As Passed by the Senate 1
122nd General Assembly 4
Regular Session Am. 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-OELSLAGER-DRAKE- 17
HORN-KEARNS-SCHAFRATH-FINAN-GARDNER-HOWARD 18
20
A B I L L
To amend sections 1751.02 to 1751.04, 1751.12, 22
1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 24
4121.121, 4123.01, 4123.25, 4123.35, and 4123.512
and to enact sections 1751.521, 1751.73 to 26
1751.75, 1751.77 to 1751.86, 1753.01, 1753.03 to 28
1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 29
1753.24, 1753.28, and 1753.30 of the Revised Code 30
to adopt the Physician-Health Plan Partnership 31
Act, to authorize the Administrator of Workers' 33
Compensation to transfer surplus computers and 34
computer equipment directly to an accredited
public school within Ohio, to specify 36
circumstances under which a board of county
commissioners may be granted status as a 37
self-insuring employer for purposes of the
Workers' Compensation Law, and to declare an 38
emergency.
2
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 40
Section 1. That sections 1751.02, 1751.03, 1751.04, 42
1751.12, 1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 4121.121, 43
4123.01, 4123.25, 4123.35, and 4123.512 be amended and sections 44
1751.521, 1751.73, 1751.74, 1751.75, 1751.77, 1751.78, 1751.79, 45
1751.80, 1751.81, 1751.82, 1751.83, 1751.84, 1751.85, 1751.86, 46
1753.01, 1753.03, 1753.04, 1753.05, 1753.06, 1753.07, 1753.08, 48
1753.09, 1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 1753.24, 49
1753.28, and 1753.30 of the Revised Code be enacted to read as 51
follows:
Sec. 1751.02. (A) Notwithstanding any law in this state 60
to the contrary, any corporation, as defined in section 1751.01 62
of the Revised Code, may apply to the superintendent of insurance 64
for a certificate of authority to establish and operate a health 65
insuring corporation. If the corporation applying for a 66
certificate of authority is a foreign corporation domiciled in a 67
state without laws similar to those of this chapter, the 69
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 70
chapter.
(B) No person shall establish, operate, or perform the 73
services of a health insuring corporation in this state without 75
obtaining a certificate of authority under this chapter. 76
(C) Except as provided by division (D) of this section, no 79
political subdivision or department, office, or institution of 80
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 81
this state, shall establish, operate, or perform the services of 82
a health insuring corporation. Nothing in this section shall be 85
construed to preclude a board of county commissioners, a county 86
board of mental retardation and developmental disabilities, an 87
alcohol and drug addiction services board, a board of alcohol, 88
drug addiction, and mental health services, or a community mental 89
health board, or a public entity formed by or on behalf of any of 90
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these boards, from using managed care techniques in carrying out 91
the board's or public entity's duties pursuant to the 92
requirements of Chapters 307., 329., 340., and 5126. of the 94
Revised Code. However, no such board or public entity may 96
operate so as to compete in the private sector with health 97
insuring corporations holding certificates of authority under 98
this chapter.
(D) A corporation formed by or on behalf of a publicly 100
owned, operated, or funded hospital or health care facility may 101
apply to the superintendent for a certificate of authority under 103
division (A) of this section to establish and operate a health 104
insuring corporation.
(E) A health insuring corporation shall operate in this 107
state in compliance with this chapter AND CHAPTER 1753. OF THE 108
REVISED CODE, and with sections 3702.51 to 3702.62 of the Revised 110
Code, and shall operate in conformity with its filings with the 112
superintendent under this chapter, including filings made 113
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 114
the Revised Code. 116
(F) An insurer licensed under Title XXXIX of the Revised 120
Code need not obtain a certificate of authority as a health 121
insuring corporation to offer an open panel plan as long as the 122
providers and health care facilities participating in the open 123
panel plan receive their compensation directly from the insurer. 124
If the providers and health care facilities participating in the 125
open panel plan receive their compensation from any person other 126
than the insurer, or if the insurer offers a closed panel plan, 127
the insurer must obtain a certificate of authority as a health 128
insuring corporation.
(G) An intermediary organization need not obtain a 131
certificate of authority as a health insuring corporation, 132
regardless of the method of reimbursement to the intermediary 133
organization, as long as a health insuring corporation or a 135
self-insured employer maintains the ultimate responsibility to 136
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assure delivery of all health care services required by the
contract between the health insuring corporation and the 137
subscriber and the laws of this state or between the self-insured 138
employer and its employees. 139
Nothing in this section shall be construed to require any 141
health care facility, provider, health delivery network, or 142
intermediary organization that contracts with a health insuring 143
corporation or self-insured employer, regardless of the method of 145
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 146
certificate of authority as a health insuring corporation under 147
this chapter, unless otherwise provided, in the case of contracts 149
with a self-insured employer, by operation of the "Employee 150
Retirement Income Security Act of 1974," 88 Stat. 829, 29 155
U.S.C.A. 1001, as amended. 157
(H) Any health delivery network doing business in this 160
state that is not required to obtain a certificate of authority 161
under this chapter shall certify to the superintendent annually, 162
not later than the first day of July, and shall provide a 164
statement signed by the highest ranking official which includes 165
the following information:
(1) The health delivery network's full name and the 167
address of its principal place of business; 168
(2) A statement that the health delivery network is not 170
required to obtain a certificate of authority under this chapter 171
to conduct its business. 172
(I) The superintendent shall not issue a certificate of 175
authority to a health insuring corporation that is a provider 176
sponsored organization unless all health care plans to be offered 177
by the health insuring corporation provide basic health care 178
services. Substantially all of the physicians and hospitals with 179
ownership or control of the provider sponsored organization, as 180
defined in division (W) of section 1751.01 of the Revised Code, 183
shall also be participating providers for the provision of basic 184
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health care services for health care plans offered by the 185
provider sponsored organization. If a health insuring 186
corporation that is a provider sponsored organization offers 187
health care plans that do not provide basic health care services, 188
the health insuring corporation shall be deemed, for purposes of 189
section 1751.35 of the Revised Code, to have failed to 190
substantially comply with this chapter. 191
Except as specifically provided in this division and in 193
division (C) of section 1751.28 of the Revised Code, the 195
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 196
same manner that these provisions apply to all health insuring 197
corporations that are not provider sponsored organizations. 198
(J) Nothing in this section shall be construed to apply to 200
any multiple employer welfare arrangement operating pursuant to 201
Chapter 1739. of the Revised Code. 202
(K) Any person who violates division (B) of this section, 206
and any health delivery network that fails to comply with 207
division (H) of this section, is subject to the penalties set 208
forth in section 1751.45 of the Revised Code. 210
Sec. 1751.03. (A) Each application for a certificate of 220
authority under this chapter shall be verified by an officer or 221
authorized representative of the applicant, shall be in a format 222
prescribed by the superintendent of insurance, and shall set 223
forth or be accompanied by the following: 224
(1) A certified copy of the applicant's articles of 226
incorporation and all amendments to the articles of 227
incorporation; 228
(2) A copy of any regulations adopted for the government 230
of the corporation, any bylaws, and any similar documents, and a 231
copy of all amendments to these regulations, bylaws, and 232
documents. The corporate secretary shall certify that these 233
regulations, bylaws, documents, and amendments have been properly 235
adopted or approved.
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(3) A list of the names, addresses, and official positions 238
of the persons responsible for the conduct of the applicant, 239
including all members of the board, the principal officers, and 240
the person responsible for completing or filing financial 241
statements with the department of insurance, accompanied by a 242
completed original biographical affidavit and release of 243
information for each of these persons on forms acceptable to the 244
department;
(4) A full and complete disclosure of the extent and 246
nature of any contractual or other financial arrangement between 247
the applicant and any provider or a person listed in division 248
(A)(3) of this section, including, but not limited to, a full and 250
complete disclosure of the financial interest held by any such 251
provider or person in any health care facility, provider, or 252
insurer that has entered into a financial relationship with the 253
health insuring corporation; 254
(5) A description of the applicant, its facilities, and 256
its personnel, including, but not limited to, the location, hours 258
of operation, and telephone numbers of all contracted facilities; 259
(6) The applicant's projected annual enrollee population 261
over a three-year period; 262
(7) A clear and specific description of the health care 264
plan or plans to be used by the applicant, including a 265
description of the proposed providers, procedures for accessing 266
care, and the form of all proposed and existing contracts 267
relating to the administration, delivery, or financing of health 268
care services; 269
(8) A copy of each type of evidence of coverage and 271
identification card or similar document to be issued to 272
subscribers; 273
(9) A copy of each type of individual or group policy, 275
contract, or agreement to be used; 276
(10) The schedule of the proposed contractual periodic 278
prepayments or premium rates, or both, accompanied by appropriate 279
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supporting data; 280
(11) A financial plan which provides a three-year 282
projection of operating results, including the projected 283
expenses, income, and sources of working capital; 284
(12) The enrollee complaint procedure to be utilized as 286
required under section 1751.19 of the Revised Code; 289
(13) A description of the procedures and programs to be 291
implemented on an ongoing basis to assure the quality of health 292
care services delivered to enrollees, INCLUDING, IF APPLICABLE, A 293
DESCRIPTION OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE 295
REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE;
(14) A statement describing the geographic area or areas 297
to be served, by county; 298
(15) A copy of all solicitation documents; 300
(16) A balance sheet and other financial statements 302
showing the applicant's assets, liabilities, income, and other 303
sources of financial support; 304
(17) A description of the nature and extent of any 306
reinsurance program to be implemented, and a demonstration that 307
errors and omission insurance and, if appropriate, fidelity 308
insurance, will be in place upon the applicant's receipt of a 309
certificate of authority; 310
(18) Copies of all proposed or in force related-party or 312
intercompany agreements with an explanation of the financial 313
impact of these agreements on the applicant. If the applicant 314
intends to enter into a contract for managerial or administrative 316
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 317
description of the person to provide these services. The 319
description shall include that person's experience in managing or 320
administering health care plans, a copy of that person's most 321
recent audited financial statement, and a completed biographical 322
affidavit on a form acceptable to the superintendent for each of 323
that person's principal officers and board members and for any 324
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additional employee to be directly involved in providing 325
managerial or administrative services to the health insuring 326
corporation. If the person to provide managerial or 327
administrative services is affiliated with the health insuring 328
corporation, the contract must provide for payment for services 329
based on actual costs.
(19) A statement from the applicant's board that the 331
admitted assets of the applicant have not been and will not be 332
pledged or hypothecated; 333
(20) A statement from the applicant's board that the 335
applicant will submit monthly financial statements during the 336
first year of operations; 337
(21) The name and address of the applicant's Ohio 340
statutory agent for service of process, notice, or demand; 341
(22) Copies of all documents the applicant filed with the 343
secretary of state; 344
(23) The location of those books and records of the 346
applicant that must be maintained in Ohio; 347
(24) The applicant's federal identification number, 349
corporate address, and mailing address; 350
(25) An internal and external organizational chart; 353
(26) A list of the assets representing the initial net 355
worth of the applicant; 356
(27) If the applicant has a parent company, the parent 358
company's guaranty, on a form acceptable to the superintendent, 359
that the applicant will maintain Ohio's minimum net worth. If no 362
parent company exists, a statement regarding the availability of 363
future funds if needed.
(28) The names and addresses of the applicant's actuary 365
and external auditors; 366
(29) If the applicant is a foreign corporation, a copy of 368
the most recent financial statements filed with the insurance 369
regulatory agency in the applicant's state of domicile; 370
(30) If the applicant is a foreign corporation, a 372
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statement from the insurance regulatory agency of the applicant's 373
state of domicile stating that the regulatory agency has no 374
objection to the applicant applying for an Ohio license and that 375
the applicant is in good standing in the applicant's state of 376
domicile; 377
(31) Any other information that the superintendent may 379
require. 380
(B)(1) A health insuring corporation, unless otherwise 383
provided for in this chapter, shall file a timely notice with the 384
superintendent describing any change to the corporation's 385
articles of incorporation or regulations, or any major 386
modification to its operations as set out in the information 387
required by division (A) of this section that affects any of the 389
following:
(a) The solvency of the health insuring corporation; 392
(b) The health insuring corporation's continued provision 395
of services that it has contracted to provide; 396
(c) The manner in which the health insuring corporation 399
conducts its business.
(2) If the change or modification is to be the result of 401
an action to be taken by the health insuring corporation, the 402
notice shall be filed with the superintendent prior to the health 403
insuring corporation taking the action. The action shall be 405
deemed approved if the superintendent does not disapprove it 406
within sixty days of filing. 407
(C)(1) No health insuring corporation shall expand its 410
approved service area until a copy of the request for expansion, 411
accompanied by documentation of the network of providers, 412
enrollment projections, plan of operation, and any other changes 413
have been filed with the superintendent. 414
(2) Within ten calendar days after receipt of a complete 416
filing under division (C)(1) of this section, the superintendent 418
shall refer the appropriate jurisdictional issues to the director 419
of health pursuant to section 1751.04 of the Revised Code. 421
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(3) Within seventy-five days after the superintendent's 423
receipt of a complete filing under division (C)(1) of this 425
section, the superintendent shall determine whether the plan for 426
expansion is lawful, fair, and reasonable. The superintendent 427
may not make a determination until the superintendent has 428
received the director's certification of compliance, which the 429
director shall furnish within forty-five days after referral 430
under division (C)(2) of this section. The director shall not 432
certify that the requirements of section 1751.04 of the Revised 433
Code are not met, unless the applicant has been given an 435
opportunity for a hearing as provided in division (D) of section 437
1751.04 of the Revised Code. The forty-five-day and 438
seventy-five-day review periods provided for in division (C)(3) 440
of this section shall cease to run as of the date on which the 441
notice of the applicant's right to request a hearing is mailed 442
and shall remain suspended until the director issues a final 443
certification. 444
(4) If the superintendent has not approved or disapproved 446
all or a portion of a service area expansion within the 447
seventy-five-day period provided for in division (C)(3) of this 449
section, the filing shall be deemed approved. 450
(5) Disapproval of all or a portion of the filing shall be 453
effected by written notice, which shall state the grounds for the 454
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 455
Sec. 1751.04. (A) Upon the receipt by the superintendent 466
of insurance of a complete application for a certificate of 467
authority to establish or operate a health insuring corporation, 468
which application sets forth or is accompanied by the information 469
and documents required by division (A) of section 1751.03 of the 471
Revised Code, the superintendent shall transmit copies of the 473
application and accompanying documents to the director of health. 474
(B) The director shall review the application and 477
accompanying documents and make findings as to whether the 478
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applicant for a certificate of authority has done all of the 479
following with respect to any basic health care services and 480
supplemental health care services to be furnished: 481
(1) Demonstrated the willingness and potential ability to 483
ensure that all basic health care services and supplemental 484
health care services described in the evidence of coverage will 486
be provided to all its enrollees as promptly as is appropriate 487
and in a manner that assures continuity; 488
(2) Made effective arrangements to ensure that its 490
enrollees have reliable access to qualified providers in those 491
specialties that are generally available in the geographic area 492
or areas to be served by the applicant and that are necessary to 493
provide all basic health care services and supplemental health 494
care services described in the evidence of coverage; 496
(3) Made appropriate arrangements for the availability of 498
short-term health care services in emergencies within the 499
geographic area or areas to be served by the applicant, 500
twenty-four hours per day, seven days per week, and for the 501
provision of adequate coverage whenever an out-of-area emergency 502
arises; 503
(4) Made appropriate arrangements for an ongoing 505
evaluation and assurance of the quality of health care services 506
provided to enrollees, INCLUDING, IF APPLICABLE, THE DEVELOPMENT 507
OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE REQUIREMENTS OF 509
SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE, and the adequacy
of the personnel, facilities, and equipment by or through which 510
the services are rendered; 511
(5) Developed a procedure to gather and report statistics 513
relating to the cost and effectiveness of its operations, the 514
pattern of utilization of its services, and the quality, 515
availability, and accessibility of its services. 516
(C) Within ninety days of the director's receipt of the 518
application for issuance of a certificate of authority, the 520
director shall certify to the superintendent whether or not the 521
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applicant meets the requirements of division (B) of this section 522
and sections 3702.51 to 3702.62 of the Revised Code. If the 523
director certifies that the applicant does not meet these 524
requirements, the director shall specify in what respects it is 525
deficient. However, the director shall not certify that the 526
requirements of this section are not met unless the applicant has 527
been given an opportunity for a hearing. 528
(D) If the applicant requests a hearing, the director 531
shall hold a hearing before certifying that the applicant does 532
not meet the requirements of this section. The hearing shall be 533
held in accordance with Chapter 119. of the Revised Code. 535
(E) The ninety-day review period provided for under 538
division (C) of this section shall cease to run as of the date on 540
which the notice of the applicant's right to request a hearing is 541
mailed and shall remain suspended until the director issues a 542
final certification order.
Sec. 1751.12. (A)(1) No contractual periodic prepayment 552
and no premium rate for nongroup and conversion policies for 553
health care services, or any amendment to them, may be used by 554
any health insuring corporation at any time until the contractual 555
periodic prepayment and premium rate, or amendment, have been 556
filed with the superintendent of insurance, and shall not be 557
effective until the expiration of sixty days after their filing 558
unless the superintendent sooner gives approval. The 559
superintendent shall disapprove the filing, if the superintendent 560
determines within the sixty-day period that the contractual 561
periodic prepayment or premium rate, or amendment, is not in 562
accordance with sound actuarial principles or is not reasonably 563
related to the applicable coverage and characteristics of the 564
applicable class of enrollees. The superintendent shall notify 565
the health insuring corporation of the disapproval, and it shall 566
thereafter be unlawful for the health insuring corporation to use 567
the contractual periodic prepayment or premium rate, or 568
amendment.
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(2) No contractual periodic prepayment for group policies 571
for health care services shall be used until the contractual 572
periodic prepayment has been filed with the superintendent. The 573
superintendent may reject a filing made under division (A)(2) of 574
this section at any time, with at least thirty days' written 575
notice to a health insuring corporation, if the contractual 576
periodic prepayment is not in accordance with sound actuarial 578
principles or is not reasonably related to the applicable 579
coverage and characteristics of the applicable class of 580
enrollees.
(3) At any time, the superintendent, upon at least thirty 582
days' written notice to a health insuring corporation, may 583
withdraw the approval given under division (A)(1) of this 584
section, deemed or actual, of any contractual periodic prepayment 586
or premium rate, or amendment, based on information that either 587
of the following applies:
(a) The contractual periodic prepayment or premium rate, 590
or amendment, is not in accordance with sound actuarial 591
principles.
(b) The contractual periodic prepayment or premium rate, 594
or amendment, is not reasonably related to the applicable 595
coverage and characteristics of the applicable class of 596
enrollees.
(4) Any disapproval under division (A)(1) of this section, 598
any rejection of a filing made under division (A)(2) of this 600
section, or any withdrawal of approval under division (A)(3) of 601
this section, shall be effected by a written notice, which shall 602
state the specific basis for the disapproval, rejection, or 603
withdrawal and shall be issued in accordance with Chapter 119. of 604
the Revised Code. 605
(B) Notwithstanding division (A) of this section, a health 608
insuring corporation may use a contractual periodic prepayment or 609
premium rate for policies used for the coverage of beneficiaries 610
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 612
14
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 614
risk contract or medicare cost contract, or for policies used for 615
the coverage of beneficiaries enrolled in the federal employees 616
health benefits program pursuant to 5 U.S.C.A. 8905, or for 619
policies used for the coverage of beneficiaries enrolled in Title 620
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 622
U.S.C.A. 301, as amended, known as the medical assistance program 625
or medicaid, provided by the Ohio department of human services 626
under Chapter 5111. of the Revised Code, or for policies used for 627
the coverage of beneficiaries under any other federal health care 628
program regulated by a federal regulatory body, if both of the 629
following apply: 630
(1) The contractual periodic prepayment or premium rate 632
has been approved by the United States department of health and 633
human services, the United States office of personnel management, 635
or the Ohio department of human services.
(2) The contractual periodic prepayment or premium rate is 637
filed with the superintendent prior to use and is accompanied by 638
documentation of approval from the United States department of 640
health and human services, the United States office of personnel 642
management, or the Ohio department of human services. 644
(C) The administrative expense portion of all contractual 647
periodic prepayment or premium rate filings submitted to the 648
superintendent for review must reflect the actual cost of 649
administering the product. The superintendent may require that 650
the administrative expense portion of the filings be itemized and 651
supported.
(D)(1) Copayments and deductibles must be reasonable and 654
must not be a barrier to the necessary utilization of services by 655
enrollees.
(2) A health insuring corporation may not impose copayment 658
charges on basic health care services that exceed thirty per cent 659
of the total cost of providing any single covered health care 660
service, except for PHYSICIAN OFFICE VISITS, emergency health 661
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services, and urgent care services. The total cost of providing 662
a health care service is the cost to the health insuring 663
corporation of providing the health care service to the enrollee 664
ITS ENROLLEES as reduced by any applicable provider discount. An 667
open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of 668
providing any single covered health care service. 669
(3) To ensure that copayments are not a barrier to the 671
utilization of basic health care services, a health insuring 672
corporation may not impose, in any contract year, on any 673
subscriber or enrollee, copayments that exceed two hundred per 674
cent of the total annual premium rate to the subscriber or 675
enrollees. This limitation of two hundred per cent does not 677
include any reasonable copayments that are not a barrier to the 678
necessary utilization of health care services by enrollees and 679
that are imposed on physician office visits, emergency health 680
services, urgent care services, supplemental health care 681
services, or specialty health care services.
(E) A health insuring corporation shall not impose 684
lifetime maximums on basic health care services. However, a 685
health insuring corporation may establish a benefit limit for 686
inpatient hospital services that are provided pursuant to a 687
policy, contract, certificate, or agreement for supplemental 688
health care services.
Sec. 1751.13. (A)(1)(a) A health insuring corporation 698
shall, either directly or indirectly, enter into contracts for 699
the provision of health care services with a sufficient number 700
and types of providers and health care facilities to ensure that 701
all covered health care services will be accessible to enrollees 702
from a contracted provider or health care facility. 703
(b) A HEALTH INSURING CORPORATION SHALL NOT REFUSE TO 706
CONTRACT WITH A PHYSICIAN FOR THE PROVISION OF HEALTH CARE
SERVICES OR REFUSE TO RECOGNIZE A PHYSICIAN AS A SPECIALIST ON 707
THE BASIS THAT THE PHYSICIAN ATTENDED AN EDUCATIONAL PROGRAM OR A 709
16
RESIDENCY PROGRAM APPROVED OR CERTIFIED BY THE AMERICAN 710
OSTEOPATHIC ASSOCIATION. A HEALTH INSURING CORPORATION SHALL NOT 711
REFUSE TO CONTRACT WITH A HEALTH CARE FACILITY FOR THE PROVISION 712
OF HEALTH CARE SERVICES ON THE BASIS THAT THE HEALTH CARE 713
FACILITY IS CERTIFIED OR ACCREDITED BY THE AMERICAN OSTEOPATHIC 715
ASSOCIATION OR THAT THE HEALTH CARE FACILITY IS AN OSTEOPATHIC 716
HOSPITAL AS DEFINED IN SECTION 3702.51 OF THE REVISED CODE. 719
(c) NOTHING IN DIVISION (A)(1)(b) OF THIS SECTION SHALL BE 723
CONSTRUED TO REQUIRE A HEALTH INSURING CORPORATION TO MAKE A 724
BENEFIT PAYMENT UNDER A CLOSED PANEL PLAN TO A PHYSICIAN OR 725
HEALTH CARE FACILITY WITH WHICH THE HEALTH INSURING CORPORATION 726
DOES NOT HAVE A CONTRACT, PROVIDED THAT NONE OF THE BASES SET 727
FORTH IN THAT DIVISION ARE USED AS A REASON FOR FAILING TO MAKE A 728
BENEFIT PAYMENT.
(2) When a health insuring corporation is unable to 730
provide a covered health care service from a contracted provider 731
or health care facility, the health insuring corporation must 732
provide that health care service from a noncontracted provider or 734
health care facility consistent with the terms of the enrollee's 735
policy, contract, certificate, or agreement. The health insuring 736
corporation shall either ensure that the health care service be 737
provided at no greater cost to the enrollee than if the enrollee 738
had obtained the health care service from a contracted provider 739
or health care facility, or make other arrangements acceptable to 740
the superintendent of insurance. 741
(3) Nothing in this section shall prohibit a health 743
insuring corporation from entering into contracts with 744
out-of-state providers or health care facilities that are 745
licensed, certified, accredited, or otherwise authorized in that 746
state. 747
(B)(1) A health insuring corporation shall, either 750
directly or indirectly, enter into contracts with all providers 751
and health care facilities through which health care services are 752
provided to its enrollees.
17
(2) A health insuring corporation, upon written request, 754
shall assist its contracted providers in finding stop-loss or 755
reinsurance carriers.
(C) A health insuring corporation shall file an annual 757
certificate with the superintendent certifying that all provider 758
contracts and contracts with health care facilities through which 759
health care services are being provided contain the following: 760
(1) A description of the method by which the provider or 762
health care facility will be notified of the specific health care 764
services for which the provider or health care facility will be 765
responsible, including any limitations or conditions on such 766
services;
(2) The specific hold harmless provision specifying 768
protection of enrollees set forth as follows: 769
"[Provider/Health Care Facility< agrees that in no event, 772
including but not limited to nonpayment by the health insuring 773
corporation, insolvency of the health insuring corporation, or 774
breach of this agreement, shall [Provider/Health Care Facility< 776
bill, charge, collect a deposit from, seek remuneration or 777
reimbursement from, or have any recourse against, a subscriber, 778
enrollee, person to whom health care services have been provided, 780
or person acting on behalf of the covered enrollee, for health 781
care services provided pursuant to this agreement. This does not 782
prohibit [Provider/Health Care Facility< from collecting 783
co-insurance, deductibles, or copayments as specifically provided 785
in the evidence of coverage, or fees for uncovered health care 786
services delivered on a fee-for-service basis to persons 787
referenced above, nor from any recourse against the health 788
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 790
facility to continue to provide covered health care services to 791
enrollees in the event of the health insuring corporation's 792
insolvency or discontinuance of operations. The provisions shall 794
require the provider or health care facility to continue to 795
18
provide covered health care services to enrollees as needed to 796
complete any medically necessary procedures commenced but 797
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. If an enrollee is 798
receiving necessary inpatient care at a hospital, the provisions 799
may limit the required provision of covered health care services 800
relating to that inpatient care in accordance with division 801
(D)(3) of section 1751.11 of the Revised Code, and may also limit 803
such required provision of covered health care services to the 804
period ending thirty days after the health insuring corporation's 805
insolvency or discontinuance of operations. 806
The provisions required by division (C)(3) of this section 809
shall not require any provider or health care facility to 810
continue to provide any covered health care service after the
occurrence of any of the following: 811
(a) The end of the thirty-day period following the entry 813
of a liquidation order under Chapter 3903. of the Revised Code; 815
(b) The end of the enrollee's period of coverage for a 817
contractual prepayment or premium; 818
(c) The enrollee obtains equivalent coverage with another 820
health insuring corporation or insurer, or the enrollee's 821
employer obtains such coverage for the enrollee; 822
(d) The enrollee or the enrollee's employer terminates 824
coverage under the contract; 825
(e) A liquidator effects a transfer of the health insuring 828
corporation's obligations under the contract under division 829
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 831
responsibilities of the health insuring corporation, and of the 832
contracted providers and health care facilities, with respect to 833
administrative policies and programs, including, but not limited 834
to, payments systems, utilization review, quality ASSURANCE, 835
assessment, and improvement programs, credentialing, 836
confidentiality requirements, and any applicable federal or state 837
19
programs; 838
(5) A provision regarding the availability and 840
confidentiality of those health records maintained by providers 841
and health care facilities to monitor and evaluate the quality of 843
care, to conduct evaluations and audits, and to determine on a 844
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 845
The provision shall include terms requiring the provider or 846
health care facility to make these health records available to 847
appropriate state and federal authorities involved in assessing 848
the quality of care or in investigating the grievances or 849
complaints of enrollees, and requiring the provider or health 850
care facility to comply with applicable state and federal laws 851
related to the confidentiality of medical or health records. 853
(6) A provision that states that contractual rights and 855
responsibilities may not be assigned or delegated by the provider 857
or health care facility without the prior written consent of the 858
health insuring corporation;
(7) A provision requiring the provider or health care 860
facility to maintain adequate professional liability and 861
malpractice insurance. The provision shall also require the 862
provider or health care facility to notify the health insuring 863
corporation not more than ten days after the provider's or health 865
care facility's receipt of notice of any reduction or
cancellation of such coverage. 866
(8) A provision requiring the provider or health care 868
facility to observe, protect, and promote the rights of enrollees 870
as patients;
(9) A provision requiring the provider or health care 872
facility to provide health care services without discrimination 873
on the basis of a patient's participation in the health care 874
plan, age, sex, ethnicity, religion, sexual preference, health 875
status, or disability, and without regard to the source of 876
payments made for health care services rendered to a patient. 877
20
This requirement shall not apply to circumstances when the 878
provider or health care facility appropriately does not render 879
services due to limitations arising from the provider's or health 881
care facility's lack of training, experience, or skill, or due to 882
licensing restrictions.
(10) A provision containing the specifics of any 884
obligation on the provider or health care facility to provide, or 886
to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week; 887
(11) A provision setting forth procedures for the 889
resolution of disputes arising out of the contract; 890
(12) A provision stating that the hold harmless provision 892
required by division (C)(2) of this section shall survive the 894
termination of the contract with respect to services covered and 895
provided under the contract during the time the contract was in 896
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 897
(13) A provision requiring those terms that are used in 899
the contract and that are defined by this chapter, be used in the 901
contract in a manner consistent with those definitions. 902
(D)(1) No health insuring corporation contract with a 905
provider or health care facility shall do either CONTAIN ANY of 906
the following:
(1) Offer (a) A PROVISION THAT DIRECTLY OR INDIRECTLY 908
OFFERS an inducement to the provider or health care facility, 910
directly or indirectly, to reduce or limit medically necessary 911
health care services to a covered enrollee;
(2) Penalize (b) A PROVISION THAT PENALIZES a provider or 914
health care facility that assists an enrollee to seek a 915
reconsideration of the health insuring corporation's decision to 916
deny or limit benefits to the enrollee; 917
(c) A PROVISION THAT LIMITS OR OTHERWISE RESTRICTS THE 920
PROVIDER'S OR HEALTH CARE FACILITY'S ETHICAL AND LEGAL
RESPONSIBILITY TO FULLY ADVISE ENROLLEES ABOUT THEIR MEDICAL 921
21
CONDITION AND ABOUT MEDICALLY APPROPRIATE TREATMENT OPTIONS; 923
(d) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 926
FACILITY FOR PRINCIPALLY ADVOCATING FOR MEDICALLY NECESSARY 927
HEALTH CARE SERVICES;
(e) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 929
FACILITY FOR PROVIDING INFORMATION OR TESTIMONY TO A LEGISLATIVE 930
OR REGULATORY BODY OR AGENCY. THIS SHALL NOT BE CONSTRUED TO 931
PROHIBIT A HEALTH INSURING CORPORATION FROM PENALIZING A PROVIDER 933
OR HEALTH CARE FACILITY THAT PROVIDES INFORMATION OR TESTIMONY 934
THAT IS LIBELOUS OR SLANDEROUS OR THAT DISCLOSES TRADE SECRETS 935
WHICH THE PROVIDER OR HEALTH CARE FACILITY HAS NO PRIVILEGE OR 936
PERMISSION TO DISCLOSE.
(2) NOTHING IN THIS DIVISION SHALL BE CONSTRUED TO 938
PROHIBIT A HEALTH INSURING CORPORATION FROM DOING EITHER OF THE 939
FOLLOWING: 940
(a) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A 943
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICE; 944
(b) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION REVIEW 947
PROTOCOLS, OR DETERMINING WHETHER A PARTICULAR PROVIDER OR HEALTH 948
CARE FACILITY HAS COMPLIED WITH THESE PROTOCOLS. 949
(E) Any contract between a health insuring corporation and 952
an intermediary organization shall clearly specify that the 953
health insuring corporation must approve or disapprove the 954
participation of any provider or health care facility with which 955
the intermediary organization contracts. 956
(F) If an intermediary organization that is not a health 958
delivery network contracting solely with self-insured employers 959
subcontracts with a provider or health care facility, the 960
subcontract with the provider or health care facility shall do 961
all of the following:
(1) Contain the provisions required by divisions (C) and 964
(G) of this section, as made applicable to an intermediary 965
organization, without the inclusion of inducements or penalties 966
described in division (D) of this section; 967
22
(2) Acknowledge that the health insuring corporation is a 969
third-party beneficiary to the agreement; 970
(3) Acknowledge the health insuring corporation's role in 972
approving the participation of the provider or health care 973
facility, pursuant to division (E) of this section. 975
(G) Any provider contract or contract with a health care 978
facility shall clearly specify the health insuring corporation's 979
statutory responsibility to monitor and oversee the offering of 980
covered health care services to its enrollees. 981
(H)(1) A health insuring corporation shall maintain its 984
provider contracts and its contracts with health care facilities 985
at one or more of its places of business in this state, and shall 986
provide copies of these contracts to facilitate regulatory review 987
upon written notice by the superintendent of insurance. 988
(2) Any contract with an intermediary organization shall 990
include provisions requiring the intermediary organization to 991
provide the superintendent with regulatory access to all books, 992
records, financial information, and documents related to the 993
provision of health care services to subscribers and enrollees 994
under the contract. The contract shall require the intermediary 995
organization to maintain such books, records, financial 996
information, and documents at its principal place of business in 997
this state and to preserve them for at least three years in a 998
manner that facilitates regulatory review. 999
(I) A health insuring corporation shall provide notice of 1,002
the termination of any contract with a primary care physician or 1,003
hospital.
(J) Divisions (A) and (B) of this section do not apply to 1,006
any health insuring corporation that, on the effective date of 1,007
this section JUNE 4, 1997, holds a certificate of authority or 1,008
license to operate under Chapter 1740. of the Revised Code. 1,010
(K) NOTHING IN THIS SECTION SHALL RESTRICT THE GOVERNING 1,012
BODY OF A HOSPITAL FROM EXERCISING THE AUTHORITY GRANTED IT 1,013
PURSUANT TO SECTION 3701.351 OF THE REVISED CODE. 1,014
23
Sec. 1751.521. IF AN ENROLLEE SIGNS A MEDICAL INFORMATION 1,016
RELEASE UPON THE REQUEST OF A HEALTH INSURING CORPORATION, THE 1,017
RELEASE SHALL CLEARLY EXPLAIN WHAT INFORMATION MAY BE DISCLOSED 1,018
UNDER THE TERMS OF THE RELEASE. IF A HEALTH INSURING CORPORATION 1,019
UTILIZES THIS RELEASE TO REQUEST MEDICAL INFORMATION FROM A 1,020
HEALTH CARE FACILITY OR PROVIDER, THE HEALTH INSURING CORPORATION
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE 1,021
FACILITY OR PROVIDER, UPON REQUEST. 1,022
Sec. 1751.73. EACH HEALTH INSURING CORPORATION PROVIDING 1,025
BASIC HEALTH CARE SERVICES SHALL IMPLEMENT A QUALITY ASSURANCE 1,026
PROGRAM FOR USE IN CONNECTION WITH THOSE POLICIES, CONTRACTS, AND 1,027
AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. EACH HEALTH 1,028
INSURING CORPORATION REQUIRED TO IMPLEMENT A QUALITY ASSURANCE 1,029
PROGRAM SHALL ANNUALLY FILE A CERTIFICATE WITH THE SUPERINTENDENT 1,030
OF INSURANCE CERTIFYING THAT ITS QUALITY ASSURANCE PROGRAM DOES 1,031
ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR 1,033
DESIGNATES AN EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM 1,034
IMPLEMENTATION AND COMPLIANCE;
(B) INCLUDES A PROCESS ENABLING THE SELECTION AND 1,036
RETENTION OF QUALITY PROVIDERS AND HEALTH CARE FACILITIES THROUGH 1,037
CREDENTIALING, RECREDENTIALING, AND MONITORING PROCEDURES; 1,038
(C) PROVIDES FOR ONGOING MONITORING OF THE QUALITY 1,040
ASSURANCE PROGRAM; 1,041
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR 1,043
ENTITIES WITH WHICH THE HEALTH INSURING CORPORATION CONTRACTS FOR 1,044
SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT 1,046
QUALITY PROBLEMS. 1,047
Sec. 1751.74. (A) TO IMPLEMENT A QUALITY ASSURANCE 1,049
PROGRAM REQUIRED BY SECTION 1715.73 OF THE REVISED CODE, A HEALTH 1,050
INSURING CORPORATION SHALL DO BOTH OF THE FOLLOWING: 1,051
(1) DEVELOP AND MAINTAIN THE APPROPRIATE INFRASTRUCTURE 1,054
AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE AND REPORT, ON A 1,055
24
REGULAR BASIS, THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,056
ENROLLEES, BASED ON A SYSTEMATIC COLLECTION, ANALYSIS, AND 1,057
REPORTING OF RELEVANT DATA. THE HEALTH INSURING CORPORATION 1,058
SHALL ASSURE THAT A COMMITTEE THAT INCLUDES PARTICIPATING 1,059
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING, 1,060
IMPLEMENTING, AND EVALUATING THE QUALITY ASSURANCE PROGRAM AND 1,062
ALL OTHER PROGRAMS IMPLEMENTED BY THE HEALTH INSURING CORPORATION
THAT RELATE TO THE UTILIZATION OF HEALTH CARE SERVICES. A 1,064
COMMITTEE THAT INCLUDES PARTICIPATING PHYSICIANS SHALL ALSO HAVE 1,065
THE OPPORTUNITY TO PARTICIPATE IN THE DERIVATION OF DATA 1,066
ASSESSMENTS, STATISTICAL ANALYSES, AND OUTCOME INTERPRETATIONS 1,068
FROM PROGRAMS MONITORING THE UTILIZATION OF HEALTH CARE SERVICES. 1,069
(2) DEVELOP AND MAINTAIN AN ORGANIZATIONAL PROGRAM FOR 1,072
DESIGNING, MEASURING, ASSESSING, AND IMPROVING THE PROCESSES AND 1,073
OUTCOMES OF HEALTH CARE.
(B) A QUALITY ASSURANCE PROGRAM SHALL: 1,075
(1) ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING 1,077
OPPORTUNITIES TO IMPROVE HEALTH CARE, WHICH SYSTEM IS STRUCTURED 1,078
TO IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE 1,079
OUTCOMES, TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO 1,080
IDENTIFY THOSE PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER 1,081
EXEMPLARY OR PROBLEMATIC PATTERNS. THE QUALITY ASSURANCE PROGRAM 1,082
SHALL USE THE FINDINGS GENERATED BY THE SYSTEM TO WORK ON A 1,084
CONTINUING BASIS WITH PARTICIPATING PROVIDERS AND OTHER STAFF TO 1,085
IMPROVE THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,087
ENROLLEES.
(2) DEVELOP A WRITTEN STATEMENT OF ITS OBJECTIVES, LINES 1,089
OF AUTHORITY AND ACCOUNTABILITY, EVALUATION TOOLS, AND 1,090
PERFORMANCE IMPROVEMENT ACTIVITIES; 1,091
(3) REQUIRE AN ANNUAL EFFECTIVENESS REVIEW OF THE PROGRAM; 1,094
(4) PROVIDE A DESCRIPTION OF HOW THE HEALTH INSURING 1,097
CORPORATION INTENDS TO DO ALL OF THE FOLLOWING: 1,098
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF HEALTH CARE, 1,100
INCLUDING FOCUSED REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO 1,102
25
DISCERN THE CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE 1,104
REVIEWED BY THE QUALITY ASSURANCE PROGRAM EACH YEAR, BASED ON 1,105
CONSIDERATION OF PRACTICES AND DIAGNOSES THAT AFFECT A 1,106
SUBSTANTIAL NUMBER OF THE HEALTH INSURING CORPORATION'S ENROLLEES 1,107
OR THAT COULD PLACE ENROLLEES AT SERIOUS RISK; 1,108
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY 1,110
OF HEALTH CARE, INCLUDING COLLECTION AND ANALYSIS OF INFORMATION 1,112
ON OVER-UTILIZATION AND UNDER-UTILIZATION OF HEALTH CARE 1,113
SERVICES; EVALUATION OF COURSES OF TREATMENT AND OUTCOMES BASED 1,115
ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC 1,116
TO ENROLLEES OR PROVIDERS; 1,117
(d) COMPARE QUALITY ASSURANCE PROGRAM FINDINGS WITH PAST 1,119
PERFORMANCE, INTERNAL GOALS, AND EXTERNAL STANDARDS; 1,121
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND 1,123
CONDUCT PEER REVIEW ACTIVITIES; 1,124
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS 1,126
DEVELOPED WITH APPROPRIATE CLINICAL INPUT; 1,127
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO QUALITY 1,129
ASSURANCE PROGRAM FINDINGS; 1,130
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE 1,132
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES. 1,133
Sec. 1751.75. A HEALTH INSURING CORPORATION MAY PRESENT 1,135
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.73 1,136
AND 1751.74 OF THE REVISED CODE BY SUBMITTING CERTIFICATION TO 1,137
THE SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN 1,138
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE NATIONAL QUALITY 1,139
HEALTH COUNCIL, THE JOINT COMMISSION ON ACCREDITATION OF HEALTH 1,141
CARE ORGANIZATIONS, OR THE AMERICAN ACCREDITATION HEALTHCARE 1,142
COMMISSION/UTILIZATION REVIEW ACCREDITATION COMMISSION. THE 1,143
SUPERINTENDENT, UPON REVIEW OF THE ORGANIZATION'S ACCREDITATION 1,144
PROCESS, MAY DETERMINE THAT SUCH ACCREDITATION CONSTITUTES 1,145
26
COMPLIANCE BY THE HEALTH INSURING CORPORATION WITH THE 1,146
REQUIREMENTS OF THESE SECTIONS. 1,147
Sec. 1751.77. AS USED IN SECTIONS 1751.77 TO 1751.86 OF 1,149
THE REVISED CODE, UNLESS OTHERWISE SPECIFICALLY PROVIDED: 1,150
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A 1,152
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,153
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,155
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,156
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,158
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,159
HEALTH CARE SERVICE DOES NOT MEET THE HEALTH INSURING 1,161
CORPORATION'S REQUIREMENTS FOR BENEFIT PAYMENT, AND IS THEREFORE 1,162
DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH 1,164
CARE SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING. 1,165
(C) "CASE MANAGEMENT" MEANS A COORDINATED SET OF 1,167
ACTIVITIES CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF 1,168
SERIOUS, COMPLICATED, PROTRACTED, OR OTHER SPECIFIED HEALTH 1,169
CONDITIONS.
(D) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH 1,171
INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,173
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,174
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,175
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,177
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,178
HEALTH CARE SERVICE SATISFIES THE HEALTH INSURING CORPORATION'S 1,179
REQUIREMENTS FOR BENEFIT PAYMENT. 1,180
(E) "CLINICAL PEER" MEANS A PHYSICIAN WHEN AN EVALUATION 1,183
IS TO BE MADE OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE 1,184
SERVICES PROVIDED BY A PHYSICIAN. IF AN EVALUATION IS TO BE MADE 1,185
OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED 1,186
BY A PROVIDER WHO IS NOT A PHYSICIAN, "CLINICAL PEER" MEANS 1,187
EITHER A PHYSICIAN OR A PROVIDER HOLDING THE SAME LICENSE AS THE 1,188
PROVIDER WHO PROVIDED THE HEALTH CARE SERVICES. 1,189
27
(F) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING 1,191
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE 1,192
GUIDELINES USED BY A HEALTH INSURING CORPORATION TO DETERMINE THE 1,193
NECESSITY AND APPROPRIATENESS OF HEALTH CARE SERVICES. 1,195
(G) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED 1,197
DURING A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT. 1,198
(H) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR 1,200
DETERMINING, PRIOR TO A PATIENT'S DISCHARGE FROM A HEALTH CARE 1,201
FACILITY, THE COORDINATION AND MANAGEMENT OF THE CARE THAT THE 1,203
PATIENT IS TO RECEIVE FOLLOWING DISCHARGE FROM A HEALTH CARE 1,204
FACILITY. 1,205
(I) "PARTICIPATING PROVIDER" MEANS A PROVIDER OR HEALTH 1,207
CARE FACILITY THAT, UNDER A CONTRACT WITH A HEALTH INSURING 1,209
CORPORATION OR WITH ITS CONTRACTOR OR SUBCONTRACTOR, HAS AGREED 1,211
TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR 1,212
DEDUCTIBLES, DIRECTLY OR INDIRECTLY FROM THE HEALTH INSURING 1,213
CORPORATION.
(J) "PHYSICIAN" MEANS A PROVIDER AUTHORIZED UNDER CHAPTER 1,216
4731. OF THE REVISED CODE TO PRACTICE MEDICINE AND SURGERY OR 1,219
OSTEOPATHIC MEDICINE AND SURGERY.
(K) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS 1,221
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT. 1,222
(L) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF 1,224
MEDICAL NECESSITY THAT IS CONDUCTED AFTER HEALTH CARE SERVICES 1,225
HAVE BEEN PROVIDED TO A PATIENT. "RETROSPECTIVE REVIEW" DOES NOT 1,227
INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED TO AN EVALUATION OF 1,228
REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY OF 1,229
CODING, OR ADJUDICATION OF PAYMENT.
(M) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT 1,231
TO OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE 1,232
PROVIDER ORIGINALLY MAKING A RECOMMENDATION FOR PROPOSED HEALTH 1,233
CARE SERVICES TO ASSESS THE CLINICAL NECESSITY AND 1,234
APPROPRIATENESS OF THE PROPOSED HEALTH CARE SERVICES. 1,235
28
(N) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR 1,237
THE USE OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, 1,238
EFFICACY, OR EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR 1,239
SETTINGS. AREAS OF REVIEW MAY INCLUDE AMBULATORY REVIEW, 1,240
PROSPECTIVE REVIEW, SECOND OPINION, CERTIFICATION, CONCURRENT 1,241
REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR RETROSPECTIVE 1,242
REVIEW.
(O) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT 1,244
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH INSURING 1,245
CORPORATION PERFORMING A REVIEW OF ITS OWN HEALTH CARE PLANS. 1,247
Sec. 1751.78. (A)(1) SECTIONS 1751.77 TO 1751.86 OF THE 1,250
REVISED CODE APPLY TO ANY HEALTH INSURING CORPORATION THAT 1,251
PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES IN CONNECTION 1,252
WITH ITS POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC
HEALTH CARE SERVICES AND TO ANY DESIGNEE OF THE HEALTH INSURING 1,253
CORPORATION, OR TO ANY UTILIZATION REVIEW ORGANIZATION THAT 1,255
PERFORMS UTILIZATION REVIEW FUNCTIONS ON BEHALF OF THE HEALTH 1,256
INSURING CORPORATION IN CONNECTION WITH POLICIES, CONTRACTS, OR 1,257
AGREEMENTS OF THE HEALTH INSURING CORPORATION PROVIDING BASIC
HEALTH CARE SERVICES. 1,258
(2) NOTHING IN SECTIONS 1751.77 TO 1751.82 OR SECTION 1,260
1751.85 OF THE REVISED CODE SHALL BE CONSTRUED TO REQUIRE A 1,262
HEALTH INSURING CORPORATION TO PROVIDE OR PERFORM UTILIZATION 1,263
REVIEW SERVICES IN CONNECTION WITH HEALTH CARE SERVICES PROVIDED 1,264
UNDER A POLICY, PLAN, OR AGREEMENT OF SUPPLEMENTAL HEALTH CARE 1,265
SERVICES OR SPECIALTY HEALTH CARE SERVICES. 1,266
(B)(1) EACH HEALTH INSURING CORPORATION SHALL BE 1,269
RESPONSIBLE FOR MONITORING ALL UTILIZATION REVIEW ACTIVITIES 1,270
CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH INSURING CORPORATION 1,271
AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS 1751.77 TO 1,272
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,274
ARE MET. THE HEALTH INSURING CORPORATION SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE 1,275
CONDUCT OF THE HEALTH INSURING CORPORATION'S UTILIZATION REVIEW 1,276
29
PROGRAM. 1,277
(2) IF A HEALTH INSURING CORPORATION CONTRACTS TO HAVE A 1,279
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE 1,280
UTILIZATION REVIEW FUNCTIONS REQUIRED BY SECTIONS 1751.77 TO 1,281
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,284
THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE HEALTH INSURING 1,285
CORPORATION RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING 1,286
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE MET. 1,288
Sec. 1751.79. A HEALTH INSURING CORPORATION THAT CONDUCTS 1,290
UTILIZATION REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW 1,291
PROGRAM THAT DESCRIBES ALL REVIEW ACTIVITIES, BOTH DELEGATED AND 1,292
NONDELEGATED, FOR COVERED HEALTH CARE SERVICES PROVIDED, 1,294
INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY, 1,296
APPROPRIATENESS, EFFICACY, OR EFFICIENCY OF HEALTH CARE SERVICES; 1,298
(B) THE USE OF DATA SOURCES AND CLINICAL REVIEW CRITERIA 1,300
IN MAKING DECISIONS; 1,302
(C) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF 1,304
CRITERIA AND COMPATIBLE DECISIONS; 1,305
(D) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED 1,307
IN ASSESSING UTILIZATION OF HEALTH CARE SERVICES; 1,309
(E) MECHANISMS FOR ASSURING CONFIDENTIALITY OF CLINICAL 1,311
AND PROPRIETARY INFORMATION; 1,312
(F) THE PERIODIC ASSESSMENT OF UTILIZATION REVIEW 1,314
ACTIVITIES, AND THE REPORTING OF THESE ASSESSMENTS TO THE HEALTH 1,315
INSURING CORPORATION'S BOARD, BY A UTILIZATION REVIEW COMMITTEE, 1,316
A QUALITY ASSURANCE COMMITTEE, OR ANY SIMILAR COMMITTEE; 1,317
(G) THE FUNCTIONAL RESPONSIBILITY FOR DAY-TO-DAY PROGRAM 1,320
MANAGEMENT BY STAFF;
(H) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND 1,322
COMMUNICATED TO PROVIDERS AND HEALTH CARE FACILITIES. 1,323
Sec. 1751.80. THE UTILIZATION REVIEW PROGRAM OF A HEALTH 1,325
INSURING CORPORATION SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL 1,326
30
OF THE FOLLOWING: 1,327
(A) THE PROGRAM SHALL USE DOCUMENTED CLINICAL REVIEW 1,330
CRITERIA THAT ARE BASED ON SOUND CLINICAL EVIDENCE AND ARE 1,331
EVALUATED PERIODICALLY TO ASSURE ONGOING EFFICACY. A HEALTH 1,332
INSURING CORPORATION MAY DEVELOP ITS OWN CLINICAL REVIEW CRITERIA 1,333
OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM QUALIFIED VENDORS. 1,334
A HEALTH INSURING CORPORATION SHALL MAKE ITS CLINICAL REVIEW 1,335
RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES. THE RATIONALE MADE AVAILABLE TO AUTHORIZED GOVERNMENT 1,336
AGENCIES IS CONFIDENTIAL AND IS NOT A PUBLIC RECORD AS DEFINED IN 1,338
SECTION 149.43 OF THE REVISED CODE. 1,340
(B) QUALIFIED PROVIDERS SHALL ADMINISTER THE PROGRAM AND 1,343
OVERSEE REVIEW DETERMINATIONS. A CLINICAL PEER IN THE SAME, OR 1,345
IN A SIMILAR, SPECIALTY AS TYPICALLY MANAGES THE MEDICAL
CONDITION, PROCEDURE, OR TREATMENT UNDER REVIEW SHALL EVALUATE 1,346
THE CLINICAL APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE 1,347
THE SUBJECT OF AN APPEAL. 1,348
(C) THE HEALTH INSURING CORPORATION SHALL ISSUE 1,351
UTILIZATION REVIEW DETERMINATIONS IN A TIMELY MANNER PURSUANT TO 1,352
THE REQUIREMENTS OF SECTIONS 1751.81 AND 1751.82 OF THE REVISED 1,354
CODE AND THE ENROLLEE GRIEVANCE REQUIREMENTS. THE HEALTH 1,355
INSURING CORPORATION SHALL OBTAIN INFORMATION REQUIRED TO MAKE A 1,357
UTILIZATION REVIEW DETERMINATION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT 1,358
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA 1,359
CONSISTENTLY. 1,360
(D) IF THE HEALTH INSURING CORPORATION DELEGATES ANY 1,363
UTILIZATION REVIEW ACTIVITIES TO A UTILIZATION REVIEW 1,364
ORGANIZATION, THE HEALTH INSURING CORPORATION SHALL MAINTAIN 1,365
ADEQUATE OVERSIGHT, INCLUDING A PROCESS BY WHICH THE HEALTH 1,366
INSURING CORPORATION EVALUATES THE PERFORMANCE OF THE 1,367
ORGANIZATION, AND SHALL MAINTAIN COPIES OF BOTH OF THE FOLLOWING: 1,369
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S ACTIVITIES 1,372
AND RESPONSIBILITIES, INCLUDING REPORTING REQUIREMENTS; 1,373
31
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S 1,375
PROGRAM BY THE HEALTH INSURING CORPORATION. 1,376
(E) THE HEALTH INSURING CORPORATION OR ITS DESIGNEE 1,379
UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE ENROLLEES AND 1,380
PARTICIPATING PROVIDERS WITH ACCESS TO ITS REVIEW STAFF BY MEANS 1,381
OF A TOLL-FREE TELEPHONE NUMBER OR COLLECT-CALL TELEPHONE LINE. 1,382
(F) WHEN CONDUCTING PROSPECTIVE OR CONCURRENT REVIEW, THE 1,385
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,386
ORGANIZATION SHALL COLLECT ONLY THE INFORMATION NECESSARY TO 1,387
CERTIFY THE ADMISSION, PROCEDURE OR TREATMENT, LENGTH OF STAY, 1,388
FREQUENCY, AND DURATION OF HEALTH CARE SERVICES. 1,389
(G) COMPENSATION TO PERSONS PROVIDING UTILIZATION REVIEW 1,392
SERVICES FOR THE HEALTH INSURING CORPORATION SHALL NOT CONTAIN 1,393
INCENTIVES, DIRECT OR INDIRECT, FOR THEM TO MAKE INAPPROPRIATE 1,394
REVIEW DECISIONS.
Sec. 1751.81. (A) AS USED IN THIS SECTION: 1,396
(1) "ENROLLEE" INCLUDES THE REPRESENTATIVE OF AN ENROLLEE. 1,398
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY 1,400
FACE-TO-FACE CLINICAL EVALUATION OR SECOND OPINION THAT MAY BE 1,402
REQUIRED.
(B) A HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN 1,404
PROCEDURES FOR MAKING UTILIZATION REVIEW DETERMINATIONS AND FOR 1,406
NOTIFYING ENROLLEES, AND PARTICIPATING PROVIDERS AND HEALTH CARE 1,408
FACILITIES ACTING ON BEHALF OF ENROLLEES, OF ITS DETERMINATIONS. 1,409
(C) FOR INITIAL DETERMINATIONS, A HEALTH INSURING 1,411
CORPORATION SHALL MAKE THE DETERMINATION WITHIN TWO BUSINESS DAYS 1,413
AFTER OBTAINING ALL NECESSARY INFORMATION REGARDING A PROPOSED 1,415
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE REQUIRING A REVIEW 1,416
DETERMINATION. 1,417
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN 1,419
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE, THE HEALTH INSURING 1,420
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,421
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN THREE 1,422
BUSINESS DAYS AFTER MAKING THE INITIAL CERTIFICATION, AND SHALL 1,424
32
PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,425
FACILITY WITHIN TWO BUSINESS DAYS AFTER MAKING THE TELEPHONE 1,427
NOTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,429
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,431
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,432
THREE BUSINESS DAYS AFTER MAKING THE ADVERSE DETERMINATION, AND 1,433
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE 1,434
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,435
FACILITY WITHIN ONE BUSINESS DAY AFTER MAKING THE TELEPHONE 1,436
NOTIFICATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH 1,438
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN ONE 1,440
BUSINESS DAY AFTER OBTAINING ALL NECESSARY INFORMATION. 1,441
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED 1,443
STAY OR ADDITIONAL HEALTH CARE SERVICES, THE HEALTH INSURING 1,444
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,445
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE 1,446
BUSINESS DAY AFTER MAKING THE CERTIFICATION, AND SHALL PROVIDE 1,448
WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER 1,449
THE TELEPHONE NOTIFICATION. THE WRITTEN NOTIFICATION SHALL 1,450
INCLUDE THE NUMBER OF EXTENDED DAYS OR NEXT REVIEW DATE, THE NEW 1,451
TOTAL NUMBER OF DAYS OF HEALTH CARE SERVICES APPROVED, AND THE 1,453
DATE OF ADMISSION OR INITIATION OF HEALTH CARE SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,455
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,456
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,457
ONE BUSINESS DAY AFTER MAKING THE ADVERSE DETERMINATION, AND 1,458
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE 1,459
AND THE PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY 1,460
AFTER THE TELEPHONE NOTIFICATION. THE HEALTH CARE SERVICE TO THE 1,461
ENROLLEE SHALL BE CONTINUED, WITH STANDARD COPAYMENTS AND 1,463
33
DEDUCTIBLES, IF APPLICABLE, UNTIL THE ENROLLEE HAS BEEN NOTIFIED 1,464
OF THE DETERMINATION. 1,465
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH 1,467
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN THIRTY 1,470
BUSINESS DAYS AFTER RECEIVING ALL NECESSARY INFORMATION. 1,471
(1) IN THE CASE OF A CERTIFICATION, THE HEALTH INSURING 1,473
CORPORATION MAY NOTIFY THE ENROLLEE AND THE PROVIDER OR HEALTH 1,475
CARE FACILITY RENDERING THE HEALTH CARE SERVICE IN WRITING. 1,476
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,478
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE AND THE PROVIDER 1,480
OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, IN 1,481
WRITING, WITHIN FIVE BUSINESS DAYS AFTER MAKING THE ADVERSE 1,482
DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND 1,485
(E) OF THIS SECTION FOR DETERMINATIONS AND NOTIFICATIONS SHALL 1,486
PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,487
ENROLLEE OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE
HEALTH INSURING CORPORATION. THE HEALTH INSURING CORPORATION 1,488
SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING EXPEDITED 1,490
UTILIZATION REVIEW DETERMINATIONS AND NOTIFICATIONS OF ENROLLEES 1,491
AND PROVIDERS OR HEALTH CARE FACILITIES WHEN WARRANTED BY THE 1,492
MEDICAL CONDITION OF THE ENROLLEE. 1,493
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION 1,495
SHALL INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE 1,496
DETERMINATION, INSTRUCTIONS FOR INITIATING AN APPEAL OR 1,497
RECONSIDERATION OF THE DETERMINATION, AND INSTRUCTIONS FOR 1,498
REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE USED TO 1,499
MAKE THE DETERMINATION. A HEALTH INSURING CORPORATION SHALL
PROVIDE THE CLINICAL RATIONALE FOR AN ADVERSE DETERMINATION IN 1,501
WRITING TO ANY PARTY WHO RECEIVED NOTICE OF THE ADVERSE 1,503
DETERMINATION AND WHO FOLLOWS THE INSTRUCTIONS FOR A REQUEST. 1,504
(H) A HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 1,506
PROCEDURES TO ADDRESS THE FAILURE OR INABILITY OF A HEALTH CARE 1,509
FACILITY, PROVIDER, OR ENROLLEE TO PROVIDE ALL NECESSARY 1,511
34
INFORMATION FOR REVIEW. IF THE HEALTH CARE FACILITY, PROVIDER,
OR ENROLLEE WILL NOT RELEASE NECESSARY INFORMATION, THE HEALTH 1,513
INSURING CORPORATION MAY DENY CERTIFICATION. 1,514
Sec. 1751.82. (A) IN A CASE INVOLVING AN INITIAL 1,517
DETERMINATION OR A CONCURRENT REVIEW DETERMINATION, A HEALTH 1,518
INSURING CORPORATION SHALL GIVE THE PROVIDER OR HEALTH CARE 1,519
FACILITY RENDERING THE HEALTH CARE SERVICE AN OPPORTUNITY TO 1,520
REQUEST IN WRITING ON BEHALF OF THE ENROLLEE A RECONSIDERATION OF 1,521
AN ADVERSE DETERMINATION BY THE REVIEWER MAKING THE ADVERSE 1,522
DETERMINATION. THE RECONSIDERATION SHALL OCCUR WITHIN THREE 1,523
BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION'S RECEIPT OF 1,524
THE WRITTEN REQUEST FOR RECONSIDERATION, AND SHALL BE CONDUCTED 1,525
BETWEEN THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH 1,526
CARE SERVICE AND THE REVIEWER WHO MADE THE ADVERSE DETERMINATION. 1,528
IF THAT REVIEWER CANNOT BE AVAILABLE WITHIN THREE BUSINESS DAYS, 1,529
THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION 1,532
(A) OF THIS SECTION DOES NOT RESOLVE THE DIFFERENCE OF OPINION, 1,533
THE ADVERSE DETERMINATION MAY BE APPEALED BY THE ENROLLEE OR THE 1,534
PROVIDER OR HEALTH CARE FACILITY ON BEHALF OF THE ENROLLEE. 1,535
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR 1,537
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION. 1,538
(D) THE TIME PERIOD ALLOWED BY DIVISION (A) OF THIS 1,541
SECTION FOR A RECONSIDERATION OF AN ADVERSE DETERMINATION SHALL 1,542
NOT APPLY IF THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,543
ENROLLEE REQUIRES A MORE EXPEDITED RECONSIDERATION. THE HEALTH 1,544
INSURING CORPORATION SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING 1,545
SUCH AN EXPEDITED RECONSIDERATION. 1,546
Sec. 1751.83. A HEALTH INSURING CORPORATION MAY PRESENT 1,549
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.77 1,550
TO 1751.82 OF THE REVISED CODE BY SUBMITTING EVIDENCE TO THE 1,551
SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE 1,552
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE NATIONAL QUALITY 1,553
35
HEALTH COUNCIL, THE JOINT COMMISSION ON ACCREDITATION OF HEALTH 1,555
CARE ORGANIZATIONS, OR THE AMERICAN ACCREDITATION HEALTHCARE
COMMISSION/UTILIZATION REVIEW ACCREDITATION COMMISSION. THE 1,557
SUPERINTENDENT, UPON REVIEW OF THE ORGANIZATION'S ACCREDITATION 1,558
PROCESS, MAY DETERMINE THAT SUCH ACCREDITATION CONSTITUTES 1,559
COMPLIANCE BY THE HEALTH INSURING CORPORATION WITH THE 1,560
REQUIREMENTS OF THESE SECTIONS.
Sec. 1751.84. EACH PARTICIPATING PROVIDER OR HEALTH CARE 1,562
FACILITY SUBMITTING A CLAIM SHALL COOPERATE WITH THE UTILIZATION 1,564
REVIEW PROGRAM OF A HEALTH INSURING CORPORATION OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE HEALTH INSURING 1,565
CORPORATION OR ITS DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL 1,566
RECORDS DURING REGULAR BUSINESS HOURS, OR COPIES OF THOSE RECORDS 1,567
AT A REASONABLE COST. 1,568
Sec. 1751.85. A HEALTH INSURING CORPORATION SHALL ANNUALLY 1,570
FILE A CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE 1,571
CERTIFYING ITS COMPLIANCE WITH SECTIONS 1751.77 TO 1751.82 OF THE 1,572
REVISED CODE. 1,574
Sec. 1751.86. (A) NO HEALTH INSURING CORPORATION SHALL 1,577
FAIL TO COMPLY WITH SECTIONS 1751.77 TO 1751.82 OF THE REVISED 1,578
CODE.
(B) WHOEVER VIOLATES DIVISION (A) OF THIS SECTION IS 1,581
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE 1,583
IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 1,584
THE REVISED CODE.
Sec. 1753.01. AS USED IN THIS CHAPTER: 1,586
(A) "ECONOMIC PROFILING" MEANS A HEALTH INSURING 1,588
CORPORATION'S USE OF ECONOMIC PERFORMANCE DATA AND ECONOMIC 1,589
INFORMATION IN DETERMINING WHETHER TO CONTRACT WITH A PROVIDER 1,590
FOR THE PROVISION OF COVERED HEALTH CARE SERVICES TO ENROLLEES AS 1,592
A PARTICIPATING PROVIDER.
(B) "BASIC HEALTH CARE SERVICES," "ENROLLEE," "HEALTH CARE 1,594
FACILITY," "HEALTH CARE SERVICES," "HEALTH INSURING CORPORATION," 1,595
"MEDICAL RECORD," "PROVIDER," AND "SUPPLEMENTAL HEALTH CARE 1,596
36
SERVICES" HAVE THE SAME MEANINGS AS IN SECTION 1751.01 OF THE 1,598
REVISED CODE.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL 1,600
PRESCRIBE A STANDARD CREDENTIALING FORM TO BE USED BY ALL HEALTH 1,601
INSURING CORPORATIONS WHEN CREDENTIALING PROVIDERS IN CONNECTION 1,602
WITH POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH 1,603
CARE SERVICES. THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS 1,604
TO THE SUPERINTENDENT FOR SUCH A STANDARD CREDENTIALING FORM. IF 1,605
THE DIRECTOR MAKES SUCH RECOMMENDATIONS, THE DIRECTOR SHALL TAKE 1,606
INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY 1,607
THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE AMERICAN 1,609
MEDICAL ASSOCIATION, THE AMERICAN ASSOCIATION OF HEALTH PLANS, 1,611
AND ANY OTHER NATIONAL ORGANIZATION THAT HAS DEVELOPED SUCH A 1,612
FORM. IN PRESCRIBING A STANDARD CREDENTIALING FORM, THE 1,613
SUPERINTENDENT SHALL CONSIDER ANY RECOMMENDATIONS MADE BY THE 1,614
DIRECTOR. THE SUPERINTENDENT MAY AMEND OR REVISE THE PRESCRIBED 1,615
STANDARD CREDENTIALING FORM AS NECESSARY.
Sec. 1753.04. BEGINNING ONE HUNDRED TWENTY DAYS AFTER THE 1,617
SUPERINTENDENT OF INSURANCE PRESCRIBES A STANDARD CREDENTIALING 1,618
FORM UNDER SECTION 1753.03 OF THE REVISED CODE, NO HEALTH 1,621
INSURING CORPORATION SHALL FAIL TO USE THE PRESCRIBED STANDARD 1,622
CREDENTIALING FORM WHEN INITIALLY CREDENTIALING OR 1,623
RECREDENTIALING PROVIDERS IN CONNECTION WITH POLICIES, CONTRACTS, 1,624
AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. IF THE 1,625
SUPERINTENDENT AMENDS OR REVISES THE STANDARD CREDENTIALING FORM, 1,627
A HEALTH INSURING CORPORATION SHALL USE THE AMENDED OR REVISED 1,628
FORM TO CREDENTIAL OR RECREDENTIAL PROVIDERS. 1,629
A HEALTH INSURING CORPORATION MAY REQUEST SUCH INFORMATION 1,632
FROM A PROVIDER, IN ADDITION TO THAT INFORMATION TO BE PROVIDED
ON THE STANDARD CREDENTIALING FORM, AS NECESSITATED BY THE HEALTH 1,634
INSURING CORPORATION'S CREDENTIALING STANDARDS.
Sec. 1753.05. (A) A HEALTH INSURING CORPORATION MAY USE 1,637
ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A PROVIDER, 1,638
HOWEVER, SUCH ECONOMIC PROFILING SHALL TAKE INTO CONSIDERATION 1,639
37
THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS. 1,640
(B) FOR AN INITIAL APPLICANT, A HEALTH INSURING 1,642
CORPORATION MAY REQUEST INFORMATION NECESSARY TO PERFORM AN 1,643
ECONOMIC PROFILE. IF INFORMATION ON CASE MIX, SEVERITY OF 1,644
ILLNESS, AND AGE OF PATIENTS IS REQUESTED BY A HEALTH INSURING 1,645
CORPORATION AND NOT PRODUCED BY THE APPLICANT, THE HEALTH 1,646
INSURING CORPORATION IS NOT REQUIRED TO TAKE THESE FACTORS INTO 1,647
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PROVIDER. 1,648
(C) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,651
CORPORATION FROM TAKING INTO CONSIDERATION THE QUALITY AND 1,652
APPROPRIATENESS OF CARE PROVIDED BY A PROVIDER WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE PROVIDER. 1,654
Sec. 1753.06. A HEALTH INSURING CORPORATION SHALL NOTIFY A 1,657
PROVIDER SEEKING TO ENTER INTO A PARTICIPATION CONTRACT WITH THE
HEALTH INSURING CORPORATION OF THE STATUS OF THE PROVIDER'S 1,658
APPLICATION WITHIN ONE HUNDRED TWENTY DAYS AFTER THE HEALTH 1,659
INSURING CORPORATION'S RECEIPT OF THE PROVIDER'S COMPLETED 1,660
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY A HEALTH 1,661
INSURING CORPORATION IF, DUE TO EXTENUATING CIRCUMSTANCES, THE 1,662
HEALTH INSURING CORPORATION NEEDS ADDITIONAL TIME TO CONSIDER THE 1,663
APPLICATION AND NOTIFIES THE PROVIDER OF THE REASON FOR THE 1,664
DELAY.
Sec. 1753.07. (A) PRIOR TO ENTERING INTO A PARTICIPATION 1,667
CONTRACT WITH A PROVIDER UNDER SECTION 1751.13 OF THE REVISED 1,668
CODE, A HEALTH INSURING CORPORATION SHALL DISCLOSE BASIC 1,669
INFORMATION REGARDING ITS PROGRAMS AND PROCEDURES TO THE 1,670
PROVIDER, UPON THE PROVIDER'S REQUEST. THE INFORMATION SHALL 1,671
INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PARTICIPATING PROVIDER IS REIMBURSED FOR THE 1,673
PARTICIPATING PROVIDER'S SERVICES, INCLUDING THE RANGE AND 1,675
STRUCTURE OF ANY FINANCIAL RISK SHARING ARRANGEMENTS, A 1,676
DESCRIPTION OF ANY INCENTIVE PLANS, AND, IF REIMBURSED ACCORDING 1,677
TO A TYPE OF FEE-FOR-SERVICE ARRANGEMENT, THE LEVEL OF 1,678
REIMBURSEMENT FOR THE PARTICIPATING PROVIDER'S SERVICES; 1,679
38
(2) HOW REFERRALS TO OTHER PARTICIPATING PROVIDERS OR TO 1,681
NONPARTICIPATING PROVIDERS ARE MADE; 1,682
(3) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND 1,684
THE POTENTIAL FOR COST TO BE INCURRED; 1,685
(4) HOW A PARTICIPATING PROVIDER'S NAME AND ADDRESS WILL 1,687
BE USED IN MARKETING MATERIALS. 1,688
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE ALL OF THE 1,691
FOLLOWING TO A PARTICIPATING PROVIDER:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE 1,693
PARTICIPATION CONTRACT, THAT IS NOT OTHERWISE AVAILABLE AS A 1,694
PUBLIC RECORD, IF SUCH MATERIAL AFFECTS THE PARTICIPATING 1,695
PROVIDER;
(2) ADMINISTRATIVE MANUALS RELATED TO PROVIDER 1,697
PARTICIPATION, IF ANY; 1,698
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION 1,700
CONTRACT. 1,701
Sec. 1753.08. (A) A HEALTH INSURING CORPORATION SHALL 1,703
NOTIFY A PARTICIPATING PROVIDER PRIOR TO THE EFFECTIVE DATE OF AN 1,705
AMENDMENT TO THE PARTICIPATING PROVIDER'S CONTRACT WITH THE 1,707
HEALTH INSURING CORPORATION, AND PRIOR TO THE EFFECTIVE DATE OF
AN AMENDMENT TO ANY DOCUMENT INCORPORATED BY REFERENCE INTO THE 1,709
CONTRACT IF THE AMENDMENT OF THE DOCUMENT DIRECTLY AND MATERIALLY 1,710
AFFECTS THE PARTICIPATING PROVIDER. SUCH AMENDMENTS SHALL NOT BE 1,712
EFFECTIVE WITH REGARD TO A PARTICIPATING PROVIDER UNTIL THE 1,713
PARTICIPATING PROVIDER HAS HAD REASONABLE TIME, AS DEFINED IN THE 1,714
CONTRACT, TO EXERCISE THE PARTICIPATING PROVIDER'S RIGHT TO 1,715
TERMINATE ITS PARTICIPATION STATUS IN ACCORDANCE WITH THE TERMS 1,716
AND CONDITIONS OF THE CONTRACT. 1,717
(B) DIVISION (A) OF THIS SECTION DOES NOT APPLY IF THE 1,720
DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD RESULT IN 1,721
IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS REQUIRED BY 1,722
STATE OR FEDERAL LAW, RULE, OR REGULATION. 1,723
Sec. 1753.09. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF 1,726
THIS SECTION, PRIOR TO TERMINATING THE PARTICIPATION OF A 1,727
39
PROVIDER ON THE BASIS OF THE PARTICIPATING PROVIDER'S FAILURE TO 1,728
MEET THE HEALTH INSURING CORPORATION'S STANDARDS FOR QUALITY OR 1,729
UTILIZATION IN THE DELIVERY OF HEALTH CARE SERVICES, A HEALTH 1,731
INSURING CORPORATION SHALL GIVE THE PARTICIPATING PROVIDER NOTICE 1,732
OF THE REASON OR REASONS FOR ITS DECISION TO TERMINATE THE 1,733
PROVIDER'S PARTICIPATION AND AN OPPORTUNITY TO TAKE CORRECTIVE 1,734
ACTION. THE HEALTH INSURING CORPORATION SHALL DEVELOP A 1,735
PERFORMANCE IMPROVEMENT PLAN IN CONJUNCTION WITH THE
PARTICIPATING PROVIDER. IF AFTER BEING AFFORDED THE OPPORTUNITY 1,736
TO COMPLY WITH THE PERFORMANCE IMPROVEMENT PLAN, THE 1,737
PARTICIPATING PROVIDER FAILS TO DO SO, THE HEALTH INSURING 1,738
CORPORATION MAY TERMINATE THE PARTICIPATION OF THE PROVIDER. 1,739
(B)(1) A PARTICIPATING PROVIDER WHOSE PARTICIPATION HAS 1,741
BEEN TERMINATED UNDER DIVISION (A) OF THIS SECTION MAY APPEAL THE 1,744
TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE HEALTH 1,745
INSURING CORPORATION. THE MEDICAL DIRECTOR SHALL GIVE THE 1,746
PARTICIPATING PROVIDER AN OPPORTUNITY TO DISCUSS WITH THE MEDICAL 1,747
DIRECTOR THE REASON OR REASONS FOR THE TERMINATION.
(2) IF A SATISFACTORY RESOLUTION OF A PARTICIPATING 1,749
PROVIDER'S APPEAL CANNOT BE REACHED UNDER DIVISION (B)(1) OF THIS 1,751
SECTION, THE PARTICIPATING PROVIDER MAY APPEAL THE TERMINATION TO 1,752
A PANEL COMPOSED OF PARTICIPATING PROVIDERS WHO HAVE COMPARABLE 1,754
OR HIGHER LEVELS OF EDUCATION AND TRAINING THAN THE PARTICIPATING 1,755
PROVIDER MAKING THE APPEAL. A REPRESENTATIVE OF THE 1,756
PARTICIPATING PROVIDER'S SPECIALTY SHALL BE A MEMBER OF THE 1,757
PANEL, IF POSSIBLE. THIS PANEL SHALL HOLD A HEARING, AND SHALL 1,758
RENDER ITS RECOMMENDATION IN THE APPEAL WITHIN THIRTY DAYS AFTER 1,759
HOLDING THE HEARING. THE RECOMMENDATION SHALL BE PRESENTED TO 1,760
THE MEDICAL DIRECTOR AND TO THE PARTICIPATING PROVIDER. 1,761
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE 1,763
PANEL'S RECOMMENDATION BEFORE MAKING A DECISION. THE DECISION 1,764
RENDERED BY THE MEDICAL DIRECTOR SHALL BE FINAL. 1,765
(C) A PROVIDER'S STATUS AS A PARTICIPATING PROVIDER SHALL 1,768
REMAIN IN EFFECT DURING THE APPEAL PROCESS SET FORTH IN DIVISION 1,770
40
(B) OF THIS SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF 1,771
THE REASONS LISTED IN DIVISION (D) OF THIS SECTION. 1,773
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A 1,775
PROVIDER'S PARTICIPATION MAY BE IMMEDIATELY TERMINATED IF THE 1,777
PARTICIPATING PROVIDER'S CONDUCT PRESENTS AN IMMINENT RISK OF 1,778
HARM TO AN ENROLLEE OR ENROLLEES; OR IF THERE HAS OCCURRED 1,779
UNACCEPTABLE QUALITY OF CARE, FRAUD, PATIENT ABUSE, LOSS OF 1,780
CLINICAL PRIVILEGES, LOSS OF PROFESSIONAL LIABILITY COVERAGE, 1,781
INCOMPETENCE, OR LOSS OF AUTHORITY TO PRACTICE IN THE 1,782
PARTICIPATING PROVIDER'S FIELD; OR IF A GOVERNMENTAL ACTION HAS 1,783
IMPAIRED THE PARTICIPATING PROVIDER'S ABILITY TO PRACTICE. 1,784
(E) DIVISIONS (A) TO (D) OF THIS SECTION APPLY ONLY TO 1,787
PROVIDERS WHO ARE NATURAL PERSONS.
(F)(1) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,790
CORPORATION FROM REJECTING A PROVIDER'S APPLICATION FOR 1,791
PARTICIPATION, OR FROM TERMINATING A PARTICIPATING PROVIDER'S 1,792
CONTRACT, IF THE HEALTH INSURING CORPORATION DETERMINES THAT THE 1,793
HEALTH CARE NEEDS OF ITS ENROLLEES ARE BEING MET AND NO NEED 1,794
EXISTS FOR THE PROVIDER'S OR PARTICIPATING PROVIDER'S SERVICES. 1,795
(2) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 1,797
PROHIBITING A HEALTH INSURING CORPORATION FROM TERMINATING A 1,798
PARTICIPATING PROVIDER WHO DOES NOT MEET THE TERMS AND CONDITIONS 1,800
OF THE PARTICIPATING PROVIDER'S CONTRACT.
(G) THE SUPERINTENDENT OF INSURANCE MAY ADOPT RULES AS 1,803
NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF 1,804
THE REVISED CODE. SUCH RULES SHALL BE ADOPTED IN ACCORDANCE WITH 1,806
CHAPTER 119. OF THE REVISED CODE. THE DIRECTOR OF HEALTH MAY 1,810
MAKE RECOMMENDATIONS TO THE SUPERINTENDENT FOR RULES NECESSARY TO 1,811
IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF THE REVISED 1,812
CODE. IN ADOPTING ANY RULES PURSUANT TO THIS DIVISION, THE 1,814
SUPERINTENDENT SHALL CONSIDER THE RECOMMENDATIONS OF THE 1,815
DIRECTOR.
Sec. 1753.10. NOTHING IN THIS CHAPTER OR CHAPTER 1751. OF 1,818
THE REVISED CODE REQUIRES A HEALTH INSURING CORPORATION TO EMPLOY 1,821
41
OR CONTRACT WITH, OR PROHIBITS A HEALTH INSURING CORPORATION FROM 1,822
EMPLOYING OR CONTRACTING WITH, ANY CATEGORY OF PROVIDER FOR THE 1,823
PROVISION OF BASIC OR SUPPLEMENTAL HEALTH CARE SERVICES, WHICH 1,824
HEALTH CARE SERVICES ARE WITHIN THE RECOGNIZED SCOPE OF PRACTICE 1,825
OF THAT CATEGORY OF PROVIDER. 1,826
Sec. 1753.14. (A) A HEALTH INSURING CORPORATION THAT DOES 1,829
NOT ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL ESTABLISH AND 1,830
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY RECEIVE A STANDING 1,831
REFERRAL TO A SPECIALIST. THE PROCEDURE SHALL PROVIDE FOR A 1,832
STANDING REFERRAL TO A SPECIALIST IF A PRIMARY CARE PROVIDER 1,833
DETERMINES IN CONSULTATION WITH A SPECIALIST THAT AN ENROLLEE 1,834
NEEDS CONTINUING CARE FROM A SPECIALIST. THE REFERRAL SHALL BE 1,835
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,836
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, A 1,837
SPECIALIST, AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE 1,838
NUMBER OF VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT 1,839
THE VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE 1,840
THE PRIMARY CARE PROVIDER WITH REGULAR REPORTS ON THE HEALTH CARE 1,842
PROVIDED TO THE ENROLLEE.
(B) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 1,845
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR 1,846
DISEASE THAT REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED 1,847
PERIOD OF TIME AND IS LIFE-THREATENING, DEGENERATIVE, OR 1,848
DISABLING MAY RECEIVE A REFERRAL TO A SPECIALIST WHO HAS 1,849
EXPERTISE IN TREATING THE CONDITION OR DISEASE FOR THE PURPOSE OF 1,850
HAVING THE SPECIALIST COORDINATE THE ENROLLEE'S HEALTH CARE. THE 1,852
PROCEDURE SHALL PROVIDE FOR SUCH A REFERRAL IF A PRIMARY CARE 1,853
PROVIDER DETERMINES IN CONSULTATION WITH THE SPECIALIST THAT THE 1,854
ENROLLEE NEEDS THE SPECIALIST'S EXPERTISE. THE REFERRAL SHALL BE 1,856
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,858
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, THE 1,859
SPECIALIST, AND THE ENROLLEE. AFTER THE REFERRAL IS MADE, THE 1,860
SPECIALIST IS AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE 1,861
ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE 1,862
42
PROVIDER, SUBJECT TO THE TERMS OF THE TREATMENT PLAN. 1,863
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS (A) AND (B) 1,867
OF THIS SECTION SHALL BE MADE WITHIN THREE BUSINESS DAYS AFTER A 1,868
REQUEST FOR THE DETERMINATION IS MADE BY THE ENROLLEE OR THE 1,869
ENROLLEE'S PRIMARY CARE PROVIDER AND ALL APPROPRIATE MEDICAL 1,870
RECORDS AND OTHER ITEMS OF INFORMATION NECESSARY TO MAKE THE 1,871
DETERMINATION HAVE BEEN PROVIDED. 1,872
(D) ONCE A DETERMINATION IN FAVOR OF A REFERRAL IS MADE, 1,874
THE REFERRAL SHALL BE MADE WITHIN FOUR BUSINESS DAYS AFTER THE 1,876
DETERMINATION. THIS TIME PERIOD DOES NOT APPLY TO STANDING 1,877
REFERRALS INVOLVING A RARE OR UNUSUAL CONDITION FOR WHICH 1,878
APPROPRIATE SPECIALISTS ARE LIMITED IN NUMBER OR OTHERWISE 1,879
DIFFICULT TO IDENTIFY. 1,880
DIVISIONS (A) AND (B) OF THIS SECTION DO NOT REQUIRE A 1,884
HEALTH INSURING CORPORATION TO PERMIT AN ENROLLEE TO ELECT 1,885
REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER CONTRACT 1,886
WITH THE HEALTH INSURING CORPORATION FOR THE PROVISION OF HEALTH 1,887
CARE SERVICES TO THE HEALTH INSURING CORPORATION'S ENROLLEES. 1,888
Sec. 1753.16. A HEALTH INSURING CORPORATION OR UTILIZATION 1,891
REVIEW ORGANIZATION THAT AUTHORIZES A PROPOSED ADMISSION, 1,892
TREATMENT, OR HEALTH CARE SERVICE BY A PARTICIPATING PROVIDER
BASED UPON THE COMPLETE AND ACCURATE SUBMISSION OF ALL NECESSARY 1,893
INFORMATION RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT 1,894
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PROVIDER RENDERS THE 1,895
HEALTH CARE SERVICE IN GOOD FAITH AND PURSUANT TO THE 1,896
AUTHORIZATION AND ALL OF THE TERMS AND CONDITIONS OF THE 1,897
PROVIDER'S CONTRACT WITH THE HEALTH INSURING CORPORATION. 1,898
Sec. 1753.21. (A) IF A POLICY, CONTRACT, OR AGREEMENT OF 1,900
A HEALTH INSURING CORPORATION USES A RESTRICTED FORMULARY OF 1,903
PRESCRIPTION DRUGS, THE HEALTH INSURING CORPORATION SHALL DO BOTH 1,904
OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND WITH 1,907
THE APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY 1,908
OF THE MEMBERS OF WHICH ARE PHYSICIANS AFFILIATED WITH THE HEALTH 1,909
43
INSURING CORPORATION WHO MAY PRESCRIBE PRESCRIPTION DRUGS AND 1,910
PHARMACISTS AFFILIATED WITH THE HEALTH INSURING CORPORATION; OR 1,911
IN CONSULTATION WITH AND WITH THE APPROVAL OF A PHARMACY AND 1,912
THERAPEUTICS COMMITTEE THAT IS INDEPENDENT OF THE HEALTH INSURING 1,913
CORPORATION CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE 1,914
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS 1,915
WHO ARE AUTHORIZED TO PRACTICE IN THEIR STATE OF LICENSURE; 1,917
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, 1,920
WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED 1,921
FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH 1,922
INSURING CORPORATION, COVERAGE OF A SPECIFIC NONFORMULARY DRUG 1,923
WHEN THE PRESCRIBER DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD 1,924
AND CERTIFIES THAT THE FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE 1,925
IN THE TREATMENT OF THE ENROLLEE'S DISEASE OR CONDITION, OR THAT 1,926
THE FORMULARY ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE 1,927
PRESCRIBER TO CAUSE A HARMFUL OR ADVERSE REACTION IN THE 1,928
ENROLLEE.
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 1,931
A HEALTH INSURING CORPORATION TO PLACE ANY PARTICULAR 1,932
PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT ON ANY 1,933
FORMULARY, OR TO PROHIBIT A HEALTH INSURING CORPORATION FROM 1,934
RESTRICTING PAYMENTS FOR ANY SPECIFIC PHARMACEUTICAL PRODUCT OR 1,935
THERAPEUTIC CLASS OF PRODUCT, INCLUDING, BUT NOT LIMITED TO, A 1,936
REQUIREMENT THAT THE PRODUCT BE PRESCRIBED ONLY BY A DEFINED 1,937
SPECIALIST OR SUBSPECIALIST.
Sec. 1753.23. A HEALTH INSURING CORPORATION THAT PROVIDES 1,940
BASIC HEALTH CARE SERVICES SHALL ESTABLISH OR USE AN INTERNAL
TECHNOLOGY ASSESSMENT PROCESS FOR ASSESSING WHETHER A DRUG, 1,942
DEVICE, PROTOCOL, PROCEDURE, OR OTHER THERAPY IS PROVEN TO BE 1,943
SAFE AND EFFICACIOUS FOR A PARTICULAR INDICATION OR CONDITION 1,944
WHEN COMPARED TO ALTERNATIVE THERAPIES, OR WHETHER IT REMAINS 1,945
EXPERIMENTAL OR INVESTIGATIONAL. THE HEALTH INSURING 1,946
CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT PROCESS SHALL MEET 1,947
ALL OF THE FOLLOWING CRITERIA:
44
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING 1,950
PHYSICIANS.
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL 1,953
EVIDENCE, INCLUDING THE FOLLOWING, IF AVAILABLE: 1,954
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE 1,957
SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT 1,959
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS 1,961
THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER INSTITUTE, 1,962
THE UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,964
FINANCE ADMINISTRATION, AND THE AGENCY FOR HEALTH CARE POLICY AND 1,965
RESEARCH; 1,966
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED 1,968
SPECIALTY SOCIETIES. 1,969
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS 1,972
PROCESS, THAT EXCLUDE DRUGS, DEVICES, PROTOCOLS, PROCEDURES, OR 1,973
OTHER THERAPIES ON THE BASIS THAT THEY ARE NOT SAFE OR 1,974
EFFICACIOUS AND REMAIN EXPERIMENTAL OR INVESTIGATIONAL, ARE 1,975
REVIEWED AND UPDATED AS NEW SCIENTIFIC EVIDENCE BECOMES 1,976
AVAILABLE.
(D) A DESCRIPTION OF THE HEALTH INSURING CORPORATION'S 1,979
INTERNAL TECHNOLOGY ASSESSMENT PROCESS IS MADE AVAILABLE TO 1,980
PARTICIPATING PROVIDERS AND ENROLLEES, UPON REQUEST. 1,981
(E) A COPY OF THE HEALTH INSURING CORPORATION'S SPECIFIC 1,984
COVERAGE PROTOCOLS AND PROCEDURES IS MADE AVAILABLE TO 1,985
PARTICIPATING PROVIDERS AND ENROLLEES UPON THE REQUEST OF AN 1,986
ENROLLEE WHO HAS BEEN DENIED COVERAGE FOR A DRUG, DEVICE, 1,987
PROTOCOL, PROCEDURE, OR OTHER THERAPY ON THE BASIS THAT IT HAS 1,988
BEEN ASSESSED AS NOT BEING SAFE OR EFFICACIOUS FOR A PARTICULAR 1,989
INDICATION OR CONDITION. SPECIFIC COVERAGE PROTOCOLS AND 1,990
PROCEDURES SHALL INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH 1,991
THE PROTOCOL OR PROCEDURE IS BASED, AND SHALL CONTAIN THE DATE 1,992
THE PROTOCOL OR PROCEDURE WAS ADOPTED. 1,993
(F) A DRUG OR DEVICE THAT HAS RECEIVED FULL MARKET 1,996
45
APPROVAL BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION FOR 1,999
TREATMENT OF A PARTICULAR INDICATION OR CONDITION CANNOT, FOR 2,000
PURPOSES OF THIS ASSESSMENT PROCESS, BE CONSIDERED EXPERIMENTAL 2,001
OR INVESTIGATIONAL FOR THAT INDICATION OR CONDITION. 2,002
Sec. 1753.24. (A) EACH HEALTH INSURING CORPORATION SHALL 2,004
ESTABLISH A REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO 2,006
EXAMINE THE HEALTH INSURING CORPORATION'S COVERAGE DECISIONS FOR 2,008
ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING 2,010
TO THE CURRENT DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH 2,011
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 2,012
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE 2,014
HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION 2,015
AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,016
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,018
IMPROVING THE CONDITION OF THE ENROLLEE; 2,020
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,023
THE ENROLLEE;
(c) THERE IS NO STANDARD THERAPY COVERED BY THE HEALTH 2,026
INSURING CORPORATION THAT IS MORE BENEFICIAL THAN THERAPY 2,027
DESCRIBED IN DIVISION (A)(3) OF THIS SECTION. 2,028
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,030
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,031
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE, IN 2,032
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR, THE 2,034
ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,035
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,036
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE HEALTH 2,038
INSURING CORPORATION FOR A DRUG, DEVICE, PROCEDURE, OR OTHER 2,041
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,042
THIS SECTION, AND HAS EXHAUSTED ALL INTERNAL APPEALS.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, 2,044
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 2,046
46
SECTION, WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT FOR THE 2,048
HEALTH INSURING CORPORATION'S DETERMINATION THAT THE DRUG,
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,050
INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,052
BY A HEALTH INSURING CORPORATION SHALL MEET ALL OF THE FOLLOWING 2,053
CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 2,055
THE PROCESS SHALL OFFER ALL ENROLLEES WHO MEET THE CRITERIA SET 2,056
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,058
HEALTH INSURING CORPORATION'S DECISION TO DENY COVERAGE OF THE 2,059
RECOMMENDED OR REQUESTED THERAPY REVIEWED UNDER THE PROCESS. 2,060
EACH ELIGIBLE ENROLLEE SHALL BE NOTIFIED OF THAT OPPORTUNITY 2,061
WITHIN FIVE BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION 2,062
DENIES COVERAGE.
(2) THE REVIEW OF THE HEALTH INSURING CORPORATION'S 2,064
DECISION SHALL BE CONDUCTED BY EXPERTS SELECTED BY AN INDEPENDENT 2,065
ENTITY THAT HAS BEEN RETAINED BY THE HEALTH INSURING CORPORATION 2,066
FOR THIS PURPOSE. THE INDEPENDENT ENTITY SHALL BE EITHER AN 2,067
ACADEMIC MEDICAL CENTER OR AN ENTITY THAT HAS AS ITS PRIMARY 2,068
FUNCTION, AND THAT RECEIVES A MAJORITY OF ITS REVENUE FROM, THE 2,069
PROVISION OF EXPERT REVIEWS AND RELATED SERVICES. 2,070
THE INDEPENDENT ENTITY SHALL SELECT A PANEL TO CONDUCT THE 2,073
REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST THREE 2,074
PHYSICIANS OR OTHER PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF 2,075
THE ENROLLEE'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,076
RECOMMENDED OR REQUESTED THERAPY. IF THE INDEPENDENT ENTITY 2,077
RETAINED BY THE HEALTH INSURING CORPORATION IS AN ACADEMIC 2,079
MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS AFFILIATED WITH OR 2,080
EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,081
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,084
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,085
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,086
PROVIDERS:
47
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,089
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN ENROLLEE HAS 2,090
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL; 2,091
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,094
OR OTHER PROVIDER IF ONLY ONE EXPERT PHYSICIAN OR OTHER PROVIDER 2,095
IS AVAILABLE FOR THE REVIEW.
(3) NEITHER THE HEALTH INSURING CORPORATION NOR THE 2,097
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE PHYSICIAN OR 2,099
OTHER PROVIDER EXPERTS.
(4) NEITHER THE EXPERTS NOR THE INDEPENDENT ENTITY 2,101
ARRANGING FOR THE EXPERTS' REVIEW SHALL HAVE ANY PROFESSIONAL, 2,102
FAMILIAL, OR FINANCIAL AFFILIATION WITH THE HEALTH INSURING 2,104
CORPORATION, EXCEPT THAT EXPERTS AFFILIATED WITH ACADEMIC MEDICAL 2,105
CENTERS WHO PROVIDE HEALTHCARE SERVICES TO ENROLLEES OF THE 2,106
HEALTH INSURING CORPORATION MAY SERVE AS EXPERTS ON THE REVIEW 2,107
PANEL. THIS NONAFFILIATION PROVISION DOES NOT PRECLUDE A HEALTH 2,109
INSURING CORPORATION FROM PAYING FOR THE EXPERTS' REVIEW, AS
SPECIFIED IN DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL 2,111
HAVE NO PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH 2,112
AN ENROLLEE WHOSE REQUEST FOR THERAPY IS UNDER REVIEW OR WITH A 2,113
PROVIDER WHOSE RECOMMENDATION FOR THERAPY IS UNDER REVIEW. 2,114
(5) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE 2,116
EXTERNAL, INDEPENDENT REVIEW. THE COSTS OF THE REVIEW SHALL BE 2,117
BORNE BY THE HEALTH INSURING CORPORATION. 2,118
(6) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE 2,120
INDEPENDENT ENTITY ARRANGING FOR THE EXPERTS' REVIEW AND TO THE 2,122
ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE MEDICAL 2,123
RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION THAT ARE
RELEVANT TO THE ENROLLEE'S CONDITION FOR WHICH THERAPY HAS BEEN 2,126
RECOMMENDED OR REQUESTED. THE MEDICAL RECORDS SHALL BE DISCLOSED 2,127
SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE 2,128
PURPOSE OF THIS SECTION. 2,129
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL SHALL BE 2,131
RENDERED WITHIN THIRTY DAYS AFTER THE ENROLLEE'S REQUEST FOR 2,133
48
REVIEW. IF THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY 2,135
WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, 2,136
THE OPINIONS SHALL BE RENDERED WITHIN SEVEN DAYS AFTER THE
ENROLLEE'S REQUEST FOR REVIEW. 2,137
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,139
ENTITY WITH A PROFESSIONAL OPINION AS TO WHETHER THERE IS 2,140
SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED OR 2,141
REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE 2,142
THAN STANDARD THERAPIES. 2,143
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,145
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,147
(a) A DESCRIPTION OF THE ENROLLEE'S CONDITION; 2,149
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,151
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,152
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,154
TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES; 2,155
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,157
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,158
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,159
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE 2,161
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,162
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,164
(10) THE INDEPENDENT ENTITY SHALL PROVIDE THE HEALTH 2,166
INSURING CORPORATION WITH THE OPINIONS OF THE EXPERTS. THE 2,168
HEALTH INSURING CORPORATION SHALL MAKE THE EXPERTS' OPINIONS
AVAILABLE TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN, UPON 2,170
REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE 2,172
PANEL, RENDERED PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS 2,173
BINDING ON THE HEALTH INSURING CORPORATION WITH RESPECT TO THAT 2,174
ENROLLEE. IF THE OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY 2,175
DIVIDED AS TO WHETHER THE THERAPY SHOULD BE COVERED, THEN THE 2,176
HEALTH INSURING CORPORATION'S FINAL DECISION SHALL BE IN FAVOR OF 2,178
COVERAGE. IF LESS THAN A MAJORITY OF THE EXPERTS ON THE PANEL 2,179
49
RECOMMEND COVERAGE OF THE THERAPY, THE HEALTH INSURING 2,180
CORPORATION MAY, IN ITS DISCRETION, COVER THE THERAPY. HOWEVER, 2,182
ANY COVERAGE PROVIDED PURSUANT TO DIVISION (B)(11) OF THIS
SECTION IS SUBJECT TO THE TERMS AND CONDITIONS OF THE ENROLLEE'S 2,183
CONTRACT WITH THE HEALTH INSURING CORPORATION. 2,184
(12) THE HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 2,186
POLICIES DESCRIBING THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,188
THE HEALTH INSURING CORPORATION SHALL DISCLOSE THE AVAILABILITY 2,189
OF THE EXTERNAL, INDEPENDENT REVIEW PROCESS IN THE HEALTH 2,190
INSURING CORPORATION'S EVIDENCE OF COVERAGE AND DISCLOSURE FORMS. 2,192
(C) IF A HEALTH INSURING CORPORATION'S INITIAL DENIAL OF 2,194
COVERAGE FOR A THERAPY RECOMMENDED OR REQUESTED PURSUANT TO 2,195
DIVISION (A)(3) OF THIS SECTION IS BASED UPON AN EXTERNAL, 2,196
INDEPENDENT REVIEW OF THAT THERAPY MEETING THE REQUIREMENTS OF 2,197
DIVISION (B) OF THIS SECTION, THIS SECTION SHALL NOT BE A BASIS 2,199
FOR REQUIRING A SECOND EXTERNAL, INDEPENDENT REVIEW OF THE
RECOMMENDED OR REQUESTED THERAPY. 2,200
(D) THE HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A 2,202
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS 2,203
COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION. 2,204
Sec. 1753.28. (A) AS USED IN THIS SECTION: 2,206
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 2,208
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 2,209
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 2,210
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 2,211
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 2,212
RESULT IN ANY OF THE FOLLOWING: 2,213
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,216
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,217
IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,220
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,223
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 2,225
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 2,228
50
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 2,229
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 2,230
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 2,231
MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 2,234
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 2,235
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 2,236
BURN CENTER OF THE HOSPITAL. 2,237
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH MEDICAL 2,240
TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE 2,241
MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF AN 2,242
INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR OCCUR 2,243
DURING A TRANSFER, IF THE MEDICAL CONDITION COULD RESULT IN ANY 2,244
OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,247
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,248
IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,251
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,254
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS, 2,256
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO 2,257
DELIVER, INCLUDING THE PLACENTA. 2,258
(4) "TRANSFER" HAS THE SAME MEANING AS IN SECTION 1867 OF 2,260
THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,262
1395dd, AS AMENDED.
(B) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,264
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,266
COVER EMERGENCY SERVICES FOR ENROLLEES WITH EMERGENCY MEDICAL 2,267
CONDITIONS WITHOUT REGARD TO THE DAY OR TIME THE EMERGENCY 2,268
SERVICES ARE RENDERED OR TO WHETHER THE ENROLLEE, THE HOSPITAL'S 2,269
EMERGENCY DEPARTMENT WHERE THE SERVICES ARE RENDERED, OR AN 2,270
EMERGENCY PHYSICIAN TREATING THE ENROLLEE, OBTAINED PRIOR 2,271
AUTHORIZATION FOR THE EMERGENCY SERVICES.
51
(C) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,273
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,275
COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,277
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,278
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION; 2,279
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,281
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,283
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION AND ONE OF THE 2,284
FOLLOWING CIRCUMSTANCES APPLIES: 2,285
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, 2,288
THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR HEALTH. 2,290
(b) A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 2,293
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 2,294
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 2,295
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 2,296
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 2,297
THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH INSURING CORPORATION 2,299
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT 2,300
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT. 2,301
(d) AN AMBULANCE TAKES THE ENROLLEE TO A NONPARTICIPATING 2,303
HOSPITAL OTHER THAN AT THE DIRECTION OF THE ENROLLEE. 2,304
(e) THE ENROLLEE IS UNCONSCIOUS. 2,306
(f) A NATURAL DISASTER PRECLUDED THE USE OF A 2,308
PARTICIPATING EMERGENCY DEPARTMENT. 2,309
(g) THE STATUS OF A HOSPITAL CHANGED FROM PARTICIPATING TO 2,311
NONPARTICIPATING WITH RESPECT TO EMERGENCY SERVICES DURING A 2,312
CONTRACT YEAR AND NO GOOD FAITH EFFORT WAS MADE BY THE HEALTH 2,313
INSURING CORPORATION TO INFORM ENROLLEES OF THIS CHANGE. 2,314
(D) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 2,317
FOR EMERGENCY SERVICES SHALL INFORM ENROLLEES OF ALL OF THE 2,318
FOLLOWING:
52
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 2,320
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 2,323
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 2,324
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 2,325
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES; 2,327
(4) THE PROCEDURES FOR OBTAINING EMERGENCY SERVICES AND 2,329
OTHER MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE 2,330
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS 2,331
AND WITH THE LOCATION AND AVAILABILITY OF OTHER PARTICIPATING 2,332
FACILITIES OR SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL 2,333
SERVICES.
Sec. 1753.30. NOTHING IN THIS CHAPTER SHALL PREVENT OR 2,335
OTHERWISE AFFECT THE APPLICATION TO ANY HEALTH CARE PLAN OF THOSE 2,336
PROVISIONS OF TITLE XVII OR XXXIX OF THE REVISED CODE THAT WOULD 2,338
OTHERWISE APPLY.
Sec. 3901.04. (A) As used in this section: 2,347
(1) "Laws of this state relating to insurance" include but 2,349
are not limited to Chapter 1751. notwithstanding section 1751.08, 2,351
CHAPTER 1753., Title XXXIX, sections 5725.18 to 5725.25, and 2,352
Chapter 5729. of the Revised Code. 2,353
(2) "Person" has the meaning defined in division (A) of 2,355
section 3901.19 of the Revised Code. 2,356
(B) Whenever it appears to the superintendent of 2,358
insurance, from the superintendent's files, upon complaint or 2,360
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 2,361
prohibited by the laws of this state relating to insurance, or 2,362
defined as unfair or deceptive by such laws, or when the 2,363
superintendent believes it to be in the best interest of the 2,364
public and necessary for the protection of the people in this 2,365
state, the superintendent or anyone designated by the 2,366
superintendent under the superintendent's official seal may do 2,367
any one or more of the following:
(1) Require any person to file with the superintendent, on 2,369
53
a form that is appropriate for review by the superintendent, an 2,370
original or additional statement or report in writing, under oath 2,371
or otherwise, as to any facts or circumstances concerning the 2,372
person's conduct of the business of insurance within this state 2,373
and as to any other information that the superintendent considers 2,374
to be material or relevant to such business; 2,375
(2) Administer oaths, summon and compel by order or 2,377
subpoena the attendance of witnesses to testify in relation to 2,378
any matter which, by the laws of this state relating to 2,379
insurance, is the subject of inquiry and investigation, and 2,380
require the production of any book, paper, or document pertaining 2,381
to such matter. A subpoena, notice, or order under this section 2,382
may be served by certified mail, return receipt requested. If 2,383
the subpoena, notice, or order is returned because of inability 2,384
to deliver, or if no return is received within thirty days of the 2,385
date of mailing, the subpoena, notice, or order may be served by 2,386
ordinary mail. If no return of ordinary mail is received within 2,387
thirty days after the date of mailing, service shall be deemed to 2,388
have been made. If the subpoena, notice, or order is returned 2,389
because of inability to deliver, the superintendent may designate 2,390
a person or persons to effect either personal or residence 2,391
service upon the witness. Service of any subpoena, notice, or 2,392
order and return may also be made in any manner authorized under 2,393
the Rules of Civil Procedure. Such service shall be made by an 2,394
employee of the department designated by the superintendent, a 2,395
sheriff, a deputy sheriff, an attorney, or any person authorized 2,396
by the Rules of Civil Procedure to serve process. 2,397
In the case of disobedience of any notice, order, or 2,399
subpoena served on a person or the refusal of a witness to 2,400
testify to a matter regarding which the person may lawfully be 2,402
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 2,403
obedience by attachment proceedings for contempt, as in the case 2,404
of disobedience of the requirements of a subpoena issued from 2,405
54
such court, or a refusal to testify therein. Witnesses shall 2,406
receive the fees and mileage allowed by section 2335.06 of the 2,407
Revised Code. All such fees, upon the presentation of proper 2,408
vouchers approved by the superintendent, shall be paid out of the 2,409
appropriation for the contingent fund of the department of 2,410
insurance. The fees and mileage of witnesses not summoned by the 2,411
superintendent or the superintendent's designee shall not be paid 2,413
by the state.
(3) In a case in which there is no administrative 2,415
procedure available to the superintendent to resolve a matter at 2,416
issue, request the attorney general to commence an action for a 2,417
declaratory judgment under Chapter 2721. of the Revised Code with 2,418
respect to the matter. 2,419
(4) Initiate criminal proceedings by presenting evidence 2,421
of the commission of any criminal offense established under the 2,422
laws of this state relating to insurance to the prosecuting 2,423
attorney of any county in which the offense may be prosecuted. 2,424
At the request of the prosecuting attorney, the attorney general 2,425
may assist in the prosecution of the violation with all the 2,426
rights, privileges, and powers conferred by law on prosecuting 2,427
attorneys including, but not limited to, the power to appear 2,428
before grand juries and to interrogate witnesses before grand 2,429
juries. 2,430
Sec. 3901.041. The superintendent of insurance shall 2,440
adopt, amend, and rescind rules and make adjudications, necessary 2,441
to discharge the superintendent's duties and exercise the 2,442
superintendent's powers, including, but not limited to, the 2,443
superintendent's duties and powers under Chapter CHAPTERS 1751. 2,445
AND 1753. and Title XXXIX of the Revised Code, subject to Chapter 2,446
119. of the Revised Code.
Sec. 3901.16. Any association, company, or corporation, 2,456
including a health insuring corporation, which violates any law 2,457
relating to the superintendent of insurance, any provision of 2,458
Chapter 1751. OR 1753. of the Revised Code, or any insurance law 2,460
55
of this state, for the violation of which no forfeiture or 2,461
penalty is elsewhere provided in the Revised Code, shall forfeit 2,462
and pay not less than one thousand nor more than ten thousand 2,463
dollars, to be recovered by an action in the name of the state 2,464
and on collection to be paid to the superintendent, who shall pay
such sum into the state treasury. 2,465
Sec. 3924.10. (A) The board of directors of the Ohio 2,475
health reinsurance program shall design the SEHC plan which, when 2,477
offered by a carrier, is eligible for reinsurance under the 2,478
program. The board shall establish the form and level of 2,479
coverage to be made available by carriers in their SEHC plan. In 2,480
designing the plan the board shall also establish benefit levels, 2,481
deductibles, coinsurance factors, exclusions, and limitations for 2,482
the plan. The forms and levels of coverage established by the 2,483
board shall specify which components of a health benefit plan 2,484
offered by a carrier may be reinsured. The SEHC plan is subject 2,485
to division (C) of section 3924.02 of the Revised Code and to the 2,487
provisions in Chapters 1751., 1753., 3923., and any other chapter 2,489
of the Revised Code that require coverage or the offer of 2,490
coverage of a health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 2,493
eighty days after its appointment. The plan may include cost 2,494
containment features including any of the following:
(1) Utilization review of health care services, including 2,496
review of the medical necessity of hospital and physician 2,497
services; 2,498
(2) Case management benefit alternatives; 2,500
(3) Selective contracting with hospitals, physicians, and 2,502
other health care providers; 2,503
(4) Reasonable benefit differentials applicable to 2,505
participating and nonparticipating providers; 2,506
(5) Employee assistance program options that provide 2,508
preventive and early intervention mental health and substance 2,509
abuse services; 2,510
56
(6) Other provisions for the cost-effective management of 2,512
the plan. 2,513
(C) An SEHC plan established for use by health insuring 2,516
corporations shall be consistent with the basic method of 2,518
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 2,520
insurance, in the form and manner prescribed by the 2,521
superintendent, that the SEHC plan filed by the carrier is in 2,523
substantial compliance with the provisions of the board SEHC 2,524
plan. Upon receipt by the superintendent of the certification, 2,525
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 2,527
date that the program becomes operational and as a condition of 2,528
transacting business in this state, renew coverage provided to 2,529
any individual or group under its SEHC plan. 2,530
Sec. 4121.121. (A) There is hereby created the bureau of 2,541
workers' compensation, which shall be administered by the 2,542
administrator of workers' compensation. A person appointed to 2,543
the position of administrator shall possess significant 2,544
management experience in effectively managing an organization or 2,545
organizations of substantial size and complexity. The governor 2,546
shall appoint the administrator as provided in section 121.03 of
the Revised Code, and the administrator shall serve at the 2,548
pleasure of the governor. The governor shall fix the
administrator's salary on the basis of the administrator's 2,550
experience and the administrator's responsibilities and duties 2,551
under this chapter and Chapter 4123., 4127., and 4131. of the 2,553
Revised Code. The governor shall not appoint to the position of
administator ADMINISTRATOR any person who has, or whose spouse 2,554
has, given a contribution to the campaign committee of the 2,555
governor in an amount greater than one thousand dollars during 2,556
the two-year period immediately preceding the date of the 2,557
appointment of the administrator. After August 31, 2000, the 2,558
workers' compensation oversight commission shall appoint the 2,559
57
administrator as provided in division (F)(9) of section 4121.12 2,560
of the Revised Code, and the administrator shall serve at the 2,561
pleasure of the oversight commission. The oversight commission 2,562
shall fix the administrator's salary on the basis of the 2,563
administrator's experience and the administrator's 2,564
responsibilities and duties under this chapter and Chapters 2,565
4123., 4127., and 4131. of the Revised Code. 2,566
The administrator shall hold no other public office and 2,568
shall devote full time to the duties of administrator. Before 2,570
entering upon the duties of the office, the administrator shall 2,571
take an oath of office as required by sections 3.22 and 3.23 of 2,572
the Revised Code, and shall file in the office of the secretary 2,573
of state, a bond signed by the administrator and by surety
approved by the governor, for the sum of fifty thousand dollars 2,574
payable to the state, conditioned upon the faithful performance 2,575
of the administrator's duties. 2,576
(B) The administrator is responsible for the management of 2,579
the bureau of workers' compensation and for the discharge of all 2,580
administrative duties imposed upon the administrator in this 2,581
chapter and Chapters 4123., 4127., and 4131. of the Revised Code, 2,582
and in the discharge thereof shall do all of the following: 2,583
(1) Establish the overall administrative policy of the 2,586
bureau for the purposes of this chapter and Chapters 4123.,
4127., and 4131. of the Revised Code, and perform all acts and 2,587
exercise all authorities and powers, discretionary and otherwise 2,589
that are required of or vested in the bureau or any of its 2,590
employees in this chapter and Chapters 4123., 4127., and 4131. of 2,591
the Revised Code, except the acts and the exercise of authority 2,592
and power that is required of and vested in the oversight 2,593
commission or the industrial commission pursuant to those 2,594
chapters. The treasurer of state shall honor all warrants signed 2,595
by the administrator, or by one or more of the administrator's 2,596
employees, authorized by the administrator in writing, or bearing 2,598
the facsimile signature of the administrator or such employee 2,599
58
under sections 4123.42 and 4123.44 of the Revised Code. 2,600
(2) Employ, direct, and supervise all employees required 2,602
in connection with the performance of the duties assigned to the 2,603
bureau by this chapter and Chapters 4123., 4127., and 4131. of 2,604
the Revised Code, and may establish job classification plans and 2,605
compensation for all employees of the bureau provided that this 2,606
grant of authority shall not be construed as affecting any 2,607
employee for whom the state employment relations board has 2,608
established an appropriate bargaining unit under section 4117.06 2,609
of the Revised Code. All positions of employment in the bureau 2,610
are in the classified civil service except those employees the 2,611
administrator may appoint to serve at the administrator's 2,612
pleasure in the unclassified civil service pursuant to section 2,613
124.11 of the Revised Code. The administrator shall fix the 2,614
salaries of employees the administrator appoints to serve at the 2,616
administrator's pleasure, including the chief operating officer, 2,617
staff physicians, and other senior management personnel of the
bureau and shall establish the compensation of staff attorneys of 2,618
the bureau's legal section and their immediate supervisors, and 2,619
take whatever steps are necessary to provide adequate 2,620
compensation for other staff attorneys. 2,621
The administrator may appoint a person holding a certified 2,623
position in the classified service to any state position in the 2,624
unclassified service of the bureau of workers' compensation. A 2,625
person so appointed shall retain the right to resume the position 2,627
and status held by the person in the classified service
immediately prior to the person's appointment in the unclassified 2,629
service. If the position the person previously held has been 2,630
filled or placed in the unclassified service, or is otherwise 2,631
unavailable, the person shall be appointed to a position in the 2,632
classified service within the bureau that the department of 2,633
administrative services certifies is comparable in compensation
to the position the person previously held. Reinstatement to a 2,634
position in the classified service shall be to a position 2,635
59
substantially equal to that held previously, as certified by the 2,636
department of administrative services. Service in the position 2,637
in the unclassified service shall be counted as service in the 2,639
position in the classified service held by the person immediately 2,640
prior to the person's appointment in the unclassified service. 2,641
when a person is reinstated to a position in the classified 2,642
service as provided in this section, the person is entitled to 2,643
all rights, status, and benefits accruing to the position during 2,644
the person's time of service in the position in the unclassified 2,645
service. 2,646
(3) Reorganize the work of the bureau, its sections, 2,648
departments, and offices to the extent necessary to achieve the 2,649
most efficient performance of its functions and to that end may 2,650
establish, change, or abolish positions and assign and reassign 2,651
duties and responsibilities of every employee of the bureau. All 2,652
persons employed by the commission in positions that, after 2,653
November 3, 1989, are supervised and directed by the 2,654
administrator under this section are transferred to the bureau in 2,655
their respective classifications but subject to reassignment and 2,656
reclassification of position and compensation as the 2,657
administrator determines to be in the interest of efficient 2,658
administration. The civil service status of any person employed 2,659
by the commission is not affected by this section. Personnel 2,660
employed by the bureau or the commission who are subject to 2,661
Chapter 4117. of the Revised Code shall retain all of their 2,662
rights and benefits conferred pursuant to that chapter as it 2,663
presently exists or is hereafter amended and nothing in this 2,664
chapter or Chapter 4123. of the Revised Code shall be construed 2,665
as eliminating or interfering with Chapter 4117. of the Revised 2,666
Code or the rights and benefits conferred under that chapter to 2,667
public employees or to any bargaining unit. 2,668
(4) Provide offices, equipment, supplies, and other 2,670
facilities for the bureau. The administrator also shall provide 2,672
suitable office space in the service offices for the district 2,673
60
hearing officers, the staff hearing officers, and commission 2,674
employees as requested by the commission.
(5) Prepare and submit to the oversight commission 2,676
information the administrator considers pertinent or the 2,677
oversight commission requires, together with the administrator's 2,679
recommendations, in the form of administrative rules, for the 2,680
advice and consent of the oversight commission, for 2,681
classifications of occupations or industries, for premium rates 2,682
and contributions, for the amount to be credited to the surplus 2,683
fund, for rules and systems of rating, rate revisions, and merit 2,684
rating. The administrator shall obtain, prepare, and submit any 2,685
other information the oversight commission requires for the 2,687
prompt and efficient discharge of its duties.
(6) Keep the accounts required by division (A) of section 2,689
4123.34 of the Revised Code and all other accounts and records 2,690
necessary to the collection, administration, and distribution of 2,691
the workers' compensation funds and shall obtain the statistical 2,692
and other information required by section 4123.19 of the Revised 2,693
Code. 2,694
(7) Exercise the investment powers vested in the 2,696
administrator by section 4123.44 of the Revised Code in 2,697
accordance with the investment objectives, policies, and criteria 2,699
established by the oversight commission pursuant to section 2,700
4121.12 of the Revised Code. The administrator shall not engage 2,701
in any prohibited investment activity specified by the oversight 2,702
commission pursuant to division (F)(6) of section 4121.12 of the 2,703
Revised Code. All business shall be transacted, all funds 2,704
invested, all warrants for money drawn and payments made, and all 2,705
cash and securities and other property held, in the name of the 2,706
bureau, or in the name of its nominee, provided that nominees are
authorized by the administrator solely for the purpose of 2,708
facilitating the transfer of securities, and restricted to the 2,709
administrator and designated employees. 2,710
(8) Make contracts for and supervise the construction of 2,713
61
any project or improvement or the construction or repair of 2,714
buildings under the control of the bureau. 2,715
(9) Purchase supplies, materials, equipment, and services; 2,717
make contracts for, operate, and superintend the telephone, other 2,718
telecommunication, and computer services for the use of the 2,719
bureau; and make contracts in connection with office 2,720
reproduction, forms management, printing, and other services. 2,721
NOTWITHSTANDING SECTIONS 125.12 TO 125.14 OF THE REVISED CODE, 2,722
THE ADMINISTRATOR MAY TRANSFER SURPLUS COMPUTERS AND COMPUTER
EQUIPMENT DIRECTLY TO AN ACCREDITED PUBLIC SCHOOL WITHIN THE 2,723
STATE. THE COMPUTERS AND COMPUTER EQUIPMENT MAY BE REPAIRED OR 2,724
REFURBISHED PRIOR TO THE TRANSFER. 2,725
(10) Separately from the budget the industrial commission 2,728
submits, prepare and submit to the director of budget and 2,729
management a budget for each biennium. The budget submitted 2,730
shall include estimates of the costs and necessary expenditures 2,731
of the bureau in the discharge of any duty imposed by law as well 2,732
as the costs of furnishing office space to the district hearing 2,733
officers, staff hearing officers, and commission employees under 2,734
division (D) of this section. 2,735
(11) As promptly as possible in the course of efficient 2,737
administration, decentralize and relocate such of the personnel 2,738
and activities of the bureau as is appropriate to the end that 2,739
the receipt, investigation, determination, and payment of claims 2,740
may be undertaken at or near the place of injury or the residence 2,741
of the claimant and for that purpose establish regional offices, 2,742
in such places as the administrator considers proper, capable of 2,744
discharging as many of the functions of the bureau as is 2,745
practicable so as to promote prompt and efficient administration 2,746
in the processing of claims. All active and inactive lost-time 2,747
claims files shall be held at the service office responsible for 2,748
the claim. A claimant, at the claimant's request, shall be 2,749
provided with information by telephone as to the location of the 2,751
file pertaining to claim. The administrator shall ensure that 2,752
62
all service office employees report directly to the director for 2,753
their service office.
(12) Provide a written binder on new coverage where the 2,755
administrator considers it to be in the best interest of the 2,756
risk. The administrator, or any other person authorized by the 2,757
administrator, shall grant the binder upon submission of a 2,759
request for coverage by the employer. A binder is effective for 2,760
a period of thirty days from date of issuance and is 2,761
nonrenewable. Payroll reports and premium charges shall coincide 2,762
with the effective date of the binder. 2,763
(13) Set standards for the reasonable and maximum handling 2,765
time of claims payment functions, ensure, by rules, the impartial 2,766
and prompt treatment of all claims and employer risk accounts, 2,767
and establish a secure, accurate method of time stamping all 2,768
incoming mail and documents hand delivered to bureau employees. 2,769
(14) Ensure that all employees of the bureau follow the 2,771
orders and rules of the commission as such orders and rules 2,772
relate to the commission's overall adjudicatory policy-making and 2,773
management duties under this chapter and Chapters 4123., 4127., 2,774
and 4131. of the Revised Code. 2,775
(15) Manage and operate a data processing system with a 2,777
common data base for the use of both the bureau and the 2,778
commission and, in consultation with the commission, using 2,779
electronic data processing equipment, shall develop a claims 2,780
tracking system that is sufficient to monitor the status of a 2,781
claim at any time and that lists appeals that have been filed and 2,782
orders or determinations that have been issued pursuant to 2,783
section 4123.511 or 4123.512 of the Revised Code, including the 2,784
dates of such filings and issuances. 2,785
(16) Establish and maintain a medical section within the 2,787
bureau. The medical section shall do all of the following: 2,788
(a) Assist the administrator in establishing standard 2,790
medical fees, approving medical procedures, and determining 2,791
eligibility and reasonableness of the compensation payments for 2,792
63
medical, hospital, and nursing services, and in establishing 2,793
guidelines for payment policies which recognize usual, customary, 2,794
and reasonable methods of payment for covered services; 2,795
(b) Provide a resource to respond to questions from claims 2,797
examiners for employees of the bureau; 2,798
(c) Audit fee bill payments; 2,800
(d) Implement a program to utilize, to the maximum extent 2,802
possible, electronic data processing equipment for storage of 2,803
information to facilitate authorizations of compensation payments 2,804
for medical, hospital, drug, and nursing services; 2,805
(e) Perform other duties assigned to it by the 2,807
administrator. 2,808
(17) Appoint, as the administrator determines necessary, 2,810
panels to review and advise the administrator on disputes arising 2,812
over a determination that a health care service or supply 2,813
provided to a claimant is not covered under this chapter or 2,814
Chapter 4123. of the Revised Code or is medically unnecessary. 2,815
If an individual health care provider is involved in the dispute, 2,816
the panel shall consist of individuals licensed pursuant to the 2,817
same section of the Revised Code as such health care provider. 2,818
(18) Pursuant to section 4123.65 of the Revised Code, 2,820
approve applications for the final settlement of claims for 2,821
compensation or benefits under this chapter and Chapters 4123., 2,822
4127., and 4131. of the Revised Code as the administrator 2,823
determines appropriate, except in regard to the applications of 2,825
self-insuring employers and their employees. 2,826
(19) Comply with section 3517.13 of the Revised Code, and 2,828
except in regard to contracts entered into pursuant to the 2,830
authority contained in section 4121.44 of the Revised Code,
comply with the competitive bidding procedures set forth in the 2,832
Revised Code for all contracts into which the administrator 2,833
enters provided that those contracts fall within the type of 2,834
contracts and dollar amounts specified in the Revised Code for 2,835
competitive bidding and further provided that those contracts are
64
not otherwise specifically exempt from the competitive bidding 2,836
procedures contained in the Revised Code. 2,837
(20) Adopt, with the advice and consent of the oversight 2,839
commission, rules for the operation of the bureau. 2,840
(21) Prepare and submit to the oversight commission 2,842
information the administrator considers pertinent or the 2,843
oversight commission requires, together with the administrator's 2,844
recommendations, in the form of administrative rules, for the 2,845
advice and consent of the oversight commission, for the health 2,846
partnership program and the qualified health plan system, as
provided in sections 4121.44, 4121.441, and 4121.442 of the 2,847
Revised Code.
(C) The administrator, with the advice and consent of the 2,849
senate, shall appoint a chief operating officer who has 2,851
significant experience in the field of workers' compensation 2,852
insurance or other similar insurance industry experience if the
administrator does not possess such experience. The chief 2,853
operating officer shall not commence the chief operating 2,854
officer's duties until after the senate consents to the chief 2,855
operating officer's appointment. The chief operating officer 2,856
shall serve in the unclassified civil service of the state. 2,857
Sec. 4123.01. As used in this chapter: 2,866
(A)(1) "Employee" means: 2,868
(a) Every person in the service of the state, or of any 2,870
county, municipal corporation, township, or school district 2,871
therein, including regular members of lawfully constituted police 2,872
and fire departments of municipal corporations and townships, 2,873
whether paid or volunteer, and wherever serving within the state 2,874
or on temporary assignment outside thereof, and executive 2,875
officers of boards of education, under any appointment or 2,876
contract of hire, express or implied, oral or written, including 2,877
any elected official of the state, or of any county, municipal 2,878
corporation, or township, or members of boards of education; 2,879
(b) Every person in the service of any person, firm, or 2,881
65
private corporation, including any public service corporation, 2,882
that (i) employs one or more persons regularly in the same 2,883
business or in or about the same establishment under any contract 2,884
of hire, express or implied, oral or written, including aliens 2,885
and minors, household workers who earn one hundred sixty dollars 2,886
or more in cash in any calendar quarter from a single household 2,887
and casual workers who earn one hundred sixty dollars or more in 2,888
cash in any calendar quarter from a single employer, or (ii) is 2,889
bound by any such contract of hire or by any other written 2,890
contract, to pay into the state insurance fund the premiums 2,891
provided by this chapter. 2,892
(c) Every person who performs labor or provides services 2,895
pursuant to a construction contract, as defined in section 2,896
4123.79 of the Revised Code, if at least ten of the following
criteria apply:
(i) The person is required to comply with instructions 2,899
from the other contracting party regarding the manner or method 2,900
of performing services;
(ii) The person is required by the other contracting party 2,903
to have particular training;
(iii) The person's services are integrated into the 2,906
regular functioning of the other contracting party; 2,907
(iv) The person is required to perform the work 2,909
personally;
(v) The person is hired, supervised, or paid by the other 2,911
contracting party;
(vi) A continuing relationship exists between the person 2,914
and the other contracting party that contemplates continuing or 2,915
recurring work even if the work is not full time; 2,916
(vii) The person's hours of work are established by the 2,919
other contracting party;
(viii) The person is required to devote full time to the 2,922
business of the other contracting party;
(ix) The person is required to perform the work on the 2,925
66
premises of the other contracting party;
(x) The person is required to follow the order of work set 2,928
by the other contracting party;
(xi) The person is required to make oral or written 2,931
reports of progress to the other contracting party; 2,932
(xii) The person is paid for services on a regular basis 2,935
such as hourly, weekly, or monthly;
(xiii) The person's expenses are paid for by the other 2,937
contracting party;
(xiv) The person's tools and materials are furnished by 2,940
the other contracting party;
(xv) The person is provided with the facilities used to 2,942
perform services;
(xvi) The person does not realize a profit or suffer a 2,945
loss as a result of the services provided;
(xvii) The person is not performing services for a number 2,948
of employers at the same time;
(xviii) The person does not make the same services 2,950
available to the general public; 2,951
(xix) The other contracting party has a right to discharge 2,954
the person;
(xx) The person has the right to end the relationship with 2,957
the other contracting party without incurring liability pursuant 2,958
to an employment contract or agreement. 2,959
Every person in the service of any independent contractor 2,961
or subcontractor who has failed to pay into the state insurance 2,962
fund the amount of premium determined and fixed by the 2,963
administrator of workers' compensation for the person's 2,964
employment or occupation or if a self-insuring employer has 2,965
failed to pay compensation and benefits directly to the 2,966
employer's injured and to the dependents of the employer's killed 2,967
employees as required by section 4123.35 of the Revised Code, 2,969
shall be considered as the employee of the person who has entered 2,970
into a contract, whether written or verbal, with such independent 2,971
67
contractor unless such employees or their legal representatives 2,972
or beneficiaries elect, after injury or death, to regard such 2,973
independent contractor as the employer.
(2) "Employee" does not mean: 2,975
(a) A duly ordained, commissioned, or licensed minister or 2,977
assistant or associate minister of a church in the exercise of 2,978
ministry; or 2,979
(b) Any officer of a family farm corporation. 2,981
Any employer may elect to include as an "employee" within 2,983
this chapter, any person excluded from the definition of 2,984
"employee" pursuant to division (A)(2) of this section. If an 2,985
employer is a partnership, sole proprietorship, or family farm 2,986
corporation, such employer may elect to include as an "employee" 2,987
within this chapter, any member of such partnership, the owner of 2,988
the sole proprietorship, or the officers of the family farm 2,989
corporation. In the event of an election, the employer shall 2,990
serve upon the bureau of workers' compensation written notice 2,991
naming the persons to be covered, include such employee's 2,992
remuneration for premium purposes in all future payroll reports, 2,993
and no person excluded from the definition of "employee" pursuant 2,994
to division (A)(2) of this section, proprietor, or partner shall 2,995
be deemed an employee within this division until the employer has 2,996
served such notice. 2,997
For informational purposes only, the bureau shall prescribe 2,999
such language as it considers appropriate, on such of its forms 3,000
as it considers appropriate, to advise employers of their right 3,001
to elect to include as an "employee" within this chapter a sole 3,002
proprietor, any member of a partnership, the officers of a family 3,003
farm corporation, or a person excluded from the definition of 3,004
"employee" under division (A)(2)(a) of this section, that they 3,005
should check any health and disability insurance policy, or other 3,006
form of health and disability plan or contract, presently 3,007
covering them, or the purchase of which they may be considering, 3,008
to determine whether such policy, plan, or contract excludes 3,009
68
benefits for illness or injury that they might have elected to 3,010
have covered by workers' compensation. 3,011
(B) "Employer" means: 3,013
(1) The state, including state hospitals, each county, 3,015
municipal corporation, township, school district, and hospital 3,016
owned by a political subdivision or subdivisions other than the 3,017
state; 3,018
(2) Every person, firm, and private corporation, including 3,020
any public service corporation, that (a) has in service one or 3,021
more employees regularly in the same business or in or about the 3,022
same establishment under any contract of hire, express or 3,023
implied, oral or written, or (b) is bound by any such contract of 3,024
hire or by any other written contract, to pay into the insurance 3,025
fund the premiums provided by this chapter. 3,026
All such employers are subject to this chapter. Any member 3,028
of a firm or association, who regularly performs manual labor in 3,029
or about a mine, factory, or other establishment, including a 3,030
household establishment, shall be considered an employee in 3,031
determining whether such person, firm, or private corporation, or 3,032
public service corporation, has in its service, one or more 3,033
employees and the employer shall report the income derived from 3,034
such labor to the bureau as part of the payroll of such employer, 3,035
and such member shall thereupon be entitled to all the benefits 3,036
of an employee. 3,037
(C) "Injury" includes any injury, whether caused by 3,039
external accidental means or accidental in character and result, 3,040
received in the course of, and arising out of, the injured 3,041
employee's employment. "Injury" does not include: 3,042
(1) Psychiatric conditions except where the conditions 3,044
have arisen from an injury or occupational disease; 3,045
(2) Injury or disability caused primarily by the natural 3,048
deterioration of tissue, an organ, or part of the body; 3,049
(3) Injury or disability incurred in voluntary 3,051
participation in an employer-sponsored recreation or fitness 3,052
69
activity if the employee signs a waiver of the employee's right 3,053
to compensation or benefits under this chapter prior to engaging 3,054
in the recreation or fitness activity. 3,055
(D) "Child" includes a posthumous child and a child 3,057
legally adopted prior to the injury. 3,058
(E) "Family farm corporation" means a corporation founded 3,060
for the purpose of farming agricultural land in which the 3,061
majority of the voting stock is held by and the majority of the 3,062
stockholders are persons or the spouse of persons related to each 3,063
other within the fourth degree of kinship, according to the rules 3,064
of the civil law, and at least one of the related persons is 3,065
residing on or actively operating the farm, and none of whose 3,066
stockholders are a corporation. A family farm corporation does 3,067
not cease to qualify under this division where, by reason of any 3,068
devise, bequest, or the operation of the laws of descent or 3,069
distribution, the ownership of shares of voting stock is 3,070
transferred to another person, as long as that person is within 3,071
the degree of kinship stipulated in this division. 3,072
(F) "Occupational disease" means a disease contracted in 3,074
the course of employment, which by its causes and the 3,075
characteristics of its manifestation or the condition of the 3,076
employment results in a hazard which distinguishes the employment 3,077
in character from employment generally, and the employment
creates a risk of contracting the disease in greater degree and 3,078
in a different manner from the public in general. 3,079
(G) "Self-insuring employer" means any of the following 3,081
categories of employers if granted the privilege of paying 3,082
compensation and benefits directly under section 4123.35 of the 3,083
Revised Code: 3,084
(1) Any employer mentioned in division (B)(2) of this 3,086
section; 3,087
(2) A board of county hospital trustees; 3,089
(3) A publicly owned utility; 3,091
(4) A BOARD OF COUNTY COMMISSIONERS FOR THE SOLE PURPOSE 3,093
70
OF CONSTRUCTING A SPORTS FACILITY AS DEFINED IN SECTION 307.696 3,094
OF THE REVISED CODE, PROVIDED THAT THE ELECTORS OF THE COUNTY IN 3,095
WHICH THE SPORTS FACILITY IS TO BE BUILT HAVE APPROVED
CONSTRUCTION OF A SPORTS FACILITY BY BALLOT ELECTION NO LATER 3,096
THAN NOVEMBER 6, 1997. 3,097
Sec. 4123.25. (A) No employer shall misrepresent to the 3,107
bureau of workers' compensation the amount of payroll upon which 3,109
the premium under this chapter is based. Whoever violates this 3,110
division shall be liable to the state in ten times the amount of 3,112
the difference in premium paid and the amount the employer should 3,114
have paid. The liability to the state under this division shall 3,117
be enforced in a civil action in the name of the state, and all 3,118
sums collected under this division shall be paid into the state 3,119
insurance fund.
(B) No self-insuring employer shall misrepresent the 3,121
amount of paid compensation paid by such employer for purposes of 3,122
the assessments provided under this chapter and Chapter 4121. of 3,123
the Revised Code as required by section 4123.35 of the Revised 3,124
Code. Whoever violates this division is liable to the state in 3,125
an amount assessed by the self-insuring employers evaluation 3,126
board pursuant to division (C) of section 4123.352 of the Revised 3,129
Code or ten times the amount of the difference between the 3,130
assessment paid and the amount of the assessment that should have 3,131
been paid along with any other penalty as determined by the 3,132
board. The liability to the state under this division may be 3,133
enforced in a civil action in the name of the state and all sums 3,134
collected under this division shall be paid into the 3,135
self-insurance assessment fund created pursuant to division 3,137
(J)(K) of section 4123.35 of the Revised Code. 3,138
Sec. 4123.35. (A) Except as provided in this section, 3,150
every employer mentioned in division (B)(2) of section 4123.01 of 3,151
the Revised Code, and every publicly owned utility shall pay 3,152
semiannually in the months of January and July into the state 3,154
insurance fund the amount of annual premium the administrator of 3,155
71
workers' compensation fixes for the employment or occupation of 3,156
the employer, the amount of which premium to be paid by each 3,157
employer to be determined by the classifications, rules, and 3,158
rates made and published by the administrator. The employer
shall pay semiannually a further sum of money into the state 3,159
insurance fund as may be ascertained to be due from the employer 3,162
by applying the rules of the administrator, and a receipt or 3,163
certificate certifying that payment has been made shall be mailed 3,165
immediately to the employer by the bureau of workers'
compensation. The receipt or certificate is prima facie evidence 3,166
of the payment of the premium. 3,167
The bureau of workers' compensation shall verify with the 3,169
secretary of state the existence of all corporations and 3,170
organizations making application for workers' compensation 3,171
coverage and shall require every such application to include the 3,172
employer's federal identification number. 3,173
An employer as defined in division (B)(2) of section 3,175
4123.01 of the Revised Code who has contracted with a 3,176
subcontractor is liable for the unpaid premium due from any 3,177
subcontractor with respect to that part of the payroll of the 3,178
subcontractor that is for work performed pursuant to the contract 3,180
with the employer.
Division (A) of THIS section 4123.35 of the Revised Code 3,182
providing for the payment of premiums semiannually does not apply 3,184
to any employer who was a subscriber to the state insurance fund 3,185
prior to January 1, 1914, or who may first become a subscriber to 3,186
the fund in any month other than January or July. Instead, the 3,187
semiannual premiums shall be paid by those employers from time to 3,188
time upon the expiration of the respective periods for which 3,189
payments into the fund have been made by them.
The administrator shall adopt rules to permit employers to 3,191
make periodic payments of the semiannual premium due under this 3,192
division. The rules shall include provisions for the assessment 3,193
of interest charges, where appropriate, and for the assessment of 3,194
72
penalties when an employer fails to make timely premium payments. 3,196
An employer who timely pays the amounts due under this division 3,197
is entitled to all of the benefits and protections of this 3,198
chapter. Upon receipt of payment, the bureau immediately shall 3,199
mail a receipt or certificate to the employer certifying that
payment has been made, which receipt is prima-facie evidence of 3,201
payment. Workers' compensation coverage under this chapter 3,202
continues uninterrupted upon timely receipt of payment under this 3,203
division.
Every employer mentioned in division (B)(1) of section 3,205
4123.01 of the Revised Code, except boards of county hospital 3,206
trustees that are self-insuring employers under this section, 3,207
shall comply with sections 4123.38 to 4123.41, and 4123.48 of the 3,209
Revised Code in regard to the contribution of moneys to the 3,210
public insurance fund. 3,211
(B) Provided, that employers mentioned in division (B)(2) 3,213
of section 4123.01 of the Revised Code, boards of county hospital 3,214
trustees, and publicly owned utilities who will abide by the 3,215
rules of the administrator and who may be of sufficient financial 3,216
ability to render certain the payment of compensation to injured 3,217
employees or the dependents of killed employees, and the 3,218
furnishing of medical, surgical, nursing, and hospital attention 3,219
and services and medicines, and funeral expenses, equal to or 3,220
greater than is provided for in sections 4123.52, 4123.55 to 3,221
4123.62, and 4123.64 to 4123.67 of the Revised Code, and who do 3,222
not desire to insure the payment thereof or indemnify themselves 3,223
against loss sustained by the direct payment thereof, upon a 3,224
finding of such facts by the administrator, may be granted the 3,225
privilege to pay individually compensation, and furnish medical, 3,227
surgical, nursing, and hospital services and attention and 3,228
funeral expenses directly to injured employees or the dependents 3,229
of killed employees, thereby being granted status as a 3,231
self-insuring employer. The administrator may charge employers, 3,232
boards of county hospital trustees, or publicly owned utilities 3,233
73
who apply for the status as a self-insuring employer a reasonable 3,234
application fee to cover the bureau's costs in connection with 3,235
processing and making a determination with respect to an 3,236
application. All employers granted such status shall demonstrate 3,237
sufficient financial and administrative ability to assure that 3,238
all obligations under this section are promptly met. The 3,239
administrator shall deny the privilege where the employer is 3,240
unable to demonstrate the employer's ability to promptly meet all 3,241
the obligations imposed on the employer by this section. The 3,242
administrator shall consider, but is not limited to, the 3,244
following factors, where applicable, in determining the
employer's ability to meet all of the obligations imposed on the 3,245
employer by this section: 3,246
(1) The employer employs a minimum of five hundred 3,248
employees in this state; 3,249
(2) The employer has operated in this state for a minimum 3,251
of two years, provided that an employer who has purchased, 3,252
acquired, or otherwise succeeded to the operation of a business, 3,253
or any part thereof, situated in this state that has operated for 3,254
at least two years in this state, also shall qualify; 3,255
(3) Where the employer previously contributed to the state 3,257
insurance fund or is a successor employer as defined by bureau 3,258
rules, the amount of the buy-out, as defined by bureau rules; 3,259
(4) The sufficiency of the employer's assets located in 3,261
this state to insure the employer's solvency in paying 3,262
compensation directly; 3,263
(5) The financial records, documents, and data, certified 3,265
by a certified public accountant, necessary to provide the 3,266
employer's full financial disclosure. The records, documents, 3,267
and data include, but are not limited to, balance sheets and 3,268
profit and loss history for the current year and previous four 3,269
years. 3,270
(6) The employer's organizational plan for the 3,272
administration of the workers' compensation law; 3,273
74
(7) The employer's proposed plan to inform employees of 3,275
the change from a state fund insurer to a self-insuring employer, 3,276
the procedures the employer will follow as a self-insuring 3,277
employer, and the employees' rights to compensation and benefits; 3,278
and 3,279
(8) The employer has either an account in a financial 3,281
institution in this state, or if the employer maintains an 3,282
account with a financial institution outside this state, ensures 3,283
that workers' compensation checks are drawn from the same account 3,284
as payroll checks or the employer clearly indicates that payment 3,285
will be honored by a financial institution in this state. 3,286
The administrator may waive the requirements of divisions 3,288
(B)(1) and (2) of this section and the requirement of division 3,289
(B)(5) of this section that the financial records, documents, and 3,290
data be certified by a certified public accountant. The 3,291
administrator shall adopt rules establishing the criteria that an 3,292
employer shall meet in order for the administrator to waive the 3,293
requirement of division (B)(5) of this section. Such rules may 3,294
require additional security of that employer pursuant to division 3,295
(E) of section 4123.351 of the Revised Code. The administrator 3,296
shall not grant the status of self-insuring employer to any 3,297
public employer, other than publicly owned utilities and boards 3,298
of county hospital trustees. 3,299
(C) PROVIDED, THAT A BOARD OF COUNTY COMMISSIONERS 3,301
MENTIONED IN DIVISION (G)(4) OF SECTION 4123.01 OF THE REVISED 3,303
CODE, AS AN EMPLOYER, THAT WILL ABIDE BY THE RULES OF THE 3,304
ADMINISTRATOR AND THAT MAY BE OF SUFFICIENT FINANCIAL ABILITY TO 3,305
RENDER CERTAIN THE PAYMENT OF COMPENSATION TO INJURED EMPLOYEES 3,306
OR THE DEPENDENTS OF KILLED EMPLOYEES, AND THE FURNISHING OF 3,307
MEDICAL, SURGICAL, NURSING, AND HOSPITAL ATTENTION AND SERVICES 3,308
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 3,309
TO 4123.67 OF THE REVISED CODE, AND THAT DOES NOT DESIRE TO 3,312
INSURE THE PAYMENT THEREOF OR INDEMNIFY ITSELF AGAINST LOSS 3,313
75
SUSTAINED BY THE DIRECT PAYMENT THEREOF, UPON A FINDING OF SUCH 3,314
FACTS BY THE ADMINISTRATOR, MAY BE GRANTED THE PRIVILEGE TO PAY 3,315
INDIVIDUALLY COMPENSATION, AND FURNISH MEDICAL, SURGICAL, 3,316
NURSING, AND HOSPITAL SERVICES AND ATTENTION AND FUNERAL EXPENSES
DIRECTLY TO INJURED EMPLOYEES OR THE DEPENDENTS OF KILLED 3,317
EMPLOYEES, THEREBY BEING GRANTED STATUS AS A SELF-INSURING 3,318
EMPLOYER. THE ADMINISTRATOR MAY CHARGE A BOARD OF COUNTY 3,320
COMMISSIONERS MENTIONED IN DIVISION (G)(4) OF SECTION 4123.01 OF 3,321
THE REVISED CODE THAT APPLIES FOR THE STATUS AS A SELF-INSURING 3,323
EMPLOYER A REASONABLE APPLICATION FEE TO COVER THE BUREAU'S COSTS 3,324
IN CONNECTION WITH PROCESSING AND MAKING A DETERMINATION WITH 3,325
RESPECT TO AN APPLICATION. ALL EMPLOYERS GRANTED SUCH STATUS 3,326
SHALL DEMONSTRATE SUFFICIENT FINANCIAL AND ADMINISTRATIVE ABILITY
TO ASSURE THAT ALL OBLIGATIONS UNDER THIS SECTION ARE PROMPTLY 3,327
MET. THE ADMINISTRATOR SHALL DENY THE PRIVILEGE WHERE THE 3,328
EMPLOYER IS UNABLE TO DEMONSTRATE THE EMPLOYER'S ABILITY TO 3,329
PROMPTLY MEET ALL THE OBLIGATIONS IMPOSED ON THE EMPLOYER BY THIS 3,331
SECTION. THE ADMINISTRATOR SHALL CONSIDER, BUT IS NOT LIMITED 3,332
TO, THE FOLLOWING FACTORS, WHERE APPLICABLE, IN DETERMINING THE
EMPLOYER'S ABILITY TO MEET ALL OF THE OBLIGATIONS IMPOSED ON THE 3,333
BOARD AS AN EMPLOYER BY THIS SECTION: 3,334
(1) THE BOARD AS AN EMPLOYER EMPLOYS A MINIMUM OF FIVE 3,336
HUNDRED EMPLOYEES IN THIS STATE; 3,337
(2) THE BOARD HAS OPERATED IN THIS STATE FOR A MINIMUM OF 3,339
TWO YEARS;
(3) WHERE THE BOARD PREVIOUSLY CONTRIBUTED TO THE STATE 3,341
INSURANCE FUND OR IS A SUCCESSOR EMPLOYER AS DEFINED BY BUREAU 3,342
RULES, THE AMOUNT OF THE BUY-OUT, AS DEFINED BY BUREAU RULES; 3,343
(4) THE SUFFICIENCY OF THE BOARD'S ASSETS LOCATED IN THIS 3,345
STATE TO INSURE THE BOARD'S SOLVENCY IN PAYING COMPENSATION 3,346
DIRECTLY;
(5) THE FINANCIAL RECORDS, DOCUMENTS, AND DATA, CERTIFIED 3,348
BY A CERTIFIED PUBLIC ACCOUNTANT, NECESSARY TO PROVIDE THE 3,349
BOARD'S FULL FINANCIAL DISCLOSURE. THE RECORDS, DOCUMENTS, AND 3,350
76
DATA INCLUDE, BUT ARE NOT LIMITED TO, BALANCE SHEETS AND PROFIT 3,351
AND LOSS HISTORY FOR THE CURRENT YEAR AND PREVIOUS FOUR YEARS. 3,352
(6) THE BOARD'S ORGANIZATIONAL PLAN FOR THE ADMINISTRATION 3,354
OF THE WORKERS' COMPENSATION LAW; 3,355
(7) THE BOARD'S PROPOSED PLAN TO INFORM EMPLOYEES OF THE 3,357
PROPOSED SELF-INSURANCE, THE PROCEDURES THE BOARD WILL FOLLOW AS 3,358
A SELF-INSURING EMPLOYER, AND THE EMPLOYEES' RIGHTS TO 3,359
COMPENSATION AND BENEFITS;
(8) THE BOARD HAS EITHER AN ACCOUNT IN A FINANCIAL 3,361
INSTITUTION IN THIS STATE, OR IF THE BOARD MAINTAINS AN ACCOUNT 3,363
WITH A FINANCIAL INSTITUTION OUTSIDE THIS STATE, ENSURES THAT 3,364
WORKERS' COMPENSATION CHECKS ARE DRAWN FROM THE SAME ACCOUNT AS 3,365
PAYROLL CHECKS OR THE BOARD CLEARLY INDICATES THAT PAYMENT WILL 3,366
BE HONORED BY A FINANCIAL INSTITUTION IN THIS STATE; 3,367
(9) THE BOARD SHALL PROVIDE THE ADMINISTRATOR A SURETY 3,369
BOND IN AN AMOUNT EQUAL TO ONE HUNDRED TWENTY-FIVE PER CENT OF 3,370
THE PROJECTED LOSSES AS DETERMINED BY THE ADMINISTRATOR. 3,371
(D) The administrator shall require a surety bond from all 3,373
self-insuring employers, issued pursuant to section 4123.351 of 3,374
the Revised Code, that is sufficient to compel, or secure to 3,375
injured employees, or to the dependents of employees killed, the 3,376
payment of compensation and expenses, which shall in no event be 3,377
less than that paid or furnished out of the state insurance fund 3,378
in similar cases to injured employees or to dependents of killed 3,379
employees whose employers contribute to the fund, except when an 3,380
employee of the employer, who has suffered the loss of a hand, 3,381
arm, foot, leg, or eye prior to the injury for which compensation 3,382
is to be paid, and thereafter suffers the loss of any other of 3,383
the members as the result of any injury sustained in the course 3,384
of and arising out of the employee's employment, the compensation 3,386
to be paid by the self-insuring employer is limited to the
disability suffered in the subsequent injury, additional 3,387
compensation, if any, to be paid by the bureau out of the surplus 3,389
created by section 4123.34 of the Revised Code. 3,390
77
(D)(E) In addition to the requirements of this section, 3,392
the administrator shall make and publish rules governing the 3,393
manner of making application and the nature and extent of the 3,394
proof required to justify a finding of fact by the administrator 3,395
as to granting the status of a self-insuring employer, which 3,396
rules shall be general in their application, one of which rules 3,397
shall provide that all self-insuring employers shall pay into the 3,398
state insurance fund such amounts as are required to be credited 3,399
to the surplus fund in division (B) of section 4123.34 of the 3,400
Revised Code. 3,401
Employers shall secure directly from the bureau central 3,403
offices application forms upon which the bureau shall stamp a 3,404
designating number. Prior to submission of an application, an 3,405
employer shall make available to the bureau, and the bureau shall 3,406
review, the information described in divisions (B)(1) to (8) of 3,407
this section. An employer shall file the completed application 3,408
forms with an application fee, which shall cover the costs of 3,409
processing the application, as established by the administrator, 3,410
by rule, with the bureau at least ninety days prior to the 3,411
effective date of the employer's new status as a self-insuring 3,412
employer. The application form is not deemed complete until all 3,413
the required information is attached thereto. The bureau shall 3,414
only accept applications that contain the required information. 3,415
(E)(F) The bureau shall review completed applications 3,417
within a reasonable time. If the bureau determines to grant an 3,418
employer the status as a self-insuring employer, the bureau shall 3,419
issue a statement, containing its findings of fact, that is 3,420
prepared by the bureau and signed by the administrator. If the 3,421
bureau determines not to grant the status as a self-insuring 3,422
employer, the bureau shall notify the employer of the 3,423
determination and require the employer to continue to pay its 3,424
full premium into the state insurance fund. The administrator 3,425
also shall adopt rules establishing a minimum level of 3,426
performance as a criterion for granting and maintaining the 3,427
78
status as a self-insuring employer and fixing time limits beyond 3,428
which failure of the self-insuring employer to provide for the 3,429
necessary medical examinations and evaluations may not delay a 3,430
decision on a claim.
(F)(G) The administrator shall adopt rules setting forth 3,432
procedures for auditing the program of self-insuring employers. 3,433
The bureau shall conduct the audit upon a random basis or 3,434
whenever the bureau has grounds for believing that an employer is 3,435
not in full compliance with bureau rules or this chapter. 3,436
The administrator shall monitor the programs conducted by 3,438
self-insuring employers, to ensure compliance with bureau 3,439
requirements and for that purpose, shall develop and issue to 3,440
self-insuring employers standardized forms for use by the 3,441
employer in all aspects of the employers' direct compensation 3,442
program and for reporting of information to the bureau. 3,443
The bureau shall receive and transmit to the employer all 3,445
complaints concerning any self-insuring employer. In the case of 3,446
a complaint against a self-insuring employer, the administrator 3,447
shall handle the complaint through the self-insurance division of 3,448
the bureau. The bureau shall maintain a file by employer of all 3,449
complaints received that relate to the employer. The bureau 3,450
shall evaluate each complaint and take appropriate action. 3,451
The administrator shall adopt as a rule a prohibition 3,453
against any self-insuring employer from harassing, dismissing, or 3,454
otherwise disciplining any employee making a complaint, which 3,455
rule shall provide for a financial penalty to be levied by the 3,456
administrator payable by the offending employer. 3,457
(G)(H) For the purpose of making determinations as to 3,459
whether to grant status as a self-insuring employer, the 3,460
administrator may subscribe to and pay for a credit reporting 3,461
service that offers financial and other business information 3,462
about individual employers. The costs in connection with the 3,463
bureau's subscription or individual reports from the service 3,464
about an applicant may be included in the application fee charged 3,465
79
employers under this section. 3,466
(H)(I) The administrator, notwithstanding other provisions 3,469
of this chapter, may permit a self-insuring employer to resume 3,470
payment of premiums to the state insurance fund with appropriate 3,471
credit modifications to the employer's basic premium rate as such 3,472
rate is determined pursuant to section 4123.29 of the Revised 3,473
Code.
(I)(J) On the first day of July of each year, the 3,475
administrator shall calculate separately each self-insuring 3,476
employer's assessments for the safety and hygiene fund, 3,477
administrative costs pursuant to section 4123.342 of the Revised 3,478
Code, and for the portion of the surplus fund under division (B) 3,479
of section 4123.34 of the Revised Code that is not used for 3,480
handicapped reimbursement, on the basis of the paid compensation 3,481
attributable to the individual self-insuring employer according 3,482
to the following calculation: 3,483
(1) The total assessment against all self-insuring 3,485
employers as a class for each fund and for the administrative 3,486
costs for the year that the assessment is being made, as 3,487
determined by the administrator, divided by the total amount of 3,488
paid compensation for the previous calendar year attributable to 3,489
all amenable self-insuring employers; 3,490
(2) Multiply the quotient in division (I)(J)(1) of this 3,492
section by the total amount of paid compensation for the previous 3,493
calendar year that is attributable to the individual 3,494
self-insuring employer for whom the assessment is being 3,495
determined. Each self-insuring employer shall pay the assessment 3,496
that results from this calculation, unless the assessment 3,497
resulting from this calculation falls below a minimum assessment, 3,498
which minimum assessment the administrator shall determine on the 3,499
first day of July of each year with the advice and consent of the 3,500
workers' compensation oversight commission, in which event, the 3,501
self-insuring employer shall pay the minimum assessment. 3,502
In determining the total amount due for the total 3,504
80
assessment against all self-insuring employers as a class for 3,505
each fund and the administrative assessment, the administrator 3,506
shall reduce proportionately the total for each fund and 3,508
assessment by the amount of money in the self-insurance 3,509
assessment fund as of the date of the computation of the 3,510
assessment. 3,511
The administrator shall calculate the assessment for the 3,513
portion of the surplus fund under division (B) of section 4123.34 3,514
of the Revised Code that is used for handicapped reimbursement in 3,515
the same manner as set forth in divisions (I)(J)(1) and (2) of 3,516
this section except that the administrator shall calculate the 3,518
total assessment for this portion of the surplus fund only on the 3,519
basis of those self-insuring employers that retain participation 3,520
in the handicapped reimbursement program and the individual 3,521
self-insuring employer's proportion of paid compensation shall be 3,522
calculated only for those self-insuring employers who retain 3,523
participation in the handicapped reimbursement program. The 3,524
administrator, as the administrator determines appropriate, may 3,526
determine the total assessment for the handicapped portion of the 3,527
surplus fund in accordance with sound actuarial principles. 3,528
The administrator shall calculate the assessment for the 3,530
portion of the surplus fund under division (B) of section 4123.34 3,531
of the Revised Code that under division (D) of section 4121.66 of 3,532
the Revised Code is used for rehabilitation costs in the same 3,533
manner as set forth in divisions (I)(J)(1) and (2) of this 3,534
section, except that the administrator shall calculate the total 3,536
assessment for this portion of the surplus fund only on the basis 3,537
of those self-insuring employers who have not made the election 3,538
to make payments directly under division (D) of section 4121.66 3,539
of the Revised Code and an individual self-insuring employer's 3,540
proportion of paid compensation only for those self-insuring 3,541
employers who have not made that election. 3,542
An employer who no longer is a self-insuring employer in 3,544
this state or who no longer is operating in this state, shall 3,545
81
continue to pay assessments for administrative costs and for the 3,546
portion of the surplus fund under division (B) of section 4123.34 3,547
of the Revised Code that is not used for handicapped 3,548
reimbursement, based upon paid compensation attributable to 3,549
claims that occurred while the employer was a self-insuring 3,550
employer within this state. 3,551
(J)(K) There is hereby created in the state treasury the 3,553
self-insurance assessment fund. All investment earnings of the 3,554
fund shall be deposited in the fund. The administrator shall use 3,555
the money in the self-insurance assessment fund only for 3,556
administrative costs as specified in section 4123.341 of the 3,557
Revised Code. 3,558
(K)(L) Every self-insuring employer shall certify, in 3,560
affidavit form subject to the penalty for perjury, to the bureau 3,561
the amount of the self-insuring employer's paid compensation for 3,562
the previous calendar year. In reporting paid compensation paid 3,563
for the previous year, a self-insuring employer shall exclude 3,564
from the total amount of paid compensation any reimbursement the 3,565
employer receives in the previous calendar year from the surplus 3,566
fund pursuant to section 4123.512 of the Revised Code for any 3,567
paid compensation. The self-insuring employer also shall exclude 3,568
from the paid compensation reported any amount recovered under 3,569
section 4123.93 of the Revised Code and any amount that is 3,570
determined not to have been payable to or on behalf of a claimant 3,571
in any final administrative or judicial proceeding. The 3,572
self-insuring employer shall exclude such amounts from the paid 3,573
compensation reported in the reporting period subsequent to the 3,574
date the determination is made. The administrator shall adopt 3,575
rules, in accordance with Chapter 119. of the Revised Code, 3,576
establishing the date by which self-insuring employers must 3,577
submit such information and the amount of the assessments 3,578
provided for in division (I)(J) of this section for employers who 3,580
have been granted self-insuring status within the last calendar 3,581
year. 3,582
82
The administrator shall include any assessment that remains 3,584
unpaid for previous assessment periods in the calculation and 3,585
collection of any assessments due under this division or division 3,586
(I)(J) of this section. 3,587
(L)(M) As used in this section, "paid compensation" means 3,589
all amounts paid by a self-insuring employer for living 3,590
maintenance benefits, all amounts for compensation paid pursuant 3,591
to sections 4121.63, 4121.67, 4123.56, 4123.57, 4123.58, 4123.59, 3,592
4123.60, and 4123.64 of the Revised Code, all amounts paid as 3,593
wages in lieu of such compensation, all amounts paid in lieu of 3,594
such compensation under a nonoccupational accident and sickness 3,595
program fully funded by the self-insuring employer, and all 3,596
amounts paid by a self-insuring employer for a violation of a 3,597
specific safety standard pursuant to Section 35 of Article II, 3,598
Ohio Constitution and section 4121.47 of the Revised Code. 3,599
(M)(N) Should any section of this chapter or Chapter 4121. 3,601
of the Revised Code providing for self-insuring employers' 3,602
assessments based upon compensation paid be declared 3,603
unconstitutional by a final decision of any court, then that 3,604
section of the Revised Code declared unconstitutional shall 3,605
revert back to the section in existence prior to November 3, 3,606
1989, providing for assessments based upon payroll. 3,607
(N)(O) The administrator may grant a self-insuring 3,609
employer the privilege to self-insure a construction project 3,611
entered into by the self-insuring employer that is scheduled for 3,612
completion within six years after the date the project begins, 3,613
and the total cost of which is estimated to exceed one hundred 3,615
million dollars. The administrator may waive such cost and time
criteria and grant a self-insuring employer the privilege to 3,616
self-insure a construction project regardless of the time needed 3,617
to complete the construction project and provided that the cost 3,618
of the construction project is estimated to exceed fifty million 3,619
dollars. A self-insuring employer who desires to self-insure a 3,621
construction project shall submit to the administrator an
83
application listing the dates the construction project is 3,622
scheduled to begin and end, the estimated cost of the 3,624
construction project, the contractors and subcontractors whose
employees are to be self-insured by the self-insuring employer, 3,625
the provisions of a safety program that is specifically designed 3,626
for the construction project, and a statement as to whether a 3,627
collective bargaining agreement governing the rights, duties, and 3,628
obligations of each of the parties to the agreement with respect 3,629
to the construction project exists between the self-insuring 3,630
employer and a labor organization. 3,631
A self-insuring employer may apply to self-insure the 3,633
employees of either of the following: 3,634
(1) All contractors and subcontractors who perform labor 3,636
or work or provide materials for the construction project; 3,637
(2) All contractors and, at the administrator's 3,639
discretion, a substantial number of all the subcontractors who 3,640
perform labor or work or provide materials for the construction 3,641
project.
Upon approval of the application, the administrator shall 3,643
mail a certificate granting the privilege to self-insure the 3,644
construction project to the self-insuring employer. The 3,645
certificate shall contain the name of the self-insuring employer 3,646
and the name, address, and telephone number of the self-insuring 3,647
employer's representatives who are responsible for administering
workers' compensation claims for the construction project. The 3,648
self-insuring employer shall post the certificate in a 3,649
conspicuous place at the site of the construction project. 3,650
The administrator shall maintain a record of the 3,652
contractors and subcontractors whose employees are covered under 3,653
the certificate issued to the self-insured employer. A 3,654
self-insuring employer immediately shall notify the administrator 3,655
when any contractor or subcontractor is added or eliminated from 3,656
inclusion under the certificate.
Upon approval of the application, the self-insuring 3,658
84
employer is responsible for the administration and payment of all 3,659
claims under this chapter and Chapter 4121. of the Revised Code 3,660
for the employees of the contractor and subcontractors covered 3,661
under the certificate who receive injuries or are killed in the 3,662
course of and arising out of employment on the construction 3,664
project, or who contract an occupational disease in the course of 3,665
employment on the construction project. For purposes of this
chapter and Chapter 4121. of the Revised Code, a claim that is 3,667
administered and paid in accordance with this division is
considered a claim against the self-insuring employer listed in 3,668
the certificate. A contractor or subcontractor included under 3,669
the certificate shall report to the self-insuring employer listed 3,670
in the certificate, all claims that arise under this chapter and 3,671
Chapter 4121. of the Revised Code in connection with the 3,673
construction project for which the certificate is issued. 3,674
A self-insuring employer who complies with this division is 3,676
entitled to the protections provided under this chapter and 3,677
Chapter 4121. of the Revised Code with respect to the employees 3,679
of the contractors and subcontractors covered under a certificate 3,680
issued under this division for death or injuries that arise out 3,681
of, or death, injuries, or occupational diseases that arise in
the course of, those employees' employment on that construction 3,683
project, as if the employees were employees of the self-insuring 3,684
employer, provided that the self-insuring employer also complies 3,685
with this section. No employee of the contractors and
subcontractors covered under a certificate issued under this 3,686
division shall be considered the employee of the self-insuring 3,687
employer listed in that certificate for any purposes other than 3,688
this chapter and Chapter 4121. of the Revised Code. Nothing in 3,689
this division gives a self-insuring employer authority to control 3,690
the means, manner, or method of employment of the employees of 3,691
the contractors and subcontractors covered under a certificate 3,692
issued under this division. 3,693
The contractors and subcontractors included under a 3,695
85
certificate issued under this division are entitled to the 3,696
protections provided under this chapter and Chapter 4121. of the 3,697
Revised Code with respect to the contractor's or subcontractor's 3,698
employees who are employed on the construction project which is 3,699
the subject of the certificate, for death or injuries that arise 3,700
out of, or death, injuries, or occupational diseases that arise 3,701
in the course of, those employees' employment on that 3,702
construction project.
The contractors and subcontractors included under a 3,704
certificate issued under this division shall identify in their 3,705
payroll records the employees who are considered the employees of 3,706
the self-insuring employer listed in that certificate for 3,707
purposes of this chapter and Chapter 4121. of the Revised Code, 3,709
and the amount that those employees earned for employment on the 3,710
construction project that is the subject of that certificate. 3,711
Notwithstanding any provision to the contrary under this chapter
and Chapter 4121. of the Revised Code, the administrator shall 3,714
exclude the payroll that is reported for employees who are 3,715
considered the employees of the self-insuring employer listed in
that certificate, and that the employees earned for employment on 3,716
the construction project that is the subject of that certificate, 3,717
when determining those contractors' or subcontractors' premiums 3,718
or assessments required under this chapter and Chapter 4121. of 3,719
the Revised Code. A self-insuring employer issued a certificate 3,720
under this division shall include in the amount of paid 3,721
compensation it reports pursuant to division (K)(L) of this 3,722
section, the amount of paid compensation the self-insuring 3,723
employer paid pursuant to this division for the previous calendar 3,724
year.
Nothing in this division shall be construed as altering the 3,726
rights of employees under this chapter and Chapter 4121. of the 3,727
Revised Code as those rights existed prior to the effective date 3,729
of this amendment SEPTEMBER 17, 1996. Nothing in this division 3,730
shall be construed as altering the rights devolved under sections 3,732
86
2305.31 and 4123.82 of the Revised Code as those rights existed 3,733
prior to the effective date of this amendment SEPTEMBER 17, 1996. 3,734
As used in this division, "privilege to self-insure a 3,736
construction project" means privilege to pay individually 3,737
compensation, and to furnish medical, surgical, nursing, and 3,738
hospital services and attention and funeral expenses directly to 3,739
injured employees or the dependents of killed employees. 3,740
(O)(P) A self-insuring employer whose application is 3,742
granted under division (N)(O) of this section shall designate a 3,744
safety professional to be responsible for the administration and 3,746
enforcement of the safety program that is specifically designed 3,747
for the construction project that is the subject of the 3,748
application.
A self-insuring employer whose application is granted under 3,750
division (N)(O) of this section shall employ an ombudsperson for 3,752
the construction project that is the subject of the application. 3,753
The ombudsperson shall have experience in workers' compensation 3,754
or the construction industry, or both. The ombudsperson shall 3,755
perform all of the following duties:
(1) Communicate with and provide information to employees 3,757
who are injured in the course of, or whose injury arises out of 3,758
employment on the construction project, or who contract an 3,759
occupational disease in the course of employment on the 3,760
construction project;
(2) Investigate the status of a claim upon the request of 3,762
an employee to do so; 3,763
(3) Provide information to claimants, third party 3,765
administrators, employers, and other persons to assist those 3,766
persons in protecting their rights under this chapter and Chapter 3,767
4121. of the Revised Code. 3,768
A self-insuring employer whose application is granted under 3,770
division (N)(O) of this section shall post the name of the safety 3,772
professional and the ombudsperson and instructions for contacting
the safety professional and the ombudsperson in a conspicuous 3,773
87
place at the site of the construction project. 3,774
(P)(Q) The administrator may consider all of the following 3,777
when deciding whether to grant a self-insuring employer the 3,778
privilege to self-insure a construction project as provided under 3,779
division (N)(O) of this section: 3,780
(1) Whether the self-insuring employer has an 3,782
organizational plan for the administration of the workers' 3,783
compensation law; 3,784
(2) Whether the safety program that is specifically 3,786
designed for the construction project provides for the safety of 3,787
employees employed on the construction project, is applicable to 3,789
all contractors and subcontractors who perform labor or work or 3,790
provide materials for the construction project, and has a
component, a safety training program that complies with standards 3,791
adopted pursuant to the "Occupational Safety and Health Act of 3,792
1970," 84 Stat. 1590, 29 U.S.C.A. 651, and provides for 3,793
continuing management and employee involvement; 3,794
(3) Whether granting the privilege to self-insure the 3,796
construction project will reduce the costs of the construction 3,797
project; 3,798
(4) Whether the self-insuring employer has employed an 3,800
ombudsperson as required under division (O)(P) of this section; 3,802
(5) Whether the self-insuring employer has sufficient 3,804
surety to secure the payment of claims for which the 3,805
self-insuring employer would be responsible pursuant to the 3,806
granting of the privilege to self-insure a construction project 3,807
under division (N)(O) of this section. 3,809
Sec. 4123.512. (A) The claimant or the employer may 3,820
appeal an order of the industrial commission made under division 3,821
(E) of section 4123.511 of the Revised Code in any injury or 3,822
occupational disease case, other than a decision as to the extent 3,823
of disability to the court of common pleas of the county in which 3,825
the injury was inflicted or in which the contract of employment 3,826
was made if the injury occurred outside the state, or in which 3,827
88
the contract of employment was made if the exposure occurred 3,828
outside the state. If no common pleas court has jurisdiction for 3,829
the purposes of an appeal by the use of the jurisdictional 3,830
requirements described in this division, the appellant may use 3,831
the venue provisions in the Rules of Civil Procedure to vest 3,832
jurisdiction in a court. If the claim is for an occupational 3,833
disease the appeal shall be to the court of common pleas of the 3,834
county in which the exposure which caused the disease occurred. 3,835
Like appeal may be taken from an order of a staff hearing officer 3,836
made under division (D) of section 4123.511 of the Revised Code 3,837
from which the commission has refused to hear an appeal. The 3,838
appellant shall file the notice of appeal with a court of common 3,839
pleas within sixty days after the date of the receipt of the 3,840
order appealed from or the date of receipt of the order of the 3,841
commission refusing to hear an appeal of a staff hearing 3,842
officer's decision under division (D) of section 4123.511 of the 3,843
Revised Code. The filing of the notice of the appeal with the 3,844
court is the only act required to perfect the appeal.
If an action has been commenced in a court of a county 3,846
other than a court of a county having jurisdiction over the 3,847
action, the court, upon notice by any party or upon its own 3,848
motion, shall transfer the action to a court of a county having 3,849
jurisdiction. 3,850
Notwithstanding anything to the contrary in this section, 3,852
if the commission determines under section 4123.522 of the 3,853
Revised Code that an employee, employer, or their respective 3,854
representatives have not received written notice of an order or 3,855
decision which is appealable to a court under this section and 3,856
which grants relief pursuant to section 4123.522 of the Revised 3,857
Code, the party granted the relief has sixty days from receipt of 3,858
the order under section 4123.522 of the Revised Code to file a 3,859
notice of appeal under this section. 3,860
(B) The notice of appeal shall state the names of the 3,862
claimant and the employer, the number of the claim, the date of 3,863
89
the order appealed from, and the fact that the appellant appeals 3,864
therefrom. 3,865
The administrator, the claimant, and the employer shall be 3,867
parties to the appeal and the court, upon the application of the 3,868
commission, shall make the commission a party. The administrator 3,869
shall notify the employer that if he THE EMPLOYER fails to become 3,871
an active party to the appeal, then the administrator may act on 3,872
behalf of the employer and the results of the appeal could have 3,873
an adverse effect upon the employer's premium rates. 3,874
(C) The attorney general or one or more of his THE 3,876
ATTORNEY GENERAL'S assistants or special counsel designated by 3,878
him THE ATTORNEY GENERAL shall represent the administrator and 3,879
the commission. In the event the attorney general or his THE 3,880
ATTORNEY GENERAL'S designated assistants or special counsel are 3,881
absent, the administrator or the commission shall select one or 3,882
more of the attorneys in the employ of the administrator or the 3,883
commission as his THE ADMINISTRATOR'S ATTORNEY or its THE 3,885
COMMISSION'S attorney in the appeal. Any attorney so employed 3,886
shall continue his THE representation during the entire period of 3,887
the appeal and in all hearings thereof except where the continued 3,888
representation becomes impractical.
(D) Upon receipt of notice of appeal the clerk of courts 3,890
shall provide notice to all parties who are appellees and to the 3,891
commission. 3,892
The claimant shall, within thirty days after the filing of 3,894
the notice of appeal, file a petition containing a statement of 3,895
facts in ordinary and concise language showing a cause of action 3,896
to participate or to continue to participate in the fund and 3,897
setting forth the basis for the jurisdiction of the court over 3,898
the action. Further pleadings shall be had in accordance with 3,899
the Rules of Civil Procedure, provided that service of summons on 3,900
such petition shall not be required. The clerk of the court 3,901
shall, upon receipt thereof, transmit by certified mail a copy 3,902
thereof to each party named in the notice of appeal other than 3,903
90
the claimant. Any party may file with the clerk prior to the 3,904
trial of the action a deposition of any physician taken in 3,905
accordance with the provisions of the Revised Code, which 3,906
deposition may be read in the trial of the action even though the 3,907
physician is a resident of or subject to service in the county in 3,908
which the trial is had. The bureau of workers' compensation 3,909
shall pay the cost of the stenographic deposition filed in court 3,910
and of copies of the stenographic deposition for each party from 3,912
the surplus fund and charge the costs thereof against the 3,914
unsuccessful party if the claimant's right to participate or 3,915
continue to participate is finally sustained or established in 3,916
the appeal. In the event the deposition is taken and filed, the 3,917
physician whose deposition is taken is not required to respond to 3,918
any subpoena issued in the trial of the action. The court, or 3,919
the jury under the instructions of the court, if a jury is 3,920
demanded, shall determine the right of the claimant to 3,921
participate or to continue to participate in the fund upon the 3,922
evidence adduced at the hearing of the action. 3,923
(E) The court shall certify its decision to the commission 3,925
and the certificate shall be entered in the records of the court. 3,926
Appeals from the judgment are governed by the law applicable to 3,927
the appeal of civil actions. 3,928
(F) The cost of any legal proceedings authorized by this 3,930
section, including an attorney's fee to the claimant's attorney 3,931
to be fixed by the trial judge, based upon the effort expended, 3,932
in the event the claimant's right to participate or to continue 3,933
to participate in the fund is established upon the final 3,934
determination of an appeal, shall be taxed against the employer 3,935
or the commission if the commission or the administrator rather 3,936
than the employer contested the right of the claimant to 3,937
participate in the fund. The attorney's fee shall not exceed 3,938
twenty-five hundred dollars. 3,939
(G) If the finding of the court or the verdict of the jury 3,941
is in favor of the claimant's right to participate in the fund, 3,942
91
the commission and the administrator shall thereafter proceed in 3,943
the matter of the claim as if the judgment were the decision of 3,944
the commission, subject to the power of modification provided by 3,945
section 4123.52 of the Revised Code. 3,946
(H) An appeal from an order issued under division (E) of 3,948
section 4123.511 of the Revised Code or any action filed in court 3,949
in a case in which an award of compensation has been made shall 3,950
not stay the payment of compensation under the award or payment 3,951
of compensation for subsequent periods of total disability during 3,952
the pendency of the appeal. If, in a final administrative or 3,953
judicial action, it is determined that payments of compensation 3,954
or benefits, or both, made to or on behalf of a claimant should 3,955
not have been made, the amount thereof shall be charged to the 3,956
surplus fund under division (B) of section 4123.34 of the Revised 3,957
Code. In the event the employer is a state risk, the amount 3,958
shall not be charged to the employer's experience. In the event 3,959
the employer is a self-insuring employer, the self-insuring 3,960
employer shall deduct the amount from the paid compensation he 3,961
THE SELF-INSURING EMPLOYER reports to the administrator under 3,963
division (K)(L) of section 4123.35 of the Revised Code. All 3,964
actions and proceedings under this section which are the subject 3,965
of an appeal to the court of common pleas or the court of appeals 3,966
shall be preferred over all other civil actions except election 3,967
causes, irrespective of position on the calendar. 3,968
This section applies to all decisions of the commission or 3,970
the administrator on November 2, 1959, and all claims filed 3,971
thereafter are governed by sections 4123.511 and 4123.512 of the 3,972
Revised Code. 3,973
Any action pending in common pleas court or any other court 3,975
on January 1, 1986, under this section is governed by former 3,976
sections 4123.514, 4123.515, 4123.516, and 4123.519 and section 3,977
4123.522 of the Revised Code. 3,978
Section 2. That existing sections 1751.02, 1751.03, 3,980
1751.04, 1751.12, 1751.13, 3901.04, 3901.041, 3901.16, 3924.10, 3,982
92
4121.121, 4123.01, 4123.25, 4123.35, and 4123.512 of the Revised 3,983
Code are hereby repealed. 3,984
Section 3. Sections 1 and 2 of this act, except for 3,986
sections 1751.12, 4121.121, 4123.01, 4123.25, 4123.35, and 3,987
4123.512 of the Revised Code, as amended by this act, shall take 3,988
effect October 1, 1998. Sections 1751.12 and 4121.121 of the 3,989
Revised Code, as amended by this act, shall take effect on the 3,990
ninetieth day after the effective date of this act. 3,991
Section 4. This act is hereby declared to be an emergency 3,993
measure necessary for the immediate preservation of the public 3,994
peace, health, and safety. The reason for such necessity is that 3,996
immediate action is necessary to ensure that a board of county 3,997
commissioners may reserve necessary revenues at the earliest 3,998
possible time in order to self-insure the construction of a 3,999
recent voter-approved sports stadium and to assure the effective 4,000
operation of this fund. Therefore, this act shall go into 4,001
immediate effect.