As Introduced 1
122nd General Assembly 4
Regular Session H. B. No. 374 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-BRADING-CORBIN-GARCIA-HAINES-MOTTLEY- 8
NETZLEY-SCHURING-TAYLOR-TERWILLEGER-THOMAS-TIBERI 9
11
A B I L L
To amend sections 1739.05, 1742.06, 1742.12, 13
1742.16, 1742.37, 1742.39, 1742.45, 3901.21, 14
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 15
3923.59, 3923.63, 3923.64, 3924.01, 3924.03, 16
3924.07 to 3924.11, 3924.111, 3924.12 to 3924.14, 17
3924.51, 3924.61 to 3924.64, 3924.66 to 3924.68, 18
and 3924.73, to enact new section 1742.13 and 19
sections 1742.47, 3923.571, 3923.581, 3924.031, 20
3924.032, 3924.033, and 3924.27, and to repeal 21
sections 1742.13 and 3941.53 of the Revised Code 23
relative to the implementation of the federal 24
Health Insurance Portability and Accountability 25
Act of 1996, and insurance coverage of follow-up 26
care for a mother and newborn. 27
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 29
Section 1. That sections 1739.05, 1742.06, 1742.12, 31
1742.16, 1742.37, 1742.39, 1742.45, 3901.21, 3923.122, 3923.26, 32
3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 3923.64, 3924.01, 33
3924.03, 3924.07, 3924.08, 3924.09, 3924.10, 3924.11, 3924.111, 34
3924.12, 3924.13, 3924.14, 3924.51, 3924.61, 3924.62, 3924.63, 35
3924.64, 3924.66, 3924.67, 3924.68, and 3924.73 be amended and 36
new section 1742.13 and sections 1742.47, 3923.571, 3923.581, 37
3924.031, 3924.032, 3924.033, and 3924.27 of the Revised Code be 38
enacted to read as follows: 39
Sec. 1739.05. (A) A multiple employer welfare arrangement 48
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that is created pursuant to sections 1739.01 to 1739.22 of the 49
Revised Code and that operates a group self-insurance program may 50
be established only if any of the following applies: 51
(1) The arrangement has and maintains a minimum enrollment 53
of three hundred employees of two or more employers. 54
(2) The arrangement has and maintains a minimum enrollment 56
of three hundred self-employed individuals. 57
(3) The arrangement has and maintains a minimum enrollment 59
of three hundred employees or self-employed individuals in any 60
combination of divisions (A)(1) and (2) of this section. 61
(B) A multiple employer welfare arrangement that is 63
created pursuant to sections 1739.01 to 1739.22 of the Revised 64
Code and that operates a group self-insurance program shall 65
comply with all laws applicable to self-funded programs in this 66
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 67
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 68
3923.301, and 3923.38, 3923.581, 3923.63, 3924.031, 3924.032, AND 70
3924.27 of the Revised Code. 71
(C) A multiple employer welfare arrangement created 73
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 74
solicit enrollments only through agents or solicitors licensed 75
pursuant to Chapter 3905. of the Revised Code to sell or solicit 76
sickness and accident insurance. 77
(D) A multiple employer welfare arrangement created 79
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 80
provide benefits only to individuals who are members, employees 81
of members, or the dependents of members or employees, or are 82
eligible for continuation of coverage under section 1742.34 or 83
3923.38 of the Revised Code or under Title X of the "Consolidated 84
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 85
U.S.C.A. 1161, as amended. 86
Sec. 1742.06. Upon obtaining a certificate of authority as 95
required under this chapter, a health maintenance organization 96
may: 97
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(A) Enroll individuals and their dependents in either of 99
the following circumstances: 100
(1) The individual resides OR LIVES in the approved 102
service area.
(2) The individual's place of employment is located in the 104
approved service area and his place of residence is in a county 106
contiguous to the approved service area. 107
(B) Contract with health care providers and facilities for 109
the services to which enrollees are entitled under the terms of 110
its health care contracts. 111
(C) Contract with insurance companies authorized to do 113
business in this state for insurance, indemnity, or reimbursement 114
against the cost of providing emergency and nonemergency health 115
care services for enrollees, subject to the provisions set forth 116
elsewhere in this chapter and the limitations set forth elsewhere 117
in the Revised Code; 118
(D) Contract with any persons for the provision of 120
authorized services including, but not limited to, managerial and 121
administrative, marketing and enrolling, data processing, 122
actuarial analysis, billing services, and any other services 123
authorized by the superintendent of insurance. If such contracts 124
are made with insurance companies, they must be authorized to 125
engage in business in this state. 126
(E) Accept from governmental agencies, private agencies, 128
corporations, associations, groups, individuals, or other persons 129
payments covering all or part of the costs of planning, 130
development, construction, and the provision of health care 131
services. 132
(F) Purchase, lease, construct, renovate, operate, or 134
maintain health care facilities, and their ancillary equipment, 135
and any property necessary in the transaction of the business of 136
the organization. 137
(G) IMPOSE AN AFFILIATION PERIOD OF NOT MORE THAN SIXTY 140
DAYS, WHICH PERIOD BEGINS ON THE INDIVIDUAL'S DATE OF ENROLLMENT 141
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AND RUNS CONCURRENTLY WITH ANY WAITING PERIOD IMPOSED UNDER THE 142
COVERAGE. FOR PURPOSES OF THIS DIVISION, "AFFILIATION PERIOD" 143
MEANS A PERIOD OF TIME WHICH, UNDER THE TERMS OF THE COVERAGE 144
OFFERED, MUST EXPIRE BEFORE THE COVERAGE BECOMES EFFECTIVE. NO 145
HEALTH CARE SERVICES OR BENEFITS NEED TO BE PROVIDED DURING AN 146
AFFILIATION PERIOD, AND NO PERIODIC PREPAYMENTS CAN BE CHARGED 147
FOR ANY COVERAGE DURING THAT PERIOD. 148
(H) IF A HEALTH MAINTENANCE ORGANIZATION OFFERS COVERAGE 151
IN THE SMALL GROUP MARKET THROUGH A NETWORK PLAN, LIMIT OR DENY 152
THE COVERAGE IN ACCORDANCE WITH SECTION 3924.031 OF THE REVISED 155
CODE.
(I) REFUSE TO ISSUE COVERAGE IN THE SMALL GROUP MARKET 158
PURSUANT TO SECTION 3924.032 OF THE REVISED CODE. 160
(J) ESTABLISH EMPLOYER CONTRIBUTION RULES OR GROUP 163
PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN CONNECTION 164
WITH A GROUP CONTRACT IN THE SMALL GROUP MARKET, AS PROVIDED IN 165
DIVISION (E)(1) OF SECTION 3924.03 OF THE REVISED CODE. 168
Nothing in this section shall be construed to limit the 170
authority of a health maintenance organization to perform those 171
functions not otherwise prohibited by law. 172
Sec. 1742.12. (A) After the health maintenance 181
organization has furnished, directly or indirectly, basic health 182
care services to enrollees for a period of twenty-four months and 183
if it currently meets the financial requirements set forth in 184
section 1742.171 of the Revised Code and had net income as 185
reported to the superintendent of insurance for at least one of 186
the preceding four calendar quarters, the organization shall hold 187
an open enrollment period of not less than thirty days at least 188
once during each calendar year. 189
(B) During the open enrollment period described in 191
division (A) of this section, the organization shall accept 192
enrollees in the order in which they apply for enrollment and in 193
accordance with any of the following: 194
(1) Up to its capacity, as determined by the organization 196
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subject to review by the superintendent; 197
(2) If less than its capacity, one per cent of the 199
organization's total number of subscribers residing in this state 200
as of the immediately preceding thirty-first day of December. 201
(C)(1) An open enrollment period shall not be considered 203
to satisfy the requirements of this section unless the 204
organization provides adequate public notice in accordance with 205
division (C)(2) of this section. 206
(2) A public notice pursuant to division (C)(1) of this 208
section shall run in at least one newspaper of general 209
circulation in the health maintenance organization's service 210
area, at least once in each of the two weeks immediately 211
preceding the month in which the open enrollment is to occur and 212
in each week of that month. The notice shall be at least twice 213
the size commonly used by the newspaper for public legal notices, 214
provide an explanation of an open enrollment period, and state 215
the period of open enrollment. 216
(D) Where a health maintenance organization demonstrates 218
to the satisfaction of the superintendent that such open 219
enrollment would jeopardize its economic viability, the 220
superintendent may: 221
(1) Waive the requirement for open enrollment; 223
(2) Impose a limit on the number of new members that must 225
be enrolled; 226
(3) Authorize WITH RESPECT TO ENROLLEES WHO ARE NOT 228
FEDERALLY ELIGIBLE INDIVIDUALS, AUTHORIZE the organization to 229
impose such underwriting restrictions upon open enrollment as are 231
necessary to:
(a) Preserve its financial stability; 233
(b) Prevent excessive adverse selection by prospective 235
enrollees; 236
(c) Avoid unreasonably high or unmarketable charges for 238
enrollee coverage of health services. 239
(E) The actions of the superintendent under division (D) 241
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of this section shall be effective for a period of not more than 242
one year. At the expiration of such time, a new showing of need 243
for such waiver, limitation, or authorization by the organization 244
shall be made before a new waiver, limitation, or authorization 245
is issued or imposed. 246
(F) A health maintenance organization shall not be 248
required to enroll individuals who are confined to a health care 249
facility because of chronic illness, permanent injury, or other 250
infirmity that would cause economic impairment to the health 251
maintenance organization if such individuals were enrolled or to 252
make the effective date of benefits for individuals enrolled 253
under this section earlier than ninety days after the date of 254
enrollment. THIS DIVISION APPLIES ONLY WITH RESPECT TO 255
INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 256
(G)(1) A health maintenance organization shall not be 258
required to cover the fees or costs, or both, for any basic 259
health care service or contract for supplemental health care 260
services related to a transplant of a body organ if the 261
transplant occurred within one year after the effective date of 262
an individual's coverage under this section. 263
(2) The limitation on coverage set forth in division 265
(G)(1) of this section does not apply to a newly born child who 266
meets the requirements for coverage under section 1742.39 of the 267
Revised Code. 268
(3) DIVISION (G) OF THIS SECTION APPLIES ONLY WITH RESPECT 272
TO INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 273
(H)(1) A HEALTH MAINTENANCE ORGANIZATION MAY DENY COVERAGE 276
UNDER THIS SECTION TO A FEDERALLY ELIGIBLE INDIVIDUAL IF THE 278
ORGANIZATION DEMONSTRATES BOTH OF THE FOLLOWING TO THE 279
SUPERINTENDENT:
(a) THE ORGANIZATION DOES NOT HAVE THE FINANCIAL RESERVES 282
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 283
(b) THE ORGANIZATION IS APPLYING DIVISION (H)(1) OF THIS 286
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THE 287
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INDIVIDUAL MARKET IN THIS STATE CONSISTENT WITH APPLICABLE LAWS 289
AND RULES OF THIS STATE AND WITHOUT REGARD TO ANY HEALTH 290
STATUS-RELATED FACTOR OF SUCH INDIVIDUALS OR WHETHER THE 291
INDIVIDUALS ARE FEDERALLY ELIGIBLE INDIVIDUALS. 292
(2) AN ORGANIZATION THAT, PURSUANT TO DIVISION (H)(1) OF 295
THIS SECTION, REFUSES TO ISSUE COVERAGE IN A SERVICE AREA, SHALL 296
NOT OFFER SUCH COVERAGE IN THE INDIVIDUAL MARKET WITHIN THAT 297
SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE 298
THE COVERAGE IS DENIED OR UNTIL THE ORGANIZATION HAS DEMONSTRATED 299
TO THE SUPERINTENDENT THAT THE ORGANIZATION HAS SUFFICIENT 300
FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE, WHICHEVER 301
IS LATER. 302
(3) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 304
DIVISION (H) OF THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 306
(I)(1) WITH RESPECT TO INDIVIDUALS WHO ARE FEDERALLY 309
ELIGIBLE INDIVIDUALS, A HEALTH MAINTENANCE ORGANIZATION MAY DO 310
BOTH OF THE FOLLOWING:
(a) LIMIT THE INDIVIDUALS WHO MAY BE ENROLLED UNDER SUCH 313
COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE SERVICE AREA; 314
(b) DENY THE COVERAGE TO SUCH INDIVIDUALS WITHIN THE 317
SERVICE AREA, IF THE ORGANIZATION HAS DEMONSTRATED BOTH OF THE 318
FOLLOWING TO THE SUPERINTENDENT: 319
(i) THE ORGANIZATION WILL NOT HAVE THE CAPACITY TO DELIVER 322
SERVICES ADEQUATELY TO ADDITIONAL INDIVIDUAL ENROLLEES BECAUSE OF 323
THE ORGANIZATION'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS 324
AND ENROLLEES AND INDIVIDUAL ENROLLEES.
(ii) THE ORGANIZATION IS APPLYING DIVISION (I)(1)(b) OF 328
THIS SECTION UNIFORMLY TO INDIVIDUALS WITHOUT REGARD TO ANY
HEALTH STATUS-RELATED FACTOR RELATING TO SUCH INDIVIDUALS AND 329
WITHOUT REGARD TO WHETHER THE INDIVIDUALS ARE FEDERALLY ELIGIBLE 330
INDIVIDUALS. 331
(2) AN ORGANIZATION THAT, PURSUANT TO DIVISION (I)(1)(b) 334
OF THIS SECTION, DENIES COVERAGE IN A SERVICE AREA, SHALL NOT 335
OFFER COVERAGE IN THE INDIVIDUAL MARKET WITHIN THAT SERVICE AREA 336
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FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE THE COVERAGE 337
IS DENIED. 338
(J) A HEALTH MAINTENANCE ORGANIZATION MAY REINSURE 341
COVERAGE OF ANY FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER THIS 342
SECTION WITH THE OPEN ENROLLMENT REINSURANCE PROGRAM IN 343
ACCORDANCE WITH DIVISION (G) OF SECTION 3924.11 OF THE REVISED 346
CODE. FIXED PERIODIC PREPAYMENT RATES CHARGED FOR COVERAGE 347
REINSURED BY THE PROGRAM SHALL BE ESTABLISHED IN ACCORDANCE WITH 348
SECTION 3924.12 OF THE REVISED CODE. 350
(K) AS USED IN THIS SECTION: 353
(1) "FEDERALLY ELIGIBLE INDIVIDUAL" HAS THE SAME MEANING 355
AS IN SECTION 2741(b) OF THE "HEALTH INSURANCE PORTABILITY AND 360
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 362
42 U.S.C.A. 300gg-41(b), AS AMENDED. 365
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 367
FOLLOWING: 368
(a) HEALTH STATUS; 370
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 373
ILLNESSES;
(c) CLAIMS EXPERIENCE; 375
(d) RECEIPT OF HEALTH CARE; 377
(e) MEDICAL HISTORY; 379
(f) GENETIC INFORMATION; 381
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 384
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 386
Sec. 1742.13. (A) EVERY GROUP CONTRACT ISSUED BY A HEALTH 388
MAINTENANCE ORGANIZATION SHALL PROVIDE AN OPTION FOR CONVERSION 389
TO A DIRECT PAYMENT BASIS TO ANY SUBSCRIBER COVERED BY THE GROUP 390
CONTRACT WHO TERMINATES EMPLOYMENT OR MEMBERSHIP IN THE GROUP 391
UNLESS:
(1) TERMINATION OF THE CONVERSION OPTION OR CONTRACT IS 393
BASED UPON NONPAYMENT OF PREMIUM AFTER REASONABLE NOTICE IN 394
WRITING; 395
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(2) THE SUBSCRIBER IS, OR IS ELIGIBLE TO BE, COVERED FOR 397
BENEFITS AT LEAST COMPARABLE TO THE GROUP POLICY UNDER: 398
(a) TITLE XVIII OF THE SOCIAL SECURITY ACT, AS AMENDED OR 402
SUPERSEDED; 403
(b) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 405
STATE OF THE UNITED STATES WHICH PROVIDES COVERAGE AT LEAST 406
COMPARABLE TO THE BENEFITS OFFERED UNDER DIVISION (A)(2)(a) OF 408
THIS SECTION;
(c) ANY POLICY OF INSURANCE OR HOSPITALIZATION PLAN 410
PROVIDING COVERAGE AT LEAST COMPARABLE TO THE BENEFITS UNDER 411
DIVISION (A)(2)(a) OF THIS SECTION. 412
(B) THE DIRECT PAYMENT CONTRACT OFFERED BY THE HEALTH 414
MAINTENANCE ORGANIZATION, PURSUANT TO DIVISION (A) OF THIS 415
SECTION, SHALL PROVIDE A BASIC AND STANDARD PLAN ESTABLISHED BY 416
THE BOARD OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR 418
PLANS SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN 419
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF 420
THIS DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 421
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 422
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 423
CONTRACTUAL PERIODIC PREPAYMENTS MAY NOT EXCEED AN AMOUNT THAT IS 424
TWO TIMES THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER 425
INDIVIDUAL OF A GROUP TO WHICH THE ORGANIZATION IS CURRENTLY 426
ACCEPTING NEW BUSINESS AND FOR WHICH SIMILAR COPAYMENTS AND 427
DEDUCTIBLES ARE APPLIED.
THE CONTRACT MAY INCLUDE A COORDINATION OF BENEFITS 430
PROVISION AS APPROVED BY THE SUPERINTENDENT.
(C) THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 432
(1) UPON THE DEATH OF THE EMPLOYEE OR MEMBER, TO THE 434
SURVIVING SPOUSE WITH RESPECT TO SUCH OF THE SPOUSE AND 435
DEPENDENTS AS ARE THEN COVERED BY THE GROUP CONTRACT; 436
(2) TO A CHILD SOLELY WITH RESPECT TO HIMSELF OR HERSELF 438
UPON ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE GROUP 439
CONTRACT WHILE COVERED AS A DEPENDENT THEREUNDER; 440
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(3) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 442
MARRIAGE OF THE EMPLOYEE OR MEMBER, TO THE DIVORCED SPOUSE, OR 443
FORMER SPOUSE IN THE EVENT OF ANNULMENT, OF SUCH EMPLOYEE OR 444
MEMBER. 445
(D) NO HEALTH MAINTENANCE ORGANIZATION SHALL USE AGE AS 447
THE BASIS FOR REFUSING TO RENEW A CONVERTED CONTRACT. 448
(E) WRITTEN NOTICE OF THE CONVERSION OPTION PROVIDED BY 450
DIVISIONS (B) AND (C) OF THIS SECTION SHALL BE GIVEN TO THE 451
SUBSCRIBER BY THE HEALTH MAINTENANCE ORGANIZATION BY MAIL TO THE 452
SUBSCRIBER'S ADDRESS IN THE RECORDS OF THE EMPLOYER UPON RECEIPT 453
OF NOTICE FROM THE EMPLOYER OF THE EVENT GIVING RISE TO THE 454
CONVERSION OPTION. IF THE EMPLOYEE OR SUBSCRIBER HAS NOT 455
RECEIVED NOTICE OF THE CONVERSION PRIVILEGE AT LEAST FIFTEEN DAYS 456
PRIOR TO THE EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD, THEN 457
THE EMPLOYEE OR SUBSCRIBER HAS AN ADDITIONAL PERIOD WITHIN WHICH 458
TO EXERCISE THE PRIVILEGE. THIS ADDITIONAL PERIOD SHALL EXPIRE 459
FIFTEEN DAYS AFTER THE EMPLOYEE OR SUBSCRIBER RECEIVES NOTICE, 460
BUT IN NO EVENT SHALL THE PERIOD EXTEND BEYOND SIXTY DAYS AFTER 461
THE EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD. 462
Sec. 1742.16. No health maintenance organization, or 471
representative thereof, may cause or knowingly permit the use of 472
any advertisement, solicitation document, or activity which is 473
untrue, misleading, or deceptive. 474
No health maintenance organization may cancel or fail to 476
renew the coverage of a subscriber because of his ANY health 478
status or his STATUS-RELATED FACTOR IN RELATION TO THE 479
SUBSCRIBER, THE SUBSCRIBER'S requirements for health care 480
services, or for any other reason designated under rules 482
promulgated by the superintendent of insurance. 483
Unless otherwise required by state or federal law, no 485
health maintenance organization, or any health care facility or 486
provider through which it has made arrangements to provide health 487
care services under its health care plan or plans, shall 488
discriminate against any individual with regard to enrollment, 489
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disenrollment, or the quality of health care services rendered to 490
enrollees, on the basis of such individual's race, color, sex, 491
age, religion, state of health, or status as a recipient of 492
medicare or medical assistance under Title XVIII or XIX of the 493
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 301, as 494
amended, OR ANY HEALTH STATUS-RELATED FACTOR IN RELATION TO THE 495
INDIVIDUAL; provided, however, an organization shall not be 496
required to accept a recipient of medicare or medical assistance, 497
if an agreement has not been reached on appropriate payment 498
mechanisms between the organization and the governmental agency 499
administering such programs, and provided further, however, 500
except during a period of open enrollment under section 1742.12 501
of the Revised Code, a health maintenance organization may reject 502
an application for non-group NONGROUP enrollment on the basis of 503
the state of ANY health of STATUS-RELATED FACTOR IN RELATION TO 505
the applicant. 506
No health maintenance organization may, unless licensed to 508
transact the business of insurance in this state, in referring to 509
or describing itself, use in its name or contracts any of the 510
words "insurance," "casualty," "surety," "mutual," or any other 511
words descriptive of the insurance, casualty, or surety business 512
or deceptively similar to the name or description of any 513
insurance or surety corporation doing business in this state. 514
AS USED IN THIS SECTION, "HEALTH STATUS-RELATED FACTOR" 517
MEANS ANY OF THE FOLLOWING:
(A) HEALTH STATUS; 520
(B) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 523
ILLNESSES;
(C) CLAIMS EXPERIENCE; 526
(D) RECEIPT OF HEALTH CARE; 529
(E) MEDICAL HISTORY; 532
(F) GENETIC INFORMATION; 535
(G) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 538
OUT OF ACTS OF DOMESTIC VIOLENCE; 539
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(H) DISABILITY. 541
Sec. 1742.37. No individual or group health maintenance 550
organization contract providing THAT MAKES family coverage 551
AVAILABLE may be delivered, issued for delivery, or renewed in 552
this state on or after January 1, 1989, unless the contract 553
covers adopted children of the subscriber on the same basis as 554
other dependents.
The coverage required by this section is subject to the 556
requirements and restrictions set forth in section 3924.51 of the 557
Revised Code. 558
Sec. 1742.39. (A) Each individual or group evidence of 567
coverage that is delivered, issued for delivery, or renewed by a 568
health maintenance organization in this state on or after January 569
1, 1992, and that provides MAKES coverage AVAILABLE for family 571
members of a subscriber also shall provide that coverage 572
applicable to children is payable from the moment of birth with 573
respect to a newly born child of the subscriber or subscriber's 574
spouse.
(B) Coverage for a newly born child is effective for a 576
period of thirty-one days from the date of birth. 577
(C) To continue coverage for a newly born child beyond the 579
thirty-one-day period described in division (B) of this section, 580
the subscriber shall notify the organization within that period. 581
(D) If payment of a specific fixed periodic prepayment is 583
required to provide coverage under this section for an additional 584
child, the evidence of coverage may require the subscriber to 585
make this payment to the organization within the thirty-one-day 586
period described in division (B) of this section in order to 587
continue the coverage beyond that period. 588
Sec. 1742.45. (A) Notwithstanding section 3901.71 of the 598
Revised Code, each individual or group health maintenance 599
organization contract delivered, issued for delivery, or renewed 600
in this state that provides maternity benefits shall provide 601
coverage of inpatient care and follow-up care for a mother and 602
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her newborn as follows:
(1) The contract shall cover a minimum of forty-eight 604
hours of inpatient care following a normal vaginal delivery and a 605
minimum of ninety-six hours of inpatient care following a 608
cesarean delivery. Services covered as inpatient care shall 609
include medical, educational, and any other services that are
consistent with the inpatient care recommended in the protocols 610
and guidelines developed by national organizations that represent 611
pediatric, obstetric, and nursing professionals. 612
(2) The contract shall cover a physician-directed source 614
of follow-up care. Services covered as follow-up care shall 615
include physical assessment of the mother and newborn, parent 616
education, assistance and training in breast or bottle feeding, 617
assessment of the home support system, performance of any 618
medically necessary and appropriate clinical tests, and any other 619
services that are consistent with the follow-up care recommended 620
in the protocols and guidelines developed by national 621
organizations that represent pediatric, obstetric, and nursing 622
professionals. The coverage shall apply to services provided in 623
a medical setting or through home health care visits. The 624
coverage shall apply to a home health care visit only if the 625
health care professional who conducts the visit is knowledgeable 626
and experienced in maternity and newborn care.
When a decision is made in accordance with division (B) of 628
this section to discharge a mother or newborn prior to the 629
expiration of the applicable number of hours of inpatient care 630
required to be covered, the coverage of follow-up care shall 631
apply to all follow-up care that is provided within forty-eight 632
SEVENTY-TWO hours after discharge. When a mother or newborn 633
receives at least the number of hours of inpatient care required 634
to be covered, the coverage of follow-up care shall apply to 635
follow-up care that is determined to be medically necessary by 636
the health care professionals responsible for discharging the 637
mother or newborn.
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(B) Any decision to shorten the length of inpatient stay 640
to less than that specified under division (A)(1) of this section 642
shall be made by the physician attending the mother or newborn, 643
except that if a nurse-midwife is attending the mother in 644
collaboration with a physician, the decision may be made by the 645
nurse-midwife. Decisions regarding early discharge shall be made 646
only after conferring with the mother or a person responsible for 647
the mother or newborn. For purposes of this division, a person 648
responsible for the mother or newborn may include a parent, 649
guardian, or any other person with authority to make medical 650
decisions for the mother or newborn.
(C)(1) No health maintenance organization may do either of 653
the following:
(a) Terminate the participation of a health care 656
professional or health care facility as a provider under an
individual or group health maintenance organization contract 657
solely for making recommendations for inpatient or follow-up care 659
for a particular mother or newborn that are consistent with the 660
care required to be covered by this section;
(b) Establish or offer monetary or other financial 663
incentives for the purpose of encouraging a person to decline the 664
inpatient or follow-up care required to be covered by this 665
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 669
section has engaged in an unfair and deceptive act or practice in 670
the business of insurance under sections 3901.19 to 3901.26 of 671
the Revised Code. 673
(D) This section does not do any of the following: 676
(1) Require a contract to cover inpatient or follow-up 679
care that is not received in accordance with the contract's terms 680
pertaining to the health care professionals and facilities from 681
which an individual is authorized to receive health care 682
services.
(2) Require a mother or newborn to stay in a hospital or 685
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other inpatient setting for a fixed period of time following
delivery; 686
(3) Require a child to be delivered in a hospital or other 689
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 691
authority to practice nurse-midwifery in accordance with Chapter 693
4723. of the Revised Code; 695
(5) Establish minimum standards of medical diagnosis, 697
care, or treatment for inpatient or follow-up care for a mother 698
or newborn. A deviation from the care required to be covered 699
under this section shall not, solely on the basis of this 700
section, give rise to a medical claim or derivative medical 701
claim, as those terms are defined in section 2305.11 of the 702
Revised Code. 704
Sec. 1742.47. THE FOLLOWING CONDITIONS APPLY TO ALL 706
INDIVIDUAL HEALTH MAINTENANCE ORGANIZATION CONTRACTS AND ALL 707
GROUP HEALTH MAINTENANCE ORGANIZATION CONTRACTS THAT ARE NOT 708
SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 711
(A) EXCEPT AS PROVIDED IN SECTION 2742(b) TO (e) OF THE 715
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 720
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 725
AMENDED, A HEALTH MAINTENANCE ORGANIZATION THAT PROVIDES 726
INDIVIDUAL COVERAGE TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN 727
FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 728
(B) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 732
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 736
A HEALTH MAINTENANCE ORGANIZATION OFFERS COVERAGE IN THE SMALL OR 737
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE 738
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT 739
THE OPTION OF THE CONTRACT HOLDER. 740
(C) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISIONS (A) AND 743
(E)(1) OF SECTION 3924.03 AND SECTIONS 3924.033 AND 3924.27 OF 744
THE REVISED CODE. 746
Sec. 3901.21. The following are hereby defined as unfair 755
16
and deceptive acts or practices in the business of insurance: 756
(A) Making, issuing, circulating, or causing or permitting 758
to be made, issued, or circulated, or preparing with intent to so 759
use, any estimate, illustration, circular, or statement 760
misrepresenting the terms of any policy issued or to be issued or 761
the benefits or advantages promised thereby or the dividends or 762
share of the surplus to be received thereon, or making any false 763
or misleading statements as to the dividends or share of surplus 764
previously paid on similar policies, or making any misleading 765
representation or any misrepresentation as to the financial 766
condition of any insurer as shown by the last preceding verified 767
statement made by it to the insurance department of this state, 768
or as to the legal reserve system upon which any life insurer 769
operates, or using any name or title of any policy or class of 770
policies misrepresenting the true nature thereof, or making any 771
misrepresentation or incomplete comparison to any person for the 772
purpose of inducing or tending to induce such person to purchase, 773
amend, lapse, forfeit, change, or surrender insurance. 774
Any written statement concerning the premiums for a policy 776
which refers to the net cost after credit for an assumed 777
dividend, without an accurate written statement of the gross 778
premiums, cash values, and dividends based on the insurer's 779
current dividend scale, which are used to compute the net cost 780
for such policy, and a prominent warning that the rate of 781
dividend is not guaranteed, is a misrepresentation for the 782
purposes of this division. 783
(B) Making, publishing, disseminating, circulating, or 785
placing before the public or causing, directly or indirectly, to 786
be made, published, disseminated, circulated, or placed before 787
the public, in a newspaper, magazine, or other publication, or in 788
the form of a notice, circular, pamphlet, letter, or poster, or 789
over any radio station, or in any other way, or preparing with 790
intent to so use, an advertisement, announcement, or statement 791
containing any assertion, representation, or statement, with 792
17
respect to the business of insurance or with respect to any 793
person in the conduct of his THE PERSON'S insurance business, 794
which is untrue, deceptive, or misleading. 795
(C) Making, publishing, disseminating, or circulating, 797
directly or indirectly, or aiding, abetting, or encouraging the 798
making, publishing, disseminating, or circulating, or preparing 799
with intent to so use, any statement, pamphlet, circular, 800
article, or literature, which is false as to the financial 801
condition of an insurer and which is calculated to injure any 802
person engaged in the business of insurance. 803
(D) Filing with any supervisory or other public official, 805
or making, publishing, disseminating, circulating, or delivering 806
to any person, or placing before the public, or causing directly 807
or indirectly to be made, published, disseminated, circulated, 808
delivered to any person, or placed before the public, any false 809
statement of financial condition of an insurer. 810
Making any false entry in any book, report, or statement of 812
any insurer with intent to deceive any agent or examiner lawfully 813
appointed to examine into its condition or into any of its 814
affairs, or any public official to whom such insurer is required 815
by law to report, or who has authority by law to examine into its 816
condition or into any of its affairs, or, with like intent, 817
willfully omitting to make a true entry of any material fact 818
pertaining to the business of such insurer in any book, report, 819
or statement of such insurer, or mutilating, destroying, 820
suppressing, withholding, or concealing any of its records. 821
(E) Issuing or delivering or permitting agents, officers, 823
or employees to issue or deliver agency company stock or other 824
capital stock or benefit certificates or shares in any common-law 825
corporation or securities or any special or advisory board 826
contracts or other contracts of any kind promising returns and 827
profits as an inducement to insurance. 828
(F) Making or permitting any unfair discrimination among 830
individuals of the same class and equal expectation of life in 831
18
the rates charged for any contract of life insurance or of life 832
annuity or in the dividends or other benefits payable thereon, or 833
in any other of the terms and conditions of such contract. 834
(G)(1) Except as otherwise expressly provided by law, 836
knowingly permitting or offering to make or making any contract 837
of life insurance, life annuity or accident and health insurance, 838
or agreement as to such contract other than as plainly expressed 839
in the contract issued thereon, or paying or allowing, or giving 840
or offering to pay, allow, or give, directly or indirectly, as 841
inducement to such insurance, or annuity, any rebate of premiums 842
payable on the contract, or any special favor or advantage in the 843
dividends or other benefits thereon, or any valuable 844
consideration or inducement whatever not specified in the 845
contract; or giving, or selling, or purchasing, or offering to 846
give, sell, or purchase, as inducement to such insurance or 847
annuity or in connection therewith, any stocks, bonds, or other 848
securities, or other obligations of any insurance company or 849
other corporation, association, or partnership, or any dividends 850
or profits accrued thereon, or anything of value whatsoever not 851
specified in the contract. 852
(2) Nothing in division (F) or division (G)(1) of this 854
section shall be construed as prohibiting any of the following 855
practices: (a) in the case of any contract of life insurance or 856
life annuity, paying bonuses to policyholders or otherwise 857
abating their premiums in whole or in part out of surplus 858
accumulated from nonparticipating insurance, provided that any 859
such bonuses or abatement of premiums shall be fair and equitable 860
to policyholders and for the best interests of the company and 861
its policyholders; (b) in the case of life insurance policies 862
issued on the industrial debit plan, making allowance to 863
policyholders who have continuously for a specified period made 864
premium payments directly to an office of the insurer in an 865
amount which fairly represents the saving in collection expenses; 866
(c) readjustment of the rate of premium for a group insurance 867
19
policy based on the loss or expense experience thereunder, at the 868
end of the first or any subsequent policy year of insurance 869
thereunder, which may be made retroactive only for such policy 870
year. 871
(H) Making, issuing, circulating, or causing or permitting 873
to be made, issued, or circulated, or preparing with intent to so 874
use, any statement to the effect that a policy of life insurance 875
is, is the equivalent of, or represents shares of capital stock 876
or any rights or options to subscribe for or otherwise acquire 877
any such shares in the life insurance company issuing that policy 878
or any other company. 879
(I) Making, issuing, circulating, or causing or permitting 881
to be made, issued or circulated, or preparing with intent to so 882
issue, any statement to the effect that payments to a 883
policyholder of the principal amounts of a pure endowment are 884
other than payments of a specific benefit for which specific 885
premiums have been paid. 886
(J) Making, issuing, circulating, or causing or permitting 888
to be made, issued, or circulated, or preparing with intent to so 889
use, any statement to the effect that any insurance company was 890
required to change a policy form or related material to comply 891
with Title XXXIX of the Revised Code or any regulation of the 892
superintendent of insurance, for the purpose of inducing or 893
intending to induce any policyholder or prospective policyholder 894
to purchase, amend, lapse, forfeit, change, or surrender 895
insurance. 896
(K) Aiding or abetting another to violate this section. 898
(L) Refusing to issue any policy of insurance, or 900
canceling or declining to renew such policy because of the sex or 901
marital status of the applicant, prospective insured, insured, or 902
policyholder. 903
(M) Making or permitting any unfair discrimination between 905
individuals of the same class and of essentially the same hazard 906
in the amount of premium, policy fees, or rates charged for any 907
20
policy or contract of insurance, other than life insurance, or in 908
the benefits payable thereunder, or in underwriting standards and 909
practices or eligibility requirements, or in any of the terms or 910
conditions of such contract, or in any other manner whatever. 911
(N) Refusing to make available disability income insurance 913
solely because the applicant's principal occupation is that of 914
managing a household. 915
(O) Refusing, when offering maternity benefits under any 917
individual or group sickness and accident insurance policy, to 918
make maternity benefits available to the policyholder for the 919
individual or individuals to be covered under any comparable 920
policy to be issued for delivery in this state, including family 921
members if the policy otherwise provides coverage for family 922
members. Nothing in this division shall be construed to prohibit 923
an insurer from imposing a reasonable waiting period for such 924
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE 925
POLICY, but in no event shall such waiting period exceed two 926
hundred seventy days. 927
(P) Using, or permitting to be used, a pattern settlement 929
as the basis of any offer of settlement. As used in this 930
division, "pattern settlement" means a method by which liability 931
is routinely imputed to a claimant without an investigation of 932
the particular occurrence upon which the claim is based and by 933
using a predetermined formula for the assignment of liability 934
arising out of occurrences of a similar nature. Nothing in this 935
division shall be construed to prohibit an insurer from 936
determining a claimant's liability by applying formulas or 937
guidelines to the facts and circumstances disclosed by the 938
insurer's investigation of the particular occurrence upon which a 939
claim is based. 940
(Q) Refusing to insure, or refusing to continue to insure, 942
or limiting the amount, extent, or kind of life or sickness and 943
accident insurance or annuity coverage available to an 944
individual, or charging an individual a different rate for the 945
21
same coverage solely because of blindness or partial blindness. 946
With respect to all other conditions, including the underlying 947
cause of blindness or partial blindness, persons who are blind or 948
partially blind shall be subject to the same standards of sound 949
actuarial principles or actual or reasonably anticipated 950
actuarial experience as are sighted persons. Refusal to insure 951
includes, but is not limited to, denial by an insurer of 952
disability insurance coverage on the grounds that the policy 953
defines "disability" as being presumed in the event that the 954
eyesight of the insured is lost. However, an insurer may exclude 955
from coverage disabilities consisting solely of blindness or 956
partial blindness when such conditions existed at the time the 957
policy was issued. To the extent that the provisions of this 958
division may appear to conflict with any provision of section 959
3999.16 of the Revised Code, this division applies. 960
(R)(1) Directly or indirectly offering to sell, selling, 962
or delivering, issuing for delivery, renewing, or using or 963
otherwise marketing any policy of insurance or insurance product 964
in connection with or in any way related to the grant of a 965
student loan guaranteed in whole or in part by an agency or 966
commission of this state or the United States, except insurance 967
that is required under federal or state law as a condition for 968
obtaining such a loan and the premium for which is included in 969
the fees and charges applicable to the loan; or, in the case of 970
an insurer or insurance agent, knowingly permitting any lender 971
making such loans to engage in such acts or practices in 972
connection with the insurer's or agent's insurance business. 973
(2) Except in the case of a violation of division (G) of 975
this section, division (R)(1) of this section does not apply to 976
either of the following: 977
(a) Acts or practices of an insurer, its agents, 979
representatives, or employees in connection with the grant of a 980
guaranteed student loan to its insured or the insured's spouse or 981
dependent children where such acts or practices take place more 982
22
than ninety days after the effective date of the insurance; 983
(b) Acts or practices of an insurer, its agents, 985
representatives, or employees in connection with the 986
solicitation, processing, or issuance of an insurance policy or 987
product covering the student loan borrower or his THE BORROWER'S 988
spouse or dependent children, where such acts or practices take 989
place more than one hundred eighty days after the date on which 990
the borrower is notified that the student loan was approved. 991
(S) Denying coverage, under any health insurance or health 993
care policy, contract, or plan providing family coverage, to any 994
natural or adopted child of the named insured or subscriber 995
solely on the basis that the child does not reside in the 996
household of the named insured or subscriber. 997
(T)(1) Using any underwriting standard or engaging in any 999
other act or practice that, directly or indirectly, due solely to 1,000
the actual or expected ANY health condition of STATUS-RELATED 1,002
FACTOR IN RELATION TO one or more individuals, does either of the 1,003
following:
(a) Terminates or fails to renew an existing individual 1,005
policy, contract, or plan of health benefits, or a health benefit 1,006
plan issued to a small AN employer as those terms are defined in 1,007
section 3924.01 of the Revised Code, for which an individual 1,008
would otherwise be eligible;
(b) With respect to a health benefit plan issued to a 1,010
small AN employer, as those terms are defined in section 3924.01 1,011
of the Revised Code, excludes or causes the exclusion of an 1,013
individual from coverage under an existing employer-provided 1,014
policy, contract, or plan of health benefits, except that an 1,015
insurer may exclude, on the basis of health status, a late 1,016
enrollee as defined in section 3924.01 of the Revised Code. 1,017
(2) The superintendent of insurance may adopt rules in 1,019
accordance with Chapter 119. of the Revised Code for purposes of 1,020
implementing division (T)(1) of this section. 1,021
(3) FOR PURPOSES OF DIVISION (T)(1) OF THIS SECTION, 1,025
23
"HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING: 1,026
(a) HEALTH STATUS; 1,028
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,031
ILLNESSES;
(c) CLAIMS EXPERIENCE; 1,033
(d) RECEIPT OF HEALTH CARE; 1,035
(e) MEDICAL HISTORY; 1,037
(f) GENETIC INFORMATION; 1,039
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,042
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 1,044
(U) With respect to a health benefit plan issued to a 1,046
small employer, as those terms are defined in section 3924.01 of 1,047
the Revised Code, negligently or willfully placing coverage for 1,048
adverse risks with a certain carrier, as defined in section 1,049
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 1,051
or practice that, directly or indirectly, causes or results in 1,052
the placing of coverage for adverse risks with another carrier, 1,053
as defined in section 3924.01 of the Revised Code. 1,054
(W) Failing to comply with section 3923.23, 3923.231, 1,056
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 1,057
in any unfair, discriminatory reimbursement practice. 1,058
(X) Intentionally establishing an unfair premium for, or 1,060
misrepresenting the cost of, any insurance policy financed under 1,061
a premium finance agreement of an insurance premium finance 1,062
company. 1,063
With respect to private passenger automobile insurance, no 1,065
insurer shall charge different premium rates to persons residing 1,066
within the limits of any municipal corporation based solely on 1,067
the location of the residence of the insured within those limits. 1,068
The enumeration in sections 3901.19 to 3901.26 of the 1,070
Revised Code of specific unfair or deceptive acts or practices in 1,071
the business of insurance is not exclusive or restrictive or 1,072
24
intended to limit the powers of the superintendent of insurance 1,073
to adopt rules to implement this section, or to take action under 1,074
other sections of the Revised Code. 1,075
This section does not prohibit the sale of shares of any 1,077
investment company registered under the "Investment Company Act 1,078
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 1,079
policies, annuities, or other contracts described in section 1,080
3907.15 of the Revised Code. 1,081
As used in this section, "estimate," "statement," 1,083
"representation," "misrepresentation," "advertisement," or 1,084
"announcement" includes oral or written occurrences. 1,085
Sec. 3923.122. (A) Every policy of group sickness and 1,095
accident insurance providing hospital, surgical, or medical 1,096
expense coverage for other than specific diseases or accidents 1,097
only, and delivered, issued for delivery, or renewed in this 1,098
state on or after January 1, 1976, shall include a provision 1,099
giving each insured the option to convert to any of the 1,100
individual policies of hospital, surgical, or medical expense 1,101
insurance then being issued by the insurer with benefit limits 1,102
not to exceed those in effect under the group policy A BASIC OR 1,103
STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF THE OHIO 1,105
HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY SIMILAR TO THE 1,106
BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED 1,107
SERVICES. FOR PURPOSES OF THIS DIVISION, THE SUPERINTENDENT OF 1,109
INSURANCE SHALL DETERMINE WHETHER A PLAN IS SUBSTANTIALLY SIMILAR 1,110
TO THE BASIC OR STANDARD PLAN IN BENEFIT DESIGN AND SCOPE OF 1,111
COVERED SERVICES.
(B) An option for conversion to an individual policy shall 1,113
be available without evidence of insurability to every insured, 1,114
including any person eligible under division (D) of this section, 1,115
who terminates his employment or membership in the group holding 1,116
the policy after having been continuously insured thereunder for 1,117
at least one year. 1,118
Upon receipt of the insured's written application and upon 1,120
25
payment of at least the first quarterly premium not later than 1,121
thirty-one days after the termination of coverage under the group 1,122
policy, the insurer shall issue a converted policy on a form then 1,123
available for conversion. The premium shall be in accordance 1,124
with the insurer's table of premium rates in effect on the later 1,125
of the following dates: 1,126
(1) The effective date of the converted policy; 1,128
(2) The date of application therefor; and shall be 1,130
applicable to the class of risk to which each person covered 1,132
belongs and to the form and amount of the policy at his THE
PERSON'S then attained age. HOWEVER, PREMIUMS MAY NOT EXCEED AN 1,134
AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE STANDARD RATE 1,135
CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH THE INSURER IS 1,136
CURRENTLY ACCEPTING NEW BUSINESS AND FOR WHICH SIMILAR COPAYMENTS 1,137
AND DEDUCTIBLES ARE APPLIED. 1,138
At the election of the insurer, a separate converted policy 1,140
may be issued to cover any dependent of an employee or member of 1,141
the group. 1,142
Except as provided in division (H) of this section, any 1,144
converted policy shall become effective as of the day following 1,145
the date of termination of insurance under the group policy. 1,146
Any probationary or waiting period set forth in the 1,148
converted policy is deemed to commence on the effective date of 1,149
the insured's coverage under the group policy. 1,150
(C) No insurer shall be required to issue a converted 1,152
policy to any person who is, or is eligible to be, covered for 1,153
benefits at least comparable to the group policy under: 1,154
(1) Title XVIII of the Social Security Act, as amended or 1,156
superseded; 1,157
(2) Any act of congress or law under this or any other 1,159
state of the United States that duplicates coverage offered under 1,160
division (C)(1) of this section; 1,161
(3) Any policy that duplicates coverage offered under 1,163
division (C)(1) of this section; 1,164
26
(4) Any other group sickness and accident insurance 1,166
providing hospital, surgical, or medical expense coverage for 1,167
other than specific diseases or accidents only. 1,168
(D) The option for conversion shall be available: 1,170
(1) Upon the death of the employee or member, to the 1,172
surviving spouse with respect to such of the spouse and 1,173
dependents as are then covered by the group policy; 1,174
(2) To a child solely with respect to himself OR HERSELF 1,176
upon his attaining the limiting age of coverage under the group 1,178
policy while covered as a dependent thereunder; 1,179
(3) Upon the divorce, dissolution, or annulment of the 1,181
marriage of the employee or member, to the divorced spouse, or 1,182
former spouse in the event of annulment, of such employee or 1,183
member, or upon the legal separation of the spouse from such 1,184
employee or member, to the spouse. 1,185
Persons possessing the option for conversion pursuant to 1,187
this division shall be considered members for the purposes of 1,188
division (H) of this section. 1,189
(E) If coverage is continued under a group policy on an 1,191
employee following his retirement prior to the time he THE 1,192
EMPLOYEE is, or is eligible to be, covered by Title XVIII of the 1,194
Social Security Act, he THE EMPLOYEE may elect, in lieu of the 1,195
continuance of group insurance, to have the same conversion 1,197
rights as would apply had his THE EMPLOYEE'S insurance terminated 1,199
at retirement by reason of termination of employment. 1,200
(F) If the insurer and the group policyholder agree upon 1,202
one or more additional plans of benefits to be available for 1,203
converted policies, the applicant for the converted policy may 1,204
elect such a plan in lieu of a converted policy. 1,205
(G) The converted policy may contain provisions for 1,207
avoiding duplication of benefits provided pursuant to divisions 1,208
(C)(1), (2), (3), and (4) of this section or provided under any 1,209
other insured or noninsured plan or program. 1,210
(H) If an employee or member becomes entitled to obtain a 1,212
27
converted policy pursuant to this section, and if the employee or 1,213
member has not received notice of the conversion privilege at 1,214
least fifteen days prior to the expiration of the thirty-one-day 1,215
conversion period provided in division (B) of this section, then 1,216
the employee or member has an additional period within which to 1,217
exercise the privilege. This additional period shall expire 1,218
fifteen days after the employee or member receives notice, but in 1,219
no event shall the period extend beyond sixty days after the 1,220
expiration of the thirty-one-day conversion period. 1,221
Written notice presented to the employee or member, or 1,223
mailed by the policyholder to the last known address of the 1,224
employee or member as indicated on its records, constitutes 1,225
notice for the purpose of this division. In the case of a person 1,226
who is eligible for a converted policy under division (D) (2) or 1,227
(D)(3) of this section, a policyholder shall not be responsible 1,228
for presenting or mailing such notice, unless such policyholder 1,229
has actual knowledge of the person's eligibility for a converted 1,230
policy. 1,231
If an additional period is allowed by an employee or member 1,233
for the exercise of a conversion privilege, and if written 1,234
application for the converted policy, accompanied by at least the 1,235
first quarterly premium, is made after the expiration of the 1,236
thirty-one-day conversion period, but within the additional 1,237
period allowed an employee or member in accordance with this 1,238
division, the effective date of the converted policy shall be the 1,239
date of application. 1,240
(I) The converted policy may provide: 1,242
(1) That any hospital, surgical, or medical expense 1,244
benefits otherwise payable with respect to any person may be 1,245
reduced by the amount of any such benefits payable under the 1,246
group policy for the same loss after termination of coverage; 1,247
(2) For termination of coverage on any person who is, or 1,249
is eligible to be, covered pursuant to division (C) of this 1,250
section; 1,251
28
(3) That the insurer may request information in advance of 1,253
any premium due date of the policy as to whether the insured is, 1,254
or is eligible to be, covered pursuant to division (C) of this 1,255
section. If the insured is, or is eligible to be, covered, and 1,256
he THE INSURED fails to furnish the details of his THE INSURED'S 1,258
coverage or eligibility to the insurer within thirty-one days 1,259
after the date of the request, the benefits payable under the 1,260
converted policy may be based on the hospital, surgical, or 1,261
medical expenses actually incurred after excluding expenses to 1,262
the extent of the amount of benefits for which the insured is, or 1,263
is eligible to be, covered pursuant to division (C) of this 1,264
section.
(J) The converted policy may contain: 1,266
(1) Any exclusion, reduction, or limitation contained in 1,268
the group policy or customarily used in individual policies 1,269
issued by the insurer; 1,270
(2) Any provision permitted in this section; 1,272
(3) Any other provision not prohibited by law. 1,274
Any provision required or permitted in this section may be 1,276
made a part of any converted policy by means of an endorsement or 1,277
rider. 1,278
(K) The time limit specified in a converted policy for 1,280
certain defenses with respect to any person who was covered by a 1,281
group policy shall commence on the effective date of such 1,282
person's coverage under the group policy. 1,283
(L) No insurer shall use deterioration of health as the 1,285
basis for refusing to renew a converted policy. 1,286
(M) No insurer shall use age as the basis for refusing to 1,288
renew a converted policy. 1,289
(N) A converted policy made available pursuant to this 1,291
section shall, if delivery of the policy is to be made in this 1,292
state, comply with this section. If delivery of a converted 1,293
policy is to be made in another state, it may be on a form 1,294
offered by the insurer in the jurisdiction where the delivery is 1,295
29
to be made and which provides benefits substantially in 1,296
compliance with those required in a policy delivered in this 1,297
state. 1,298
Sec. 3923.26. Every certificate furnished by an insurer in 1,307
connection with, or pursuant to any provision of, any group 1,308
sickness and accident insurance policy providing coverage on an 1,309
expense incurred basis, and every individual sickness and 1,310
accident insurance policy which provides coverage on an expense 1,311
incurred basis, either of which provides MAKES coverage AVAILABLE 1,313
for family members of the insured, shall, as to such family 1,314
members' coverage, also provide that any sickness and accident 1,315
insurance benefits applicable for children shall be payable with 1,316
respect to a newly born child of the insured from the moment of 1,317
birth.
The coverage for newly born children shall consist of 1,319
coverage of injury or sickness, including the necessary care and 1,320
treatment of medically diagnosed congenital defects and birth 1,321
abnormalities. 1,322
If payment of a specific premium is required to provide 1,324
coverage for an additional child, the certificate or policy may 1,325
require that notification of birth of a newly born child and 1,326
payment of the required premium must be furnished to the insurer 1,327
within thirty-one days after the date of birth in order to have 1,328
the coverage continue beyond such period. 1,329
The requirements of this section apply to all such 1,331
individual or group sickness and accident insurance policies 1,332
delivered or issued for delivery in this state on or after 1,333
January 1, 1975, and all such individual or group sickness and 1,334
accident insurance policies renewed in this state on or after 1,335
January 1, 1978. 1,336
Sec. 3923.40. No individual or group policy of sickness 1,345
and accident insurance providing THAT MAKES family coverage 1,346
AVAILABLE may be delivered, issued for delivery, or renewed in 1,348
this state on or after January 1, 1989, unless the policy covers
30
adopted children of the insured on the same basis as other 1,349
dependents.
The coverage required by this section is subject to the 1,351
requirements and restrictions set forth in section 3924.51 of the 1,352
Revised Code. 1,353
Sec. 3923.57. Notwithstanding any provision of this 1,362
chapter, every individual policy of sickness and accident 1,363
insurance that is delivered, issued for delivery, or renewed in 1,364
this state is subject to the following conditions, as applicable: 1,365
(A) Pre-existing conditions provisions shall not exclude 1,367
or limit coverage for a period beyond twelve months following the 1,368
policyholder's effective date of coverage and may only relate to 1,369
conditions during the six months immediately preceding the 1,370
effective date of coverage. 1,371
(B) In determining whether a pre-existing conditions 1,373
provision applies to a policyholder or dependent, each policy 1,374
shall credit the time the policyholder or dependent was covered 1,375
under a previous policy, contract, or plan if the previous 1,377
coverage was continuous to a date not more than thirty days prior 1,379
to the effective date of the new coverage, exclusive of any 1,380
applicable service waiting period under the policy. 1,381
(C) Any such policy shall be renewable with respect to the 1,383
policyholder, or dependents of the policyholder, at the option of 1,384
the policyholder, except for any of the following reasons: 1,385
(1) Nonpayment of the required premiums by the 1,387
policyholder; 1,388
(2) Fraud or misrepresentation of the policyholder; 1,390
(3) When the insurer ceases to do the business of 1,392
individual sickness and accident insurance in this state, 1,393
provided that all of the following conditions are met: 1,394
(a) Notice of the decision to cease doing the business of 1,396
individual sickness and accident insurance is provided to the 1,397
department of insurance and the policyholder. 1,398
(b) An individual policy shall not be canceled by the 1,400
31
insurer for ninety days after the date of the notice required 1,402
under division (C)(3)(a) of this section unless the business has 1,403
been sold to another insurer. 1,404
(c) An insurer that ceases to do the business of 1,406
individual sickness and accident insurance in this state shall 1,407
not resume such business in this state for a period of five years 1,408
from the date of the notice required under division (C)(3)(a) of 1,409
this section (1) EXCEPT AS OTHERWISE PROVIDED IN DIVISION (C) OF 1,411
THIS SECTION, AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND 1,412
ACCIDENT INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR 1,413
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 1,414
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF AN 1,417
INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE OF 1,418
THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR CONTRIBUTIONS 1,421
IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE INSURER HAS NOT 1,422
RECEIVED TIMELY PREMIUM PAYMENTS.
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE THAT 1,425
CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION OF 1,426
MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN THE 1,429
INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION (D) OF THIS SECTION 1,430
AND THE APPLICABLE LAWS OF THIS STATE. 1,431
(d) IF THE INSURER OFFERS COVERAGE IN THE MARKET THROUGH A 1,434
NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES, LIVES, OR WORKS 1,435
IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE INSURER IS 1,436
AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT SUCH COVERAGE 1,437
IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY HEALTH 1,438
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e) IF THE COVERAGE IS MADE AVAILABLE IN THE INDIVIDUAL 1,441
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS, THE 1,442
MEMBERSHIP OF THE INDIVIDUAL IN THE ASSOCIATION, ON THE BASIS OF 1,443
WHICH THE COVERAGE IS PROVIDED, CEASES; PROVIDED, HOWEVER, THAT 1,444
SUCH COVERAGE IS TERMINATED UNDER DIVISION (C)(2)(e) OF THIS 1,447
32
SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH STATUS-RELATED 1,448
FACTOR OF COVERED INDIVIDUALS.
(D)(1) IF AN INSURER DECIDES TO DISCONTINUE OFFERING A 1,451
PARTICULAR TYPE OF HEALTH INSURANCE COVERAGE OFFERED IN THE 1,452
INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE MAY BE DISCONTINUED BY 1,453
THE INSURER IF THE INSURER DOES ALL OF THE FOLLOWING: 1,454
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED COVERAGE 1,457
OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT LEAST 1,458
NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF THE 1,459
COVERAGE;
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE OF THIS 1,462
TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER INDIVIDUAL 1,463
HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY THE INSURER 1,464
FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF 1,467
THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE UNDER DIVISION 1,469
(D)(1)(b) OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY 1,470
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF 1,471
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE. 1,472
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL 1,474
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS STATE, 1,476
HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE INSURER ONLY 1,477
IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE DEPARTMENT OF 1,480
INSURANCE AND TO EACH INDIVIDUAL OF THE DISCONTINUATION AT LEAST 1,481
ONE HUNDRED EIGHTY DAYS PRIOR TO THE DATE OF THE EXPIRATION OF 1,482
THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED FOR DELIVERY 1,485
IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND COVERAGE UNDER 1,486
THAT HEALTH INSURANCE IN THAT MARKET IS NOT RENEWED. 1,487
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION 1,490
(D)(2) OF THIS SECTION IN THE INDIVIDUAL MARKET, THE INSURER 1,491
SHALL NOT PROVIDE FOR THE ISSUANCE OF ANY HEALTH INSURANCE 1,492
COVERAGE IN THE MARKET AND THIS STATE DURING THE FIVE-YEAR PERIOD 1,493
33
BEGINNING ON THE DATE OF THE DISCONTINUATION OF THE LAST HEALTH 1,494
INSURANCE COVERAGE NOT SO RENEWED. 1,495
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 1,498
section, both of the following apply:
(1) The benefit structure of any such policy may be 1,501
changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new 1,502
individual insureds. 1,503
(2) Any such policy may be rescinded for fraud, material 1,505
misrepresentation, or concealment by an applicant, policyholder, 1,506
or dependent AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, 1,508
MODIFY THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO 1,509
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS 1,510
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM 1,511
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM. 1,512
IN APPLYING DIVISIONS (C) TO (E) OF THIS SECTION WITH 1,516
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY AN 1,518
INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH ONE 1,519
OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER. 1,520
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS THE 1,523
SAME MEANING AS IN SECTION 3924.03 OF THE REVISED CODE, AND 1,525
"HEALTH-STATUS RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME 1,526
MEANINGS AS IN SECTION 3924.031 OF THE REVISED CODE. 1,528
This section does not apply to any policy that provides 1,530
coverage for specific diseases or accidents only, or to any 1,531
hospital indemnity, medicare supplement, long-term care, 1,532
disability income, one-time-limited-duration policy of no longer 1,533
than six months, or other policy that offers only supplemental 1,534
benefits. 1,535
Sec. 3923.571. THE FOLLOWING CONDITIONS APPLY TO ALL GROUP 1,538
POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE NOT SUBJECT 1,539
TO SECTION 3924.03 OF THE REVISED CODE: 1,541
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF 1,543
34
DIVISION (A) OF SECTION 3924.03 OF THE REVISED CODE. 1,547
(B) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 1,551
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 1,556
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-12, AS 1,561
AMENDED, IF AN INSURER OFFERS COVERAGE IN THE SMALL OR LARGE 1,562
GROUP MARKET IN CONNECTION WITH A GROUP POLICY, THE INSURER SHALL 1,563
RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE 1,564
POLICYHOLDER.
(C)(1) NO GROUP POLICY, OR INSURER OFFERING HEALTH 1,567
INSURANCE COVERAGE IN CONNECTION WITH A GROUP POLICY, SHALL 1,568
REQUIRE ANY INDIVIDUAL, AS A CONDITION OF COVERAGE OR CONTINUED 1,569
COVERAGE UNDER THE POLICY, TO PAY A PREMIUM OR CONTRIBUTION THAT 1,570
IS GREATER THAN THE PREMIUM OR CONTRIBUTION FOR A SIMILARLY 1,571
SITUATED INDIVIDUAL COVERED UNDER THE POLICY ON THE BASIS OF ANY 1,572
HEALTH STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO 1,573
AN INDIVIDUAL COVERED UNDER THE PLAN AS A DEPENDENT OF THE 1,574
INDIVIDUAL. 1,575
(2) NOTHING IN DIVISION (C)(1) OF THIS SECTION SHALL BE 1,578
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 1,579
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY, 1,580
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM 1,581
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE 1,582
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO 1,583
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION. 1,584
(D) SUCH POLICIES SHALL PROVIDE FOR THE SPECIAL ENROLLMENT 1,587
PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH INSURANCE 1,591
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 1,593
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 1,602
of the Revised Code: 1,603
(1) "Case characteristics," "eligible employee," "health 1,605
HEALTH benefit plan," "late enrollee," AND "MEWA," and 1,608
"pre-existing conditions provision" have the same meanings as in
section 3924.01 of the Revised Code. 1,610
(2) "Insurer" means any sickness and accident insurance 1,612
35
company authorized to issue health benefit plans DO BUSINESS in 1,613
this state, or MEWA authorized to issue insured health benefit 1,615
plans in this state. "Insurer" does not include any health 1,616
maintenance organization that is owned or operated by an insurer. 1,617
(3) "Small employer" means any person, firm, corporation, 1,619
or partnership actively engaged in business whose total employed 1,620
work force, on at least fifty per cent of its working days during 1,621
the preceding year, consisted of at least two unrelated eligible 1,622
employees but no more than twenty-five eligible employees, the 1,623
majority of whom were employed within this state. In determining 1,624
the number of eligible employees, companies that are affiliated 1,625
companies or that are eligible to file a combined tax return for 1,626
purposes of state taxation shall be considered one employer. In 1,627
determining whether the members of an association are small 1,628
employers, each member of the association shall be considered as 1,629
a separate person, firm, corporation, or partnership PRE-EXISTING 1,630
CONDITIONS PROVISION" MEANS A POLICY PROVISION THAT EXCLUDES OR 1,632
LIMITS COVERAGE FOR CHARGES OR EXPENSES INCURRED DURING A 1,633
SPECIFIED PERIOD FOLLOWING THE INSURED'S EFFECTIVE DATE OF 1,634
COVERAGE AS TO A CONDITION WHICH, DURING A SPECIFIED PERIOD 1,635
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE, HAD 1,636
MANIFESTED ITSELF IN SUCH A MANNER AS WOULD CAUSE AN ORDINARILY 1,637
PRUDENT PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR 1,638
TREATMENT OR FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR 1,639
TREATMENT WAS RECOMMENDED OR RECEIVED, OR A PREGNANCY EXISTING ON 1,640
THE EFFECTIVE DATE OF COVERAGE.
(4) "Small employer group" means any group consisting of 1,642
all of the eligible employees of a small employer, except those 1,643
employees who are covered, or are eligible for coverage, under 1,644
any other private or public health benefits arrangement, 1,645
including the medicare program established under Title XVIII of 1,646
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 1,647
as amended, or any other act of congress or law of this or any 1,648
other state of the United States that provides benefits 1,649
36
comparable to the benefits provided under this section. 1,650
(B) Beginning in January of each year, insurers IN THE 1,653
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 1,654
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 1,656
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 1,657
3923.122 OF THE REVISED CODE, shall accept applicants for open 1,661
enrollment coverage, as set forth in divisions (B)(1) and (2) of 1,662
this section DIVISION, in the order in which they apply for 1,664
coverage and subject to the limitation set forth in division (G) 1,665
of this section:.
(1) Insurers in the business of issuing health benefit 1,667
plans to small employer groups shall accept small employer groups 1,668
for which coverage is not otherwise available and for whom 1,669
coverage had not been terminated by the employer or by an insurer 1,670
or health maintenance organization during the preceding 1,671
twelve-month period; 1,672
(2) Insurers in the business of issuing individual 1,674
policies of sickness and accident insurance as contemplated by 1,675
section 3923.021 of the Revised Code, except individual policies 1,676
issued pursuant to section 3923.122 of the Revised Code, shall 1,677
either accept individuals pursuant to the open enrollment 1,678
requirements of section 3941.53 of the Revised Code, if subject 1,679
to that section, or accept for coverage pursuant to this section 1,681
individuals to whom both of the following conditions apply: 1,682
(a)(1) The individual is not applying for coverage as an 1,684
employee of an employer, as a member of an association, or as a 1,685
member of any other group. 1,686
(b)(2) The individual is not covered, and is not eligible 1,688
for coverage, under any other private or public health benefits 1,689
arrangement, including the medicare program established under 1,690
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 1,691
U.S.C.A. 301, as amended, or any other act of congress or law of 1,692
this or any other state of the United States that provides 1,693
benefits comparable to the benefits provided under this section, 1,694
37
any medicare supplement policy, or any conversion or continuation 1,695
of coverage policy under state or federal law. 1,696
(C) An insurer shall offer to any individual or small 1,698
employer group accepted under this section the small employer 1,700
health care plan established by the board of directors of the 1,701
Ohio small employer health reinsurance program under division (A) 1,703
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 1,704
plan in benefit plan design and scope of covered services. 1,705
An insurer may offer other health benefit plans in addition 1,707
to, but not in lieu of, the plan required to be offered under 1,708
this division. These additional health benefit plans shall 1,709
provide, at a minimum, the coverage provided by the small 1,710
employer health care plan or any health benefit plan that is 1,711
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 1,712
For purposes of this division, the superintendent of 1,714
insurance shall determine whether a health benefit plan is 1,715
substantially similar to the small employer health care plan in 1,716
benefit plan design and scope of covered services. 1,717
(D) Health benefit plans issued under this section may 1,720
establish pre-existing conditions provisions that exclude or 1,721
limit coverage for a period of up to twelve months following the 1,722
individual's effective date of coverage and that may relate only 1,723
to conditions during the six months immediately preceding the 1,724
effective date of coverage. However, an insurer may exclude a 1,725
late enrollee for a period of up to eighteen months following the 1,726
individual's date of application for coverage. 1,727
(E) Premiums charged to groups or individuals under this 1,729
section may not exceed an amount that is two and one-half times 1,730
the highest rate charged any other group with similar case 1,731
characteristics or any other individual to which the insurer is 1,732
currently accepting new business, and for which similar 1,733
copayments and deductibles are applied. 1,734
38
(F) In offering health benefit plans under this section, 1,736
an insurer may require the purchase of health benefit plans that 1,737
condition the reimbursement of health services upon the use of a 1,738
specific network of providers. 1,739
(G)(1) In no event shall an insurer be required to accept 1,743
annually under this section either individuals or small employer 1,744
groups that WHO, in the aggregate, would cause the insurer to 1,745
have a total number of new insureds that is more than one-half 1,747
per cent of its total number of insured individuals in this state 1,748
per year, as contemplated by section 3923.021 of the Revised 1,749
Code, and small group certificate holders of health benefit plans 1,750
in this state per year, calculated as of the immediately 1,753
preceding thirty-first day of December and excluding the 1,754
insurer's medicare supplement policies and conversion or 1,756
continuation of coverage policies under state or federal law and 1,757
any policies described in division (N)(M) of this section. If an 1,758
insurer is subject to, and elects to operate under, the 1,760
individual open enrollment requirements of section 3941.53 of the 1,761
Revised Code, in no event shall the insurer be required to accept 1,762
annually under this section small employer groups that would 1,763
cause the insurer to have a total number of new insureds that is 1,764
more than one-half per cent of its total number of small group 1,765
certificate holders calculated as set forth in division (G)(1) of 1,766
this section.
(2) An officer of the insurer shall certify to the 1,768
department of insurance when it has met the enrollment limit set 1,769
forth in division (G)(1) of this section. Upon providing such 1,770
certification, the insurer shall be relieved of its open 1,771
enrollment requirement under this section for the remainder of 1,772
the calendar year. 1,773
(H) An insurer shall not be required to accept under this 1,775
section applicants who, at the time of enrollment, are confined 1,776
to a health care facility because of chronic illness, permanent 1,777
injury, or other infirmity that would cause economic impairment 1,778
39
to the insurer if the applicants were accepted, or to make the 1,779
effective date of benefits for individuals or groups accepted 1,780
under this section earlier than ninety days after the date of 1,781
acceptance. 1,782
(I) The requirements of this section do not apply to any 1,784
insurer that is currently in a state of supervision, insolvency, 1,785
or liquidation. If an insurer demonstrates to the satisfaction 1,786
of the superintendent that the requirements of this section would 1,788
place the insurer in a state of supervision, insolvency, or 1,789
liquidation, the superintendent may waive or modify the 1,790
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 1,792
a period of not more than one year. At the expiration of such 1,793
time, a new showing of need for a waiver or modification by the 1,794
insurer shall be made before a new waiver or modification is 1,795
issued or imposed.
(J) No hospital, health care facility, or health care 1,797
practitioner, and no person who employs any health care 1,798
practitioner, shall balance bill any individual or dependent of 1,799
an individual or any eligible employee or dependent of an 1,801
employee for any health care supplies or services provided to the 1,802
individual or dependent or the eligible employee or dependent, 1,803
who is insured under a policy or enrolled under a health benefit 1,805
plan issued under this section. The hospital, health care 1,806
facility, or health care practitioner, or any person that employs 1,807
the health care practitioner, shall accept payments made to it by 1,808
the insurer under the terms of the policy or contract insuring or 1,810
covering such individual as payment in full for such health care 1,811
supplies or services. 1,812
As used in this division, "hospital" has the same meaning 1,814
as in section 3727.01 of the Revised Code; "health care 1,815
practitioner" has the same meaning as in section 4769.01 of the 1,816
Revised Code; and "balance bill" means charging or collecting an 1,817
amount in excess of the amount reimbursable or payable under the 1,818
40
policy or health care service contract issued to an individual or 1,819
group under this section for such health care supply or service. 1,820
"Balance bill" does not include charging for or collecting 1,821
copayments or deductibles required by the policy or contract. 1,822
(K) An insurer shall pay an agent a commission in the 1,824
amount of five per cent of the premium charged for initial 1,825
placement or for otherwise securing the issuance of a policy or 1,826
contract issued to an individual or small employer group under 1,827
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 1,828
adopt, in accordance with Chapter 119. of the Revised Code, such 1,829
rules as are necessary to enforce this division. 1,830
(L) Except as otherwise provided in this section, sections 1,832
3924.01 to 3924.06 of the Revised Code apply to all health 1,833
benefit plans issued under this section. 1,834
(M) Individuals accepted for coverage under this section 1,836
may be issued contracts and certificates subject to the 1,837
requirements of section 3923.12 of the Revised Code. The 1,838
coverage issued to such individuals is not subject to the 1,839
requirements of section 3923.021 of the Revised Code. 1,840
(N)(M) This section does not apply to any policy that 1,842
provides coverage for specific diseases or accidents only, or to 1,844
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 1,846
than six months, or other policy that offers only supplemental 1,847
benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION: 1,849
(1) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE 1,851
INDIVIDUAL AS DEFINED IN SECTION 2741(b) OF THE "HEALTH INSURANCE 1,853
PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 1,854
110 STAT. 1955, 42 U.S.C.A. 300gg-41, AS AMENDED. 1,855
(2) "HEALTH BENEFIT PLAN," "MEWA," AND "PRE-EXISTING 1,857
CONDITIONS PROVISION" HAVE THE SAME MEANINGS AS IN SECTION 1,858
3924.01 OF THE REVISED CODE.
41
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 1,860
FOLLOWING:
(a) HEALTH STATUS; 1,862
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,864
ILLNESSES; 1,865
(c) CLAIMS EXPERIENCE; 1,867
(d) RECEIPT OF HEALTH CARE; 1,869
(e) MEDICAL HISTORY; 1,871
(f) GENETIC INFORMATION; 1,873
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,875
OUT OF ACTS OF DOMESTIC VIOLENCE; 1,876
(h) DISABILITY. 1,878
(4) "INSURER" MEANS ANY SICKNESS AND ACCIDENT INSURANCE 1,880
COMPANY OR MEWA AUTHORIZED TO DO BUSINESS IN THIS STATE. 1,881
"INSURER" DOES NOT INCLUDE ANY HEALTH MAINTENANCE ORGANIZATION 1,882
THAT IS OWNED OR OPERATED BY AN INSURER. 1,883
(5) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR 1,885
CASE CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE 1,886
APPLICABLE INSURER FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF 1,887
THE APPLICABLE BASE PREMIUM RATE AND THE CORRESPONDING HIGHEST 1,888
PREMIUM RATE.
(6) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF AN 1,890
INSURER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 1,891
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 1,892
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 1,893
UNDER CONTRACT WITH THE INSURER.
(B) BEGINNING IN JANUARY OF EACH YEAR, INSURERS IN THE 1,895
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 1,896
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 1,897
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 1,898
3923.122 OF THE REVISED CODE, SHALL ACCEPT FEDERALLY ELIGIBLE
INDIVIDUALS FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS 1,899
SECTION, IN THE ORDER IN WHICH THEY APPLY FOR COVERAGE AND 1,900
SUBJECT TO THE LIMITATION SET FORTH IN DIVISION (J) OF THIS 1,901
42
SECTION.
(C) NO INSURER SHALL DO EITHER OF THE FOLLOWING: 1,903
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT 1,905
OF, SUCH INDIVIDUALS; 1,906
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH 1,908
COVERAGE.
(D) AN INSURER SHALL OFFER TO FEDERALLY ELIGIBLE 1,910
INDIVIDUALS THE BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD 1,911
OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS 1,912
SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT 1,913
DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF THIS 1,914
DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER 1,915
A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 1,916
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY 1,918
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED 1,919
ANY OTHER INDIVIDUAL TO WHICH THE INSURER IS CURRENTLY ACCEPTING 1,920
NEW BUSINESS, AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES 1,921
ARE APPLIED.
(F) IF AN INSURER OFFERS A HEALTH BENEFIT PLAN IN THE 1,923
INDIVIDUAL MARKET THROUGH A NETWORK PLAN, THE INSURER MAY DO BOTH 1,924
OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY 1,926
APPLY FOR SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE 1,927
SERVICE AREA OF THE NETWORK PLAN; 1,928
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 1,930
COVERAGE TO FEDERALLY ELIGIBLE INDIVIDUALS IF THE INSURER HAS 1,931
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 1,932
(a) THE INSURER WILL NOT HAVE THE CAPACITY TO DELIVER 1,934
SERVICES ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE 1,935
INSURER'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS AND 1,936
INDIVIDUALS.
(b) THE INSURER IS APPLYING DIVISION (F)(2) OF THIS 1,938
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT 1,939
43
REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS. 1,940
(G) AN INSURER THAT, PURSUANT TO DIVISION (F)(2) OF THIS 1,942
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF 1,943
A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET 1,944
WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS 1,945
AFTER THE DATE THE COVERAGE IS DENIED. 1,946
(H) AN INSURER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO 1,948
FEDERALLY ELIGIBLE INDIVIDUALS IF THE INSURER HAS DEMONSTRATED 1,949
BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 1,950
(1) THE INSURER DOES NOT HAVE THE FINANCIAL RESERVES 1,952
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 1,953
(2) THE INSURER IS APPLYING DIVISION (H) OF THIS SECTION 1,955
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE 1,956
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND 1,957
WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 1,958
THOSE INDIVIDUALS.
(I) AN INSURER THAT, PURSUANT TO DIVISION (H) OF THIS 1,960
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY 1,961
ELIGIBLE INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 1,962
INDIVIDUAL MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY 1,963
DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE INSURER 1,964
HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE INSURER HAS 1,965
SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER. 1,966
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 1,969
SECTION, AN INSURER SHALL NOT BE REQUIRED TO ACCEPT ANNUALLY 1,971
UNDER THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS WHO, IN THE 1,972
AGGREGATE, WOULD CAUSE THE INSURER TO HAVE A TOTAL NUMBER OF NEW 1,973
INSUREDS THAT IS MORE THAN ONE-HALF PER CENT OF ITS TOTAL NUMBER 1,974
OF INSURED INDIVIDUALS IN THIS STATE PER YEAR, AS CONTEMPLATED BY 1,975
SECTION 3923.021 OF THE REVISED CODE, CALCULATED AS OF THE 1,976
IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF DECEMBER AND EXCLUDING 1,977
THE INSURER'S MEDICARE SUPPLEMENT POLICIES AND CONVERSION OR 1,979
CONTINUATION OF COVERAGE POLICIES UNDER STATE OR FEDERAL LAW AND 1,980
44
ANY POLICIES DESCRIBED IN DIVISION (M) OF SECTION 3923.58 OF THE 1,981
REVISED CODE.
(2) AN OFFICER OF THE INSURER SHALL CERTIFY TO THE 1,983
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET 1,984
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH 1,985
CERTIFICATION, THE INSURER SHALL BE RELIEVED OF ITS OPEN 1,986
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF 1,987
THE CALENDAR YEAR UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, 1,989
ALL THE INSURERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET 1,990
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 1,992
SECTION. IN THAT EVENT, INSURERS SHALL AGAIN ACCEPT APPLICANTS 1,993
FOR OPEN ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO 1,994
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 1,996
SECTION.
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 1,998
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 1,999
(L) THE REQUIREMENT OF THIS SECTION SHALL NOT APPLY TO ANY 2,001
HEALTH BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 2,002
OF THE REVISED CODE.
Sec. 3923.59. Any insurer may reinsure coverage of any 2,011
individual, small employer group, or member of that group 2,012
acquired under section 3923.58 OR 3923.581 of the Revised Code 2,014
with the Ohio small employer health OPEN ENROLLMENT reinsurance 2,015
program in accordance with division (G) of section 3924.11 of the 2,016
Revised Code. Premium rates charged for coverage reinsured by 2,017
the program shall be established in accordance with section 2,018
3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the 2,027
Revised Code, each individual or group policy of sickness and 2,029
accident insurance delivered, issued for delivery, or renewed in 2,030
this state that provides maternity benefits shall provide
coverage of inpatient care and follow-up care for a mother and 2,031
her newborn as follows:
(1) The policy shall cover a minimum of forty-eight hours 2,034
45
of inpatient care following a normal vaginal delivery and a 2,035
minimum of ninety-six hours of inpatient care following a 2,036
cesarean delivery. Services covered as inpatient care shall 2,037
include medical, educational, and any other services that are 2,038
consistent with the inpatient care recommended in the protocols 2,039
and guidelines developed by national organizations that represent 2,040
pediatric, obstetric, and nursing professionals. 2,041
(2) The policy shall cover a physician-directed source of 2,043
follow-up care. Services covered as follow-up care shall include 2,044
physical assessment of the mother and newborn, parent education, 2,045
assistance and training in breast or bottle feeding, assessment 2,046
of the home support system, performance of any medically 2,047
necessary and appropriate clinical tests, and any other services 2,048
that are consistent with the follow-up care recommended in the 2,049
protocols and guidelines developed by national organizations that 2,051
represent pediatric, obstetric, and nursing professionals. The 2,052
coverage shall apply to services provided in a medical setting or 2,053
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,054
conducts the visit is knowledgeable and experienced in maternity 2,055
and newborn care.
When a decision is made in accordance with division (B) of 2,057
this section to discharge a mother or newborn prior to the 2,058
expiration of the applicable number of hours of inpatient care 2,059
required to be covered, the coverage of follow-up care shall 2,060
apply to all follow-up care that is provided within forty-eight 2,061
SEVENTY-TWO hours after discharge. When a mother or newborn 2,062
receives at least the number of hours of inpatient care required 2,063
to be covered, the coverage of follow-up care shall apply to 2,064
follow-up care that is determined to be medically necessary by 2,065
the health care professionals responsible for discharging the 2,066
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,069
to less than that specified under division (A)(1) of this section 2,071
46
shall be made by the physician attending the mother or newborn, 2,072
except that if a nurse-midwife is attending the mother in 2,073
collaboration with a physician, the decision may be made by the 2,074
nurse-midwife. Decisions regarding early discharge shall be made 2,075
only after conferring with the mother or a person responsible for 2,076
the mother or newborn. For purposes of this division, a person 2,077
responsible for the mother or newborn may include a parent, 2,078
guardian, or any other person with authority to make medical 2,079
decisions for the mother or newborn.
(C)(1) No sickness and accident insurer may do either of 2,082
the following:
(a) Terminate the participation of a health care 2,085
professional or health care facility as a provider under a
sickness and accident insurance policy solely for making 2,086
recommendations for inpatient or follow-up care for a particular 2,087
mother or newborn that are consistent with the care required to 2,088
be covered by this section; 2,089
(b) Establish or offer monetary or other financial 2,092
incentives for the purpose of encouraging a person to decline the 2,093
inpatient or follow-up care required to be covered by this 2,094
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,098
section has engaged in an unfair and deceptive act or practice in 2,099
the business of insurance under sections 3901.19 to 3901.26 of 2,100
the Revised Code. 2,102
(D) This section does not do any of the following: 2,105
(1) Require a policy to cover inpatient or follow-up care 2,108
that is not received in accordance with the policy's terms 2,109
pertaining to the health care professionals and facilities from 2,110
which an individual is authorized to receive health care 2,111
services.;
(2) Require a mother or newborn to stay in a hospital or 2,114
other inpatient setting for a fixed period of time following
delivery; 2,115
47
(3) Require a child to be delivered in a hospital or other 2,118
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,120
authority to practice nurse-midwifery in accordance with Chapter 2,122
4723. of the Revised Code; 2,124
(5) Establish minimum standards of medical diagnosis, care 2,127
or treatment for inpatient or follow-up care for a mother or 2,128
newborn. A deviation from the care required to be covered under 2,129
this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those 2,130
terms are defined in section 2305.11 of the Revised Code. 2,133
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the 2,142
Revised Code, each public employee benefit plan established or 2,144
modified in this state that provides maternity benefits shall 2,145
provide coverage of inpatient care and follow-up care for a 2,146
mother and her newborn as follows: 2,147
(1) The plan shall cover a minimum of forty-eight hours of 2,149
inpatient care following a normal vaginal delivery and a minimum 2,151
of ninety-six hours of inpatient care following a cesarean 2,152
delivery. Services covered as inpatient care shall include 2,153
medical, educational, and any other services that are consistent 2,154
with the inpatient care recommended in the protocols and 2,155
guidelines developed by national organizations that represent 2,156
pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of 2,158
follow-up care. Services covered as follow-up care shall include 2,159
physical assessment of the mother and newborn, parent education, 2,160
assistance and training in breast or bottle feeding, assessment 2,161
of the home support system, performance of any medically 2,162
necessary and appropriate clinical tests, and any other services 2,163
that are consistent with the follow-up care recommended in the 2,164
protocols and guidelines developed by national organizations that 2,166
represent pediatric, obstetric, and nursing professionals. The 2,167
coverage shall apply to services provided in a medical setting or 2,168
48
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,169
conducts the visit is knowledgeable and experienced in maternity 2,170
and newborn care.
When a decision is made in accordance with division (B) of 2,172
this section to discharge a mother or newborn prior to the 2,173
expiration of the applicable number of hours of inpatient care 2,174
required to be covered, the coverage of follow-up care shall 2,175
apply to all follow-up care that is provided within forty-eight 2,176
SEVENTY-TWO hours after discharge. When a mother or newborn 2,177
receives at least the number of hours of inpatient care required 2,178
to be covered, the coverage of follow-up care shall apply to 2,179
follow-up care that is determined to be medically necessary by 2,180
the health care professionals responsible for discharging the 2,181
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,184
to less than that specified under division (A)(1) of this section 2,186
shall be made by the physician attending the mother or newborn, 2,187
except that if a nurse-midwife is attending the mother in 2,188
collaboration with a physician, the decision may be made by the 2,189
nurse-midwife. Decisions regarding early discharge shall be made 2,190
only after conferring with the mother or a person responsible for 2,191
the mother or newborn. For purposes of this division, a person 2,192
responsible for the mother or newborn may include a parent, 2,193
guardian, or any other person with authority to make medical 2,194
decisions for the mother or newborn.
(C)(1) No public employer who offers an employee benefit 2,197
plan may do either of the following: 2,198
(a) Terminate the participation of a health care 2,201
professional or health care facility as a provider under the plan 2,202
solely for making recommendations for inpatient or follow-up care 2,203
for a particular mother or newborn that are consistent with the 2,204
care required to be covered by this section; 2,205
(b) Establish or offer monetary or other financial 2,208
49
incentives for the purpose of encouraging a person to decline the 2,209
inpatient or follow-up care required to be covered by this 2,210
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,214
section has engaged in an unfair and deceptive act or practice in 2,215
the business of insurance under sections 3901.19 to 3901.26 of 2,216
the Revised Code. 2,218
(D) This section does not do any of the following: 2,221
(1) Require a plan to cover inpatient or follow-up care 2,224
that is not received in accordance with the plan's terms 2,225
pertaining to the health care professionals and facilities from 2,226
which an individual is authorized to receive health care 2,227
services.;
(2) Require a mother or newborn to stay in a hospital or 2,230
other inpatient setting for a fixed period of time following
delivery; 2,231
(3) Require a child to be delivered in a hospital or other 2,234
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,236
authority to practice nurse-midwifery in accordance with Chapter 2,238
4723. of the Revised Code; 2,240
(5) Establish minimum standards of medical diagnosis, 2,242
care, or treatment for inpatient or follow-up care for a mother 2,243
or newborn. A deviation from the care required to be covered 2,244
under this section shall not, solely on the basis of this 2,245
section, give rise to a medical claim or derivative medical 2,246
claim, as those terms are defined in section 2305.11 of the 2,247
Revised Code. 2,249
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 2,258
the Revised Code: 2,259
(A) "Actuarial certification" means a written statement 2,261
prepared by a member of the American academy of actuaries, or by 2,262
any other person acceptable to the superintendent of insurance, 2,263
that states that, based upon the person's examination, a carrier 2,264
50
offering health benefit plans to small employers is in compliance 2,265
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 2,266
certification" shall include a review of the appropriate records 2,267
of, and the actuarial assumptions and methods used by, the 2,268
carrier relative to establishing premium rates for the health 2,269
benefit plans. 2,270
(B) "Adjusted average market premium price" means the 2,272
average market premium price as determined by the board of 2,274
directors of the Ohio small employer health reinsurance program 2,275
either on the basis of the arithmetic mean of all carriers' 2,276
premium rates for an SEHC plan sold to groups with similar case 2,277
characteristics by all carriers selling SEHC plans in the state, 2,279
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 2,281
plan that is issued by a carrier and that covers at least two but 2,282
no more than fifty employees of a small employer, the lowest 2,284
premium rate for a new or existing business prescribed by the 2,285
carrier for the same or similar coverage under a plan or 2,286
arrangement covering any small employer with similar case 2,287
characteristics.
(D) "Carrier" means any sickness and accident insurance 2,289
company or health maintenance organization authorized to issue 2,290
health benefit plans in this state or a MEWA. A sickness and 2,292
accident insurance company that owns or operates a health 2,293
maintenance organization, either as a separate corporation or as 2,294
a line of business, shall be considered as a separate carrier 2,295
from that health maintenance organization for purposes of 2,296
sections 3924.01 to 3924.14 of the Revised Code. 2,297
(E) "Case characteristics" means, with respect to a small 2,299
employer, the geographic area in which the employees work; the 2,300
age and sex of the individual employees and their dependents; the 2,301
appropriate industry classification as determined by the carrier; 2,302
the number of employees and dependents; and such other objective 2,303
criteria as may be established by the carrier. "Case 2,304
51
characteristics" does not include claims experience, health 2,305
status, or duration of coverage from the date of issue. 2,306
(F) "Dependent" means the spouse or child of an eligible 2,308
employee, subject to applicable terms of the health benefits plan 2,309
covering the employee. 2,310
(G) "Eligible employee" means an employee who works a 2,312
normal work week of twenty-five or more hours. "Eligible 2,313
employee" does not include a temporary or substitute employee, or 2,315
a seasonal employee who works only part of the calendar year on 2,316
the basis of natural or suitable times or circumstances. 2,317
(H) "Financially impaired" means a program member that, 2,319
after April 14, 1993, is not insolvent but is determined by the 2,322
superintendent to be potentially unable to fulfill its 2,323
contractual obligations, or is placed under an order of 2,324
rehabilitation or conservation by a court of competent 2,325
jurisdiction or under an order of supervision by the 2,326
superintendent.
(I) "Health benefit plan" means any hospital or medical 2,328
expense policy or certificate or any health plan provided by a 2,330
carrier, that is delivered, issued for delivery, renewed, or used 2,332
in this state on or after the date occurring six months after the 2,333
effective date of this amendment NOVEMBER 24, 1995. "Health 2,334
benefit plan" does not include policies covering only accident, 2,335
credit, dental, disability income, long-term care, hospital 2,336
indemnity, medicare supplement, specified disease, or vision 2,337
care; coverage under a one-time-limited-duration policy of no 2,338
longer than six months; coverage issued by a health care 2,339
corporation; coverage issued by a prepaid dental plan 2,341
organization solely or in conjunction with a carrier; coverage 2,342
issued as a supplement to liability insurance; insurance arising 2,343
out of a workers' compensation or similar law; automobile 2,344
medical-payment insurance; or insurance under which benefits are 2,345
payable with or without regard to fault and which is statutorily 2,346
required to be contained in any liability insurance policy or 2,347
52
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 2,349
period immediately following any service waiting period 2,350
established by an employer. 2,351
(K)(I) "Late enrollee" means an eligible employee or 2,353
dependent who requests enrollment ENROLLS in a small employer's 2,354
health benefit plan following OTHER THAN DURING the initial 2,355
enrollment FIRST period provided under the terms of the first 2,357
plan for IN which the employee or dependent was IS eligible 2,358
through the small employer, unless any of the following apply: 2,359
(1) The individual: 2,361
(a) Was covered under another health benefit plan at the 2,364
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 2,366
coverage under another health benefit plan was the reason for 2,369
declining enrollment;
(c) Has lost coverage under another health benefit plan as 2,372
a result of the termination of employment, a reduction of hours 2,373
worked per week, the termination of the other plan's coverage, 2,374
death of a spouse, or divorce; and 2,375
(d) Requests enrollment within thirty days after the 2,377
termination of coverage under another health benefit plan. 2,378
(2) The individual is employed by an employer who offers 2,380
multiple health benefit plans and the individual elects a 2,381
different health benefit plan during an open enrollment period. 2,382
(3) A court has ordered coverage to be provided for a 2,384
spouse or minor child under a covered employee's plan and a 2,385
request for enrollment is made within thirty days after issuance 2,386
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 2,387
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 2,391
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. 2,397
NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg, AS AMENDED. 2,400
(L)(J) "MEWA" means any "multiple employer welfare 2,403
arrangement" as defined in section 3 of the "Federal Employee 2,404
53
Retirement Income Security Act of 1974," 88 Stat. 832, 29 2,405
U.S.C.A. 1001, as amended, except for any arrangement which is 2,406
fully insured as defined in division (b)(6)(D) of section 514 of 2,407
that act. 2,408
(M)(K) "Midpoint rate" means, for small employers with 2,410
similar case characteristics and plan designs and as determined 2,411
by the applicable carrier for a rating period, the arithmetic 2,412
average of the applicable base premium rate and the corresponding 2,413
highest premium rate. 2,414
(N)(L) "Pre-existing conditions provision" means a policy 2,417
provision that excludes or limits coverage for charges or 2,418
expenses incurred during a specified period following the 2,419
insured's effective ENROLLMENT date of coverage as to a condition 2,421
which, during a specified period immediately preceding the 2,422
effective date of coverage, had manifested itself in such a 2,423
manner as would cause an ordinarily prudent person to seek 2,424
medical advice, diagnosis, care, or treatment or for which 2,425
medical advice, diagnosis, care, or treatment was recommended or 2,426
received, or DURING a pregnancy existing on SPECIFIED PERIOD 2,428
IMMEDIATELY PRECEDING the effective ENROLLMENT date of coverage. 2,429
GENETIC INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN 2,430
THE ABSENCE OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH 2,431
INFORMATION.
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, 2,433
WITH RESPECT TO AN INDIVIDUAL COVERED UNDER A GROUP HEALTH 2,435
BENEFIT PLAN, THE DATE OF ENROLLMENT OF THE INDIVIDUAL IN THE 2,436
PLAN OR, IF EARLIER, THE FIRST DAY OF THE WAITING PERIOD FOR SUCH 2,437
ENROLLMENT.
(O)(M) "Service waiting period" means the period of time 2,440
after employment begins before an eligible employee may enroll in 2,441
IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any
applicable health benefit plan offered by the small employer. 2,442
(P)(N)(1) "Small employer" means any person, firm, 2,445
corporation, partnership, or association actively engaged in 2,446
54
business whose total, IN CONNECTION WITH A GROUP HEALTH BENEFIT 2,448
PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN YEAR, AN 2,449
EMPLOYER WHO employed work force consisted of, on at least fifty 2,450
per cent of its working days during the preceding year, AN 2,451
AVERAGE OF at least two but no more than fifty eligible 2,452
employees, the majority of whom were employed within the state ON 2,454
BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND WHO EMPLOYS 2,455
AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN YEAR. 2,456
(2) In determining the number of eligible employees for 2,458
FOR purposes of division (P)(N)(1) of this section, companies 2,460
which are affiliated companies or which are eligible to file a
combined tax return for purposes of state taxation ALL PERSONS 2,462
TREATED AS A SINGLE EMPLOYER UNDER SUBSECTION (b), (c), (m), OR 2,465
(o) OF SECTION 414 OF THE "INTERNAL REVENUE CODE OF 1986," 100 2,469
STAT. 2085, 26 U.S.C. 1, AS AMENDED, shall be considered one 2,471
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE 2,472
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF 2,473
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED 2,474
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS REASONABLY 2,476
EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN THE CURRENT 2,477
CALENDAR YEAR. ANY REFERENCE IN DIVISION (N) OF THIS SECTION TO 2,478
AN "EMPLOYER" INCLUDES ANY PREDECESSOR OF THE EMPLOYER. Except 2,480
as otherwise specifically provided, provisions of sections 2,481
3924.01 to 3924.14 of the Revised Code that apply to a small 2,482
employer that has a health benefit plan shall continue to apply 2,483
until the plan anniversary following the date the employer no 2,484
longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small employer health 2,487
care plan, which is a health benefit plan for INDIVIDUALS AND 2,488
small employers established by the board in accordance with 2,489
section 3924.10 of the Revised Code. 2,490
Sec. 3924.03. Health benefit plans covering small 2,499
employers are subject to the following conditions, as applicable: 2,500
(A)(1) Pre-existing conditions provisions shall not 2,502
55
exclude or limit coverage for a period beyond twelve months, OR 2,503
EIGHTEEN MONTHS IN THE CASE OF A LATE ENROLLEE, following the 2,504
individual's effective ENROLLMENT date of coverage and may only 2,505
relate to conditions during A PHYSICAL OR MENTAL CONDITION, 2,506
REGARDLESS OF THE CAUSE OF THE CONDITION, FOR WHICH MEDICAL 2,508
ADVICE, DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED 2,509
WITHIN the six months immediately preceding the effective 2,511
ENROLLMENT date of coverage.
DIVISION (A)(1) OF THIS SECTION IS SUBJECT TO THE 2,514
EXCEPTIONS SET FORTH IN SECTION 2701(d) AND SECTION 2721 OF THE 2,516
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 2,521
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg AND 2,526
300gg-21, AS AMENDED.
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION 2,528
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF 2,529
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR 2,530
DEPENDENT AS OF THE ENROLLMENT DATE. 2,531
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE COUNTED, 2,534
WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A GROUP HEALTH 2,535
BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE ENROLLMENT 2,536
DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL OF WHICH THE 2,537
INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE COVERAGE. 2,538
SUBSECTIONS (c)(2) TO (4) AND (e) OF SECTION 2701 OF THE "HEALTH 2,540
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996" APPLY WITH 2,544
RESPECT TO CREDITING PREVIOUS COVERAGE. 2,545
(4) AS USED IN DIVISION (A) OF THIS SECTION: 2,548
(a) "CREDITABLE COVERAGE" HAS THE SAME MEANING AS IN 2,551
SECTION 2701(c)(1) OF THE "HEALTH INSURANCE PORTABILITY AND 2,555
ACCOUNTABILITY ACT OF 1996." 2,556
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN INDIVIDUAL 2,559
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF ENROLLMENT 2,560
OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE FIRST DAY OF 2,561
THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions 2,563
56
provision applies to an eligible employee or dependent, all 2,564
health benefit plans shall credit the time the person was covered 2,565
under a previous employer-based health benefit plan provided by a 2,566
carrier if the previous coverage was continuous to a date not 2,568
more than thirty days prior to the effective date of the new 2,570
coverage, exclusive of any applicable service waiting period 2,571
under the plan. 2,572
(C) Any such health benefit plan shall be renewable with 2,574
respect to all eligible employees or dependents at the option of 2,575
the policyholder, contract holder, or small employer, except for 2,576
any of the following reasons: 2,577
(1) Nonpayment of the required premiums by the 2,579
policyholder, contract holder, or employer; 2,580
(2) Fraud or misrepresentation of the policyholder, 2,582
contract holder, or employer or, with respect to coverage of 2,583
individual insureds, the insureds or their representatives ; 2,585
(3) When the total number of insured individuals covered 2,587
under all of the health benefit plans of any one employer is less 2,588
than the total number of individuals or percentage of individuals 2,589
required by participation requirements under any specific health 2,590
benefit plan of that employer; 2,591
(4) Noncompliance with any plan provision that has been 2,593
approved by the superintendent of insurance; 2,594
(5) When the carrier ceases doing business in the small 2,596
employer market, provided that all of the following conditions 2,597
are met: 2,598
(a) Notice of the decision to cease to do business in the 2,600
small employer market is provided to the department of insurance, 2,601
the board of directors of the Ohio small employer health 2,602
reinsurance program, the policyholder or contract holder, and the 2,603
employer. 2,604
(b) Health benefit plans subject to sections 3924.01 to 2,606
3924.14 of the Revised Code shall not be canceled by the carrier 2,607
for ninety days after the date of the notice required under 2,609
57
division (C)(5)(a) of this section unless the business has been 2,610
sold to another carrier or the cancellations are approved by the 2,611
superintendent. 2,612
(c) A carrier that ceases to do business in the small 2,614
employer marketplace is prohibited from re-entering the small 2,615
employer marketplace for a period of five years from the date of 2,616
the notice required under division (C)(5)(a) of this section. 2,617
(D) Notwithstanding division (C) of this section, any such 2,619
health benefit plan or any coverage provided to an individual 2,620
under such a plan may be rescinded for fraud, material 2,621
misrepresentation, or concealment by an applicant, employee, 2,622
dependent, or small employer. 2,623
(E) Every carrier doing business in the small employer 2,625
market may underwrite and rate small employer groups, as 2,626
permitted by sections 3924.01 to 3924.14 of the Revised Code, 2,627
using accepted underwriting and actuarial practices. 2,628
(F) A carrier shall not exclude any eligible employee or 2,630
dependent, who would otherwise be covered under a health benefit 2,631
plan, on the basis of any actual or expected health condition of 2,633
the employee or dependent. However, a carrier may exclude a late 2,634
enrollee for a period of up to twenty-four months or may, in the 2,635
discretion of the carrier, extend coverage to the late enrollee
at any time during that period. A carrier also may medically 2,637
underwrite a late enrollee EXCEPT AS PROVIDED IN SECTION 2712(b) 2,638
TO (e) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 2,644
ACT OF 1996," IF A CARRIER OFFERS COVERAGE IN THE SMALL EMPLOYER 2,645
MARKET IN CONNECTION WITH A GROUP HEALTH BENEFIT PLAN, THE 2,646
CARRIER SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT THE 2,647
OPTION OF THE PLAN SPONSOR OF THE PLAN. 2,648
(C) If, prior to the effective date of this amendment 2,651
NOVEMBER 24, 1995, a carrier excluded an eligible employee or 2,652
dependent, other than a late enrollee, on the basis of an actual 2,653
or expected health condition, the carrier shall, upon the initial 2,654
renewal of the coverage on or after that date, extend coverage to 2,655
58
the employee or dependent if all other eligibility requirements 2,656
are met.
(G)(D) No health benefit plan issued by a carrier shall 2,659
limit or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 2,661
medical condition, or accident, except for pre-existing 2,662
conditions as permitted under division (A) of this section. If a 2,663
health benefit plan that is delivered or issued for delivery 2,665
prior to April 14, 1993, contains such limitations or exclusions, 2,667
by use of a rider or amendment applicable to a specific 2,668
individual, the plan shall eliminate the use of such riders or 2,669
amendments within eighteen months after April 14, 1993. 2,670
(H)(E)(1) EXCEPT AS PROVIDED IN SECTIONS 3924.031 AND 2,673
3924.032 OF THE REVISED CODE, AND SUBJECT TO SUCH RULES AS MAY BE 2,676
ADOPTED BY THE SUPERINTENDENT IN ACCORDANCE WITH CHAPTER 119. OF 2,677
THE REVISED CODE, A CARRIER SHALL ISSUE A HEALTH BENEFIT PLAN TO 2,680
EVERY SMALL EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH 2,681
COVERAGE.
DIVISION (E)(1) OF THIS SECTION DOES NOT APPLY TO A HEALTH 2,684
BENEFIT PLAN THAT A CARRIER MAKES AVAILABLE IN THE SMALL EMPLOYER 2,685
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS. 2,686
DIVISION (E)(1) OF THIS SECTION SHALL NOT BE CONSTRUED TO 2,689
PRECLUDE A CARRIER FROM ESTABLISHING EMPLOYER CONTRIBUTION RULES 2,690
OR GROUP PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN 2,691
CONNECTION WITH A GROUP HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER 2,692
MARKET, AS ALLOWED UNDER THE LAW OF THIS STATE. AS USED IN 2,693
DIVISION (E)(1) OF THIS SECTION, "EMPLOYER CONTRIBUTION RULE" 2,695
MEANS A REQUIREMENT RELATING TO THE MINIMUM LEVEL OR AMOUNT OF 2,696
EMPLOYER CONTRIBUTION TOWARD THE PREMIUM FOR ENROLLMENT OF 2,697
EMPLOYEES AND DEPENDENTS AND "GROUP PARTICIPATION RULE" MEANS A 2,698
REQUIREMENT RELATING TO THE MINIMUM NUMBER OF EMPLOYEES OR 2,699
DEPENDENTS THAT MUST BE ENROLLED IN RELATION TO A SPECIFIED 2,700
PERCENTAGE OR NUMBER OF ELIGIBLE INDIVIDUALS OR EMPLOYEES OF AN 2,701
EMPLOYER.
59
(2) Each health benefit plan, at the time of initial group 2,703
enrollment, shall make coverage available to all the eligible 2,704
employees of a small employer without a service waiting period. 2,705
The decision of whether to impose a service waiting period shall 2,707
be made by the small employer. Such waiting periods shall not be 2,708
greater than ninety days. 2,709
(I)(F) The benefit structure of any health benefit plan 2,712
may, AT THE TIME OF COVERAGE RENEWAL, be changed by the carrier 2,714
to make it consistent with the benefit structure contained in 2,715
health benefit plans being marketed to new small employer groups. 2,716
IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE SMALL EMPLOYER 2,718
MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW OF 2,720
THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL EMPLOYER 2,721
GROUP PLANS.
(J)(G) A carrier may obtain any facts and information 2,723
necessary to apply this section, or supply those facts and 2,724
information to any other third-party payer, without the consent 2,725
of the beneficiary. Each person claiming benefits under a health 2,726
benefit plan shall provide any facts and information necessary to 2,727
apply this section. 2,728
FOR PURPOSES OF THIS SECTION, "BONA FIDE ASSOCIATION" MEANS 2,731
AN ASSOCIATION THAT HAS BEEN ACTIVELY IN EXISTENCE FOR AT LEAST 2,732
FIVE YEARS; HAS BEEN FORMED AND MAINTAINED IN GOOD FAITH FOR 2,733
PURPOSES OTHER THAN OBTAINING INSURANCE; DOES NOT CONDITION 2,734
MEMBERSHIP IN THE ASSOCIATION ON ANY HEALTH STATUS-RELATED 2,735
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 2,737
RELATING TO AN INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; 2,738
MAKES HEALTH INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION 2,739
AVAILABLE TO ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED 2,740
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 2,743
RELATING TO SUCH MEMBERS OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE 2,744
THROUGH A MEMBER; DOES NOT MAKE HEALTH INSURANCE COVERAGE OFFERED 2,745
THROUGH THE ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A 2,746
60
MEMBER OF THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT 2,747
IMPOSED BY THE SUPERINTENDENT. 2,748
Sec. 3924.031. (A) AS USED IN THIS SECTION AND SECTION 2,751
3924.032 OF THE REVISED CODE: 2,753
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 2,755
FOLLOWING: 2,756
(a) HEALTH STATUS; 2,758
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 2,761
ILLNESSES;
(c) CLAIMS EXPERIENCE; 2,763
(d) RECEIPT OF HEALTH CARE; 2,765
(e) MEDICAL HISTORY; 2,767
(f) GENETIC INFORMATION; 2,769
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 2,772
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 2,774
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 2,776
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 2,777
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 2,778
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 2,780
UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE SMALL 2,783
EMPLOYER MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 2,784
OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH 2,786
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR 2,787
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN; 2,788
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 2,790
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH 2,791
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE: 2,792
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 2,795
SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL GROUPS 2,796
BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT 2,797
HOLDERS AND MEMBERS.
61
(b) THE CARRIER IS APPLYING DIVISION (B)(2) OF THIS 2,800
SECTION UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE 2,801
CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES 2,802
AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 2,803
SUCH EMPLOYEES AND DEPENDENTS. 2,804
(C) A CARRIER THAT, PURSUANT TO DIVISION (B)(2) OF THIS 2,808
SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE AREA 2,809
OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL EMPLOYER 2,810
MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY 2,811
DAYS AFTER THE DATE THE COVERAGE IS DENIED. 2,812
Sec. 3924.032. (A) A CARRIER MAY REFUSE TO ISSUE HEALTH 2,815
BENEFIT PLANS IN THE SMALL EMPLOYER MARKET IF THE CARRIER HAS 2,816
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT OF 2,817
INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 2,819
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 2,820
(2) THE CARRIER IS APPLYING DIVISION (A) OF THIS SECTION 2,823
UNIFORMLY TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS 2,824
STATE CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE 2,825
AND WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS 2,826
AND THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH 2,827
STATUS-RELATED FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS. 2,828
(B) A CARRIER THAT, PURSUANT TO DIVISION (A) OF THIS 2,832
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 2,833
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED 2,834
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE 2,835
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER 2,836
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL 2,837
COVERAGE, WHICHEVER IS LATER. 2,838
(C) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 2,841
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 2,842
Sec. 3924.033. (A) EACH CARRIER, IN CONNECTION WITH THE 2,845
OFFERING OF A HEALTH BENEFIT PLAN TO A SMALL EMPLOYER, SHALL 2,846
62
DISCLOSE TO THE EMPLOYER, AS PART OF ITS SOLICITATION AND SALES 2,847
MATERIALS, THAT THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 2,848
SECTION IS AVAILABLE UPON REQUEST. 2,849
(B) A CARRIER SHALL PROVIDE THE FOLLOWING INFORMATION TO A 2,852
SMALL EMPLOYER UPON REQUEST: 2,853
(1) THE PROVISIONS OF THE PLAN CONCERNING THE CARRIER'S 2,856
RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY AFFECT 2,857
CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO RENEWABILITY OF 2,860
COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY 2,862
PRE-EXISTING CONDITION EXCLUSION; 2,863
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL HEALTH 2,866
BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 2,870
SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER 2,871
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE 2,872
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT PLAN. 2,874
(D) NOTHING IN THIS SECTION REQUIRES A CARRIER TO DISCLOSE 2,877
ANY INFORMATION THAT IS BY LAW PROPRIETARY AND TRADE SECRET 2,878
INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit 2,887
entity to be known as the "Ohio small employer health reinsurance 2,889
program." Any carrier issuing health benefit plans in this state 2,890
on or after April 14, 1993, may be a member of the program. 2,891
(B) A carrier may elect to be a member of the program by 2,893
filing a written intention to participate with the superintendent 2,895
of insurance at least thirty days prior to the implementation of 2,896
the program. Any carrier that does not file a written intention 2,897
to participate within that time period may not participate for 2,898
three years after April 14, 1993, and may file an intention to 2,900
participate only at that time or on any subsequent three-year 2,901
anniversary date. However, the superintendent may permit a 2,902
63
carrier to participate in the program at other intervals for 2,903
reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A 2,905
CARRIER TO PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE 2,906
SHOWN. THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 2,907
CARRIERS SEEKING TO CHANGE THEIR STATUS UNDER THIS DIVISION. 2,908
Sec. 3924.08. (A) The board of directors of the Ohio 2,917
small employer health reinsurance program shall consist of nine 2,918
appointed members who shall serve staggered terms as determined 2,919
by the initial board for its members and by the plan of operation 2,920
of the program for members of subsequent boards. Within thirty 2,921
days after April 14, 1993, the members of the board shall be 2,922
appointed, as follows: 2,923
(1) The chairperson of the senate committee having 2,925
jurisdiction over insurance shall appoint the following members: 2,926
(a) Two member carriers that are small employer carriers; 2,928
(b) One member carrier that is a health maintenance 2,930
organization predominantly in the small employer market; 2,931
(c) One representative of providers of health care. 2,933
(2) The chairperson of the committee in the house of 2,935
representatives having jurisdiction over insurance shall appoint 2,936
the following members: 2,937
(a) One member carrier that is a small employer carrier; 2,939
(b) One member carrier whose principal health insurance 2,941
business is in the large employer market; 2,942
(c) One representative of an employer with fifty or fewer 2,944
employees; 2,945
(d) One representative of consumers in this state. 2,947
(3) The superintendent OF INSURANCE shall appoint a 2,949
representative of a member carrier operating in the small 2,951
employer market who is a fellow of the society of actuaries. 2,952
The superintendent, a member of the house of 2,954
representatives appointed by the speaker of the house of 2,955
representatives, and a member of the senate appointed by the 2,956
64
president of the senate, shall be ex-officio members of the 2,957
board. The membership of all boards subsequent to the initial 2,958
board shall reflect the distribution described in division (A) of 2,960
this section.
The chairperson of the initial board and each subsequent 2,962
board shall represent a small employer member carrier and shall 2,963
be elected by a majority of the voting members of the board. 2,964
Each chairperson shall serve for the maximum duration established 2,965
in the plan of operation. 2,966
(B) Within one hundred eighty days after the appointment 2,968
of the initial board, the board shall establish a plan of 2,969
operation and, thereafter, any amendments to the plan that are 2,970
necessary or suitable, to assure the fair, reasonable, and 2,971
equitable administration of the program. The board shall, 2,972
immediately upon adoption, provide to the superintendent copies 2,973
of the plan of operation and all subsequent amendments to it. 2,974
(C) The plan of operation shall establish rules, 2,976
conditions, and procedures for all of the following: 2,977
(1) The handling and accounting of assets and moneys of 2,979
the program and for an annual fiscal reporting to the 2,980
superintendent; 2,981
(2) Filling vacancies on the board; 2,983
(3) Selecting an administering insurer, which shall be a 2,985
carrier as defined in section 3924.01 of the Revised Code, and 2,986
setting forth the powers and duties of the administering insurer; 2,987
(4) Reinsuring risks in accordance with sections 3924.07 2,989
to 3924.14 of the Revised Code; 2,990
(5) Collecting assessments subject to section 3924.13 of 2,992
the Revised Code from all members to provide for claims reinsured 2,993
by the program and for administrative expenses incurred or 2,994
estimated to be incurred during the period for which the 2,995
assessment is made; 2,996
(6) Providing protection for carriers from the financial 2,998
risk associated with small employers that present poor credit 2,999
65
risks; 3,000
(7) Establishing standards for the coverage of small 3,002
employers that have a high turnover of employees; 3,003
(8) Establishing an appeals process for carriers to seek 3,005
relief when a carrier has experienced an unfair share of 3,006
administrative and credit risks; 3,007
(9) Establishing the adjusted average market premium 3,009
prices for use by the SEHC plan for groups of two to twenty-five 3,010
employees and for groups of twenty-six to fifty employees that 3,011
are offered in the state; 3,012
(10) Establishing participation standards at issue and 3,014
renewal for reinsured cases; 3,015
(11) Reinsuring risks and collecting assessments in 3,017
accordance with division (G) of section 3924.11 of the Revised 3,018
Code; 3,019
(12) Any additional matters as determined by the board. 3,021
Sec. 3924.09. The Ohio small employer health reinsurance 3,031
program shall have the general powers and authority granted under 3,032
the laws of the state to insurance companies licensed to transact 3,033
sickness and accident insurance, except the power to issue 3,034
insurance. The board of directors of the program also shall have 3,035
the specific authority to do all of the following: 3,036
(A) Enter into contracts as are necessary or proper to 3,038
carry out the provisions and purposes of sections 3924.07 to 3,039
3924.14 of the Revised Code, including the authority to enter 3,040
into contracts with similar programs of other states for the 3,041
joint performance of common functions, or with persons or other 3,042
organizations for the performance of administrative functions; 3,043
(B) Sue or be sued, including taking any legal actions 3,045
necessary or proper for recovery of any assessments for, on 3,046
behalf of, or against any program or board member; 3,047
(C) Take such legal action as is necessary to avoid the 3,049
payment of improper claims against the program; 3,050
(D) Design the SEHC plan which, when offered by a carrier, 3,052
66
is eligible for reinsurance and issue reinsurance policies in 3,053
accordance with the requirements of sections 3924.07 to 3924.14 3,054
of the Revised Code; 3,055
(E) Establish rules, conditions, and procedures pertaining 3,057
to the reinsurance of members' risks by the program; 3,058
(F) Establish appropriate rates, rate schedules, rate 3,060
adjustments, rate classifications, and any other actuarial 3,061
functions appropriate to the operation of the program; 3,062
(G) Assess members in accordance with division (G) of 3,065
section 3924.11 and the provisions of section 3924.13 of the 3,066
Revised Code, and make such advance interim assessments as may be 3,067
reasonable and necessary for organizational and interim operating 3,068
expenses. Any interim assessments shall be credited as offsets 3,069
against any regular assessments due following the close of the 3,070
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 3,072
other committees if necessary to provide technical assistance 3,073
with respect to the operation of the program, policy and other 3,074
contract design, and any other function within the authority of 3,075
the program; 3,076
(I) Borrow money to effect the purposes of the program. 3,078
Any notes or other evidence of indebtedness of the program not in 3,079
default shall be legal investments for carriers and may be 3,080
carried as admitted assets. 3,081
(J) Reinsure risks, collect assessments, and otherwise 3,083
carry out its duties under division (G) of section 3924.11 of the 3,084
Revised Code.; 3,085
(K) Study the operation of the Ohio small employer health 3,088
reinsurance program and the open enrollment reinsurance program 3,089
and, based on its findings, make legislative recommendations to 3,090
the general assembly for improvements in the effectiveness, 3,091
operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF 3,093
SECTIONS 1742.13, 3923.122, AND 3923.581 OF THE REVISED CODE. 3,094
67
Sec. 3924.10. (A) The board of directors of the Ohio 3,103
small employer health reinsurance program shall design the SEHC 3,104
plan which, when offered by a carrier, is eligible for 3,105
reinsurance under the program. The board shall establish the 3,106
form and level of coverage to be made available by carriers in 3,107
their SEHC plan. In designing the plan the board shall also 3,109
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 3,110
of coverage established by the board shall specify which 3,111
components of a health benefit plan offered by a small employer 3,112
carrier may be reinsured. The SEHC plan is subject to division 3,114
(C) of section 3924.02 of the Revised Code and to the provisions 3,115
in Chapters 1742., 3923., and any other chapter of the Revised 3,116
Code that require coverage or the offer of coverage of a health 3,117
care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 3,120
eighty days after its appointment. The plan may include cost 3,121
containment features including any of the following:
(1) Utilization review of health care services, including 3,123
review of the medical necessity of hospital and physician 3,124
services; 3,125
(2) Case management benefit alternatives; 3,127
(3) Selective contracting with hospitals, physicians, and 3,129
other health care providers; 3,130
(4) Reasonable benefit differentials applicable to 3,132
participating and nonparticipating providers; 3,133
(5) Employee assistance program options that provide 3,135
preventive and early intervention mental health and substance 3,136
abuse services; 3,137
(6) Other provisions for the cost-effective management of 3,139
the plan. 3,140
(C) An SEHC plan established for use by health maintenance 3,143
organizations shall be consistent with the basic method of 3,144
operation of such organizations.
68
(D) Each carrier shall certify to the superintendent of 3,146
insurance, in the form and manner prescribed by the 3,147
superintendent, that the SEHC plan filed by the carrier is in 3,149
substantial compliance with the provisions of the board SEHC 3,150
plan. Upon receipt by the superintendent of the certification, 3,151
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 3,153
date that the program becomes operational and as a condition of 3,154
transacting business in this state, renew coverage provided to 3,155
any individual or group under its SEHC plan. 3,156
(F) A carrier shall not be required to renew coverage 3,158
where the superintendent finds that renewal of coverage would 3,159
place the carrier in a financially impaired condition. The 3,160
superintendent shall determine when the carrier is no longer 3,161
financially impaired and is, therefore, subject to the guaranteed 3,162
renewability requirements. 3,163
Sec. 3924.11. Any member of the Ohio small employer health 3,173
reinsurance program may reinsure small employer groups or 3,174
individuals in accordance with the following conditions and 3,175
limitations: 3,176
(A) With respect to eligible employees and their 3,178
dependents who are hired subsequent to the commencement of the 3,179
employer's coverage by a carrier and who are not late enrollees, 3,180
and with respect to employees of an employer who are otherwise 3,181
eligible for insurance but were excluded by the carrier's 3,182
underwriting and who are not late enrollees, coverage may be 3,183
reinsured in either of the following ways: 3,184
(1) Except in the case of late enrollees, within sixty 3,186
days after the commencement of their coverage under the plan; 3,187
(2) In the case of late enrollees, eighteen months after 3,189
the date the late enrollee becomes a member of the small 3,190
employer's plan. 3,191
(B)(1) The carrier may reinsure either the entire eligible 3,194
group or any eligible individual, in accordance with the premium 3,196
69
rates established in section 3924.12 of the Revised Code, upon 3,198
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 3,201
dependents of an eligible employee, who were previously excluded 3,202
from group coverage for medical reasons, and shall reinsure such 3,203
employees or dependents within sixty days after the carrier is 3,204
required to include them in the group coverage.
(C) With respect to an SEHC plan, the program shall 3,207
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 3,209
the program shall reinsure the level of coverage provided up to, 3,210
but not exceeding, the level of coverage provided in an SEHC 3,211
plan. In the coverage provided to small employers, carriers 3,212
shall be required to use high-cost care management, hospital 3,213
precertification techniques, and other cost containment 3,214
mechanisms established by the program. 3,215
(E) A carrier may not reinsure existing business, except 3,217
pursuant to division (A) of this section. 3,218
(F) If an employer group is covered under a plan other 3,220
than an SEHC plan and the carrier chooses to reinsure the group 3,221
subsequent to the initial coverage period, or if a new individual 3,222
joins the group and the carrier wants to reinsure that 3,223
individual, the carrier shall not force the employer to change to 3,225
an SEHC plan. The carrier shall allow the employer to maintain 3,226
the same benefit plan and reinsure only that portion of the plan 3,227
that is consistent with an SEHC plan.
(G) With respect to coverage provided to a small employer 3,229
group or AN individual acquired under section 3923.58 OR A 3,230
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 1742.12 OR 3,231
3923.581 of the Revised Code, the following conditions and 3,232
limitations apply: 3,233
(1) Within sixty days after the commencement of the 3,236
initial coverage, any carrier may reinsure coverage of an entire 3,237
small employer group, or of eligible employees or dependents of 3,238
70
such group, or any SUCH AN individual acquired under section 3,239
3923.58 of the Revised Code with the OPEN ENROLLMENT REINSURANCE 3,241
program IN ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A 3,242
carrier may reinsure, within sixty days after the effective date 3,244
of coverage, an employee eligible for coverage under section 3,246
3923.58 of the Revised Code. Premium rates charged for coverage 3,247
reinsured by the program shall be established in accordance with 3,248
section 3924.12 of the Revised Code. 3,249
(2) The board of directors of the OHIO HEALTH REINSURANCE 3,252
program shall establish the open enrollment reinsurance fund for 3,253
coverage provided under section 3923.58 of the Revised Code AND, 3,254
WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, COVERAGE PROVIDED 3,255
UNDER SECTIONS 1742.12 AND 3923.581 OF THE REVISED CODE. The 3,256
fund shall be maintained separately from any reinsurance fund 3,258
established for small employer health care plans issued pursuant 3,259
to sections 3924.07 to 3924.14 of the Revised Code. The board 3,260
shall calculate, on a retrospective basis, the amount needed for 3,261
maintenance of the open enrollment reinsurance fund and, on the 3,262
basis of that calculation, shall determine the amount to be 3,263
assessed each carrier that is required to provide open enrollment 3,264
coverage. 3,265
Assessments shall be apportioned by the board among all 3,267
carriers participating in the open enrollment reinsurance program 3,268
in proportion to their respective shares of the total premiums, 3,269
net of reinsurance premiums paid by a carrier for open enrollment 3,270
coverage and net of reinsurance premiums paid by the carrier for 3,271
all other small group and individual health benefit plans, earned 3,272
in this state from all health benefit plans covering small 3,273
employers and individuals that are issued by all such carriers 3,274
during the calendar year coinciding with or ending during the 3,275
fiscal year of the open enrollment program, or on any other 3,276
equitable basis reflecting coverage of small employers and 3,277
individuals in this state as may be provided in the plan of 3,278
operation adopted by the board. In no event shall the assessment 3,279
71
of any carrier under this section exceed, on an annual basis, 3,281
three per cent of its Ohio premiums for health benefit plans 3,282
covering small employers and individuals as reported on its most 3,283
recent annual statement filed with the superintendent of 3,284
insurance.
The board shall submit its determination of the amount of 3,286
the assessment to the superintendent for review of the accuracy 3,288
of the calculation of the assessment. Upon approval by the 3,289
superintendent, each carrier shall, within thirty days after 3,290
receipt of the notice of assessment, submit the assessment to the 3,291
board for purposes of the open enrollment reinsurance fund. 3,292
(3) If the assessments made and collected pursuant to 3,294
division (G)(2) of this section are not sufficient to pay the 3,295
claims reinsured under division (G) of this section and the 3,296
allocated administrative expenses, incurred or estimated to be 3,297
incurred during the period for which the assessment was made, the 3,298
secretary of the board shall immediately notify the 3,299
superintendent, and the superintendent shall suspend the 3,300
operation of open enrollment under section 3923.58 of the Revised 3,301
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER 3,302
SECTIONS 1742.12 AND 3923.581 OF THE REVISED CODE until the board 3,303
has collected in subsequent years through assessments made 3,304
pursuant to division (G)(2) of this section an amount sufficient 3,305
to pay such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 3,307
under section 3923.58 of the Revised Code may elect not to 3,309
participate in the open enrollment reinsurance program under 3,310
division (G) of this section by filing an application with the 3,311
superintendent and obtaining the superintendent's approval. In 3,312
determining whether to approve an application, the superintendent 3,313
shall consider whether the carrier meets all of the following 3,314
standards: 3,315
(i) Demonstration by the carrier of a substantial and 3,317
established market presence; 3,318
72
(ii) Demonstrated experience in the small employer group 3,320
INDIVIDUAL market and history of rating and underwriting small 3,321
employer groups INDIVIDUAL PLANS; 3,323
(iii) Commitment to comply with the requirements of 3,325
section 3923.58 of the Revised Code; 3,326
(iv) Financial ability to assume and manage the risk of 3,328
enrolling open enrollment groups and individuals without the need 3,329
for, or protection of, reinsurance. 3,330
(b) A carrier whose application for nonparticipation has 3,332
been rejected by the superintendent may appeal the decision in 3,333
accordance with Chapter 119. of the Revised Code. A carrier that 3,334
has received approval of the superintendent not to participate in 3,335
the open enrollment reinsurance program shall, on or before the 3,336
first day of December, annually certify to the superintendent 3,337
that it continues to meet the standards described in division 3,338
(G)(4)(a) of this section. 3,339
(c) In any year subsequent to the year in which its 3,341
application not to participate has been approved, a carrier may 3,342
elect to participate in the open enrollment reinsurance program 3,343
by giving notice to the superintendent and board on or before the 3,344
thirty-first day of December. If, after a period of 3,345
nonparticipation, a carrier elects to participate in the open 3,346
enrollment reinsurance program, the carrier retains the risks it 3,347
assumed during the period when it was not participating. 3,348
(d) The superintendent may, at any time, authorize a 3,350
carrier to modify an election not to participate if the risk from 3,351
the carrier's open enrollment business jeopardizes the financial 3,352
condition of the carrier. If the superintendent authorizes the 3,353
carrier to again participate in the open enrollment reinsurance 3,354
program, the carrier shall retain the risks it assumed during the 3,355
period of nonparticipation. 3,356
(5) At the time of acquiring a small employer group, a 3,358
carrier shall determine whether to reinsure the entire group or 3,359
any individual pursuant to section 3924.12 of the Revised Code. 3,360
73
(6)(a) The open enrollment reinsurance program shall be 3,363
operated separately from the Ohio small employer health 3,364
reinsurance program.
(b) A carrier's election to participate in the open 3,366
enrollment reinsurance program under division (G) of this section 3,368
shall not be construed as an election to participate in the Ohio 3,369
small employer health reinsurance program under section 3924.07 3,370
of the Revised Code.
Sec. 3924.111. (A) The Ohio small employer health 3,381
reinsurance program shall not provide reinsurance for any 3,382
individual reinsured under the program until five thousand 3,383
dollars in benefit payments have been made by a member of the 3,384
program for services provided to that individual during a
calendar year, which payments would have been reimbursed through 3,385
the program but for the five-thousand-dollar deductible. The 3,386
member shall retain ten per cent of the next fifty thousand 3,387
dollars of benefit payments made during that calendar year, and 3,388
the program shall reinsure the remainder. However, a member's 3,389
maximum liability under this section with respect to any one 3,390
individual reinsured under the program shall not exceed ten 3,391
thousand dollars in any one calendar year. 3,392
(B) The board of directors of the Ohio small employer 3,395
health reinsurance program shall periodically review the 3,396
deductible amount and the maximum liability amount set forth in 3,397
division (A) of this section and, considering the rate of 3,398
inflation, adjust each amount as the board considers necessary. 3,399
Sec. 3924.12. (A) Except as provided in division (B) of 3,409
this section, premium rates charged for coverage reinsured by the 3,410
Ohio small employer health reinsurance program shall be 3,411
established as follows: 3,412
(1) For whole group reinsurance coverage, one and one-half 3,414
times the adjusted average market premium price established by 3,415
the program for that classification or group with similar 3,416
characteristics and coverage, with respect to the eligible 3,417
74
employees of a small employer and their dependents, all of whose 3,418
coverage is reinsured with the program, minus a ceding expense 3,419
factor determined by the board of directors of the program; 3,420
(2) For individual reinsurance coverage, five times the 3,422
adjusted average market premium price established by the program 3,423
for an individual in that classification or group with similar 3,424
characteristics and coverage, with respect to an eligible 3,425
employee or his dependents, minus a ceding expense factor 3,426
determined by the board. 3,427
(B) Premium rates charged for reinsurance by the program 3,429
to a health maintenance organization that is approved by the 3,430
secretary of health and human services as a federally qualified 3,431
health maintenance organization pursuant to the "Social Security 3,432
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as 3,433
such is subject to requirements that limit the amount of risk 3,434
that may be ceded to the program, may be modified to reflect the 3,435
portion of risk that may be ceded to the program. 3,436
Sec. 3924.13. (A) Following the close of each calendar 3,445
year, the administering insurer of the Ohio small employer health 3,446
reinsurance program shall determine the net premiums, the program 3,447
expenses for administration, and the incurred losses, if any, for 3,448
the year, taking into account investment income and other 3,449
appropriate gains and losses. For purposes of this section, 3,450
health benefit plan premiums earned by MEWAs shall be established 3,451
by adding paid claim losses and administrative expenses of the 3,452
MEWA. Health benefit plan premiums and benefits paid by a 3,454
carrier that are less than an amount determined by the board of 3,455
directors of the program to justify the cost of collection shall 3,456
not be considered for purposes of determining assessments. For 3,457
purposes of this division, "net premiums" means health benefit 3,458
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 3,460
assessments of carriers in accordance with this division. 3,461
Assessments shall be apportioned by the board among all carriers 3,462
75
participating in the program in proportion to their respective 3,463
shares of the total premiums, net of reinsurance premiums paid 3,464
for coverage under this program earned in the state from health 3,465
benefit plans covering small employers that are issued by 3,466
participating members during the calendar year coinciding with or 3,467
ending during the fiscal year of the program, or on any other 3,468
equitable basis reflecting coverage of small employers as may be 3,469
provided in the plan of operation. An assessment shall be made 3,470
pursuant to this division against a health maintenance 3,471
organization that is approved by the secretary of health and 3,472
human services as a federally qualified health maintenance 3,473
organization pursuant to the "Social Security Act," 49 Stat. 620 3,474
(1935), 42 U.S.C.A. 301, as amended, subject to an assessment 3,475
adjustment formula adopted by the board for such health 3,476
maintenance organizations that recognizes the restrictions 3,477
imposed on the organizations by federal law. The adjustment 3,478
formula shall be adopted by the board prior to the first 3,479
anniversary of the program's operation. In no event shall the 3,480
assessment made pursuant to this division exceed, on an annual 3,482
basis, one per cent of the carrier's Ohio small employer group 3,484
premium as reported on its most recent annual statement filed 3,485
with the superintendent of insurance. If an excess is
actuarially projected, the superintendent may take any action 3,486
necessary to lower the assessment to the maximum level of one per 3,487
cent.
(C) If assessments exceed actual losses and administrative 3,489
expenses of the program, the excess shall be held at interest and 3,490
used by the board to offset future losses or to reduce program 3,491
premiums. As used in this division, "future losses" includes 3,492
reserves for incurred but not reported claims. 3,493
(D) Each carrier's proportion of participation in the 3,495
program shall be determined annually by the board based on annual 3,497
statements and other reports deemed necessary by the board and 3,498
filed by the carrier with the board. MEWAs shall report to the 3,499
76
board claims payments made and administrative expenses incurred 3,500
in this state on an annual basis on a form prescribed by the 3,501
superintendent.
(E) Provision shall be made in the plan of operation for 3,503
the imposition of an interest penalty for late payment of 3,504
assessments. 3,505
(F) A carrier may seek from the superintendent a 3,507
deferment, in whole or in part, from any assessment issued by the 3,508
board. The superintendent may defer, in whole or in part, the 3,509
assessment of a carrier if, in the opinion of the superintendent, 3,510
payment of the assessment would endanger the carrier's ability to 3,511
fulfill its contractual obligations. 3,512
(G) In the event an assessment against a carrier is 3,514
deferred in whole or in part, the amount by which the assessment 3,515
is deferred may be assessed against the other carriers in a 3,516
manner consistent with the basis for assessments set forth in 3,517
this section. In such event, the other carriers assessed shall 3,518
have a claim in the amount of the assessment against the carrier 3,519
receiving the deferment. The carrier receiving the deferment 3,520
shall remain liable to the program for the amount deferred. The 3,521
superintendent may attach appropriate conditions to any 3,522
deferment. 3,523
Sec. 3924.14. Neither the participation as members of the 3,533
Ohio small employer health reinsurance program or as members of 3,534
the board of directors of the program, the establishment of 3,536
rates, forms, or procedures for coverage issued by the program, 3,537
nor any other joint or collective action required by sections
3924.01 to 3924.14 of the Revised Code, shall be the basis of any 3,538
legal action or any criminal or civil liability or penalty 3,539
against the program, the board, or any of its members either 3,540
jointly or separately.
Sec. 3924.27. (A) AS USED IN THIS SECTION: 3,543
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE 3,545
THE SAME MEANINGS AS IN SECTION 3924.01 OF THE REVISED CODE. 3,546
77
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 3,548
FOLLOWING: 3,549
(a) HEALTH STATUS; 3,551
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 3,554
ILLNESSES;
(c) CLAIMS EXPERIENCE; 3,556
(d) RECEIPT OF HEALTH CARE; 3,558
(e) MEDICAL HISTORY; 3,560
(f) GENETIC INFORMATION; 3,562
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 3,565
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 3,567
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING 3,569
HEALTH INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH 3,570
BENEFIT PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF 3,571
ENROLLMENT OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A 3,572
PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR 3,573
CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE 3,574
PLAN ON THE BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION 3,575
TO THE INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS 3,576
A DEPENDENT OF THE INDIVIDUAL. 3,577
(C) NOTHING IN DIVISION (B) OF THIS SECTION SHALL BE 3,581
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 3,582
FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO PREVENT A 3,583
GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING GROUP HEALTH 3,584
INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM DISCOUNTS OR 3,585
REBATES OR MODIFYING OTHERWISE APPLICABLE COPAYMENTS OR 3,586
DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF HEALTH 3,587
PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section: 3,596
(1) "Child" means, in connection with any adoption or 3,598
placement for adoption of the child, an individual who has not 3,599
attained age eighteen as of the date of the adoption or placement 3,600
for adoption. 3,601
78
(2) "Health insurer" has the same meaning as in section 3,603
3924.41 of the Revised Code. 3,604
(3) "Placement for adoption" means the assumption and 3,606
retention by a person of a legal obligation for total or partial 3,607
support of a child in anticipation of the adoption of the child. 3,608
The child's placement with a person terminates upon the 3,609
termination of that legal obligation. 3,610
(B) If an individual or group health plan of a health 3,612
insurer provides MAKES coverage AVAILABLE for dependent children 3,614
of participants or beneficiaries, the plan shall provide benefits 3,615
to dependent children placed with participants or beneficiaries 3,616
for adoption under the same terms and conditions as apply to the 3,617
natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become 3,618
final. 3,619
(C) A health plan described in division (B) of this 3,621
section shall not restrict coverage under the plan of any 3,623
dependent child adopted by a participant or beneficiary, or 3,624
placed with a participant or beneficiary for adoption, solely on 3,625
the basis of a pre-existing condition of the child at the time 3,626
that the child would otherwise become eligible for coverage under 3,627
the plan, if the adoption or placement for adoption occurs while 3,628
the participant or beneficiary is eligible for coverage under the 3,629
plan.
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 3,638
the Revised Code: 3,639
(A) "Account holder" means the natural person who opens a 3,642
medical savings account or on whose behalf a medical savings 3,643
account is opened.
(B) "Eligible medical expense" means any expense for a 3,646
service rendered by a licensed health care provider or a 3,647
christian science CHRISTIAN SCIENCE practitioner, or for an 3,648
article, device, or drug prescribed by a licensed health care 3,649
provider or provided by a christian science CHRISTIAN SCIENCE 3,650
79
practitioner, when intended for use in the mitigation, treatment, 3,652
or prevention of disease; ANY AMOUNT PAID FOR TRANSPORTATION TO 3,653
THE LOCATION AT WHICH SUCH A SERVICE IS RENDERED; ANY AMOUNT PAID 3,654
FOR LODGING NECESSITATED BY THE RECEIPT OF CARE AT A NONLOCAL
HOSPITAL; or premiums paid for comprehensive sickness and 3,656
accident insurance, coverage under a health care plan of a health 3,657
maintenance organization organized under Chapter 1742. of the 3,658
Revised Code, long-term care insurance as defined in section 3,659
3923.41 of the Revised Code, Medicare supplemental coverage as 3,660
defined in section 3923.33 of the Revised Code, or payments made 3,661
pursuant to cost sharing agreements under comprehensive sickness 3,662
and accident plans. An "eligible medical expense" does not 3,664
include expenses otherwise paid or reimbursed, including medical 3,665
expenses paid or reimbursed under an automobile or motor vehicle
insurance policy, a workers' compensation insurance policy or 3,666
plan, or an employer-sponsored health coverage policy, plan, or 3,667
contract.
(C) "Qualified dependent" means a child of an account 3,670
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 3,673
twenty-three years of age and a full-time student at an
accredited college or university; 3,674
(2) The child is not self-sufficient due to physical or 3,676
mental disorders or impairments; 3,677
(3) The child is legally entitled to the provision of 3,679
proper or necessary subsistence, education, medical care, or 3,680
other care necessary for the child's health, guidance, or 3,681
well-being and is not otherwise emancipated, self-supporting, 3,682
married, or a member of the armed forces of the United States 3,684
DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE 3,685
"INTERNAL REVENUE CODE OF 1986," 100 STAT. 2085, 26 U.S.C.A. 1, 3,686
AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened 3,695
by or on behalf of any natural person, to pay the person's 3,696
80
eligible medical expenses and the eligible medical expenses of 3,697
that person's spouse or qualified dependent. A medical savings 3,698
account may be opened by or on behalf of a person only if that 3,701
person participates in a sickness or accident insurance plan, a 3,702
plan offered by a health maintenance organization organized under
Chapter 1742. of the Revised Code, or a self-funded, 3,704
employer-sponsored health benefit plan established pursuant to 3,705
the "Employee Retirement Income Security Act of 1974," 88 Stat. 3,706
832, 29 U.S.C.A. 1001, as amended. While the medical savings 3,708
account is open, the account holder shall continue to participate 3,709
in such a plan.
(B) A person who refuses to participate in a policy, plan, 3,712
or contract of health coverage that is funded by the person's 3,713
employer, and who receives additional monetary compensation by 3,714
virtue of refusing that coverage, may not open a medical savings 3,715
account unless the medical savings account also is sponsored by 3,716
the person's employer. 3,717
Sec. 3924.63. The owners of interest in a medical savings 3,727
account are the account holder, AND the account holder's spouse, 3,728
and qualified dependents. No medical savings account shall be 3,729
subject to garnishment or attachment. 3,731
Sec. 3924.64. (A) At the time a medical savings account 3,741
is opened, an administrator for the account shall be designated. 3,742
If an employer opens an account for an employee, the employer may 3,743
designate the administrator. If an account is opened by any 3,744
person other than an employer, or if an employer chooses not to 3,745
designate an administrator for an account opened for an employee, 3,746
the account holder shall designate the administrator. The 3,747
administrator shall manage the account in a fiduciary capacity 3,748
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 3,751
of the following:
(1) A federally or state-chartered bank, savings and loan 3,754
association, savings bank, or credit union;
81
(2) A trust company authorized to act as a fiduciary; 3,756
(3) An insurer authorized under Title XXXIX of the Revised 3,759
Code to engage in the business of sickness and accident 3,760
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 3,763
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 3,766
Revised Code;
(6) A certified public accountant; 3,768
(7) An employer that administers an employee benefit plan 3,771
subject to regulation under the "Employee Retirement Income 3,772
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 3,774
amended, or that maintains medical savings accounts for its 3,775
employees;
(8) Health maintenance organizations organized under 3,777
Chapter 1742. of the Revised Code. 3,778
(C) Each administrator shall send to the account holder, 3,781
at least annually, a statement setting forth the balance 3,782
remaining in the account holder's account and detailing the 3,783
activity in the account since the last statement was issued. 3,784
Upon an administrator's receipt of a written request from an 3,785
account holder for a current statement, the administrator shall 3,786
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 3,789
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 3,790
account holder, OR the account holder's spouse, or qualified 3,792
dependents, the administrator shall reimburse the account holder 3,793
for, or shall pay for, the eligible medical expense with funds 3,794
from the account holder's account, if sufficient funds are 3,795
available in the account holder's account. If there are not 3,796
sufficient funds in the account to fully reimburse the account 3,797
holder or pay the expenses, the administrator shall reimburse the 3,799
account holder or pay the expenses using whatever funds are in 3,800
82
the account. The reimbursement or payment shall be made within 3,801
thirty days of the administrator's receipt of the documentation. 3,802
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 3,803
expense does not count toward meeting the deductible or other 3,804
obligation for the receipt of benefits that is required by the 3,805
insurer or other third-party payer providing health coverage to 3,806
the account holder. The administrator shall keep a record of the 3,807
amounts disbursed from the account for documented eligible 3,808
medical expenses and of the dates on which the expenses were 3,809
incurred. This record shall be made available to any sickness 3,810
and accident insurer or other third-party payer providing health 3,811
coverage to the account holder, for use by the insurer or 3,812
third-party payer in determining whether the account holder has 3,813
met the deductible or other obligation required for the receipt 3,814
of benefits from the insurer or third-party payer. 3,815
(E) When an account is opened, the administrator shall 3,818
give written notice to the account holder of the date of the last 3,819
business day of the administrator's business year. 3,820
Sec. 3924.66. (A) In determining Ohio adjusted gross 3,829
income under Chapter 5747. of the Revised Code, an account holder 3,830
may deduct an amount equaling the total of the deposits that the 3,832
account holder, the account holder's spouse, or the account 3,833
holder's employer made to the account during the taxable year, to 3,834
the extent that the funds for the deposits have not otherwise 3,835
been deducted or excluded in determining the account holder's
federal adjusted gross income. The amount deducted by an account 3,837
holder for a taxable year shall not exceed three thousand 3,838
dollars. If two married persons each have an account, each 3,839
spouse may claim the deduction described in this section, and the 3,841
amount deducted by each spouse shall not exceed three thousand 3,842
dollars, whether the spouses file returns jointly or separately. 3,843
(B) The maximum deduction allowed under division (A) of 3,845
this section shall be adjusted annually by the department of 3,846
83
taxation to reflect increases in the consumer price index for all 3,847
items for all urban consumers for the north central region, as 3,848
published by the United States bureau of labor statistics. 3,849
(C) In determining Ohio adjusted gross income under 3,851
Chapter 5747. of the Revised Code, an account holder may deduct 3,852
the investment earnings of a medical savings account from the 3,853
account holder's federal adjusted gross income, to the extent 3,854
that these earnings have been included in the account holder's 3,855
federal adjusted gross income.
(D) In determining Ohio adjusted gross income under 3,857
Chapter 5747. of the Revised Code, an account holder shall add to 3,858
the account holder's federal adjusted gross income an amount 3,859
equal to the sum of the amounts described in divisions (D)(1) and 3,861
(2) of this section to the extent that those amounts were 3,862
included in the account holder's federal adjusted gross income 3,863
and previously deducted in determining the account holder's Ohio 3,865
adjusted gross income. In determining the extent to which 3,866
amounts withdrawn from the account shall be included in the 3,867
account holder's Ohio adjusted gross income, the tax commissioner 3,869
shall be guided by the provisions of sections 72 and 408 of the 3,870
Internal Revenue Code governing the determination of the amount 3,871
of withdrawals from an individual retirement account to be 3,872
included in federal gross income.
(1) Amounts withdrawn from the account during the taxable 3,875
year used for any purpose other than to reimburse the account 3,876
holder for, or to pay, the eligible medical expenses of the 3,877
account holder, OR the account holder's spouse, or qualified 3,879
dependents; 3,880
(2) Investment earnings during the taxable year on amounts 3,882
withdrawn from the account that are described in division (D)(1) 3,883
of this section. 3,884
(E) Amounts withdrawn from a medical savings account to 3,886
reimburse the account holder for, or to pay, the account holder's 3,887
eligible medical expenses, or the eligible medical expenses of 3,888
84
the account holder's spouse or qualified dependents, shall not be 3,890
included in the account holder's Ohio adjusted gross income in 3,891
determining taxes due under Chapter 5747. of the Revised Code. 3,892
(F) If a qualified dependent of an account holder becomes 3,895
ineligible to continue to participate in the account holder's 3,897
policy, plan, or contract of health coverage, the account holder 3,898
may withdraw funds from the account holder's account and use
those funds to pay the premium for the first year of a policy, 3,899
plan, or contract of health coverage for the qualified dependent 3,900
and to pay any deductible for the first year of that policy, 3,902
plan, or contract. Funds withdrawn and used for that purpose 3,903
shall not be included in the account holder's Ohio adjusted gross 3,904
income in determining taxes due under Chapter 5747. of the 3,905
Revised Code. 3,906
Sec. 3924.67. An account holder may withdraw funds from 3,916
the account holder's account at any time, for any purpose.
However, the administrator of a medical savings account shall not 3,917
disburse funds to an account holder during the year in which the 3,919
funds were deposited, except to reimburse the account holder for, 3,920
or pay for, a documented eligible medical expense of the account 3,921
holder, OR the account holder's spouse, or a qualified dependent. 3,922
Sec. 3924.68. (A) If an account holder, whose medical 3,932
savings account has been opened by the account holder's employer, 3,933
later ceases to be employed by that employer, the account holder 3,934
may, within sixty days of the account holder's final date of 3,935
employment, request in writing to the administrator of the 3,937
account that the administrator continue to administer the 3,938
account.
(1) If the administrator agrees to continue to administer 3,941
the account, funds in the account may continue to be used to pay 3,942
the eligible medical expenses of the account holder, AND the 3,943
account holder's spouse, and qualified dependents, pursuant to 3,944
sections 3924.61 to 3924.74 of the Revised Code. 3,946
If the account holder later becomes employed by a new 3,948
85
employer that opens a new medical savings account on the account 3,949
holder's behalf, the account holder may transfer any funds 3,951
remaining in the account opened by the account holder's former 3,952
employer to the account opened by the account holder's new 3,953
employer. For purposes of determining taxes due under Chapter 3,955
5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, 3,956
nor shall it be considered a deposit to a medical savings 3,957
account.
(2) If the administrator does not agree to continue to 3,960
administer the account, or if the account holder requests that 3,961
the account be closed, the administrator shall close the account 3,962
and mail a check or other negotiable instrument in the amount of 3,963
the account balance as of that date to the account holder. The 3,964
amount distributed shall be included in the account holder's Ohio 3,965
adjusted gross income in determining taxes due under Chapter 3,966
5747. of the Revised Code. 3,967
(B) Within sixty days of the account holder's final date 3,969
of employment, the account holder may transfer any funds 3,971
remaining in the account opened by the account holder's former 3,972
employer to another medical savings account owned by the account 3,973
holder. For purposes of determining taxes due under Chapter 3,974
5747,. of the Revised Code, this transfer of funds shall not be 3,975
considered a withdrawal of funds from a medical savings account, 3,976
nor shall it be considered a deposit to a medical savings
account. 3,977
(C) An administrator of an account opened by an employer 3,979
shall not close an account without the permission of the account 3,980
holder until at least sixty-one days after the account holder's 3,981
final date of employment. The employer shall notify the 3,982
administrator of the employee's final date of employment. 3,983
Sec. 3924.73. (A) As used in this section: 3,993
(1) "Health care insurer" means any person legally engaged 3,995
in the business of providing sickness and accident insurance 3,996
86
contracts in this state, a health maintenance organization 3,997
organized under Chapter 1742. of the Revised Code, or any legal 3,998
entity that is self-insured and provides health care benefits to 4,000
its employees or members. 4,001
(2) "Small employer" has the same meaning as in division 4,003
(P) of section 3924.01 of the Revised Code. 4,004
(B)(1) Subject to division (B)(2) of this section, nothing 4,007
in sections 3924.61 to 3924.74 of the Revised Code shall be 4,008
construed to limit the rights, privileges, or protections of 4,009
employees or small employers under sections 3924.01 to 3924.14 of 4,010
the Revised Code. 4,011
(2) If any account holder enrolls or applies to enroll in 4,013
a policy or contract offered by a health care insurer providing 4,014
sickness and accident coverage that is more comprehensive than, 4,015
and has a deductible amount that is less than, the coverage and 4,016
deductible amount of the policy under which the account holder 4,017
currently is enrolled, the health care insurer to which the 4,018
account holder applies may subject the account holder to the same 4,020
medical review, waiting periods, and underwriting requirements to 4,021
which the health care insurer generally subjects other enrollees 4,022
or applicants, unless the account holder enrolls or applies to 4,023
enroll during a designated period of open enrollment. 4,024
Section 2. That existing sections 1739.05, 1742.06, 4,026
1742.12, 1742.16, 1742.37, 1742.39, 1742.45, 3901.21, 3923.122, 4,027
3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 3923.64, 4,028
3924.01, 3924.03, 3924.07, 3924.08, 3924.09, 3924.10, 3924.11, 4,029
3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 3924.61, 3924.62, 4,030
3924.63, 3924.64, 3924.66, 3924.67, 3924.68, and 3924.73 and
sections 1742.13 and 3941.53 of the Revised Code are hereby 4,031
repealed. 4,032
Section 3. The amendments to sections 1742.37, 1742.39, 4,034
3923.122, 3923.26, 3923.40, and 3924.51 of the Revised Code by 4,035
this act shall apply to contracts, evidences of coverage, 4,036
policies, and plans that are delivered, issued for delivery, 4,037
87
renewed, or established in this state on or after the effective 4,038
date of this section. 4,039