN ANY of 905
the following:
(1) Offer (a) A PROVISION THAT DIRECTLY OR INDIRECTLY 907
OFFERS an inducement to the provider or health care facility, 909
directly or indirectly, to reduce or limit medically necessary 910
health care services to a covered enrollee;
(2) Penalize (b) A PROVISION THAT PENALIZES a provider or 913
health care facility that assists an enrollee to seek a 914
reconsideration of the health insuring corporation's decision to 915
deny or limit benefits to the enrollee; 916
(c) A PROVISION THAT LIMITS OR OTHERWISE RESTRICTS THE 919
PROVIDER'S OR HEALTH CARE FACILITY'S ETHICAL AND LEGAL
RESPONSIBILITY TO FULLY ADVISE ENROLLEES ABOUT THEIR MEDICAL 920
CONDITION AND ABOUT MEDICALLY APPROPRIATE TREATMENT OPTIONS; 922
21
(d) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 925
FACILITY FOR PRINCIPALLY ADVOCATING FOR MEDICALLY NECESSARY 926
HEALTH CARE SERVICES;
(e) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 928
FACILITY FOR PROVIDING INFORMATION OR TESTIMONY TO A LEGISLATIVE 929
OR REGULATORY BODY OR AGENCY. THIS SHALL NOT BE CONSTRUED TO 930
PROHIBIT A HEALTH INSURING CORPORATION FROM PENALIZING A PROVIDER 932
OR HEALTH CARE FACILITY THAT PROVIDES INFORMATION OR TESTIMONY 933
THAT IS LIBELOUS OR SLANDEROUS OR THAT DISCLOSES TRADE SECRETS 934
WHICH THE PROVIDER OR HEALTH CARE FACILITY HAS NO PRIVILEGE OR 935
PERMISSION TO DISCLOSE.
(2) NOTHING IN THIS DIVISION SHALL BE CONSTRUED TO 937
PROHIBIT A HEALTH INSURING CORPORATION FROM DOING EITHER OF THE 938
FOLLOWING: 939
(a) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A 942
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICE; 943
(b) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION REVIEW 946
PROTOCOLS, OR DETERMINING WHETHER A PARTICULAR PROVIDER OR HEALTH 947
CARE FACILITY HAS COMPLIED WITH THESE PROTOCOLS. 948
(E) Any contract between a health insuring corporation and 951
an intermediary organization shall clearly specify that the 952
health insuring corporation must approve or disapprove the 953
participation of any provider or health care facility with which 954
the intermediary organization contracts. 955
(F) If an intermediary organization that is not a health 957
delivery network contracting solely with self-insured employers 958
subcontracts with a provider or health care facility, the 959
subcontract with the provider or health care facility shall do 960
all of the following:
(1) Contain the provisions required by divisions (C) and 963
(G) of this section, as made applicable to an intermediary 964
organization, without the inclusion of inducements or penalties 965
described in division (D) of this section; 966
(2) Acknowledge that the health insuring corporation is a 968
22
third-party beneficiary to the agreement; 969
(3) Acknowledge the health insuring corporation's role in 971
approving the participation of the provider or health care 972
facility, pursuant to division (E) of this section. 974
(G) Any provider contract or contract with a health care 977
facility shall clearly specify the health insuring corporation's 978
statutory responsibility to monitor and oversee the offering of 979
covered health care services to its enrollees. 980
(H)(1) A health insuring corporation shall maintain its 983
provider contracts and its contracts with health care facilities 984
at one or more of its places of business in this state, and shall 985
provide copies of these contracts to facilitate regulatory review 986
upon written notice by the superintendent of insurance. 987
(2) Any contract with an intermediary organization shall 989
include provisions requiring the intermediary organization to 990
provide the superintendent with regulatory access to all books, 991
records, financial information, and documents related to the 992
provision of health care services to subscribers and enrollees 993
under the contract. The contract shall require the intermediary 994
organization to maintain such books, records, financial 995
information, and documents at its principal place of business in 996
this state and to preserve them for at least three years in a 997
manner that facilitates regulatory review. 998
(I) A health insuring corporation shall provide notice of 1,001
the termination of any contract with a primary care physician or 1,002
hospital.
(J) Divisions (A) and (B) of this section do not apply to 1,005
any health insuring corporation that, on the effective date of 1,006
this section JUNE 4, 1997, holds a certificate of authority or 1,007
license to operate under Chapter 1740. of the Revised Code. 1,009
(K) NOTHING IN THIS SECTION SHALL RESTRICT THE GOVERNING 1,011
BODY OF A HOSPITAL FROM EXERCISING THE AUTHORITY GRANTED IT 1,012
PURSUANT TO SECTION 3701.351 OF THE REVISED CODE. 1,013
Sec. 1751.521. IF AN ENROLLEE SIGNS A MEDICAL INFORMATION 1,015
23
RELEASE UPON THE REQUEST OF A HEALTH INSURING CORPORATION, THE 1,016
RELEASE SHALL CLEARLY EXPLAIN WHAT INFORMATION MAY BE DISCLOSED 1,017
UNDER THE TERMS OF THE RELEASE. IF A HEALTH INSURING CORPORATION 1,018
UTILIZES THIS RELEASE TO REQUEST MEDICAL INFORMATION FROM A 1,019
HEALTH CARE FACILITY OR PROVIDER, THE HEALTH INSURING CORPORATION
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE 1,020
FACILITY OR PROVIDER, UPON REQUEST. 1,021
Sec. 1751.73. EACH HEALTH INSURING CORPORATION PROVIDING 1,024
BASIC HEALTH CARE SERVICES SHALL IMPLEMENT A QUALITY ASSURANCE 1,025
PROGRAM FOR USE IN CONNECTION WITH THOSE POLICIES, CONTRACTS, AND 1,026
AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. EACH HEALTH 1,027
INSURING CORPORATION REQUIRED TO IMPLEMENT A QUALITY ASSURANCE 1,028
PROGRAM SHALL ANNUALLY FILE A CERTIFICATE WITH THE SUPERINTENDENT 1,029
OF INSURANCE CERTIFYING THAT ITS QUALITY ASSURANCE PROGRAM DOES 1,030
ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR 1,032
DESIGNATES AN EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM 1,033
IMPLEMENTATION AND COMPLIANCE;
(B) INCLUDES A PROCESS ENABLING THE SELECTION AND 1,035
RETENTION OF QUALITY PROVIDERS AND HEALTH CARE FACILITIES THROUGH 1,036
CREDENTIALING, RECREDENTIALING, AND MONITORING PROCEDURES; 1,037
(C) PROVIDES FOR ONGOING MONITORING OF THE QUALITY 1,039
ASSURANCE PROGRAM; 1,040
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR 1,042
ENTITIES WITH WHICH THE HEALTH INSURING CORPORATION CONTRACTS FOR 1,043
SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT 1,045
QUALITY PROBLEMS. 1,046
Sec. 1751.74. (A) TO IMPLEMENT A QUALITY ASSURANCE 1,048
PROGRAM REQUIRED BY SECTION 1715.73 OF THE REVISED CODE, A HEALTH 1,049
INSURING CORPORATION SHALL DO BOTH OF THE FOLLOWING: 1,050
(1) DEVELOP AND MAINTAIN THE APPROPRIATE INFRASTRUCTURE 1,053
AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE AND REPORT, ON A 1,054
REGULAR BASIS, THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,055
24
ENROLLEES, BASED ON A SYSTEMATIC COLLECTION, ANALYSIS, AND 1,056
REPORTING OF RELEVANT DATA. THE HEALTH INSURING CORPORATION 1,057
SHALL ASSURE THAT A COMMITTEE THAT INCLUDES PARTICIPATING 1,058
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING, 1,059
IMPLEMENTING, AND EVALUATING THE QUALITY ASSURANCE PROGRAM AND 1,061
ALL OTHER PROGRAMS IMPLEMENTED BY THE HEALTH INSURING CORPORATION
THAT RELATE TO THE UTILIZATION OF HEALTH CARE SERVICES. A 1,063
COMMITTEE THAT INCLUDES PARTICIPATING PHYSICIANS SHALL ALSO HAVE 1,064
THE OPPORTUNITY TO PARTICIPATE IN THE DERIVATION OF DATA 1,065
ASSESSMENTS, STATISTICAL ANALYSES, AND OUTCOME INTERPRETATIONS 1,067
FROM PROGRAMS MONITORING THE UTILIZATION OF HEALTH CARE SERVICES. 1,068
(2) DEVELOP AND MAINTAIN AN ORGANIZATIONAL PROGRAM FOR 1,071
DESIGNING, MEASURING, ASSESSING, AND IMPROVING THE PROCESSES AND 1,072
OUTCOMES OF HEALTH CARE.
(B) A QUALITY ASSURANCE PROGRAM SHALL: 1,074
(1) ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING 1,076
OPPORTUNITIES TO IMPROVE HEALTH CARE, WHICH SYSTEM IS STRUCTURED 1,077
TO IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE 1,078
OUTCOMES, TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO 1,079
IDENTIFY THOSE PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER 1,080
EXEMPLARY OR PROBLEMATIC PATTERNS. THE QUALITY ASSURANCE PROGRAM 1,081
SHALL USE THE FINDINGS GENERATED BY THE SYSTEM TO WORK ON A 1,083
CONTINUING BASIS WITH PARTICIPATING PROVIDERS AND OTHER STAFF TO 1,084
IMPROVE THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,086
ENROLLEES.
(2) DEVELOP A WRITTEN STATEMENT OF ITS OBJECTIVES, LINES 1,088
OF AUTHORITY AND ACCOUNTABILITY, EVALUATION TOOLS, AND 1,089
PERFORMANCE IMPROVEMENT ACTIVITIES; 1,090
(3) REQUIRE AN ANNUAL EFFECTIVENESS REVIEW OF THE PROGRAM; 1,093
(4) PROVIDE A DESCRIPTION OF HOW THE HEALTH INSURING 1,096
CORPORATION INTENDS TO DO ALL OF THE FOLLOWING: 1,097
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF HEALTH CARE, 1,099
INCLUDING FOCUSED REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO 1,101
DISCERN THE CAUSES OF VARIATION;
25
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE 1,103
REVIEWED BY THE QUALITY ASSURANCE PROGRAM EACH YEAR, BASED ON 1,104
CONSIDERATION OF PRACTICES AND DIAGNOSES THAT AFFECT A 1,105
SUBSTANTIAL NUMBER OF THE HEALTH INSURING CORPORATION'S ENROLLEES 1,106
OR THAT COULD PLACE ENROLLEES AT SERIOUS RISK; 1,107
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY 1,109
OF HEALTH CARE, INCLUDING COLLECTION AND ANALYSIS OF INFORMATION 1,111
ON OVER-UTILIZATION AND UNDER-UTILIZATION OF HEALTH CARE 1,112
SERVICES; EVALUATION OF COURSES OF TREATMENT AND OUTCOMES BASED 1,114
ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC 1,115
TO ENROLLEES OR PROVIDERS; 1,116
(d) COMPARE QUALITY ASSURANCE PROGRAM FINDINGS WITH PAST 1,118
PERFORMANCE, INTERNAL GOALS, AND EXTERNAL STANDARDS; 1,120
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND 1,122
CONDUCT PEER REVIEW ACTIVITIES; 1,123
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS 1,125
DEVELOPED WITH APPROPRIATE CLINICAL INPUT; 1,126
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO QUALITY 1,128
ASSURANCE PROGRAM FINDINGS; 1,129
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE 1,131
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES. 1,132
Sec. 1751.75. A HEALTH INSURING CORPORATION MAY PRESENT 1,134
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.73 1,135
AND 1751.74 OF THE REVISED CODE BY SUBMITTING CERTIFICATION TO 1,136
THE SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN 1,137
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,138
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,139
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,141
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,142
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,143
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING 1,144
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,145
26
Sec. 1751.77. AS USED IN SECTIONS 1751.77 TO 1751.86 OF 1,147
THE REVISED CODE, UNLESS OTHERWISE SPECIFICALLY PROVIDED: 1,148
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A 1,150
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,151
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,153
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,154
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,156
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,157
HEALTH CARE SERVICE DOES NOT MEET THE HEALTH INSURING 1,159
CORPORATION'S REQUIREMENTS FOR BENEFIT PAYMENT, AND IS THEREFORE 1,160
DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH 1,162
CARE SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING. 1,163
(C) "CASE MANAGEMENT" MEANS A COORDINATED SET OF 1,165
ACTIVITIES CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF 1,166
SERIOUS, COMPLICATED, PROTRACTED, OR OTHER SPECIFIED HEALTH 1,167
CONDITIONS.
(D) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH 1,169
INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,171
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,172
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,173
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,175
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,176
HEALTH CARE SERVICE SATISFIES THE HEALTH INSURING CORPORATION'S 1,177
REQUIREMENTS FOR BENEFIT PAYMENT. 1,178
(E) "CLINICAL PEER" MEANS A PHYSICIAN WHEN AN EVALUATION 1,181
IS TO BE MADE OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE 1,182
SERVICES PROVIDED BY A PHYSICIAN. IF AN EVALUATION IS TO BE MADE 1,183
OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED 1,184
BY A PROVIDER WHO IS NOT A PHYSICIAN, "CLINICAL PEER" MEANS 1,185
EITHER A PHYSICIAN OR A PROVIDER HOLDING THE SAME LICENSE AS THE 1,186
PROVIDER WHO PROVIDED THE HEALTH CARE SERVICES. 1,187
(F) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING 1,189
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE 1,190
27
GUIDELINES USED BY A HEALTH INSURING CORPORATION TO DETERMINE THE 1,191
NECESSITY AND APPROPRIATENESS OF HEALTH CARE SERVICES. 1,193
(G) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED 1,195
DURING A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT. 1,196
(H) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR 1,198
DETERMINING, PRIOR TO A PATIENT'S DISCHARGE FROM A HEALTH CARE 1,199
FACILITY, THE COORDINATION AND MANAGEMENT OF THE CARE THAT THE 1,201
PATIENT IS TO RECEIVE FOLLOWING DISCHARGE FROM A HEALTH CARE 1,202
FACILITY. 1,203
(I) "PARTICIPATING PROVIDER" MEANS A PROVIDER OR HEALTH 1,205
CARE FACILITY THAT, UNDER A CONTRACT WITH A HEALTH INSURING 1,207
CORPORATION OR WITH ITS CONTRACTOR OR SUBCONTRACTOR, HAS AGREED 1,209
TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR 1,210
DEDUCTIBLES, DIRECTLY OR INDIRECTLY FROM THE HEALTH INSURING 1,211
CORPORATION.
(J) "PHYSICIAN" MEANS A PROVIDER AUTHORIZED UNDER CHAPTER 1,214
4731. OF THE REVISED CODE TO PRACTICE MEDICINE AND SURGERY OR 1,217
OSTEOPATHIC MEDICINE AND SURGERY.
(K) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS 1,219
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT. 1,220
(L) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF 1,222
MEDICAL NECESSITY THAT IS CONDUCTED AFTER HEALTH CARE SERVICES 1,223
HAVE BEEN PROVIDED TO A PATIENT. "RETROSPECTIVE REVIEW" DOES NOT 1,225
INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED TO AN EVALUATION OF 1,226
REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY OF 1,227
CODING, OR ADJUDICATION OF PAYMENT.
(M) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT 1,229
TO OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE 1,230
PROVIDER ORIGINALLY MAKING A RECOMMENDATION FOR PROPOSED HEALTH 1,231
CARE SERVICES TO ASSESS THE CLINICAL NECESSITY AND 1,232
APPROPRIATENESS OF THE PROPOSED HEALTH CARE SERVICES. 1,233
(N) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR 1,235
THE USE OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, 1,236
28
EFFICACY, OR EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR 1,237
SETTINGS. AREAS OF REVIEW MAY INCLUDE AMBULATORY REVIEW, 1,238
PROSPECTIVE REVIEW, SECOND OPINION, CERTIFICATION, CONCURRENT 1,239
REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR RETROSPECTIVE 1,240
REVIEW.
(O) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT 1,242
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH INSURING 1,243
CORPORATION PERFORMING A REVIEW OF ITS OWN HEALTH CARE PLANS. 1,245
Sec. 1751.78. (A)(1) SECTIONS 1751.77 TO 1751.86 OF THE 1,248
REVISED CODE APPLY TO ANY HEALTH INSURING CORPORATION THAT 1,249
PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES IN CONNECTION 1,250
WITH ITS POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC
HEALTH CARE SERVICES AND TO ANY DESIGNEE OF THE HEALTH INSURING 1,251
CORPORATION, OR TO ANY UTILIZATION REVIEW ORGANIZATION THAT 1,253
PERFORMS UTILIZATION REVIEW FUNCTIONS ON BEHALF OF THE HEALTH 1,254
INSURING CORPORATION IN CONNECTION WITH POLICIES, CONTRACTS, OR 1,255
AGREEMENTS OF THE HEALTH INSURING CORPORATION PROVIDING BASIC
HEALTH CARE SERVICES. 1,256
(2) NOTHING IN SECTIONS 1751.77 TO 1751.82 OR SECTION 1,258
1751.85 OF THE REVISED CODE SHALL BE CONSTRUED TO REQUIRE A 1,260
HEALTH INSURING CORPORATION TO PROVIDE OR PERFORM UTILIZATION 1,261
REVIEW SERVICES IN CONNECTION WITH HEALTH CARE SERVICES PROVIDED 1,262
UNDER A POLICY, PLAN, OR AGREEMENT OF SUPPLEMENTAL HEALTH CARE 1,263
SERVICES OR SPECIALTY HEALTH CARE SERVICES. 1,264
(B)(1) EACH HEALTH INSURING CORPORATION SHALL BE 1,267
RESPONSIBLE FOR MONITORING ALL UTILIZATION REVIEW ACTIVITIES 1,268
CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH INSURING CORPORATION 1,269
AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS 1751.77 TO 1,270
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,272
ARE MET. THE HEALTH INSURING CORPORATION SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE 1,273
CONDUCT OF THE HEALTH INSURING CORPORATION'S UTILIZATION REVIEW 1,274
PROGRAM. 1,275
(2) IF A HEALTH INSURING CORPORATION CONTRACTS TO HAVE A 1,277
29
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE 1,278
UTILIZATION REVIEW FUNCTIONS REQUIRED BY SECTIONS 1751.77 TO 1,279
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,282
THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE HEALTH INSURING 1,283
CORPORATION RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING 1,284
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE MET. 1,286
Sec. 1751.79. A HEALTH INSURING CORPORATION THAT CONDUCTS 1,288
UTILIZATION REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW 1,289
PROGRAM THAT DESCRIBES ALL REVIEW ACTIVITIES, BOTH DELEGATED AND 1,290
NONDELEGATED, FOR COVERED HEALTH CARE SERVICES PROVIDED, 1,292
INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY, 1,294
APPROPRIATENESS, EFFICACY, OR EFFICIENCY OF HEALTH CARE SERVICES; 1,296
(B) THE USE OF DATA SOURCES AND CLINICAL REVIEW CRITERIA 1,298
IN MAKING DECISIONS; 1,300
(C) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF 1,302
CRITERIA AND COMPATIBLE DECISIONS; 1,303
(D) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED 1,305
IN ASSESSING UTILIZATION OF HEALTH CARE SERVICES; 1,307
(E) MECHANISMS FOR ASSURING CONFIDENTIALITY OF CLINICAL 1,309
AND PROPRIETARY INFORMATION; 1,310
(F) THE PERIODIC ASSESSMENT OF UTILIZATION REVIEW 1,312
ACTIVITIES, AND THE REPORTING OF THESE ASSESSMENTS TO THE HEALTH 1,313
INSURING CORPORATION'S BOARD, BY A UTILIZATION REVIEW COMMITTEE, 1,314
A QUALITY ASSURANCE COMMITTEE, OR ANY SIMILAR COMMITTEE; 1,315
(G) THE FUNCTIONAL RESPONSIBILITY FOR DAY-TO-DAY PROGRAM 1,318
MANAGEMENT BY STAFF;
(H) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND 1,320
COMMUNICATED TO PROVIDERS AND HEALTH CARE FACILITIES. 1,321
Sec. 1751.80. THE UTILIZATION REVIEW PROGRAM OF A HEALTH 1,323
INSURING CORPORATION SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL 1,324
OF THE FOLLOWING: 1,325
(A) THE PROGRAM SHALL USE DOCUMENTED CLINICAL REVIEW 1,328
30
CRITERIA THAT ARE BASED ON SOUND CLINICAL EVIDENCE AND ARE 1,329
EVALUATED PERIODICALLY TO ASSURE ONGOING EFFICACY. A HEALTH 1,330
INSURING CORPORATION MAY DEVELOP ITS OWN CLINICAL REVIEW CRITERIA 1,331
OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM QUALIFIED VENDORS. 1,332
A HEALTH INSURING CORPORATION SHALL MAKE ITS CLINICAL REVIEW 1,333
RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES. THE RATIONALE MADE AVAILABLE TO AUTHORIZED GOVERNMENT 1,334
AGENCIES IS CONFIDENTIAL AND IS NOT A PUBLIC RECORD AS DEFINED IN 1,336
SECTION 149.43 OF THE REVISED CODE. 1,338
(B) QUALIFIED PROVIDERS SHALL ADMINISTER THE PROGRAM AND 1,341
OVERSEE REVIEW DETERMINATIONS. A CLINICAL PEER IN THE SAME, OR 1,343
IN A SIMILAR, SPECIALTY AS TYPICALLY MANAGES THE MEDICAL
CONDITION, PROCEDURE, OR TREATMENT UNDER REVIEW SHALL EVALUATE 1,344
THE CLINICAL APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE 1,345
THE SUBJECT OF AN APPEAL. 1,346
(C) THE HEALTH INSURING CORPORATION SHALL ISSUE 1,349
UTILIZATION REVIEW DETERMINATIONS IN A TIMELY MANNER PURSUANT TO 1,350
THE REQUIREMENTS OF SECTIONS 1751.81 AND 1751.82 OF THE REVISED 1,352
CODE AND THE ENROLLEE GRIEVANCE REQUIREMENTS. THE HEALTH 1,353
INSURING CORPORATION SHALL OBTAIN INFORMATION REQUIRED TO MAKE A 1,355
UTILIZATION REVIEW DETERMINATION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT 1,356
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA 1,357
CONSISTENTLY. 1,358
(D) IF THE HEALTH INSURING CORPORATION DELEGATES ANY 1,361
UTILIZATION REVIEW ACTIVITIES TO A UTILIZATION REVIEW 1,362
ORGANIZATION, THE HEALTH INSURING CORPORATION SHALL MAINTAIN 1,363
ADEQUATE OVERSIGHT, INCLUDING A PROCESS BY WHICH THE HEALTH 1,364
INSURING CORPORATION EVALUATES THE PERFORMANCE OF THE 1,365
ORGANIZATION, AND SHALL MAINTAIN COPIES OF BOTH OF THE FOLLOWING: 1,367
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S ACTIVITIES 1,370
AND RESPONSIBILITIES, INCLUDING REPORTING REQUIREMENTS; 1,371
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S 1,373
PROGRAM BY THE HEALTH INSURING CORPORATION. 1,374
31
(E) THE HEALTH INSURING CORPORATION OR ITS DESIGNEE 1,377
UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE ENROLLEES AND 1,378
PARTICIPATING PROVIDERS WITH ACCESS TO ITS REVIEW STAFF BY MEANS 1,379
OF A TOLL-FREE TELEPHONE NUMBER OR COLLECT-CALL TELEPHONE LINE. 1,380
(F) WHEN CONDUCTING PROSPECTIVE OR CONCURRENT REVIEW, THE 1,383
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,384
ORGANIZATION SHALL COLLECT ONLY THE INFORMATION NECESSARY TO 1,385
CERTIFY THE ADMISSION, PROCEDURE OR TREATMENT, LENGTH OF STAY, 1,386
FREQUENCY, AND DURATION OF HEALTH CARE SERVICES. 1,387
(G) COMPENSATION TO PERSONS PROVIDING UTILIZATION REVIEW 1,390
SERVICES FOR THE HEALTH INSURING CORPORATION SHALL NOT CONTAIN 1,391
INCENTIVES, DIRECT OR INDIRECT, FOR THEM TO MAKE INAPPROPRIATE 1,392
REVIEW DECISIONS.
Sec. 1751.81. (A) AS USED IN THIS SECTION: 1,394
(1) "ENROLLEE" INCLUDES THE REPRESENTATIVE OF AN ENROLLEE. 1,396
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY 1,398
FACE-TO-FACE CLINICAL EVALUATION OR SECOND OPINION THAT MAY BE 1,400
REQUIRED.
(B) A HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN 1,402
PROCEDURES FOR MAKING UTILIZATION REVIEW DETERMINATIONS AND FOR 1,404
NOTIFYING ENROLLEES, AND PARTICIPATING PROVIDERS AND HEALTH CARE 1,406
FACILITIES ACTING ON BEHALF OF ENROLLEES, OF ITS DETERMINATIONS. 1,407
(C) FOR INITIAL DETERMINATIONS, A HEALTH INSURING 1,409
CORPORATION SHALL MAKE THE DETERMINATION WITHIN TWO BUSINESS DAYS 1,411
AFTER OBTAINING ALL NECESSARY INFORMATION REGARDING A PROPOSED 1,413
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE REQUIRING A REVIEW 1,414
DETERMINATION. 1,415
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN 1,417
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE, THE HEALTH INSURING 1,418
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,419
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN THREE 1,420
BUSINESS DAYS AFTER MAKING THE INITIAL CERTIFICATION, AND SHALL 1,422
PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,423
32
FACILITY WITHIN TWO BUSINESS DAYS AFTER MAKING THE TELEPHONE 1,425
NOTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,427
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,429
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,430
THREE BUSINESS DAYS AFTER MAKING THE ADVERSE DETERMINATION, AND 1,431
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE 1,432
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,433
FACILITY WITHIN ONE BUSINESS DAY AFTER MAKING THE TELEPHONE 1,434
NOTIFICATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH 1,436
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN ONE 1,438
BUSINESS DAY AFTER OBTAINING ALL NECESSARY INFORMATION. 1,439
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED 1,441
STAY OR ADDITIONAL HEALTH CARE SERVICES, THE HEALTH INSURING 1,442
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,443
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE 1,444
BUSINESS DAY AFTER MAKING THE CERTIFICATION, AND SHALL PROVIDE 1,446
WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER 1,447
THE TELEPHONE NOTIFICATION. THE WRITTEN NOTIFICATION SHALL 1,448
INCLUDE THE NUMBER OF EXTENDED DAYS OR NEXT REVIEW DATE, THE NEW 1,449
TOTAL NUMBER OF DAYS OF HEALTH CARE SERVICES APPROVED, AND THE 1,451
DATE OF ADMISSION OR INITIATION OF HEALTH CARE SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,453
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,454
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,455
ONE BUSINESS DAY AFTER MAKING THE ADVERSE DETERMINATION, AND 1,456
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE 1,457
AND THE PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY 1,458
AFTER THE TELEPHONE NOTIFICATION. THE HEALTH CARE SERVICE TO THE 1,459
ENROLLEE SHALL BE CONTINUED, WITH STANDARD COPAYMENTS AND 1,461
DEDUCTIBLES, IF APPLICABLE, UNTIL THE ENROLLEE HAS BEEN NOTIFIED 1,462
OF THE DETERMINATION. 1,463
33
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH 1,465
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN THIRTY 1,468
BUSINESS DAYS AFTER RECEIVING ALL NECESSARY INFORMATION. 1,469
(1) IN THE CASE OF A CERTIFICATION, THE HEALTH INSURING 1,471
CORPORATION MAY NOTIFY THE ENROLLEE AND THE PROVIDER OR HEALTH 1,473
CARE FACILITY RENDERING THE HEALTH CARE SERVICE IN WRITING. 1,474
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,476
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE AND THE PROVIDER 1,478
OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, IN 1,479
WRITING, WITHIN FIVE BUSINESS DAYS AFTER MAKING THE ADVERSE 1,480
DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND 1,483
(E) OF THIS SECTION FOR DETERMINATIONS AND NOTIFICATIONS SHALL 1,484
PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,485
ENROLLEE OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE
HEALTH INSURING CORPORATION. THE HEALTH INSURING CORPORATION 1,486
SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING EXPEDITED 1,488
UTILIZATION REVIEW DETERMINATIONS AND NOTIFICATIONS OF ENROLLEES 1,489
AND PROVIDERS OR HEALTH CARE FACILITIES WHEN WARRANTED BY THE 1,490
MEDICAL CONDITION OF THE ENROLLEE. 1,491
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION 1,493
SHALL INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE 1,494
DETERMINATION, INSTRUCTIONS FOR INITIATING AN APPEAL OR 1,495
RECONSIDERATION OF THE DETERMINATION, AND INSTRUCTIONS FOR 1,496
REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE USED TO 1,497
MAKE THE DETERMINATION. A HEALTH INSURING CORPORATION SHALL
PROVIDE THE CLINICAL RATIONALE FOR AN ADVERSE DETERMINATION IN 1,499
WRITING TO ANY PARTY WHO RECEIVED NOTICE OF THE ADVERSE 1,501
DETERMINATION AND WHO FOLLOWS THE INSTRUCTIONS FOR A REQUEST. 1,502
(H) A HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 1,504
PROCEDURES TO ADDRESS THE FAILURE OR INABILITY OF A HEALTH CARE 1,507
FACILITY, PROVIDER, OR ENROLLEE TO PROVIDE ALL NECESSARY 1,509
INFORMATION FOR REVIEW. IF THE HEALTH CARE FACILITY, PROVIDER,
OR ENROLLEE WILL NOT RELEASE NECESSARY INFORMATION, THE HEALTH 1,511
34
INSURING CORPORATION MAY DENY CERTIFICATION. 1,512
Sec. 1751.82. (A) IN A CASE INVOLVING AN INITIAL 1,515
DETERMINATION OR A CONCURRENT REVIEW DETERMINATION, A HEALTH 1,516
INSURING CORPORATION SHALL GIVE THE PROVIDER OR HEALTH CARE 1,517
FACILITY RENDERING THE HEALTH CARE SERVICE AN OPPORTUNITY TO 1,518
REQUEST IN WRITING ON BEHALF OF THE ENROLLEE A RECONSIDERATION OF 1,519
AN ADVERSE DETERMINATION BY THE REVIEWER MAKING THE ADVERSE 1,520
DETERMINATION. THE RECONSIDERATION SHALL OCCUR WITHIN THREE 1,521
BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION'S RECEIPT OF 1,522
THE WRITTEN REQUEST FOR RECONSIDERATION, AND SHALL BE CONDUCTED 1,523
BETWEEN THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH 1,524
CARE SERVICE AND THE REVIEWER WHO MADE THE ADVERSE DETERMINATION. 1,526
IF THAT REVIEWER CANNOT BE AVAILABLE WITHIN THREE BUSINESS DAYS, 1,527
THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION 1,530
(A) OF THIS SECTION DOES NOT RESOLVE THE DIFFERENCE OF OPINION, 1,531
THE ADVERSE DETERMINATION MAY BE APPEALED BY THE ENROLLEE OR THE 1,532
PROVIDER OR HEALTH CARE FACILITY ON BEHALF OF THE ENROLLEE. 1,533
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR 1,535
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION. 1,536
(D) THE TIME PERIOD ALLOWED BY DIVISION (A) OF THIS 1,539
SECTION FOR A RECONSIDERATION OF AN ADVERSE DETERMINATION SHALL 1,540
NOT APPLY IF THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,541
ENROLLEE REQUIRES A MORE EXPEDITED RECONSIDERATION. THE HEALTH 1,542
INSURING CORPORATION SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING 1,543
SUCH AN EXPEDITED RECONSIDERATION. 1,544
Sec. 1751.83. A HEALTH INSURING CORPORATION MAY PRESENT 1,547
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.77 1,548
TO 1751.82 OF THE REVISED CODE BY SUBMITTING EVIDENCE TO THE 1,549
SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE 1,550
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,551
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,552
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,553
35
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,555
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,556
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,557
Sec. 1751.84. EACH PARTICIPATING PROVIDER OR HEALTH CARE 1,559
FACILITY SUBMITTING A CLAIM SHALL COOPERATE WITH THE UTILIZATION 1,561
REVIEW PROGRAM OF A HEALTH INSURING CORPORATION OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE HEALTH INSURING 1,562
CORPORATION OR ITS DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL 1,563
RECORDS DURING REGULAR BUSINESS HOURS, OR COPIES OF THOSE RECORDS 1,564
AT A REASONABLE COST. 1,565
Sec. 1751.85. A HEALTH INSURING CORPORATION SHALL ANNUALLY 1,567
FILE A CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE 1,568
CERTIFYING ITS COMPLIANCE WITH SECTIONS 1751.77 TO 1751.82 OF THE 1,569
REVISED CODE. 1,571
Sec. 1751.86. (A) NO HEALTH INSURING CORPORATION SHALL 1,574
FAIL TO COMPLY WITH SECTIONS 1751.77 TO 1751.82 OF THE REVISED 1,575
CODE.
(B) WHOEVER VIOLATES DIVISION (A) OF THIS SECTION IS 1,578
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE 1,580
IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 1,581
THE REVISED CODE.
Sec. 1753.01. AS USED IN THIS CHAPTER: 1,583
(A) "ECONOMIC PROFILING" MEANS A HEALTH INSURING 1,585
CORPORATION'S USE OF ECONOMIC PERFORMANCE DATA AND ECONOMIC 1,586
INFORMATION IN DETERMINING WHETHER TO CONTRACT WITH A PROVIDER 1,587
FOR THE PROVISION OF COVERED HEALTH CARE SERVICES TO ENROLLEES AS 1,589
A PARTICIPATING PROVIDER.
(B) "BASIC HEALTH CARE SERVICES," "ENROLLEE," "HEALTH CARE 1,591
FACILITY," "HEALTH CARE SERVICES," "HEALTH INSURING CORPORATION," 1,592
"MEDICAL RECORD," "PROVIDER," AND "SUPPLEMENTAL HEALTH CARE 1,593
SERVICES" HAVE THE SAME MEANINGS AS IN SECTION 1751.01 OF THE 1,595
REVISED CODE.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL 1,597
36
PRESCRIBE A STANDARD CREDENTIALING FORM TO BE USED BY ALL HEALTH 1,598
INSURING CORPORATIONS WHEN CREDENTIALING PROVIDERS IN CONNECTION 1,599
WITH POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH 1,600
CARE SERVICES. THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS 1,601
TO THE SUPERINTENDENT FOR SUCH A STANDARD CREDENTIALING FORM. IF 1,602
THE DIRECTOR MAKES SUCH RECOMMENDATIONS, THE DIRECTOR SHALL TAKE 1,603
INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY 1,604
THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE AMERICAN 1,606
MEDICAL ASSOCIATION, THE AMERICAN ASSOCIATION OF HEALTH PLANS, 1,608
AND ANY OTHER NATIONAL ORGANIZATION THAT HAS DEVELOPED SUCH A 1,609
FORM. IN PRESCRIBING A STANDARD CREDENTIALING FORM, THE 1,610
SUPERINTENDENT SHALL CONSIDER ANY RECOMMENDATIONS MADE BY THE 1,611
DIRECTOR. THE SUPERINTENDENT MAY AMEND OR REVISE THE PRESCRIBED 1,612
STANDARD CREDENTIALING FORM AS NECESSARY.
Sec. 1753.04. BEGINNING ONE HUNDRED TWENTY DAYS AFTER THE 1,614
SUPERINTENDENT OF INSURANCE PRESCRIBES A STANDARD CREDENTIALING 1,615
FORM UNDER SECTION 1753.03 OF THE REVISED CODE, NO HEALTH 1,618
INSURING CORPORATION SHALL FAIL TO USE THE PRESCRIBED STANDARD 1,619
CREDENTIALING FORM WHEN INITIALLY CREDENTIALING OR 1,620
RECREDENTIALING PROVIDERS IN CONNECTION WITH POLICIES, CONTRACTS, 1,621
AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. IF THE 1,622
SUPERINTENDENT AMENDS OR REVISES THE STANDARD CREDENTIALING FORM, 1,624
A HEALTH INSURING CORPORATION SHALL USE THE AMENDED OR REVISED 1,625
FORM TO CREDENTIAL OR RECREDENTIAL PROVIDERS. 1,626
A HEALTH INSURING CORPORATION MAY REQUEST SUCH INFORMATION 1,629
FROM A PROVIDER, IN ADDITION TO THAT INFORMATION TO BE PROVIDED
ON THE STANDARD CREDENTIALING FORM, AS NECESSITATED BY THE HEALTH 1,631
INSURING CORPORATION'S CREDENTIALING STANDARDS.
Sec. 1753.05. (A) A HEALTH INSURING CORPORATION MAY USE 1,634
ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A PROVIDER, 1,635
HOWEVER, SUCH ECONOMIC PROFILING SHALL TAKE INTO CONSIDERATION 1,636
THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS. 1,637
(B) FOR AN INITIAL APPLICANT, A HEALTH INSURING 1,639
CORPORATION MAY REQUEST INFORMATION NECESSARY TO PERFORM AN 1,640
37
ECONOMIC PROFILE. IF INFORMATION ON CASE MIX, SEVERITY OF 1,641
ILLNESS, AND AGE OF PATIENTS IS REQUESTED BY A HEALTH INSURING 1,642
CORPORATION AND NOT PRODUCED BY THE APPLICANT, THE HEALTH 1,643
INSURING CORPORATION IS NOT REQUIRED TO TAKE THESE FACTORS INTO 1,644
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PROVIDER. 1,645
(C) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,648
CORPORATION FROM TAKING INTO CONSIDERATION THE QUALITY AND 1,649
APPROPRIATENESS OF CARE PROVIDED BY A PROVIDER WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE PROVIDER. 1,651
Sec. 1753.06. A HEALTH INSURING CORPORATION SHALL NOTIFY A 1,654
PROVIDER SEEKING TO ENTER INTO A PARTICIPATION CONTRACT WITH THE
HEALTH INSURING CORPORATION OF THE STATUS OF THE PROVIDER'S 1,655
APPLICATION WITHIN ONE HUNDRED TWENTY DAYS AFTER THE HEALTH 1,656
INSURING CORPORATION'S RECEIPT OF THE PROVIDER'S COMPLETED 1,657
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY A HEALTH 1,658
INSURING CORPORATION IF, DUE TO EXTENUATING CIRCUMSTANCES, THE 1,659
HEALTH INSURING CORPORATION NEEDS ADDITIONAL TIME TO CONSIDER THE 1,660
APPLICATION AND NOTIFIES THE PROVIDER OF THE REASON FOR THE 1,661
DELAY.
Sec. 1753.07. (A) PRIOR TO ENTERING INTO A PARTICIPATION 1,664
CONTRACT WITH A PROVIDER UNDER SECTION 1751.13 OF THE REVISED 1,665
CODE, A HEALTH INSURING CORPORATION SHALL DISCLOSE BASIC 1,666
INFORMATION REGARDING ITS PROGRAMS AND PROCEDURES TO THE 1,667
PROVIDER, UPON THE PROVIDER'S REQUEST. THE INFORMATION SHALL 1,668
INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PARTICIPATING PROVIDER IS REIMBURSED FOR THE 1,670
PARTICIPATING PROVIDER'S SERVICES, INCLUDING THE RANGE AND 1,672
STRUCTURE OF ANY FINANCIAL RISK SHARING ARRANGEMENTS, A 1,673
DESCRIPTION OF ANY INCENTIVE PLANS, AND, IF REIMBURSED ACCORDING 1,674
TO A TYPE OF FEE-FOR-SERVICE ARRANGEMENT, THE LEVEL OF 1,675
REIMBURSEMENT FOR THE PARTICIPATING PROVIDER'S SERVICES; 1,676
(2) HOW REFERRALS TO OTHER PARTICIPATING PROVIDERS OR TO 1,678
NONPARTICIPATING PROVIDERS ARE MADE; 1,679
(3) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND 1,681
38
THE POTENTIAL FOR COST TO BE INCURRED; 1,682
(4) HOW A PARTICIPATING PROVIDER'S NAME AND ADDRESS WILL 1,684
BE USED IN MARKETING MATERIALS. 1,685
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE ALL OF THE 1,688
FOLLOWING TO A PARTICIPATING PROVIDER:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE 1,690
PARTICIPATION CONTRACT, THAT IS NOT OTHERWISE AVAILABLE AS A 1,691
PUBLIC RECORD, IF SUCH MATERIAL AFFECTS THE PARTICIPATING 1,692
PROVIDER;
(2) ADMINISTRATIVE MANUALS RELATED TO PROVIDER 1,694
PARTICIPATION, IF ANY; 1,695
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION 1,697
CONTRACT. 1,698
Sec. 1753.08. (A) A HEALTH INSURING CORPORATION SHALL 1,700
NOTIFY A PARTICIPATING PROVIDER PRIOR TO THE EFFECTIVE DATE OF AN 1,702
AMENDMENT TO THE PARTICIPATING PROVIDER'S CONTRACT WITH THE 1,704
HEALTH INSURING CORPORATION, AND PRIOR TO THE EFFECTIVE DATE OF
AN AMENDMENT TO ANY DOCUMENT INCORPORATED BY REFERENCE INTO THE 1,706
CONTRACT IF THE AMENDMENT OF THE DOCUMENT DIRECTLY AND MATERIALLY 1,707
AFFECTS THE PARTICIPATING PROVIDER. SUCH AMENDMENTS SHALL NOT BE 1,709
EFFECTIVE WITH REGARD TO A PARTICIPATING PROVIDER UNTIL THE 1,710
PARTICIPATING PROVIDER HAS HAD REASONABLE TIME, AS DEFINED IN THE 1,711
CONTRACT, TO EXERCISE THE PARTICIPATING PROVIDER'S RIGHT TO 1,712
TERMINATE ITS PARTICIPATION STATUS IN ACCORDANCE WITH THE TERMS 1,713
AND CONDITIONS OF THE CONTRACT. 1,714
(B) DIVISION (A) OF THIS SECTION DOES NOT APPLY IF THE 1,717
DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD RESULT IN 1,718
IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS REQUIRED BY 1,719
STATE OR FEDERAL LAW, RULE, OR REGULATION. 1,720
Sec. 1753.09. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF 1,723
THIS SECTION, PRIOR TO TERMINATING THE PARTICIPATION OF A 1,724
PROVIDER ON THE BASIS OF THE PARTICIPATING PROVIDER'S FAILURE TO 1,725
MEET THE HEALTH INSURING CORPORATION'S STANDARDS FOR QUALITY OR 1,726
UTILIZATION IN THE DELIVERY OF HEALTH CARE SERVICES, A HEALTH 1,728
39
INSURING CORPORATION SHALL GIVE THE PARTICIPATING PROVIDER NOTICE 1,729
OF THE REASON OR REASONS FOR ITS DECISION TO TERMINATE THE 1,730
PROVIDER'S PARTICIPATION AND AN OPPORTUNITY TO TAKE CORRECTIVE 1,731
ACTION. THE HEALTH INSURING CORPORATION SHALL DEVELOP A 1,732
PERFORMANCE IMPROVEMENT PLAN IN CONJUNCTION WITH THE
PARTICIPATING PROVIDER. IF AFTER BEING AFFORDED THE OPPORTUNITY 1,733
TO COMPLY WITH THE PERFORMANCE IMPROVEMENT PLAN, THE 1,734
PARTICIPATING PROVIDER FAILS TO DO SO, THE HEALTH INSURING 1,735
CORPORATION MAY TERMINATE THE PARTICIPATION OF THE PROVIDER. 1,736
(B)(1) A PARTICIPATING PROVIDER WHOSE PARTICIPATION HAS 1,738
BEEN TERMINATED UNDER DIVISION (A) OF THIS SECTION MAY APPEAL THE 1,741
TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE HEALTH 1,742
INSURING CORPORATION. THE MEDICAL DIRECTOR SHALL GIVE THE 1,743
PARTICIPATING PROVIDER AN OPPORTUNITY TO DISCUSS WITH THE MEDICAL 1,744
DIRECTOR THE REASON OR REASONS FOR THE TERMINATION.
(2) IF A SATISFACTORY RESOLUTION OF A PARTICIPATING 1,746
PROVIDER'S APPEAL CANNOT BE REACHED UNDER DIVISION (B)(1) OF THIS 1,748
SECTION, THE PARTICIPATING PROVIDER MAY APPEAL THE TERMINATION TO 1,749
A PANEL COMPOSED OF PARTICIPATING PROVIDERS WHO HAVE COMPARABLE 1,751
OR HIGHER LEVELS OF EDUCATION AND TRAINING THAN THE PARTICIPATING 1,752
PROVIDER MAKING THE APPEAL. A REPRESENTATIVE OF THE 1,753
PARTICIPATING PROVIDER'S SPECIALTY SHALL BE A MEMBER OF THE 1,754
PANEL, IF POSSIBLE. THIS PANEL SHALL HOLD A HEARING, AND SHALL 1,755
RENDER ITS RECOMMENDATION IN THE APPEAL WITHIN THIRTY DAYS AFTER 1,756
HOLDING THE HEARING. THE RECOMMENDATION SHALL BE PRESENTED TO 1,757
THE MEDICAL DIRECTOR AND TO THE PARTICIPATING PROVIDER. 1,758
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE 1,760
PANEL'S RECOMMENDATION BEFORE MAKING A DECISION. THE DECISION 1,761
RENDERED BY THE MEDICAL DIRECTOR SHALL BE FINAL. 1,762
(C) A PROVIDER'S STATUS AS A PARTICIPATING PROVIDER SHALL 1,765
REMAIN IN EFFECT DURING THE APPEAL PROCESS SET FORTH IN DIVISION 1,767
(B) OF THIS SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF 1,768
THE REASONS LISTED IN DIVISION (D) OF THIS SECTION. 1,770
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A 1,772
40
PROVIDER'S PARTICIPATION MAY BE IMMEDIATELY TERMINATED IF THE 1,774
PARTICIPATING PROVIDER'S CONDUCT PRESENTS AN IMMINENT RISK OF 1,775
HARM TO AN ENROLLEE OR ENROLLEES; OR IF THERE HAS OCCURRED 1,776
UNACCEPTABLE QUALITY OF CARE, FRAUD, PATIENT ABUSE, LOSS OF 1,777
CLINICAL PRIVILEGES, LOSS OF PROFESSIONAL LIABILITY COVERAGE, 1,778
INCOMPETENCE, OR LOSS OF AUTHORITY TO PRACTICE IN THE 1,779
PARTICIPATING PROVIDER'S FIELD; OR IF A GOVERNMENTAL ACTION HAS 1,780
IMPAIRED THE PARTICIPATING PROVIDER'S ABILITY TO PRACTICE. 1,781
(E) DIVISIONS (A) TO (D) OF THIS SECTION APPLY ONLY TO 1,784
PROVIDERS WHO ARE NATURAL PERSONS.
(F)(1) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,787
CORPORATION FROM REJECTING A PROVIDER'S APPLICATION FOR 1,788
PARTICIPATION, OR FROM TERMINATING A PARTICIPATING PROVIDER'S 1,789
CONTRACT, IF THE HEALTH INSURING CORPORATION DETERMINES THAT THE 1,790
HEALTH CARE NEEDS OF ITS ENROLLEES ARE BEING MET AND NO NEED 1,791
EXISTS FOR THE PROVIDER'S OR PARTICIPATING PROVIDER'S SERVICES. 1,792
(2) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 1,794
PROHIBITING A HEALTH INSURING CORPORATION FROM TERMINATING A 1,795
PARTICIPATING PROVIDER WHO DOES NOT MEET THE TERMS AND CONDITIONS 1,797
OF THE PARTICIPATING PROVIDER'S CONTRACT.
(G) THE SUPERINTENDENT OF INSURANCE MAY ADOPT RULES AS 1,800
NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF 1,801
THE REVISED CODE. SUCH RULES SHALL BE ADOPTED IN ACCORDANCE WITH 1,803
CHAPTER 119. OF THE REVISED CODE. THE DIRECTOR OF HEALTH MAY 1,807
MAKE RECOMMENDATIONS TO THE SUPERINTENDENT FOR RULES NECESSARY TO 1,808
IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF THE REVISED 1,809
CODE. IN ADOPTING ANY RULES PURSUANT TO THIS DIVISION, THE 1,811
SUPERINTENDENT SHALL CONSIDER THE RECOMMENDATIONS OF THE 1,812
DIRECTOR.
Sec. 1753.10. NOTHING IN THIS CHAPTER OR CHAPTER 1751. OF 1,815
THE REVISED CODE REQUIRES A HEALTH INSURING CORPORATION TO EMPLOY 1,818
OR CONTRACT WITH, OR PROHIBITS A HEALTH INSURING CORPORATION FROM 1,819
EMPLOYING OR CONTRACTING WITH, ANY CATEGORY OF PROVIDER FOR THE 1,820
PROVISION OF BASIC OR SUPPLEMENTAL HEALTH CARE SERVICES, WHICH 1,821
41
HEALTH CARE SERVICES ARE WITHIN THE RECOGNIZED SCOPE OF PRACTICE 1,822
OF THAT CATEGORY OF PROVIDER. 1,823
Sec. 1753.14. (A) A HEALTH INSURING CORPORATION THAT DOES 1,826
NOT ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL ESTABLISH AND 1,827
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY RECEIVE A STANDING 1,828
REFERRAL TO A SPECIALIST. THE PROCEDURE SHALL PROVIDE FOR A 1,829
STANDING REFERRAL TO A SPECIALIST IF A PRIMARY CARE PROVIDER 1,830
DETERMINES IN CONSULTATION WITH A SPECIALIST THAT AN ENROLLEE 1,831
NEEDS CONTINUING CARE FROM A SPECIALIST. THE REFERRAL SHALL BE 1,832
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,833
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, A 1,834
SPECIALIST, AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE 1,835
NUMBER OF VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT 1,836
THE VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE 1,837
THE PRIMARY CARE PROVIDER WITH REGULAR REPORTS ON THE HEALTH CARE 1,839
PROVIDED TO THE ENROLLEE.
(B) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 1,842
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR 1,843
DISEASE THAT REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED 1,844
PERIOD OF TIME AND IS LIFE-THREATENING, DEGENERATIVE, OR 1,845
DISABLING MAY RECEIVE A REFERRAL TO A SPECIALIST WHO HAS 1,846
EXPERTISE IN TREATING THE CONDITION OR DISEASE FOR THE PURPOSE OF 1,847
HAVING THE SPECIALIST COORDINATE THE ENROLLEE'S HEALTH CARE. THE 1,849
PROCEDURE SHALL PROVIDE FOR SUCH A REFERRAL IF A PRIMARY CARE 1,850
PROVIDER DETERMINES IN CONSULTATION WITH THE SPECIALIST THAT THE 1,851
ENROLLEE NEEDS THE SPECIALIST'S EXPERTISE. THE REFERRAL SHALL BE 1,853
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,855
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, THE 1,856
SPECIALIST, AND THE ENROLLEE. AFTER THE REFERRAL IS MADE, THE 1,857
SPECIALIST IS AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE 1,858
ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE 1,859
PROVIDER, SUBJECT TO THE TERMS OF THE TREATMENT PLAN. 1,860
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS (A) AND (B) 1,864
OF THIS SECTION SHALL BE MADE WITHIN THREE BUSINESS DAYS AFTER A 1,865
42
REQUEST FOR THE DETERMINATION IS MADE BY THE ENROLLEE OR THE 1,866
ENROLLEE'S PRIMARY CARE PROVIDER AND ALL APPROPRIATE MEDICAL 1,867
RECORDS AND OTHER ITEMS OF INFORMATION NECESSARY TO MAKE THE 1,868
DETERMINATION HAVE BEEN PROVIDED. 1,869
(D) ONCE A DETERMINATION IN FAVOR OF A REFERRAL IS MADE, 1,871
THE REFERRAL SHALL BE MADE WITHIN FOUR BUSINESS DAYS AFTER THE 1,873
DETERMINATION. THIS TIME PERIOD DOES NOT APPLY TO STANDING 1,874
REFERRALS INVOLVING A RARE OR UNUSUAL CONDITION FOR WHICH 1,875
APPROPRIATE SPECIALISTS ARE LIMITED IN NUMBER OR OTHERWISE 1,876
DIFFICULT TO IDENTIFY. 1,877
DIVISIONS (A) AND (B) OF THIS SECTION DO NOT REQUIRE A 1,881
HEALTH INSURING CORPORATION TO PERMIT AN ENROLLEE TO ELECT 1,882
REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER CONTRACT 1,883
WITH THE HEALTH INSURING CORPORATION FOR THE PROVISION OF HEALTH 1,884
CARE SERVICES TO THE HEALTH INSURING CORPORATION'S ENROLLEES. 1,885
Sec. 1753.16. A HEALTH INSURING CORPORATION OR UTILIZATION 1,888
REVIEW ORGANIZATION THAT AUTHORIZES A PROPOSED ADMISSION, 1,889
TREATMENT, OR HEALTH CARE SERVICE BY A PARTICIPATING PROVIDER
BASED UPON THE COMPLETE AND ACCURATE SUBMISSION OF ALL NECESSARY 1,890
INFORMATION RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT 1,891
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PROVIDER RENDERS THE 1,892
HEALTH CARE SERVICE IN GOOD FAITH AND PURSUANT TO THE 1,893
AUTHORIZATION AND ALL OF THE TERMS AND CONDITIONS OF THE 1,894
PROVIDER'S CONTRACT WITH THE HEALTH INSURING CORPORATION. 1,895
Sec. 1753.21. (A) IF A POLICY, CONTRACT, OR AGREEMENT OF 1,897
A HEALTH INSURING CORPORATION USES A RESTRICTED FORMULARY OF 1,900
PRESCRIPTION DRUGS, THE HEALTH INSURING CORPORATION SHALL DO BOTH 1,901
OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND WITH 1,904
THE APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY 1,905
OF THE MEMBERS OF WHICH ARE PHYSICIANS AFFILIATED WITH THE HEALTH 1,906
INSURING CORPORATION WHO MAY PRESCRIBE PRESCRIPTION DRUGS AND 1,907
PHARMACISTS AFFILIATED WITH THE HEALTH INSURING CORPORATION; OR 1,908
IN CONSULTATION WITH AND WITH THE APPROVAL OF A PHARMACY AND 1,909
43
THERAPEUTICS COMMITTEE THAT IS INDEPENDENT OF THE HEALTH INSURING 1,910
CORPORATION CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE 1,911
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS 1,912
WHO ARE AUTHORIZED TO PRACTICE IN THEIR STATE OF LICENSURE; 1,914
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, 1,917
WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED 1,918
FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH 1,919
INSURING CORPORATION, COVERAGE OF A SPECIFIC NONFORMULARY DRUG 1,920
WHEN THE PRESCRIBER DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD 1,921
AND CERTIFIES THAT THE FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE 1,922
IN THE TREATMENT OF THE ENROLLEE'S DISEASE OR CONDITION, OR THAT 1,923
THE FORMULARY ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE 1,924
PRESCRIBER TO CAUSE A HARMFUL OR ADVERSE REACTION IN THE 1,925
ENROLLEE.
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 1,928
A HEALTH INSURING CORPORATION TO PLACE ANY PARTICULAR 1,929
PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT ON ANY 1,930
FORMULARY, OR TO PROHIBIT A HEALTH INSURING CORPORATION FROM 1,931
RESTRICTING PAYMENTS FOR ANY SPECIFIC PHARMACEUTICAL PRODUCT OR 1,932
THERAPEUTIC CLASS OF PRODUCT, INCLUDING, BUT NOT LIMITED TO, A 1,933
REQUIREMENT THAT THE PRODUCT BE PRESCRIBED ONLY BY A DEFINED 1,934
SPECIALIST OR SUBSPECIALIST.
Sec. 1753.23. A HEALTH INSURING CORPORATION THAT PROVIDES 1,937
BASIC HEALTH CARE SERVICES SHALL ESTABLISH OR USE AN INTERNAL
TECHNOLOGY ASSESSMENT PROCESS FOR ASSESSING WHETHER A DRUG, 1,939
DEVICE, PROTOCOL, PROCEDURE, OR OTHER THERAPY IS PROVEN TO BE 1,940
SAFE AND EFFICACIOUS FOR A PARTICULAR INDICATION OR CONDITION 1,941
WHEN COMPARED TO ALTERNATIVE THERAPIES, OR WHETHER IT REMAINS 1,942
EXPERIMENTAL OR INVESTIGATIONAL. THE HEALTH INSURING 1,943
CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT PROCESS SHALL MEET 1,944
ALL OF THE FOLLOWING CRITERIA:
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING 1,947
PHYSICIANS.
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL 1,950
44
EVIDENCE, INCLUDING THE FOLLOWING, IF AVAILABLE: 1,951
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE 1,954
SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT 1,956
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS 1,958
THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER INSTITUTE, 1,959
THE UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,961
FINANCE ADMINISTRATION, AND THE AGENCY FOR HEALTH CARE POLICY AND 1,962
RESEARCH; 1,963
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED 1,965
SPECIALTY SOCIETIES. 1,966
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS 1,969
PROCESS, THAT EXCLUDE DRUGS, DEVICES, PROTOCOLS, PROCEDURES, OR 1,970
OTHER THERAPIES ON THE BASIS THAT THEY ARE NOT SAFE OR 1,971
EFFICACIOUS AND REMAIN EXPERIMENTAL OR INVESTIGATIONAL, ARE 1,972
REVIEWED AND UPDATED AS NEW SCIENTIFIC EVIDENCE BECOMES 1,973
AVAILABLE.
(D) A DESCRIPTION OF THE HEALTH INSURING CORPORATION'S 1,976
INTERNAL TECHNOLOGY ASSESSMENT PROCESS IS MADE AVAILABLE TO 1,977
PARTICIPATING PROVIDERS AND ENROLLEES, UPON REQUEST. 1,978
(E) A COPY OF THE HEALTH INSURING CORPORATION'S SPECIFIC 1,981
COVERAGE PROTOCOLS AND PROCEDURES IS MADE AVAILABLE TO 1,982
PARTICIPATING PROVIDERS AND ENROLLEES UPON THE REQUEST OF AN 1,983
ENROLLEE WHO HAS BEEN DENIED COVERAGE FOR A DRUG, DEVICE, 1,984
PROTOCOL, PROCEDURE, OR OTHER THERAPY ON THE BASIS THAT IT HAS 1,985
BEEN ASSESSED AS NOT BEING SAFE OR EFFICACIOUS FOR A PARTICULAR 1,986
INDICATION OR CONDITION. SPECIFIC COVERAGE PROTOCOLS AND 1,987
PROCEDURES SHALL INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH 1,988
THE PROTOCOL OR PROCEDURE IS BASED, AND SHALL CONTAIN THE DATE 1,989
THE PROTOCOL OR PROCEDURE WAS ADOPTED. 1,990
Sec. 1753.24. (A) EACH HEALTH INSURING CORPORATION SHALL 1,992
ESTABLISH A REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO 1,994
EXAMINE THE HEALTH INSURING CORPORATION'S COVERAGE DECISIONS FOR 1,996
ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
45
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING 1,998
TO THE CURRENT DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH 1,999
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 2,000
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE 2,002
HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION 2,003
AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,004
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,006
IMPROVING THE CONDITION OF THE ENROLLEE; 2,008
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,011
THE ENROLLEE;
(c) THERE IS NO STANDARD THERAPY COVERED BY THE HEALTH 2,014
INSURING CORPORATION THAT IS MORE BENEFICIAL THAN THERAPY 2,015
DESCRIBED IN DIVISION (A)(3) OF THIS SECTION. 2,016
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,018
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,019
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE, IN 2,020
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR, THE 2,022
ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,023
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,024
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE HEALTH 2,026
INSURING CORPORATION FOR A DRUG, DEVICE, PROCEDURE, OR OTHER 2,029
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,030
THIS SECTION, AND HAS EXHAUSTED ALL INTERNAL APPEALS.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, 2,032
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 2,034
SECTION, WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT FOR THE 2,036
HEALTH INSURING CORPORATION'S DETERMINATION THAT THE DRUG,
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,038
INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,040
BY A HEALTH INSURING CORPORATION SHALL MEET ALL OF THE FOLLOWING 2,041
CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 2,043
46
THE PROCESS SHALL OFFER ALL ENROLLEES WHO MEET THE CRITERIA SET 2,044
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,046
HEALTH INSURING CORPORATION'S DECISION TO DENY COVERAGE OF THE 2,047
RECOMMENDED OR REQUESTED THERAPY REVIEWED UNDER THE PROCESS. 2,048
EACH ELIGIBLE ENROLLEE SHALL BE NOTIFIED OF THAT OPPORTUNITY 2,049
WITHIN FIVE BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION 2,050
DENIES COVERAGE.
(2) THE REVIEW OF THE HEALTH INSURING CORPORATION'S 2,052
DECISION SHALL BE CONDUCTED BY EXPERTS SELECTED BY AN INDEPENDENT 2,053
ENTITY THAT HAS BEEN RETAINED BY THE HEALTH INSURING CORPORATION 2,054
FOR THIS PURPOSE. THE INDEPENDENT ENTITY SHALL BE EITHER AN 2,055
ACADEMIC MEDICAL CENTER OR AN ENTITY THAT HAS AS ITS PRIMARY 2,056
FUNCTION, AND THAT RECEIVES A MAJORITY OF ITS REVENUE FROM, THE 2,057
PROVISION OF EXPERT REVIEWS AND RELATED SERVICES. 2,058
THE INDEPENDENT ENTITY SHALL SELECT A PANEL TO CONDUCT THE 2,061
REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST THREE 2,062
PHYSICIANS OR OTHER PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF 2,063
THE ENROLLEE'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,064
RECOMMENDED OR REQUESTED THERAPY. IF THE INDEPENDENT ENTITY 2,065
RETAINED BY THE HEALTH INSURING CORPORATION IS AN ACADEMIC 2,067
MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS AFFILIATED WITH OR 2,068
EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,069
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,072
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,073
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,074
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,077
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN ENROLLEE HAS 2,078
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL; 2,079
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,082
OR OTHER PROVIDER IF ONLY ONE EXPERT PHYSICIAN OR OTHER PROVIDER 2,083
IS AVAILABLE FOR THE REVIEW.
(3) NEITHER THE HEALTH INSURING CORPORATION NOR THE 2,085
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE PHYSICIAN OR 2,087
47
OTHER PROVIDER EXPERTS.
(4) NEITHER THE EXPERTS NOR THE INDEPENDENT ENTITY 2,089
ARRANGING FOR THE EXPERTS' REVIEW SHALL HAVE ANY PROFESSIONAL, 2,090
FAMILIAL, OR FINANCIAL AFFILIATION WITH THE HEALTH INSURING 2,092
CORPORATION, EXCEPT THAT EXPERTS AFFILIATED WITH ACADEMIC MEDICAL 2,093
CENTERS WHO PROVIDE HEALTHCARE SERVICES TO ENROLLEES OF THE 2,094
HEALTH INSURING CORPORATION MAY SERVE AS EXPERTS ON THE REVIEW 2,095
PANEL. THIS NONAFFILIATION PROVISION DOES NOT PRECLUDE A HEALTH 2,097
INSURING CORPORATION FROM PAYING FOR THE EXPERTS' REVIEW, AS
SPECIFIED IN DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL 2,099
HAVE NO PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH 2,100
AN ENROLLEE WHOSE REQUEST FOR THERAPY IS UNDER REVIEW OR WITH A 2,101
PROVIDER WHOSE RECOMMENDATION FOR THERAPY IS UNDER REVIEW. 2,102
(5) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE 2,104
EXTERNAL, INDEPENDENT REVIEW. THE COSTS OF THE REVIEW SHALL BE 2,105
BORNE BY THE HEALTH INSURING CORPORATION. 2,106
(6) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE 2,108
INDEPENDENT ENTITY ARRANGING FOR THE EXPERTS' REVIEW AND TO THE 2,110
ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE MEDICAL 2,111
RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION THAT ARE
RELEVANT TO THE ENROLLEE'S CONDITION FOR WHICH THERAPY HAS BEEN 2,114
RECOMMENDED OR REQUESTED. THE MEDICAL RECORDS SHALL BE DISCLOSED 2,115
SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE 2,116
PURPOSE OF THIS SECTION. 2,117
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL SHALL BE 2,119
RENDERED WITHIN THIRTY DAYS AFTER THE ENROLLEE'S REQUEST FOR 2,121
REVIEW. IF THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY 2,123
WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, 2,124
THE OPINIONS SHALL BE RENDERED WITHIN SEVEN DAYS AFTER THE
ENROLLEE'S REQUEST FOR REVIEW. 2,125
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,127
ENTITY WITH A PROFESSIONAL OPINION AS TO WHETHER THERE IS 2,128
SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED OR 2,129
REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE 2,130
48
THAN STANDARD THERAPIES. 2,131
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,133
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,135
(a) A DESCRIPTION OF THE ENROLLEE'S CONDITION; 2,137
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,139
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,140
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,142
TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES; 2,143
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,145
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,146
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,147
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE 2,149
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,150
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,152
(10) THE INDEPENDENT ENTITY SHALL PROVIDE THE HEALTH 2,154
INSURING CORPORATION WITH THE OPINIONS OF THE EXPERTS. THE 2,156
HEALTH INSURING CORPORATION SHALL MAKE THE EXPERTS' OPINIONS
AVAILABLE TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN, UPON 2,158
REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE 2,160
PANEL, RENDERED PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS 2,161
BINDING ON THE HEALTH INSURING CORPORATION. IF THE OPINIONS OF 2,163
THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO WHETHER THE 2,164
THERAPY SHOULD BE COVERED, THEN THE HEALTH INSURING CORPORATION'S
FINAL DECISION SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A 2,167
MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE 2,168
THERAPY, THE HEALTH INSURING CORPORATION MAY, IN ITS DISCRETION, 2,169
COVER THE THERAPY. HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO 2,170
DIVISION (B)(11) OF THIS SECTION IS SUBJECT TO THE TERMS AND 2,171
CONDITIONS OF THE ENROLLEE'S CONTRACT WITH THE HEALTH INSURING 2,172
CORPORATION.
(12) THE HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 2,174
POLICIES DESCRIBING THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,176
THE HEALTH INSURING CORPORATION SHALL DISCLOSE THE AVAILABILITY 2,177
49
OF THE EXTERNAL, INDEPENDENT REVIEW PROCESS IN THE HEALTH 2,178
INSURING CORPORATION'S EVIDENCE OF COVERAGE AND DISCLOSURE FORMS. 2,180
(C) IF A HEALTH INSURING CORPORATION'S INITIAL DENIAL OF 2,182
COVERAGE FOR A THERAPY RECOMMENDED OR REQUESTED PURSUANT TO 2,183
DIVISION (A)(3) OF THIS SECTION IS BASED UPON AN EXTERNAL, 2,184
INDEPENDENT REVIEW OF THAT THERAPY MEETING THE REQUIREMENTS OF 2,185
DIVISION (B) OF THIS SECTION, THIS SECTION SHALL NOT BE A BASIS 2,187
FOR REQUIRING A SECOND EXTERNAL, INDEPENDENT REVIEW OF THE
RECOMMENDED OR REQUESTED THERAPY. 2,188
(D) THE HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A 2,190
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS 2,191
COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION. 2,192
Sec. 1753.28. (A) AS USED IN THIS SECTION: 2,194
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 2,196
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 2,197
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 2,198
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 2,199
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 2,200
RESULT IN ANY OF THE FOLLOWING: 2,201
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,204
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,205
IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,208
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,211
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 2,213
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 2,216
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 2,217
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 2,218
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 2,219
MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 2,222
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 2,223
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 2,224
50
BURN CENTER OF THE HOSPITAL. 2,225
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH MEDICAL 2,228
TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE 2,229
MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF AN 2,230
INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR OCCUR 2,231
DURING A TRANSFER, IF THE MEDICAL CONDITION COULD RESULT IN ANY 2,232
OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,235
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,236
IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,239
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,242
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS, 2,244
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO 2,245
DELIVER, INCLUDING THE PLACENTA. 2,246
(4) "TRANSFER" HAS THE SAME MEANING AS IN SECTION 1867 OF 2,248
THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,250
1395dd, AS AMENDED.
(B) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,252
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,254
COVER EMERGENCY SERVICES FOR ENROLLEES WITH EMERGENCY MEDICAL 2,255
CONDITIONS WITHOUT REGARD TO THE DAY OR TIME THE EMERGENCY 2,256
SERVICES ARE RENDERED OR TO WHETHER THE ENROLLEE, THE HOSPITAL'S 2,257
EMERGENCY DEPARTMENT WHERE THE SERVICES ARE RENDERED, OR AN 2,258
EMERGENCY PHYSICIAN TREATING THE ENROLLEE, OBTAINED PRIOR 2,259
AUTHORIZATION FOR THE EMERGENCY SERVICES.
(C) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,261
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,263
COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,265
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,266
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION; 2,267
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,269
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,271
51
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION AND ONE OF THE 2,272
FOLLOWING CIRCUMSTANCES APPLIES: 2,273
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, 2,276
THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR HEALTH. 2,278
(b) A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 2,281
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 2,282
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 2,283
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 2,284
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 2,285
THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH INSURING CORPORATION 2,287
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT 2,288
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT. 2,289
(d) AN AMBULANCE TAKES THE ENROLLEE TO A NONPARTICIPATING 2,291
HOSPITAL OTHER THAN AT THE DIRECTION OF THE ENROLLEE. 2,292
(e) THE ENROLLEE IS UNCONSCIOUS. 2,294
(f) A NATURAL DISASTER PRECLUDED THE USE OF A 2,296
PARTICIPATING EMERGENCY DEPARTMENT. 2,297
(g) THE STATUS OF A HOSPITAL CHANGED FROM PARTICIPATING TO 2,299
NONPARTICIPATING WITH RESPECT TO EMERGENCY SERVICES DURING A 2,300
CONTRACT YEAR AND NO GOOD FAITH EFFORT WAS MADE BY THE HEALTH 2,301
INSURING CORPORATION TO INFORM ENROLLEES OF THIS CHANGE. 2,302
(D) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 2,305
FOR EMERGENCY SERVICES SHALL INFORM ENROLLEES OF ALL OF THE 2,306
FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 2,308
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 2,311
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 2,312
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 2,313
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES; 2,315
(4) THE PROCEDURES FOR OBTAINING EMERGENCY SERVICES AND 2,317
OTHER MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE 2,318
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS 2,319
52
AND WITH THE LOCATION AND AVAILABILITY OF OTHER PARTICIPATING 2,320
FACILITIES OR SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL 2,321
SERVICES.
Sec. 1753.30. NOTHING IN THIS CHAPTER SHALL PREVENT OR 2,323
OTHERWISE AFFECT THE APPLICATION TO ANY HEALTH CARE PLAN OF THOSE 2,324
PROVISIONS OF TITLE XVII OR XXXIX OF THE REVISED CODE THAT WOULD 2,326
OTHERWISE APPLY.
Sec. 3901.04. (A) As used in this section: 2,335
(1) "Laws of this state relating to insurance" include but 2,337
are not limited to Chapter 1751. notwithstanding section 1751.08, 2,339
CHAPTER 1753., Title XXXIX, sections 5725.18 to 5725.25, and 2,340
Chapter 5729. of the Revised Code. 2,341
(2) "Person" has the meaning defined in division (A) of 2,343
section 3901.19 of the Revised Code. 2,344
(B) Whenever it appears to the superintendent of 2,346
insurance, from the superintendent's files, upon complaint or 2,348
otherwise, that any person has engaged in, is engaged in, or is
about to engage in any act or practice declared to be illegal or 2,349
prohibited by the laws of this state relating to insurance, or 2,350
defined as unfair or deceptive by such laws, or when the 2,351
superintendent believes it to be in the best interest of the 2,352
public and necessary for the protection of the people in this 2,353
state, the superintendent or anyone designated by the 2,354
superintendent under the superintendent's official seal may do 2,355
any one or more of the following:
(1) Require any person to file with the superintendent, on 2,357
a form that is appropriate for review by the superintendent, an 2,358
original or additional statement or report in writing, under oath 2,359
or otherwise, as to any facts or circumstances concerning the 2,360
person's conduct of the business of insurance within this state 2,361
and as to any other information that the superintendent considers 2,362
to be material or relevant to such business; 2,363
(2) Administer oaths, summon and compel by order or 2,365
subpoena the attendance of witnesses to testify in relation to 2,366
53
any matter which, by the laws of this state relating to 2,367
insurance, is the subject of inquiry and investigation, and 2,368
require the production of any book, paper, or document pertaining 2,369
to such matter. A subpoena, notice, or order under this section 2,370
may be served by certified mail, return receipt requested. If 2,371
the subpoena, notice, or order is returned because of inability 2,372
to deliver, or if no return is received within thirty days of the 2,373
date of mailing, the subpoena, notice, or order may be served by 2,374
ordinary mail. If no return of ordinary mail is received within 2,375
thirty days after the date of mailing, service shall be deemed to 2,376
have been made. If the subpoena, notice, or order is returned 2,377
because of inability to deliver, the superintendent may designate 2,378
a person or persons to effect either personal or residence 2,379
service upon the witness. Service of any subpoena, notice, or 2,380
order and return may also be made in any manner authorized under 2,381
the Rules of Civil Procedure. Such service shall be made by an 2,382
employee of the department designated by the superintendent, a 2,383
sheriff, a deputy sheriff, an attorney, or any person authorized 2,384
by the Rules of Civil Procedure to serve process. 2,385
In the case of disobedience of any notice, order, or 2,387
subpoena served on a person or the refusal of a witness to 2,388
testify to a matter regarding which the person may lawfully be 2,390
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 2,391
obedience by attachment proceedings for contempt, as in the case 2,392
of disobedience of the requirements of a subpoena issued from 2,393
such court, or a refusal to testify therein. Witnesses shall 2,394
receive the fees and mileage allowed by section 2335.06 of the 2,395
Revised Code. All such fees, upon the presentation of proper 2,396
vouchers approved by the superintendent, shall be paid out of the 2,397
appropriation for the contingent fund of the department of 2,398
insurance. The fees and mileage of witnesses not summoned by the 2,399
superintendent or the superintendent's designee shall not be paid 2,401
by the state.
54
(3) In a case in which there is no administrative 2,403
procedure available to the superintendent to resolve a matter at 2,404
issue, request the attorney general to commence an action for a 2,405
declaratory judgment under Chapter 2721. of the Revised Code with 2,406
respect to the matter. 2,407
(4) Initiate criminal proceedings by presenting evidence 2,409
of the commission of any criminal offense established under the 2,410
laws of this state relating to insurance to the prosecuting 2,411
attorney of any county in which the offense may be prosecuted. 2,412
At the request of the prosecuting attorney, the attorney general 2,413
may assist in the prosecution of the violation with all the 2,414
rights, privileges, and powers conferred by law on prosecuting 2,415
attorneys including, but not limited to, the power to appear 2,416
before grand juries and to interrogate witnesses before grand 2,417
juries. 2,418
Sec. 3901.041. The superintendent of insurance shall 2,428
adopt, amend, and rescind rules and make adjudications, necessary 2,429
to discharge the superintendent's duties and exercise the 2,430
superintendent's powers, including, but not limited to, the 2,431
superintendent's duties and powers under Chapter CHAPTERS 1751. 2,433
AND 1753. and Title XXXIX of the Revised Code, subject to Chapter 2,434
119. of the Revised Code.
Sec. 3901.16. Any association, company, or corporation, 2,444
including a health insuring corporation, which violates any law 2,445
relating to the superintendent of insurance, any provision of 2,446
Chapter 1751. OR 1753. of the Revised Code, or any insurance law 2,448
of this state, for the violation of which no forfeiture or 2,449
penalty is elsewhere provided in the Revised Code, shall forfeit 2,450
and pay not less than one thousand nor more than ten thousand 2,451
dollars, to be recovered by an action in the name of the state 2,452
and on collection to be paid to the superintendent, who shall pay
such sum into the state treasury. 2,453
Sec. 3924.10. (A) The board of directors of the Ohio 2,463
health reinsurance program shall design the SEHC plan which, when 2,465
55
offered by a carrier, is eligible for reinsurance under the 2,466
program. The board shall establish the form and level of 2,467
coverage to be made available by carriers in their SEHC plan. In 2,468
designing the plan the board shall also establish benefit levels, 2,469
deductibles, coinsurance factors, exclusions, and limitations for 2,470
the plan. The forms and levels of coverage established by the 2,471
board shall specify which components of a health benefit plan 2,472
offered by a carrier may be reinsured. The SEHC plan is subject 2,473
to division (C) of section 3924.02 of the Revised Code and to the 2,475
provisions in Chapters 1751., 1753., 3923., and any other chapter 2,477
of the Revised Code that require coverage or the offer of 2,478
coverage of a health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 2,481
eighty days after its appointment. The plan may include cost 2,482
containment features including any of the following:
(1) Utilization review of health care services, including 2,484
review of the medical necessity of hospital and physician 2,485
services; 2,486
(2) Case management benefit alternatives; 2,488
(3) Selective contracting with hospitals, physicians, and 2,490
other health care providers; 2,491
(4) Reasonable benefit differentials applicable to 2,493
participating and nonparticipating providers; 2,494
(5) Employee assistance program options that provide 2,496
preventive and early intervention mental health and substance 2,497
abuse services; 2,498
(6) Other provisions for the cost-effective management of 2,500
the plan. 2,501
(C) An SEHC plan established for use by health insuring 2,504
corporations shall be consistent with the basic method of 2,506
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 2,508
insurance, in the form and manner prescribed by the 2,509
superintendent, that the SEHC plan filed by the carrier is in 2,511
56
substantial compliance with the provisions of the board SEHC 2,512
plan. Upon receipt by the superintendent of the certification, 2,513
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 2,515
date that the program becomes operational and as a condition of 2,516
transacting business in this state, renew coverage provided to 2,517
any individual or group under its SEHC plan. 2,518
Sec. 4121.121. (A) There is hereby created the bureau of 2,529
workers' compensation, which shall be administered by the 2,530
administrator of workers' compensation. A person appointed to 2,531
the position of administrator shall possess significant 2,532
management experience in effectively managing an organization or 2,533
organizations of substantial size and complexity. The governor 2,534
shall appoint the administrator as provided in section 121.03 of
the Revised Code, and the administrator shall serve at the 2,536
pleasure of the governor. The governor shall fix the
administrator's salary on the basis of the administrator's 2,538
experience and the administrator's responsibilities and duties 2,539
under this chapter and Chapter 4123., 4127., and 4131. of the 2,541
Revised Code. The governor shall not appoint to the position of
administator ADMINISTRATOR any person who has, or whose spouse 2,542
has, given a contribution to the campaign committee of the 2,543
governor in an amount greater than one thousand dollars during 2,544
the two-year period immediately preceding the date of the 2,545
appointment of the administrator. After August 31, 2000, the 2,546
workers' compensation oversight commission shall appoint the 2,547
administrator as provided in division (F)(9) of section 4121.12 2,548
of the Revised Code, and the administrator shall serve at the 2,549
pleasure of the oversight commission. The oversight commission 2,550
shall fix the administrator's salary on the basis of the 2,551
administrator's experience and the administrator's 2,552
responsibilities and duties under this chapter and Chapters 2,553
4123., 4127., and 4131. of the Revised Code. 2,554
The administrator shall hold no other public office and 2,556
57
shall devote full time to the duties of administrator. Before 2,558
entering upon the duties of the office, the administrator shall 2,559
take an oath of office as required by sections 3.22 and 3.23 of 2,560
the Revised Code, and shall file in the office of the secretary 2,561
of state, a bond signed by the administrator and by surety
approved by the governor, for the sum of fifty thousand dollars 2,562
payable to the state, conditioned upon the faithful performance 2,563
of the administrator's duties. 2,564
(B) The administrator is responsible for the management of 2,567
the bureau of workers' compensation and for the discharge of all 2,568
administrative duties imposed upon the administrator in this 2,569
chapter and Chapters 4123., 4127., and 4131. of the Revised Code, 2,570
and in the discharge thereof shall do all of the following: 2,571
(1) Establish the overall administrative policy of the 2,574
bureau for the purposes of this chapter and Chapters 4123.,
4127., and 4131. of the Revised Code, and perform all acts and 2,575
exercise all authorities and powers, discretionary and otherwise 2,577
that are required of or vested in the bureau or any of its 2,578
employees in this chapter and Chapters 4123., 4127., and 4131. of 2,579
the Revised Code, except the acts and the exercise of authority 2,580
and power that is required of and vested in the oversight 2,581
commission or the industrial commission pursuant to those 2,582
chapters. The treasurer of state shall honor all warrants signed 2,583
by the administrator, or by one or more of the administrator's 2,584
employees, authorized by the administrator in writing, or bearing 2,586
the facsimile signature of the administrator or such employee 2,587
under sections 4123.42 and 4123.44 of the Revised Code. 2,588
(2) Employ, direct, and supervise all employees required 2,590
in connection with the performance of the duties assigned to the 2,591
bureau by this chapter and Chapters 4123., 4127., and 4131. of 2,592
the Revised Code, and may establish job classification plans and 2,593
compensation for all employees of the bureau provided that this 2,594
grant of authority shall not be construed as affecting any 2,595
employee for whom the state employment relations board has 2,596
58
established an appropriate bargaining unit under section 4117.06 2,597
of the Revised Code. All positions of employment in the bureau 2,598
are in the classified civil service except those employees the 2,599
administrator may appoint to serve at the administrator's 2,600
pleasure in the unclassified civil service pursuant to section 2,601
124.11 of the Revised Code. The administrator shall fix the 2,602
salaries of employees the administrator appoints to serve at the 2,604
administrator's pleasure, including the chief operating officer, 2,605
staff physicians, and other senior management personnel of the
bureau and shall establish the compensation of staff attorneys of 2,606
the bureau's legal section and their immediate supervisors, and 2,607
take whatever steps are necessary to provide adequate 2,608
compensation for other staff attorneys. 2,609
The administrator may appoint a person holding a certified 2,611
position in the classified service to any state position in the 2,612
unclassified service of the bureau of workers' compensation. A 2,613
person so appointed shall retain the right to resume the position 2,615
and status held by the person in the classified service
immediately prior to the person's appointment in the unclassified 2,617
service. If the position the person previously held has been 2,618
filled or placed in the unclassified service, or is otherwise 2,619
unavailable, the person shall be appointed to a position in the 2,620
classified service within the bureau that the department of 2,621
administrative services certifies is comparable in compensation
to the position the person previously held. Reinstatement to a 2,622
position in the classified service shall be to a position 2,623
substantially equal to that held previously, as certified by the 2,624
department of administrative services. Service in the position 2,625
in the unclassified service shall be counted as service in the 2,627
position in the classified service held by the person immediately 2,628
prior to the person's appointment in the unclassified service. 2,629
when a person is reinstated to a position in the classified 2,630
service as provided in this section, the person is entitled to 2,631
all rights, status, and benefits accruing to the position during 2,632
59
the person's time of service in the position in the unclassified 2,633
service. 2,634
(3) Reorganize the work of the bureau, its sections, 2,636
departments, and offices to the extent necessary to achieve the 2,637
most efficient performance of its functions and to that end may 2,638
establish, change, or abolish positions and assign and reassign 2,639
duties and responsibilities of every employee of the bureau. All 2,640
persons employed by the commission in positions that, after 2,641
November 3, 1989, are supervised and directed by the 2,642
administrator under this section are transferred to the bureau in 2,643
their respective classifications but subject to reassignment and 2,644
reclassification of position and compensation as the 2,645
administrator determines to be in the interest of efficient 2,646
administration. The civil service status of any person employed 2,647
by the commission is not affected by this section. Personnel 2,648
employed by the bureau or the commission who are subject to 2,649
Chapter 4117. of the Revised Code shall retain all of their 2,650
rights and benefits conferred pursuant to that chapter as it 2,651
presently exists or is hereafter amended and nothing in this 2,652
chapter or Chapter 4123. of the Revised Code shall be construed 2,653
as eliminating or interfering with Chapter 4117. of the Revised 2,654
Code or the rights and benefits conferred under that chapter to 2,655
public employees or to any bargaining unit. 2,656
(4) Provide offices, equipment, supplies, and other 2,658
facilities for the bureau. The administrator also shall provide 2,660
suitable office space in the service offices for the district 2,661
hearing officers, the staff hearing officers, and commission 2,662
employees as requested by the commission.
(5) Prepare and submit to the oversight commission 2,664
information the administrator considers pertinent or the 2,665
oversight commission requires, together with the administrator's 2,667
recommendations, in the form of administrative rules, for the 2,668
advice and consent of the oversight commission, for 2,669
classifications of occupations or industries, for premium rates 2,670
60
and contributions, for the amount to be credited to the surplus 2,671
fund, for rules and systems of rating, rate revisions, and merit 2,672
rating. The administrator shall obtain, prepare, and submit any 2,673
other information the oversight commission requires for the 2,675
prompt and efficient discharge of its duties.
(6) Keep the accounts required by division (A) of section 2,677
4123.34 of the Revised Code and all other accounts and records 2,678
necessary to the collection, administration, and distribution of 2,679
the workers' compensation funds and shall obtain the statistical 2,680
and other information required by section 4123.19 of the Revised 2,681
Code. 2,682
(7) Exercise the investment powers vested in the 2,684
administrator by section 4123.44 of the Revised Code in 2,685
accordance with the investment objectives, policies, and criteria 2,687
established by the oversight commission pursuant to section 2,688
4121.12 of the Revised Code. The administrator shall not engage 2,689
in any prohibited investment activity specified by the oversight 2,690
commission pursuant to division (F)(6) of section 4121.12 of the 2,691
Revised Code. All business shall be transacted, all funds 2,692
invested, all warrants for money drawn and payments made, and all 2,693
cash and securities and other property held, in the name of the 2,694
bureau, or in the name of its nominee, provided that nominees are
authorized by the administrator solely for the purpose of 2,696
facilitating the transfer of securities, and restricted to the 2,697
administrator and designated employees. 2,698
(8) Make contracts for and supervise the construction of 2,701
any project or improvement or the construction or repair of 2,702
buildings under the control of the bureau. 2,703
(9) Purchase supplies, materials, equipment, and services; 2,705
make contracts for, operate, and superintend the telephone, other 2,706
telecommunication, and computer services for the use of the 2,707
bureau; and make contracts in connection with office 2,708
reproduction, forms management, printing, and other services. 2,709
NOTWITHSTANDING SECTIONS 125.12 TO 125.14 OF THE REVISED CODE, 2,710
61
THE ADMINISTRATOR MAY TRANSFER SURPLUS COMPUTERS AND COMPUTER
EQUIPMENT DIRECTLY TO AN ACCREDITED PUBLIC SCHOOL WITHIN THE 2,711
STATE. THE COMPUTERS AND COMPUTER EQUIPMENT MAY BE REPAIRED OR 2,712
REFURBISHED PRIOR TO THE TRANSFER. 2,713
(10) Separately from the budget the industrial commission 2,716
submits, prepare and submit to the director of budget and 2,717
management a budget for each biennium. The budget submitted 2,718
shall include estimates of the costs and necessary expenditures 2,719
of the bureau in the discharge of any duty imposed by law as well 2,720
as the costs of furnishing office space to the district hearing 2,721
officers, staff hearing officers, and commission employees under 2,722
division (D) of this section. 2,723
(11) As promptly as possible in the course of efficient 2,725
administration, decentralize and relocate such of the personnel 2,726
and activities of the bureau as is appropriate to the end that 2,727
the receipt, investigation, determination, and payment of claims 2,728
may be undertaken at or near the place of injury or the residence 2,729
of the claimant and for that purpose establish regional offices, 2,730
in such places as the administrator considers proper, capable of 2,732
discharging as many of the functions of the bureau as is 2,733
practicable so as to promote prompt and efficient administration 2,734
in the processing of claims. All active and inactive lost-time 2,735
claims files shall be held at the service office responsible for 2,736
the claim. A claimant, at the claimant's request, shall be 2,737
provided with information by telephone as to the location of the 2,739
file pertaining to claim. The administrator shall ensure that 2,740
all service office employees report directly to the director for 2,741
their service office.
(12) Provide a written binder on new coverage where the 2,743
administrator considers it to be in the best interest of the 2,744
risk. The administrator, or any other person authorized by the 2,745
administrator, shall grant the binder upon submission of a 2,747
request for coverage by the employer. A binder is effective for 2,748
a period of thirty days from date of issuance and is 2,749
62
nonrenewable. Payroll reports and premium charges shall coincide 2,750
with the effective date of the binder. 2,751
(13) Set standards for the reasonable and maximum handling 2,753
time of claims payment functions, ensure, by rules, the impartial 2,754
and prompt treatment of all claims and employer risk accounts, 2,755
and establish a secure, accurate method of time stamping all 2,756
incoming mail and documents hand delivered to bureau employees. 2,757
(14) Ensure that all employees of the bureau follow the 2,759
orders and rules of the commission as such orders and rules 2,760
relate to the commission's overall adjudicatory policy-making and 2,761
management duties under this chapter and Chapters 4123., 4127., 2,762
and 4131. of the Revised Code. 2,763
(15) Manage and operate a data processing system with a 2,765
common data base for the use of both the bureau and the 2,766
commission and, in consultation with the commission, using 2,767
electronic data processing equipment, shall develop a claims 2,768
tracking system that is sufficient to monitor the status of a 2,769
claim at any time and that lists appeals that have been filed and 2,770
orders or determinations that have been issued pursuant to 2,771
section 4123.511 or 4123.512 of the Revised Code, including the 2,772
dates of such filings and issuances. 2,773
(16) Establish and maintain a medical section within the 2,775
bureau. The medical section shall do all of the following: 2,776
(a) Assist the administrator in establishing standard 2,778
medical fees, approving medical procedures, and determining 2,779
eligibility and reasonableness of the compensation payments for 2,780
medical, hospital, and nursing services, and in establishing 2,781
guidelines for payment policies which recognize usual, customary, 2,782
and reasonable methods of payment for covered services; 2,783
(b) Provide a resource to respond to questions from claims 2,785
examiners for employees of the bureau; 2,786
(c) Audit fee bill payments; 2,788
(d) Implement a program to utilize, to the maximum extent 2,790
possible, electronic data processing equipment for storage of 2,791
63
information to facilitate authorizations of compensation payments 2,792
for medical, hospital, drug, and nursing services; 2,793
(e) Perform other duties assigned to it by the 2,795
administrator. 2,796
(17) Appoint, as the administrator determines necessary, 2,798
panels to review and advise the administrator on disputes arising 2,800
over a determination that a health care service or supply 2,801
provided to a claimant is not covered under this chapter or 2,802
Chapter 4123. of the Revised Code or is medically unnecessary. 2,803
If an individual health care provider is involved in the dispute, 2,804
the panel shall consist of individuals licensed pursuant to the 2,805
same section of the Revised Code as such health care provider. 2,806
(18) Pursuant to section 4123.65 of the Revised Code, 2,808
approve applications for the final settlement of claims for 2,809
compensation or benefits under this chapter and Chapters 4123., 2,810
4127., and 4131. of the Revised Code as the administrator 2,811
determines appropriate, except in regard to the applications of 2,813
self-insuring employers and their employees. 2,814
(19) Comply with section 3517.13 of the Revised Code, and 2,816
except in regard to contracts entered into pursuant to the 2,818
authority contained in section 4121.44 of the Revised Code,
comply with the competitive bidding procedures set forth in the 2,820
Revised Code for all contracts into which the administrator 2,821
enters provided that those contracts fall within the type of 2,822
contracts and dollar amounts specified in the Revised Code for 2,823
competitive bidding and further provided that those contracts are
not otherwise specifically exempt from the competitive bidding 2,824
procedures contained in the Revised Code. 2,825
(20) Adopt, with the advice and consent of the oversight 2,827
commission, rules for the operation of the bureau. 2,828
(21) Prepare and submit to the oversight commission 2,830
information the administrator considers pertinent or the 2,831
oversight commission requires, together with the administrator's 2,832
recommendations, in the form of administrative rules, for the 2,833
64
advice and consent of the oversight commission, for the health 2,834
partnership program and the qualified health plan system, as
provided in sections 4121.44, 4121.441, and 4121.442 of the 2,835
Revised Code.
(C) The administrator, with the advice and consent of the 2,837
senate, shall appoint a chief operating officer who has 2,839
significant experience in the field of workers' compensation 2,840
insurance or other similar insurance industry experience if the
administrator does not possess such experience. The chief 2,841
operating officer shall not commence the chief operating 2,842
officer's duties until after the senate consents to the chief 2,843
operating officer's appointment. The chief operating officer 2,844
shall serve in the unclassified civil service of the state. 2,845
Sec. 4123.01. As used in this chapter: 2,854
(A)(1) "Employee" means: 2,856
(a) Every person in the service of the state, or of any 2,858
county, municipal corporation, township, or school district 2,859
therein, including regular members of lawfully constituted police 2,860
and fire departments of municipal corporations and townships, 2,861
whether paid or volunteer, and wherever serving within the state 2,862
or on temporary assignment outside thereof, and executive 2,863
officers of boards of education, under any appointment or 2,864
contract of hire, express or implied, oral or written, including 2,865
any elected official of the state, or of any county, municipal 2,866
corporation, or township, or members of boards of education; 2,867
(b) Every person in the service of any person, firm, or 2,869
private corporation, including any public service corporation, 2,870
that (i) employs one or more persons regularly in the same 2,871
business or in or about the same establishment under any contract 2,872
of hire, express or implied, oral or written, including aliens 2,873
and minors, household workers who earn one hundred sixty dollars 2,874
or more in cash in any calendar quarter from a single household 2,875
and casual workers who earn one hundred sixty dollars or more in 2,876
cash in any calendar quarter from a single employer, or (ii) is 2,877
65
bound by any such contract of hire or by any other written 2,878
contract, to pay into the state insurance fund the premiums 2,879
provided by this chapter. 2,880
(c) Every person who performs labor or provides services 2,883
pursuant to a construction contract, as defined in section 2,884
4123.79 of the Revised Code, if at least ten of the following
criteria apply:
(i) The person is required to comply with instructions 2,887
from the other contracting party regarding the manner or method 2,888
of performing services;
(ii) The person is required by the other contracting party 2,891
to have particular training;
(iii) The person's services are integrated into the 2,894
regular functioning of the other contracting party; 2,895
(iv) The person is required to perform the work 2,897
personally;
(v) The person is hired, supervised, or paid by the other 2,899
contracting party;
(vi) A continuing relationship exists between the person 2,902
and the other contracting party that contemplates continuing or 2,903
recurring work even if the work is not full time; 2,904
(vii) The person's hours of work are established by the 2,907
other contracting party;
(viii) The person is required to devote full time to the 2,910
business of the other contracting party;
(ix) The person is required to perform the work on the 2,913
premises of the other contracting party;
(x) The person is required to follow the order of work set 2,916
by the other contracting party;
(xi) The person is required to make oral or written 2,919
reports of progress to the other contracting party; 2,920
(xii) The person is paid for services on a regular basis 2,923
such as hourly, weekly, or monthly;
(xiii) The person's expenses are paid for by the other 2,925
66
contracting party;
(xiv) The person's tools and materials are furnished by 2,928
the other contracting party;
(xv) The person is provided with the facilities used to 2,930
perform services;
(xvi) The person does not realize a profit or suffer a 2,933
loss as a result of the services provided;
(xvii) The person is not performing services for a number 2,936
of employers at the same time;
(xviii) The person does not make the same services 2,938
available to the general public; 2,939
(xix) The other contracting party has a right to discharge 2,942
the person;
(xx) The person has the right to end the relationship with 2,945
the other contracting party without incurring liability pursuant 2,946
to an employment contract or agreement. 2,947
Every person in the service of any independent contractor 2,949
or subcontractor who has failed to pay into the state insurance 2,950
fund the amount of premium determined and fixed by the 2,951
administrator of workers' compensation for the person's 2,952
employment or occupation or if a self-insuring employer has 2,953
failed to pay compensation and benefits directly to the 2,954
employer's injured and to the dependents of the employer's killed 2,955
employees as required by section 4123.35 of the Revised Code, 2,957
shall be considered as the employee of the person who has entered 2,958
into a contract, whether written or verbal, with such independent 2,959
contractor unless such employees or their legal representatives 2,960
or beneficiaries elect, after injury or death, to regard such 2,961
independent contractor as the employer.
(2) "Employee" does not mean: 2,963
(a) A duly ordained, commissioned, or licensed minister or 2,965
assistant or associate minister of a church in the exercise of 2,966
ministry; or 2,967
(b) Any officer of a family farm corporation. 2,969
67
Any employer may elect to include as an "employee" within 2,971
this chapter, any person excluded from the definition of 2,972
"employee" pursuant to division (A)(2) of this section. If an 2,973
employer is a partnership, sole proprietorship, or family farm 2,974
corporation, such employer may elect to include as an "employee" 2,975
within this chapter, any member of such partnership, the owner of 2,976
the sole proprietorship, or the officers of the family farm 2,977
corporation. In the event of an election, the employer shall 2,978
serve upon the bureau of workers' compensation written notice 2,979
naming the persons to be covered, include such employee's 2,980
remuneration for premium purposes in all future payroll reports, 2,981
and no person excluded from the definition of "employee" pursuant 2,982
to division (A)(2) of this section, proprietor, or partner shall 2,983
be deemed an employee within this division until the employer has 2,984
served such notice. 2,985
For informational purposes only, the bureau shall prescribe 2,987
such language as it considers appropriate, on such of its forms 2,988
as it considers appropriate, to advise employers of their right 2,989
to elect to include as an "employee" within this chapter a sole 2,990
proprietor, any member of a partnership, the officers of a family 2,991
farm corporation, or a person excluded from the definition of 2,992
"employee" under division (A)(2)(a) of this section, that they 2,993
should check any health and disability insurance policy, or other 2,994
form of health and disability plan or contract, presently 2,995
covering them, or the purchase of which they may be considering, 2,996
to determine whether such policy, plan, or contract excludes 2,997
benefits for illness or injury that they might have elected to 2,998
have covered by workers' compensation. 2,999
(B) "Employer" means: 3,001
(1) The state, including state hospitals, each county, 3,003
municipal corporation, township, school district, and hospital 3,004
owned by a political subdivision or subdivisions other than the 3,005
state; 3,006
(2) Every person, firm, and private corporation, including 3,008
68
any public service corporation, that (a) has in service one or 3,009
more employees regularly in the same business or in or about the 3,010
same establishment under any contract of hire, express or 3,011
implied, oral or written, or (b) is bound by any such contract of 3,012
hire or by any other written contract, to pay into the insurance 3,013
fund the premiums provided by this chapter. 3,014
All such employers are subject to this chapter. Any member 3,016
of a firm or association, who regularly performs manual labor in 3,017
or about a mine, factory, or other establishment, including a 3,018
household establishment, shall be considered an employee in 3,019
determining whether such person, firm, or private corporation, or 3,020
public service corporation, has in its service, one or more 3,021
employees and the employer shall report the income derived from 3,022
such labor to the bureau as part of the payroll of such employer, 3,023
and such member shall thereupon be entitled to all the benefits 3,024
of an employee. 3,025
(C) "Injury" includes any injury, whether caused by 3,027
external accidental means or accidental in character and result, 3,028
received in the course of, and arising out of, the injured 3,029
employee's employment. "Injury" does not include: 3,030
(1) Psychiatric conditions except where the conditions 3,032
have arisen from an injury or occupational disease; 3,033
(2) Injury or disability caused primarily by the natural 3,036
deterioration of tissue, an organ, or part of the body; 3,037
(3) Injury or disability incurred in voluntary 3,039
participation in an employer-sponsored recreation or fitness 3,040
activity if the employee signs a waiver of the employee's right 3,041
to compensation or benefits under this chapter prior to engaging 3,042
in the recreation or fitness activity. 3,043
(D) "Child" includes a posthumous child and a child 3,045
legally adopted prior to the injury. 3,046
(E) "Family farm corporation" means a corporation founded 3,048
for the purpose of farming agricultural land in which the 3,049
majority of the voting stock is held by and the majority of the 3,050
69
stockholders are persons or the spouse of persons related to each 3,051
other within the fourth degree of kinship, according to the rules 3,052
of the civil law, and at least one of the related persons is 3,053
residing on or actively operating the farm, and none of whose 3,054
stockholders are a corporation. A family farm corporation does 3,055
not cease to qualify under this division where, by reason of any 3,056
devise, bequest, or the operation of the laws of descent or 3,057
distribution, the ownership of shares of voting stock is 3,058
transferred to another person, as long as that person is within 3,059
the degree of kinship stipulated in this division. 3,060
(F) "Occupational disease" means a disease contracted in 3,062
the course of employment, which by its causes and the 3,063
characteristics of its manifestation or the condition of the 3,064
employment results in a hazard which distinguishes the employment 3,065
in character from employment generally, and the employment
creates a risk of contracting the disease in greater degree and 3,066
in a different manner from the public in general. 3,067
(G) "Self-insuring employer" means any of the following 3,069
categories of employers if granted the privilege of paying 3,070
compensation and benefits directly under section 4123.35 of the 3,071
Revised Code: 3,072
(1) Any employer mentioned in division (B)(2) of this 3,074
section; 3,075
(2) A board of county hospital trustees; 3,077
(3) A publicly owned utility; 3,079
(4) A BOARD OF COUNTY COMMISSIONERS FOR THE SOLE PURPOSE 3,081
OF CONSTRUCTING A SPORTS FACILITY AS DEFINED IN SECTION 307.696 3,082
OF THE REVISED CODE, PROVIDED THAT THE ELECTORS OF THE COUNTY IN 3,083
WHICH THE SPORTS FACILITY IS TO BE BUILT HAVE APPROVED
CONSTRUCTION OF A SPORTS FACILITY BY BALLOT ELECTION NO LATER 3,084
THAN NOVEMBER 6, 1997. 3,085
Sec. 4123.25. (A) No employer shall misrepresent to the 3,095
bureau of workers' compensation the amount of payroll upon which 3,097
the premium under this chapter is based. Whoever violates this 3,098
70
division shall be liable to the state in ten times the amount of 3,100
the difference in premium paid and the amount the employer should 3,102
have paid. The liability to the state under this division shall 3,105
be enforced in a civil action in the name of the state, and all 3,106
sums collected under this division shall be paid into the state 3,107
insurance fund.
(B) No self-insuring employer shall misrepresent the 3,109
amount of paid compensation paid by such employer for purposes of 3,110
the assessments provided under this chapter and Chapter 4121. of 3,111
the Revised Code as required by section 4123.35 of the Revised 3,112
Code. Whoever violates this division is liable to the state in 3,113
an amount assessed by the self-insuring employers evaluation 3,114
board pursuant to division (C) of section 4123.352 of the Revised 3,117
Code or ten times the amount of the difference between the 3,118
assessment paid and the amount of the assessment that should have 3,119
been paid along with any other penalty as determined by the 3,120
board. The liability to the state under this division may be 3,121
enforced in a civil action in the name of the state and all sums 3,122
collected under this division shall be paid into the 3,123
self-insurance assessment fund created pursuant to division 3,125
(J)(K) of section 4123.35 of the Revised Code. 3,126
Sec. 4123.35. (A) Except as provided in this section, 3,138
every employer mentioned in division (B)(2) of section 4123.01 of 3,139
the Revised Code, and every publicly owned utility shall pay 3,140
semiannually in the months of January and July into the state 3,142
insurance fund the amount of annual premium the administrator of 3,143
workers' compensation fixes for the employment or occupation of 3,144
the employer, the amount of which premium to be paid by each 3,145
employer to be determined by the classifications, rules, and 3,146
rates made and published by the administrator. The employer
shall pay semiannually a further sum of money into the state 3,147
insurance fund as may be ascertained to be due from the employer 3,150
by applying the rules of the administrator, and a receipt or 3,151
certificate certifying that payment has been made shall be mailed 3,153
71
immediately to the employer by the bureau of workers'
compensation. The receipt or certificate is prima facie evidence 3,154
of the payment of the premium. 3,155
The bureau of workers' compensation shall verify with the 3,157
secretary of state the existence of all corporations and 3,158
organizations making application for workers' compensation 3,159
coverage and shall require every such application to include the 3,160
employer's federal identification number. 3,161
An employer as defined in division (B)(2) of section 3,163
4123.01 of the Revised Code who has contracted with a 3,164
subcontractor is liable for the unpaid premium due from any 3,165
subcontractor with respect to that part of the payroll of the 3,166
subcontractor that is for work performed pursuant to the contract 3,168
with the employer.
Division (A) of THIS section 4123.35 of the Revised Code 3,170
providing for the payment of premiums semiannually does not apply 3,172
to any employer who was a subscriber to the state insurance fund 3,173
prior to January 1, 1914, or who may first become a subscriber to 3,174
the fund in any month other than January or July. Instead, the 3,175
semiannual premiums shall be paid by those employers from time to 3,176
time upon the expiration of the respective periods for which 3,177
payments into the fund have been made by them.
The administrator shall adopt rules to permit employers to 3,179
make periodic payments of the semiannual premium due under this 3,180
division. The rules shall include provisions for the assessment 3,181
of interest charges, where appropriate, and for the assessment of 3,182
penalties when an employer fails to make timely premium payments. 3,184
An employer who timely pays the amounts due under this division 3,185
is entitled to all of the benefits and protections of this 3,186
chapter. Upon receipt of payment, the bureau immediately shall 3,187
mail a receipt or certificate to the employer certifying that
payment has been made, which receipt is prima-facie evidence of 3,189
payment. Workers' compensation coverage under this chapter 3,190
continues uninterrupted upon timely receipt of payment under this 3,191
72
division.
Every employer mentioned in division (B)(1) of section 3,193
4123.01 of the Revised Code, except boards of county hospital 3,194
trustees that are self-insuring employers under this section, 3,195
shall comply with sections 4123.38 to 4123.41, and 4123.48 of the 3,197
Revised Code in regard to the contribution of moneys to the 3,198
public insurance fund. 3,199
(B) Provided, that employers mentioned in division (B)(2) 3,201
of section 4123.01 of the Revised Code, boards of county hospital 3,202
trustees, and publicly owned utilities who will abide by the 3,203
rules of the administrator and who may be of sufficient financial 3,204
ability to render certain the payment of compensation to injured 3,205
employees or the dependents of killed employees, and the 3,206
furnishing of medical, surgical, nursing, and hospital attention 3,207
and services and medicines, and funeral expenses, equal to or 3,208
greater than is provided for in sections 4123.52, 4123.55 to 3,209
4123.62, and 4123.64 to 4123.67 of the Revised Code, and who do 3,210
not desire to insure the payment thereof or indemnify themselves 3,211
against loss sustained by the direct payment thereof, upon a 3,212
finding of such facts by the administrator, may be granted the 3,213
privilege to pay individually compensation, and furnish medical, 3,215
surgical, nursing, and hospital services and attention and 3,216
funeral expenses directly to injured employees or the dependents 3,217
of killed employees, thereby being granted status as a 3,219
self-insuring employer. The administrator may charge employers, 3,220
boards of county hospital trustees, or publicly owned utilities 3,221
who apply for the status as a self-insuring employer a reasonable 3,222
application fee to cover the bureau's costs in connection with 3,223
processing and making a determination with respect to an 3,224
application. All employers granted such status shall demonstrate 3,225
sufficient financial and administrative ability to assure that 3,226
all obligations under this section are promptly met. The 3,227
administrator shall deny the privilege where the employer is 3,228
unable to demonstrate the employer's ability to promptly meet all 3,229
73
the obligations imposed on the employer by this section. The 3,230
administrator shall consider, but is not limited to, the 3,232
following factors, where applicable, in determining the
employer's ability to meet all of the obligations imposed on the 3,233
employer by this section: 3,234
(1) The employer employs a minimum of five hundred 3,236
employees in this state; 3,237
(2) The employer has operated in this state for a minimum 3,239
of two years, provided that an employer who has purchased, 3,240
acquired, or otherwise succeeded to the operation of a business, 3,241
or any part thereof, situated in this state that has operated for 3,242
at least two years in this state, also shall qualify; 3,243
(3) Where the employer previously contributed to the state 3,245
insurance fund or is a successor employer as defined by bureau 3,246
rules, the amount of the buy-out, as defined by bureau rules; 3,247
(4) The sufficiency of the employer's assets located in 3,249
this state to insure the employer's solvency in paying 3,250
compensation directly; 3,251
(5) The financial records, documents, and data, certified 3,253
by a certified public accountant, necessary to provide the 3,254
employer's full financial disclosure. The records, documents, 3,255
and data include, but are not limited to, balance sheets and 3,256
profit and loss history for the current year and previous four 3,257
years. 3,258
(6) The employer's organizational plan for the 3,260
administration of the workers' compensation law; 3,261
(7) The employer's proposed plan to inform employees of 3,263
the change from a state fund insurer to a self-insuring employer, 3,264
the procedures the employer will follow as a self-insuring 3,265
employer, and the employees' rights to compensation and benefits; 3,266
and 3,267
(8) The employer has either an account in a financial 3,269
institution in this state, or if the employer maintains an 3,270
account with a financial institution outside this state, ensures 3,271
74
that workers' compensation checks are drawn from the same account 3,272
as payroll checks or the employer clearly indicates that payment 3,273
will be honored by a financial institution in this state. 3,274
The administrator may waive the requirements of divisions 3,276
(B)(1) and (2) of this section and the requirement of division 3,277
(B)(5) of this section that the financial records, documents, and 3,278
data be certified by a certified public accountant. The 3,279
administrator shall adopt rules establishing the criteria that an 3,280
employer shall meet in order for the administrator to waive the 3,281
requirement of division (B)(5) of this section. Such rules may 3,282
require additional security of that employer pursuant to division 3,283
(E) of section 4123.351 of the Revised Code. The administrator 3,284
shall not grant the status of self-insuring employer to any 3,285
public employer, other than publicly owned utilities and boards 3,286
of county hospital trustees. 3,287
(C) PROVIDED, THAT A BOARD OF COUNTY COMMISSIONERS 3,289
MENTIONED IN DIVISION (B)(4) OF SECTION 4123.01 OF THE REVISED 3,291
CODE, AS AN EMPLOYER, THAT WILL ABIDE BY THE RULES OF THE 3,292
ADMINISTRATOR AND THAT MAY BE OF SUFFICIENT FINANCIAL ABILITY TO 3,293
RENDER CERTAIN THE PAYMENT OF COMPENSATION TO INJURED EMPLOYEES 3,294
OR THE DEPENDENTS OF KILLED EMPLOYEES, AND THE FURNISHING OF 3,295
MEDICAL, SURGICAL, NURSING, AND HOSPITAL ATTENTION AND SERVICES 3,296
AND MEDICINES, AND FUNERAL EXPENSES, EQUAL TO OR GREATER THAN IS
PROVIDED FOR IN SECTIONS 4123.52, 4123.55 TO 4123.62, AND 4123.64 3,297
TO 4123.67 OF THE REVISED CODE, AND THAT DOES NOT DESIRE TO 3,300
INSURE THE PAYMENT THEREOF OR INDEMNIFY THEMSELVES AGAINST LOSS 3,301
SUSTAINED BY THE DIRECT PAYMENT THEREOF, UPON A FINDING OF SUCH 3,302
FACTS BY THE ADMINISTRATOR, MAY BE GRANTED THE PRIVILEGE TO PAY 3,303
INDIVIDUALLY COMPENSATION, AND FURNISH MEDICAL, SURGICAL, 3,304
NURSING, AND HOSPITAL SERVICES AND ATTENTION AND FUNERAL EXPENSES
DIRECTLY TO INJURED EMPLOYEES OR THE DEPENDENTS OF KILLED 3,305
EMPLOYEES, THEREBY BEING GRANTED STATUS AS A SELF-INSURING 3,306
EMPLOYER. THE ADMINISTRATOR MAY CHARGE A BOARD OF COUNTY 3,307
COMMISSIONERS MENTIONED IN DIVISION (B)(4) OF SECTION 4123.01 OF 3,308
75
THE REVISED CODE THAT APPLIES FOR THE STATUS AS A SELF-INSURING 3,310
EMPLOYER A REASONABLE APPLICATION FEE TO COVER THE BUREAU'S COSTS 3,311
IN CONNECTION WITH PROCESSING AND MAKING A DETERMINATION WITH 3,312
RESPECT TO AN APPLICATION. ALL EMPLOYERS GRANTED SUCH STATUS 3,313
SHALL DEMONSTRATE SUFFICIENT FINANCIAL AND ADMINISTRATIVE ABILITY
TO ASSURE THAT ALL OBLIGATIONS UNDER THIS SECTION ARE PROMPTLY 3,314
MET. THE ADMINISTRATOR SHALL DENY THE PRIVILEGE WHERE THE 3,315
EMPLOYER IS UNABLE TO DEMONSTRATE THE EMPLOYER'S ABILITY TO 3,316
PROMPTLY MEET ALL THE OBLIGATIONS IMPOSED ON THE EMPLOYER BY THIS 3,317
SECTION. THE ADMINISTRATOR SHALL CONSIDER, BUT IS NOT LIMITED 3,318
TO, THE FOLLOWING FACTORS, WHERE APPLICABLE, IN DETERMINING THE
EMPLOYER'S ABILITY TO MEET ALL OF THE OBLIGATIONS IMPOSED ON THE 3,319
BOARD AS AN EMPLOYER BY THIS SECTION: 3,320
(1) THE BOARD AS AN EMPLOYER EMPLOYS A MINIMUM OF FIVE 3,322
HUNDRED EMPLOYEES IN THIS STATE; 3,323
(2) THE BOARD HAS OPERATED IN THIS STATE FOR A MINIMUM OF 3,325
TWO YEARS, PROVIDED THAT AN EMPLOYER THAT HAS PURCHASED, 3,326
ACQUIRED, OR OTHERWISE SUCCEEDED TO THE OPERATION OF A BUSINESS, 3,327
OR ANY PART THEREOF, SITUATED IN THIS STATE THAT HAS OPERATED FOR 3,328
AT LEAST TWO YEARS IN THIS STATE, ALSO SHALL QUALIFY; 3,329
(3) WHERE THE BOARD PREVIOUSLY CONTRIBUTED TO THE STATE 3,331
INSURANCE FUND; 3,332
(4) THE SUFFICIENCY OF THE BOARD'S ASSETS LOCATED IN THIS 3,334
STATE TO INSURE THE BOARD'S SOLVENCY IN PAYING COMPENSATION 3,335
DIRECTLY;
(5) THE FINANCIAL RECORDS, DOCUMENTS, AND DATA, CERTIFIED 3,337
BY A CERTIFIED PUBLIC ACCOUNTANT, NECESSARY TO PROVIDE THE 3,338
BOARD'S FULL FINANCIAL DISCLOSURE. THE RECORDS, DOCUMENTS, AND 3,339
DATA INCLUDE, BUT ARE NOT LIMITED TO, BALANCE SHEETS AND PROFIT 3,340
AND LOSS HISTORY FOR THE CURRENT YEAR AND PREVIOUS FOUR YEARS. 3,341
(6) THE BOARD'S ORGANIZATIONAL PLAN FOR THE ADMINISTRATION 3,343
OF THE WORKERS' COMPENSATION LAW; 3,344
(7) THE BOARD'S PROPOSED PLAN TO INFORM EMPLOYEES OF THE 3,346
PROPOSED SELF-INSURANCE, THE PROCEDURES THE BOARD WILL FOLLOW AS 3,347
76
A SELF-INSURING EMPLOYER, AND THE EMPLOYEES' RIGHTS TO 3,348
COMPENSATION AND BENEFITS;
(8) THE BOARD HAS EITHER AN ACCOUNT IN A FINANCIAL 3,350
INSTITUTION IN THIS STATE; 3,351
(9) THE BOARD SHALL PROVIDE THE ADMINISTRATOR A SURETY 3,353
BOND IN AN AMOUNT EQUAL TO ONE HUNDRED TWENTY-FIVE PER CENT OF 3,354
THE PROJECTED LOSSES AS DETERMINED BY THE ADMINISTRATOR. 3,355
(D) The administrator shall require a surety bond from all 3,357
self-insuring employers, issued pursuant to section 4123.351 of 3,358
the Revised Code, that is sufficient to compel, or secure to 3,359
injured employees, or to the dependents of employees killed, the 3,360
payment of compensation and expenses, which shall in no event be 3,361
less than that paid or furnished out of the state insurance fund 3,362
in similar cases to injured employees or to dependents of killed 3,363
employees whose employers contribute to the fund, except when an 3,364
employee of the employer, who has suffered the loss of a hand, 3,365
arm, foot, leg, or eye prior to the injury for which compensation 3,366
is to be paid, and thereafter suffers the loss of any other of 3,367
the members as the result of any injury sustained in the course 3,368
of and arising out of the employee's employment, the compensation 3,370
to be paid by the self-insuring employer is limited to the
disability suffered in the subsequent injury, additional 3,371
compensation, if any, to be paid by the bureau out of the surplus 3,373
created by section 4123.34 of the Revised Code. 3,374
(D)(E) In addition to the requirements of this section, 3,376
the administrator shall make and publish rules governing the 3,377
manner of making application and the nature and extent of the 3,378
proof required to justify a finding of fact by the administrator 3,379
as to granting the status of a self-insuring employer, which 3,380
rules shall be general in their application, one of which rules 3,381
shall provide that all self-insuring employers shall pay into the 3,382
state insurance fund such amounts as are required to be credited 3,383
to the surplus fund in division (B) of section 4123.34 of the 3,384
Revised Code. 3,385
77
Employers shall secure directly from the bureau central 3,387
offices application forms upon which the bureau shall stamp a 3,388
designating number. Prior to submission of an application, an 3,389
employer shall make available to the bureau, and the bureau shall 3,390
review, the information described in divisions (B)(1) to (8) of 3,391
this section. An employer shall file the completed application 3,392
forms with an application fee, which shall cover the costs of 3,393
processing the application, as established by the administrator, 3,394
by rule, with the bureau at least ninety days prior to the 3,395
effective date of the employer's new status as a self-insuring 3,396
employer. The application form is not deemed complete until all 3,397
the required information is attached thereto. The bureau shall 3,398
only accept applications that contain the required information. 3,399
(E)(F) The bureau shall review completed applications 3,401
within a reasonable time. If the bureau determines to grant an 3,402
employer the status as a self-insuring employer, the bureau shall 3,403
issue a statement, containing its findings of fact, that is 3,404
prepared by the bureau and signed by the administrator. If the 3,405
bureau determines not to grant the status as a self-insuring 3,406
employer, the bureau shall notify the employer of the 3,407
determination and require the employer to continue to pay its 3,408
full premium into the state insurance fund. The administrator 3,409
also shall adopt rules establishing a minimum level of 3,410
performance as a criterion for granting and maintaining the 3,411
status as a self-insuring employer and fixing time limits beyond 3,412
which failure of the self-insuring employer to provide for the 3,413
necessary medical examinations and evaluations may not delay a 3,414
decision on a claim.
(F)(G) The administrator shall adopt rules setting forth 3,416
procedures for auditing the program of self-insuring employers. 3,417
The bureau shall conduct the audit upon a random basis or 3,418
whenever the bureau has grounds for believing that an employer is 3,419
not in full compliance with bureau rules or this chapter. 3,420
The administrator shall monitor the programs conducted by 3,422
78
self-insuring employers, to ensure compliance with bureau 3,423
requirements and for that purpose, shall develop and issue to 3,424
self-insuring employers standardized forms for use by the 3,425
employer in all aspects of the employers' direct compensation 3,426
program and for reporting of information to the bureau. 3,427
The bureau shall receive and transmit to the employer all 3,429
complaints concerning any self-insuring employer. In the case of 3,430
a complaint against a self-insuring employer, the administrator 3,431
shall handle the complaint through the self-insurance division of 3,432
the bureau. The bureau shall maintain a file by employer of all 3,433
complaints received that relate to the employer. The bureau 3,434
shall evaluate each complaint and take appropriate action. 3,435
The administrator shall adopt as a rule a prohibition 3,437
against any self-insuring employer from harassing, dismissing, or 3,438
otherwise disciplining any employee making a complaint, which 3,439
rule shall provide for a financial penalty to be levied by the 3,440
administrator payable by the offending employer. 3,441
(G)(H) For the purpose of making determinations as to 3,443
whether to grant status as a self-insuring employer, the 3,444
administrator may subscribe to and pay for a credit reporting 3,445
service that offers financial and other business information 3,446
about individual employers. The costs in connection with the 3,447
bureau's subscription or individual reports from the service 3,448
about an applicant may be included in the application fee charged 3,449
employers under this section. 3,450
(H)(I) The administrator, notwithstanding other provisions 3,453
of this chapter, may permit a self-insuring employer to resume 3,454
payment of premiums to the state insurance fund with appropriate 3,455
credit modifications to the employer's basic premium rate as such 3,456
rate is determined pursuant to section 4123.29 of the Revised 3,457
Code.
(I)(J) On the first day of July of each year, the 3,459
administrator shall calculate separately each self-insuring 3,460
employer's assessments for the safety and hygiene fund, 3,461
79
administrative costs pursuant to section 4123.342 of the Revised 3,462
Code, and for the portion of the surplus fund under division (B) 3,463
of section 4123.34 of the Revised Code that is not used for 3,464
handicapped reimbursement, on the basis of the paid compensation 3,465
attributable to the individual self-insuring employer according 3,466
to the following calculation: 3,467
(1) The total assessment against all self-insuring 3,469
employers as a class for each fund and for the administrative 3,470
costs for the year that the assessment is being made, as 3,471
determined by the administrator, divided by the total amount of 3,472
paid compensation for the previous calendar year attributable to 3,473
all amenable self-insuring employers; 3,474
(2) Multiply the quotient in division (I)(J)(1) of this 3,476
section by the total amount of paid compensation for the previous 3,477
calendar year that is attributable to the individual 3,478
self-insuring employer for whom the assessment is being 3,479
determined. Each self-insuring employer shall pay the assessment 3,480
that results from this calculation, unless the assessment 3,481
resulting from this calculation falls below a minimum assessment, 3,482
which minimum assessment the administrator shall determine on the 3,483
first day of July of each year with the advice and consent of the 3,484
workers' compensation oversight commission, in which event, the 3,485
self-insuring employer shall pay the minimum assessment. 3,486
In determining the total amount due for the total 3,488
assessment against all self-insuring employers as a class for 3,489
each fund and the administrative assessment, the administrator 3,490
shall reduce proportionately the total for each fund and 3,492
assessment by the amount of money in the self-insurance 3,493
assessment fund as of the date of the computation of the 3,494
assessment. 3,495
The administrator shall calculate the assessment for the 3,497
portion of the surplus fund under division (B) of section 4123.34 3,498
of the Revised Code that is used for handicapped reimbursement in 3,499
the same manner as set forth in divisions (I)(J)(1) and (2) of 3,500
80
this section except that the administrator shall calculate the 3,502
total assessment for this portion of the surplus fund only on the 3,503
basis of those self-insuring employers that retain participation 3,504
in the handicapped reimbursement program and the individual 3,505
self-insuring employer's proportion of paid compensation shall be 3,506
calculated only for those self-insuring employers who retain 3,507
participation in the handicapped reimbursement program. The 3,508
administrator, as the administrator determines appropriate, may 3,510
determine the total assessment for the handicapped portion of the 3,511
surplus fund in accordance with sound actuarial principles. 3,512
The administrator shall calculate the assessment for the 3,514
portion of the surplus fund under division (B) of section 4123.34 3,515
of the Revised Code that under division (D) of section 4121.66 of 3,516
the Revised Code is used for rehabilitation costs in the same 3,517
manner as set forth in divisions (I)(J)(1) and (2) of this 3,518
section, except that the administrator shall calculate the total 3,520
assessment for this portion of the surplus fund only on the basis 3,521
of those self-insuring employers who have not made the election 3,522
to make payments directly under division (D) of section 4121.66 3,523
of the Revised Code and an individual self-insuring employer's 3,524
proportion of paid compensation only for those self-insuring 3,525
employers who have not made that election. 3,526
An employer who no longer is a self-insuring employer in 3,528
this state or who no longer is operating in this state, shall 3,529
continue to pay assessments for administrative costs and for the 3,530
portion of the surplus fund under division (B) of section 4123.34 3,531
of the Revised Code that is not used for handicapped 3,532
reimbursement, based upon paid compensation attributable to 3,533
claims that occurred while the employer was a self-insuring 3,534
employer within this state. 3,535
(J)(K) There is hereby created in the state treasury the 3,537
self-insurance assessment fund. All investment earnings of the 3,538
fund shall be deposited in the fund. The administrator shall use 3,539
the money in the self-insurance assessment fund only for 3,540
81
administrative costs as specified in section 4123.341 of the 3,541
Revised Code. 3,542
(K)(L) Every self-insuring employer shall certify, in 3,544
affidavit form subject to the penalty for perjury, to the bureau 3,545
the amount of the self-insuring employer's paid compensation for 3,546
the previous calendar year. In reporting paid compensation paid 3,547
for the previous year, a self-insuring employer shall exclude 3,548
from the total amount of paid compensation any reimbursement the 3,549
employer receives in the previous calendar year from the surplus 3,550
fund pursuant to section 4123.512 of the Revised Code for any 3,551
paid compensation. The self-insuring employer also shall exclude 3,552
from the paid compensation reported any amount recovered under 3,553
section 4123.93 of the Revised Code and any amount that is 3,554
determined not to have been payable to or on behalf of a claimant 3,555
in any final administrative or judicial proceeding. The 3,556
self-insuring employer shall exclude such amounts from the paid 3,557
compensation reported in the reporting period subsequent to the 3,558
date the determination is made. The administrator shall adopt 3,559
rules, in accordance with Chapter 119. of the Revised Code, 3,560
establishing the date by which self-insuring employers must 3,561
submit such information and the amount of the assessments 3,562
provided for in division (I)(J) of this section for employers who 3,564
have been granted self-insuring status within the last calendar 3,565
year. 3,566
The administrator shall include any assessment that remains 3,568
unpaid for previous assessment periods in the calculation and 3,569
collection of any assessments due under this division or division 3,570
(I)(J) of this section. 3,571
(L)(M) As used in this section, "paid compensation" means 3,573
all amounts paid by a self-insuring employer for living 3,574
maintenance benefits, all amounts for compensation paid pursuant 3,575
to sections 4121.63, 4121.67, 4123.56, 4123.57, 4123.58, 4123.59, 3,576
4123.60, and 4123.64 of the Revised Code, all amounts paid as 3,577
wages in lieu of such compensation, all amounts paid in lieu of 3,578
82
such compensation under a nonoccupational accident and sickness 3,579
program fully funded by the self-insuring employer, and all 3,580
amounts paid by a self-insuring employer for a violation of a 3,581
specific safety standard pursuant to Section 35 of Article II, 3,582
Ohio Constitution and section 4121.47 of the Revised Code. 3,583
(M)(N) Should any section of this chapter or Chapter 4121. 3,585
of the Revised Code providing for self-insuring employers' 3,586
assessments based upon compensation paid be declared 3,587
unconstitutional by a final decision of any court, then that 3,588
section of the Revised Code declared unconstitutional shall 3,589
revert back to the section in existence prior to November 3, 3,590
1989, providing for assessments based upon payroll. 3,591
(N)(O) The administrator may grant a self-insuring 3,593
employer the privilege to self-insure a construction project 3,595
entered into by the self-insuring employer that is scheduled for 3,596
completion within six years after the date the project begins, 3,597
and the total cost of which is estimated to exceed one hundred 3,599
million dollars. The administrator may waive such cost and time
criteria and grant a self-insuring employer the privilege to 3,600
self-insure a construction project regardless of the time needed 3,601
to complete the construction project and provided that the cost 3,602
of the construction project is estimated to exceed fifty million 3,603
dollars. A self-insuring employer who desires to self-insure a 3,605
construction project shall submit to the administrator an
application listing the dates the construction project is 3,606
scheduled to begin and end, the estimated cost of the 3,608
construction project, the contractors and subcontractors whose
employees are to be self-insured by the self-insuring employer, 3,609
the provisions of a safety program that is specifically designed 3,610
for the construction project, and a statement as to whether a 3,611
collective bargaining agreement governing the rights, duties, and 3,612
obligations of each of the parties to the agreement with respect 3,613
to the construction project exists between the self-insuring 3,614
employer and a labor organization. 3,615
83
A self-insuring employer may apply to self-insure the 3,617
employees of either of the following: 3,618
(1) All contractors and subcontractors who perform labor 3,620
or work or provide materials for the construction project; 3,621
(2) All contractors and, at the administrator's 3,623
discretion, a substantial number of all the subcontractors who 3,624
perform labor or work or provide materials for the construction 3,625
project.
Upon approval of the application, the administrator shall 3,627
mail a certificate granting the privilege to self-insure the 3,628
construction project to the self-insuring employer. The 3,629
certificate shall contain the name of the self-insuring employer 3,630
and the name, address, and telephone number of the self-insuring 3,631
employer's representatives who are responsible for administering
workers' compensation claims for the construction project. The 3,632
self-insuring employer shall post the certificate in a 3,633
conspicuous place at the site of the construction project. 3,634
The administrator shall maintain a record of the 3,636
contractors and subcontractors whose employees are covered under 3,637
the certificate issued to the self-insured employer. A 3,638
self-insuring employer immediately shall notify the administrator 3,639
when any contractor or subcontractor is added or eliminated from 3,640
inclusion under the certificate.
Upon approval of the application, the self-insuring 3,642
employer is responsible for the administration and payment of all 3,643
claims under this chapter and Chapter 4121. of the Revised Code 3,644
for the employees of the contractor and subcontractors covered 3,645
under the certificate who receive injuries or are killed in the 3,646
course of and arising out of employment on the construction 3,648
project, or who contract an occupational disease in the course of 3,649
employment on the construction project. For purposes of this
chapter and Chapter 4121. of the Revised Code, a claim that is 3,651
administered and paid in accordance with this division is
considered a claim against the self-insuring employer listed in 3,652
84
the certificate. A contractor or subcontractor included under 3,653
the certificate shall report to the self-insuring employer listed 3,654
in the certificate, all claims that arise under this chapter and 3,655
Chapter 4121. of the Revised Code in connection with the 3,657
construction project for which the certificate is issued. 3,658
A self-insuring employer who complies with this division is 3,660
entitled to the protections provided under this chapter and 3,661
Chapter 4121. of the Revised Code with respect to the employees 3,663
of the contractors and subcontractors covered under a certificate 3,664
issued under this division for death or injuries that arise out 3,665
of, or death, injuries, or occupational diseases that arise in
the course of, those employees' employment on that construction 3,667
project, as if the employees were employees of the self-insuring 3,668
employer, provided that the self-insuring employer also complies 3,669
with this section. No employee of the contractors and
subcontractors covered under a certificate issued under this 3,670
division shall be considered the employee of the self-insuring 3,671
employer listed in that certificate for any purposes other than 3,672
this chapter and Chapter 4121. of the Revised Code. Nothing in 3,673
this division gives a self-insuring employer authority to control 3,674
the means, manner, or method of employment of the employees of 3,675
the contractors and subcontractors covered under a certificate 3,676
issued under this division. 3,677
The contractors and subcontractors included under a 3,679
certificate issued under this division are entitled to the 3,680
protections provided under this chapter and Chapter 4121. of the 3,681
Revised Code with respect to the contractor's or subcontractor's 3,682
employees who are employed on the construction project which is 3,683
the subject of the certificate, for death or injuries that arise 3,684
out of, or death, injuries, or occupational diseases that arise 3,685
in the course of, those employees' employment on that 3,686
construction project.
The contractors and subcontractors included under a 3,688
certificate issued under this division shall identify in their 3,689
85
payroll records the employees who are considered the employees of 3,690
the self-insuring employer listed in that certificate for 3,691
purposes of this chapter and Chapter 4121. of the Revised Code, 3,693
and the amount that those employees earned for employment on the 3,694
construction project that is the subject of that certificate. 3,695
Notwithstanding any provision to the contrary under this chapter
and Chapter 4121. of the Revised Code, the administrator shall 3,698
exclude the payroll that is reported for employees who are 3,699
considered the employees of the self-insuring employer listed in
that certificate, and that the employees earned for employment on 3,700
the construction project that is the subject of that certificate, 3,701
when determining those contractors' or subcontractors' premiums 3,702
or assessments required under this chapter and Chapter 4121. of 3,703
the Revised Code. A self-insuring employer issued a certificate 3,704
under this division shall include in the amount of paid 3,705
compensation it reports pursuant to division (K)(L) of this 3,706
section, the amount of paid compensation the self-insuring 3,707
employer paid pursuant to this division for the previous calendar 3,708
year.
Nothing in this division shall be construed as altering the 3,710
rights of employees under this chapter and Chapter 4121. of the 3,711
Revised Code as those rights existed prior to the effective date 3,713
of this amendment SEPTEMBER 17, 1996. Nothing in this division 3,714
shall be construed as altering the rights devolved under sections 3,716
2305.31 and 4123.82 of the Revised Code as those rights existed 3,717
prior to the effective date of this amendment SEPTEMBER 17, 1996. 3,718
As used in this division, "privilege to self-insure a 3,720
construction project" means privilege to pay individually 3,721
compensation, and to furnish medical, surgical, nursing, and 3,722
hospital services and attention and funeral expenses directly to 3,723
injured employees or the dependents of killed employees. 3,724
(O)(P) A self-insuring employer whose application is 3,726
granted under division (N)(O) of this section shall designate a 3,728
safety professional to be responsible for the administration and 3,730
86
enforcement of the safety program that is specifically designed 3,731
for the construction project that is the subject of the 3,732
application.
A self-insuring employer whose application is granted under 3,734
division (N)(O) of this section shall employ an ombudsperson for 3,736
the construction project that is the subject of the application. 3,737
The ombudsperson shall have experience in workers' compensation 3,738
or the construction industry, or both. The ombudsperson shall 3,739
perform all of the following duties:
(1) Communicate with and provide information to employees 3,741
who are injured in the course of, or whose injury arises out of 3,742
employment on the construction project, or who contract an 3,743
occupational disease in the course of employment on the 3,744
construction project;
(2) Investigate the status of a claim upon the request of 3,746
an employee to do so; 3,747
(3) Provide information to claimants, third party 3,749
administrators, employers, and other persons to assist those 3,750
persons in protecting their rights under this chapter and Chapter 3,751
4121. of the Revised Code. 3,752
A self-insuring employer whose application is granted under 3,754
division (N)(O) of this section shall post the name of the safety 3,756
professional and the ombudsperson and instructions for contacting
the safety professional and the ombudsperson in a conspicuous 3,757
place at the site of the construction project. 3,758
(P)(Q) The administrator may consider all of the following 3,761
when deciding whether to grant a self-insuring employer the 3,762
privilege to self-insure a construction project as provided under 3,763
division (N)(O) of this section: 3,764
(1) Whether the self-insuring employer has an 3,766
organizational plan for the administration of the workers' 3,767
compensation law; 3,768
(2) Whether the safety program that is specifically 3,770
designed for the construction project provides for the safety of 3,771
87
employees employed on the construction project, is applicable to 3,773
all contractors and subcontractors who perform labor or work or 3,774
provide materials for the construction project, and has a
component, a safety training program that complies with standards 3,775
adopted pursuant to the "Occupational Safety and Health Act of 3,776
1970," 84 Stat. 1590, 29 U.S.C.A. 651, and provides for 3,777
continuing management and employee involvement; 3,778
(3) Whether granting the privilege to self-insure the 3,780
construction project will reduce the costs of the construction 3,781
project; 3,782
(4) Whether the self-insuring employer has employed an 3,784
ombudsperson as required under division (O)(P) of this section; 3,786
(5) Whether the self-insuring employer has sufficient 3,788
surety to secure the payment of claims for which the 3,789
self-insuring employer would be responsible pursuant to the 3,790
granting of the privilege to self-insure a construction project 3,791
under division (N)(O) of this section. 3,793
Sec. 4123.512. (A) The claimant or the employer may 3,804
appeal an order of the industrial commission made under division 3,805
(E) of section 4123.511 of the Revised Code in any injury or 3,806
occupational disease case, other than a decision as to the extent 3,807
of disability to the court of common pleas of the county in which 3,809
the injury was inflicted or in which the contract of employment 3,810
was made if the injury occurred outside the state, or in which 3,811
the contract of employment was made if the exposure occurred 3,812
outside the state. If no common pleas court has jurisdiction for 3,813
the purposes of an appeal by the use of the jurisdictional 3,814
requirements described in this division, the appellant may use 3,815
the venue provisions in the Rules of Civil Procedure to vest 3,816
jurisdiction in a court. If the claim is for an occupational 3,817
disease the appeal shall be to the court of common pleas of the 3,818
county in which the exposure which caused the disease occurred. 3,819
Like appeal may be taken from an order of a staff hearing officer 3,820
made under division (D) of section 4123.511 of the Revised Code 3,821
88
from which the commission has refused to hear an appeal. The 3,822
appellant shall file the notice of appeal with a court of common 3,823
pleas within sixty days after the date of the receipt of the 3,824
order appealed from or the date of receipt of the order of the 3,825
commission refusing to hear an appeal of a staff hearing 3,826
officer's decision under division (D) of section 4123.511 of the 3,827
Revised Code. The filing of the notice of the appeal with the 3,828
court is the only act required to perfect the appeal.
If an action has been commenced in a court of a county 3,830
other than a court of a county having jurisdiction over the 3,831
action, the court, upon notice by any party or upon its own 3,832
motion, shall transfer the action to a court of a county having 3,833
jurisdiction. 3,834
Notwithstanding anything to the contrary in this section, 3,836
if the commission determines under section 4123.522 of the 3,837
Revised Code that an employee, employer, or their respective 3,838
representatives have not received written notice of an order or 3,839
decision which is appealable to a court under this section and 3,840
which grants relief pursuant to section 4123.522 of the Revised 3,841
Code, the party granted the relief has sixty days from receipt of 3,842
the order under section 4123.522 of the Revised Code to file a 3,843
notice of appeal under this section. 3,844
(B) The notice of appeal shall state the names of the 3,846
claimant and the employer, the number of the claim, the date of 3,847
the order appealed from, and the fact that the appellant appeals 3,848
therefrom. 3,849
The administrator, the claimant, and the employer shall be 3,851
parties to the appeal and the court, upon the application of the 3,852
commission, shall make the commission a party. The administrator 3,853
shall notify the employer that if he THE EMPLOYER fails to become 3,855
an active party to the appeal, then the administrator may act on 3,856
behalf of the employer and the results of the appeal could have 3,857
an adverse effect upon the employer's premium rates. 3,858
(C) The attorney general or one or more of his THE 3,860
89
ATTORNEY GENERAL'S assistants or special counsel designated by 3,862
him THE ATTORNEY GENERAL shall represent the administrator and 3,863
the commission. In the event the attorney general or his THE 3,864
ATTORNEY GENERAL'S designated assistants or special counsel are 3,865
absent, the administrator or the commission shall select one or 3,866
more of the attorneys in the employ of the administrator or the 3,867
commission as his THE ADMINISTRATOR'S ATTORNEY or its THE 3,869
COMMISSION'S attorney in the appeal. Any attorney so employed 3,870
shall continue his THE representation during the entire period of 3,871
the appeal and in all hearings thereof except where the continued 3,872
representation becomes impractical.
(D) Upon receipt of notice of appeal the clerk of courts 3,874
shall provide notice to all parties who are appellees and to the 3,875
commission. 3,876
The claimant shall, within thirty days after the filing of 3,878
the notice of appeal, file a petition containing a statement of 3,879
facts in ordinary and concise language showing a cause of action 3,880
to participate or to continue to participate in the fund and 3,881
setting forth the basis for the jurisdiction of the court over 3,882
the action. Further pleadings shall be had in accordance with 3,883
the Rules of Civil Procedure, provided that service of summons on 3,884
such petition shall not be required. The clerk of the court 3,885
shall, upon receipt thereof, transmit by certified mail a copy 3,886
thereof to each party named in the notice of appeal other than 3,887
the claimant. Any party may file with the clerk prior to the 3,888
trial of the action a deposition of any physician taken in 3,889
accordance with the provisions of the Revised Code, which 3,890
deposition may be read in the trial of the action even though the 3,891
physician is a resident of or subject to service in the county in 3,892
which the trial is had. The bureau of workers' compensation 3,893
shall pay the cost of the stenographic deposition filed in court 3,894
and of copies of the stenographic deposition for each party from 3,896
the surplus fund and charge the costs thereof against the 3,898
unsuccessful party if the claimant's right to participate or 3,899
90
continue to participate is finally sustained or established in 3,900
the appeal. In the event the deposition is taken and filed, the 3,901
physician whose deposition is taken is not required to respond to 3,902
any subpoena issued in the trial of the action. The court, or 3,903
the jury under the instructions of the court, if a jury is 3,904
demanded, shall determine the right of the claimant to 3,905
participate or to continue to participate in the fund upon the 3,906
evidence adduced at the hearing of the action. 3,907
(E) The court shall certify its decision to the commission 3,909
and the certificate shall be entered in the records of the court. 3,910
Appeals from the judgment are governed by the law applicable to 3,911
the appeal of civil actions. 3,912
(F) The cost of any legal proceedings authorized by this 3,914
section, including an attorney's fee to the claimant's attorney 3,915
to be fixed by the trial judge, based upon the effort expended, 3,916
in the event the claimant's right to participate or to continue 3,917
to participate in the fund is established upon the final 3,918
determination of an appeal, shall be taxed against the employer 3,919
or the commission if the commission or the administrator rather 3,920
than the employer contested the right of the claimant to 3,921
participate in the fund. The attorney's fee shall not exceed 3,922
twenty-five hundred dollars. 3,923
(G) If the finding of the court or the verdict of the jury 3,925
is in favor of the claimant's right to participate in the fund, 3,926
the commission and the administrator shall thereafter proceed in 3,927
the matter of the claim as if the judgment were the decision of 3,928
the commission, subject to the power of modification provided by 3,929
section 4123.52 of the Revised Code. 3,930
(H) An appeal from an order issued under division (E) of 3,932
section 4123.511 of the Revised Code or any action filed in court 3,933
in a case in which an award of compensation has been made shall 3,934
not stay the payment of compensation under the award or payment 3,935
of compensation for subsequent periods of total disability during 3,936
the pendency of the appeal. If, in a final administrative or 3,937
91
judicial action, it is determined that payments of compensation 3,938
or benefits, or both, made to or on behalf of a claimant should 3,939
not have been made, the amount thereof shall be charged to the 3,940
surplus fund under division (B) of section 4123.34 of the Revised 3,941
Code. In the event the employer is a state risk, the amount 3,942
shall not be charged to the employer's experience. In the event 3,943
the employer is a self-insuring employer, the self-insuring 3,944
employer shall deduct the amount from the paid compensation he 3,945
THE SELF-INSURING EMPLOYER reports to the administrator under 3,947
division (K)(L) of section 4123.35 of the Revised Code. All 3,948
actions and proceedings under this section which are the subject 3,949
of an appeal to the court of common pleas or the court of appeals 3,950
shall be preferred over all other civil actions except election 3,951
causes, irrespective of position on the calendar. 3,952
This section applies to all decisions of the commission or 3,954
the administrator on November 2, 1959, and all claims filed 3,955
thereafter are governed by sections 4123.511 and 4123.512 of the 3,956
Revised Code. 3,957
Any action pending in common pleas court or any other court 3,959
on January 1, 1986, under this section is governed by former 3,960
sections 4123.514, 4123.515, 4123.516, and 4123.519 and section 3,961
4123.522 of the Revised Code. 3,962
Section 2. That existing sections 1751.02, 1751.03, 3,964
1751.04, 1751.12, 1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 3,966
4121.121, 4123.01, 4123.25, 4123.35, and 4123.512 of the Revised 3,967
Code are hereby repealed. 3,968
Section 3. Sections 1 and 2 of this act, except for 3,970
sections 1751.12, 4121.121, 4123.01, 4123.25, 4123.35, and 3,971
4123.512 of the Revised Code, as amended by this act, shall take 3,972
effect October 1, 1998. Sections 1751.12, 4121.121, 4123.01, 3,973
4123.25, 4123.35, and 4123.512 of the Revised Code, as amended by 3,974
this act, shall take effect at the earliest time permitted by 3,975
law.