As Reported by the House Insurance Committee 1
122nd General Assembly 4
Regular Session Sub. H. B. No. 374 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-BRADING-CORBIN-GARCIA-HAINES- 8
MOTTLEY-NETZLEY-SCHURING-TAYLOR-TERWILLEGER-THOMAS-TIBERI- 9
LEWIS-HOTTINGER-MAIER-TAVARES-JERSE-METELSKY-REID 10
12
A B I L L
To amend sections 1739.05, 1751.06, 1751.14, 14
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 15
1751.64, 1751.65, 1751.67, 3901.21, 3901.49, 16
3901.491, 3901.50, 3901.501, 3923.021, 3923.122, 17
3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 18
3923.63, 3923.64, 3924.01, 3924.02, 3924.03, 19
3924.07 to 3924.11, 3924.111, 3924.12 to 3924.14, 21
3924.51, 3924.61 to 3924.64, 3924.66 to 3924.68, 22
and 3924.73, to enact sections 1751.57, 1751.58, 23
3901.044, 3923.571, 3923.581, 3924.031, 3924.032, 25
3924.033, and 3924.27, and to repeal section 26
3941.53 of the Revised Code relative to the 27
implementation of the federal Health Insurance 28
Portability and Accountability Act of 1996 and 29
insurance coverage of follow-up care for a mother 30
and newborn, and to declare an emergency. 31
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 33
Section 1. That sections 1739.05, 1751.06, 1751.14, 35
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 36
1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 38
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 40
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 41
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 42
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 44
2
and 3924.73 be amended sections 1751.57, 1751.58, 3901.044, 45
3923.571, 3923.581, 3924.031, 3924.032, 3924.033, and 3924.27 of 46
the Revised Code be enacted to read as follows: 48
Sec. 1739.05. (A) A multiple employer welfare arrangement 57
that is created pursuant to sections 1739.01 to 1739.22 of the 58
Revised Code and that operates a group self-insurance program may 59
be established only if any of the following applies: 60
(1) The arrangement has and maintains a minimum enrollment 62
of three hundred employees of two or more employers. 63
(2) The arrangement has and maintains a minimum enrollment 65
of three hundred self-employed individuals. 66
(3) The arrangement has and maintains a minimum enrollment 68
of three hundred employees or self-employed individuals in any 69
combination of divisions (A)(1) and (2) of this section. 70
(B) A multiple employer welfare arrangement that is 72
created pursuant to sections 1739.01 to 1739.22 of the Revised 73
Code and that operates a group self-insurance program shall 74
comply with all laws applicable to self-funded programs in this 75
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 76
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 77
3923.301, and 3923.38, 3923.581, 3923.63, 3924.031, 3924.032, AND 80
3924.27 of the Revised Code. 81
(C) A multiple employer welfare arrangement created 83
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 84
solicit enrollments only through agents or solicitors licensed 85
pursuant to Chapter 3905. of the Revised Code to sell or solicit 86
sickness and accident insurance. 87
(D) A multiple employer welfare arrangement created 89
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 90
provide benefits only to individuals who are members, employees 91
of members, or the dependents of members or employees, or are 92
eligible for continuation of coverage under section 1751.53 or 93
3923.38 of the Revised Code or under Title X of the "Consolidated 94
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 95
3
U.S.C.A. 1161, as amended. 96
Sec. 1751.06. Upon obtaining a certificate of authority as 105
required under this chapter, a health insuring corporation may do 107
all of the following:
(A) Enroll individuals and their dependents in either of 109
the following circumstances: 110
(1) The individual resides OR LIVES in the approved 112
service area.
(2) The individual's place of employment is located in the 115
approved service area and the individual has agreed to receive 116
health care services in accordance with the evidence of coverage. 117
(B) Contract with providers and health care facilities for 119
the health care services to which enrollees are entitled under 120
the terms of the health insuring corporation's health care 121
contracts;
(C) Contract with insurance companies authorized to do 124
business in this state for insurance, indemnity, or reimbursement 125
against the cost of providing emergency and nonemergency health 126
care services for enrollees, subject to the provisions set forth 127
in this chapter and the limitations set forth in the Revised 129
Code;
(D) Contract with any person pursuant to the requirements 131
of division (A)(18) of section 1751.03 of the Revised Code for 132
managerial or administrative services, or for data processing, 133
actuarial analysis, billing services, or any other services 134
authorized by the superintendent of insurance. However, a health 136
insuring corporation shall not enter into a contract for any of 137
the services listed in this division with an insurance company 138
that is not authorized to engage in the business of insurance in 139
this state.
(E) Accept from governmental agencies, private agencies, 141
corporations, associations, groups, individuals, or other 142
persons, payments covering all or part of the costs of planning, 143
development, construction, and the provision of health care 144
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services;
(F) Purchase, lease, construct, renovate, operate, or 146
maintain health care facilities, and their ancillary equipment, 147
and any property necessary in the transaction of the business of 148
the health insuring corporation.
(G) IN THE EMPLOYER GROUP MARKET, IMPOSE AN AFFILIATION 151
PERIOD OF NOT MORE THAN SIXTY DAYS, WHICH PERIOD BEGINS ON THE 152
INDIVIDUAL'S DATE OF ENROLLMENT AND RUNS CONCURRENTLY WITH ANY 153
WAITING PERIOD IMPOSED UNDER THE COVERAGE. FOR PURPOSES OF THIS 154
DIVISION, "AFFILIATION PERIOD" MEANS A PERIOD OF TIME WHICH, 155
UNDER THE TERMS OF THE COVERAGE OFFERED, MUST EXPIRE BEFORE THE 156
COVERAGE BECOMES EFFECTIVE. NO HEALTH CARE SERVICES OR BENEFITS 157
NEED TO BE PROVIDED DURING AN AFFILIATION PERIOD, AND NO PERIODIC 158
PREPAYMENTS CAN BE CHARGED FOR ANY COVERAGE DURING THAT PERIOD. 159
(H) IF A HEALTH INSURING CORPORATION OFFERS COVERAGE IN 162
THE SMALL EMPLOYER GROUP MARKET THROUGH A NETWORK PLAN, LIMIT OR 163
DENY THE COVERAGE IN ACCORDANCE WITH SECTION 3924.031 OF THE 165
REVISED CODE. 166
(I) REFUSE TO ISSUE COVERAGE IN THE SMALL EMPLOYER GROUP 169
MARKET PURSUANT TO SECTION 3924.032 OF THE REVISED CODE. 171
(J) ESTABLISH EMPLOYER CONTRIBUTION RULES OR GROUP 174
PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN CONNECTION 175
WITH A GROUP CONTRACT IN THE SMALL EMPLOYER GROUP MARKET, AS 176
PROVIDED IN DIVISION (E)(1) OF SECTION 3924.03 OF THE REVISED 179
CODE.
Nothing in this section shall be construed as prohibiting a 181
health insuring corporation without other commercial enrollment 182
from contracting solely with federal health care programs 183
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 185
authority of a health insuring corporation to perform those 186
functions not otherwise prohibited by law. 187
Sec. 1751.14. (A) Any policy, contract, or agreement for 197
health care services authorized by this chapter that is issued, 198
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delivered, or renewed in this state and that provides that 199
coverage of an unmarried dependent child will terminate upon 200
attainment of the limiting age for dependent children specified 201
in the policy, contract, or agreement, shall also provide in 202
substance that attainment of the limiting age shall not operate 203
to terminate the coverage of the child if the child is and 204
continues to be both:
(1) Incapable of self-sustaining employment by reason of 206
mental retardation or physical handicap; 207
(2) Primarily dependent upon the subscriber for support 209
and maintenance. 210
(B) Proof of incapacity and dependence for purposes of 212
division (A) of this section shall be furnished to the health 213
insuring corporation within thirty-one days of the child's 215
attainment of the limiting age. Upon request, but not more 216
frequently than annually, the health insuring corporation may 217
require proof satisfactory to it of the continuance of such 218
incapacity and dependency.
(C) Nothing in this section shall be construed to require 221
a health insuring corporation to cover a dependent child who is 222
mentally retarded or physically handicapped if the policy, 223
contract, or agreement is underwritten on evidence of 224
insurability based on health factors set forth in the 225
application, or if the dependent child does not satisfy the 226
conditions of the policy, contract, or agreement as to any 227
requirement for evidence of insurability or any other provision 228
of the policy, contract, or agreement, satisfaction of which is 229
required for coverage thereunder to take effect. In any such 230
case, the terms of the policy, contract, or agreement shall apply 231
with regard to the coverage or exclusion of the dependent from 232
such coverage.
(D) This section does not apply to any health insuring 235
corporation, policy, contract, or agreement offering only 236
supplemental health care services or specialty health care
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services. 237
(E) THIS SECTION DOES NOT APPLY TO ANY GROUP HEALTH 240
INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT OR TO ANY 241
POLICY, CONTRACT, OR AGREEMENT WRITTEN UNDER SECTION 1751.15 OR 242
3923.581 OF THE REVISED CODE. 243
Sec. 1751.15. (A) After a health insuring corporation has 252
furnished, directly or indirectly, basic health care services for 253
a period of twenty-four months, and if it currently meets the 254
financial requirements set forth in section 1751.28 of the 255
Revised Code and had net income as reported to the superintendent 256
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 257
less than thirty days during its month of licensure FOR 259
INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 260
(B) During the open enrollment period described in 262
division (A) of this section, the health insuring corporation 263
shall accept applicants and their dependents in the order in 264
which they apply for enrollment and in accordance with any of the 265
following:
(1) Up to its capacity, as determined by the health 267
insuring corporation subject to review by the superintendent; 268
(2) If less than its capacity, one per cent of the health 270
insuring corporation's total number of subscribers residing in 271
this state as of the immediately preceding thirty-first day of 272
December. 273
(C) Where a health insuring corporation demonstrates to 275
the satisfaction of the superintendent that such open enrollment 276
would jeopardize its economic viability, the superintendent may 277
do any of the following:
(1) Waive the requirement for open enrollment; 279
(2) Impose a limit on the number of applicants and their 281
dependents that must be enrolled; 282
(3) Authorize such underwriting restrictions upon open 284
enrollment as are necessary to do any of the following: 285
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(a) Preserve its financial stability; 287
(b) Prevent excessive adverse selection; 289
(c) Avoid unreasonably high or unmarketable charges for 291
coverage of health care services. 292
(D)(1) A request to the superintendent under division (C) 295
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 296
documentation, including financial data. In reviewing the 297
request, the superintendent may consider various factors, 298
including the size of the health insuring corporation, the health 299
insuring corporation's net worth and profitability, the health 300
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 301
(2) Any action taken by the superintendent under division 303
(C) of this section shall be effective for a period of not more 305
than one year. At the expiration of such time, a new 306
demonstration of the health insuring corporation's need for the 307
restriction, limit, or waiver shall be made before a new 308
restriction, limit, or waiver is granted by the superintendent. 309
(3) Irrespective of the granting of any restriction, 311
limit, or waiver by the superintendent, a health insuring 312
corporation may reject an applicant or a dependent of the 313
applicant during its open enrollment period if the applicant or 314
dependent: 315
(a) Was eligible for and was covered under any 317
employer-sponsored health care coverage, or if employer-sponsored 318
health care coverage was available at the time of open 319
enrollment;
(b) Is eligible for conversion or continuation coverage 321
under state or federal law; 322
(c) Is eligible for medicare, and the health insuring 324
corporation does not have an agreement on appropriate payment 325
mechanisms with the governmental agency administering the 326
medicare program.
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(E) A health insuring corporation shall not be required 328
either to enroll applicants or their dependents who are confined 329
to a health care facility because of chronic illness, permanent 330
injury, or other infirmity that would cause economic impairment 331
to the health insuring corporation if such applicants or their 332
dependents were enrolled or to make the effective date of 333
benefits for applicants or their dependents enrolled under this 334
section earlier than ninety days after the date of enrollment. 335
(F) A health insuring corporation shall not be required to 337
cover the fees or costs, or both, for any basic health care 338
service related to a transplant of a body organ if the transplant 339
occurs within one year after the effective date of an enrollee's 340
coverage under this section. This limitation on coverage does 341
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 342
(G) Each health insuring corporation required to hold an 344
open enrollment pursuant to division (A) of this section shall 345
file with the superintendent, not later than sixty days prior to 346
the commencement of the proposed open enrollment period, the 347
following documents:
(1) The proposed public notice of open enrollment; 349
(2) The evidence of coverage approved pursuant to section 351
1751.11 of the Revised Code that will be used during open 353
enrollment;
(3) The contractual periodic prepayment and premium rate 355
approved pursuant to section 1751.12 of the Revised Code that 356
will be applicable during open enrollment; 357
(4) Any solicitation document approved pursuant to section 360
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 361
(5) A list of the proposed dates of publication of the 363
public notice, and the names of the newspapers in which the 364
notice will appear; 365
(6) Any request for a restriction, limit, or waiver with 367
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respect to the open enrollment period, along with any supporting 368
documentation. 369
(H)(1) An open enrollment period shall not satisfy the 371
requirements of this section unless the health insuring 372
corporation provides adequate public notice in accordance with 373
divisions (H)(2) and (3) of this section. No public notice shall 374
be used until the form of the public notice has been filed by the 375
health insuring corporation with the superintendent. If the 376
superintendent does not disapprove the public notice within sixty 377
days after it is filed, it shall be deemed approved, unless the 378
superintendent sooner gives approval for the public notice. If 379
the superintendent determines within this sixty-day period that 380
the public notice fails to meet the requirements of this section, 381
the superintendent shall so notify the health insuring 382
corporation and it shall be unlawful for the health insuring 383
corporation to use the public notice. Such disapproval shall be 384
effected by a written order, which shall state the grounds for 385
disapproval and shall be issued in accordance with Chapter 119. 386
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 388
section shall be published in at least one newspaper of general 389
circulation in each county in the health insuring corporation's 390
service area, at least once in each of the two weeks immediately 391
preceding the month in which the open enrollment is to occur and 392
in each week of that month, or until the enrollment limitation is 393
reached, whichever occurs first. The notice published during the 394
last week of open enrollment shall appear not less than five days 395
before the end of the open enrollment period. It shall be at 396
least two newspaper columns wide or two and one-half inches wide, 398
whichever is larger. The first two lines of the text shall be 399
published in not less than twelve-point, boldface type. The 400
remainder of the text of the notice shall be published in not 401
less than eight-point type. The entire public notice shall be 402
surrounded by a continuous black line not less than one-eighth of 403
10
an inch wide.
(3) The following information shall be included in the 405
public notice provided under division (H)(2) of this section: 406
(a) The dates that open enrollment will be held and the 408
date coverage obtained under the open enrollment will become 409
effective;
(b) Notice that an applicant or the applicant's dependents 411
will not be denied coverage during open enrollment because of a 412
preexisting health condition, but that some limitations and 413
restrictions may apply;
(c) The address where a person may obtain an application; 415
(d) The telephone number that a person may call to request 417
an application or to ask questions; 419
(e) The date the first payment will be due; 421
(f) The actual rates or range of rates that will be 423
applicable for applicants; 424
(g) Any limitation granted by the superintendent on the 427
number of applications that will be accepted by the health 428
insuring corporation.
(4) Within thirty days after the end of an open enrollment 431
period, the health insuring corporation shall submit to the 432
superintendent proof of publication for the public notices, and 433
shall report the total number of applicants and their dependents 434
enrolled during the open enrollment period. 435
(I)(1) No health insuring corporation may employ any 437
scheme, plan, or device that restricts the ability of any person 438
to enroll during open enrollment. 439
(2) No health insuring corporation may require enrollment 441
to be made in person. Every health insuring corporation shall 442
permit application for coverage by mail. A representative of the 444
health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 445
operations of the health insuring corporation and to answer any 446
questions the applicant may have. Every health insuring 447
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corporation shall make open enrollment applications and 448
solicitation documents readily available to any potential 449
applicant who requests such material. 450
(J) An application postmarked on the last day of an open 452
enrollment period shall qualify as a valid application, 453
regardless of the date on which it is received by the health 454
insuring corporation.
(K) This section does not apply to any health insuring 456
corporation that offers only supplemental health care services or 458
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 459
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 460
U.S.C.A. 301, as amended, and that has no other commercial 461
enrollment, or to any health insuring corporation that offers 462
plans only through other federal health care programs regulated 463
by federal regulatory bodies and that has no other commercial 464
enrollment.
(L) EACH HEALTH INSURING CORPORATION SHALL ACCEPT 467
FEDERALLY ELIGIBLE INDIVIDUALS FOR OPEN ENROLLMENT COVERAGE AS 468
PROVIDED IN SECTION 3923.581 OF THE REVISED CODE. A HEALTH 470
INSURING CORPORATION MAY REINSURE COVERAGE OF ANY FEDERALLY 471
ELIGIBLE INDIVIDUAL ACQUIRED UNDER THAT SECTION WITH THE OPEN 472
ENROLLMENT REINSURANCE PROGRAM IN ACCORDANCE WITH DIVISION (G) OF 474
SECTION 3924.11 OF THE REVISED CODE. FIXED PERIODIC PREPAYMENT 477
RATES CHARGED FOR COVERAGE REINSURED BY THE PROGRAM SHALL BE 478
ESTABLISHED IN ACCORDANCE WITH SECTION 3924.12 OF THE REVISED 480
CODE.
(M) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 483
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 485
148.103. 486
Sec. 1751.16. (A) Except as provided in division (F) of 495
this section, every group contract issued by a health insuring 496
corporation shall provide an option for conversion to an 497
individual contract issued on a direct-payment basis to any 498
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subscriber covered by the group contract who terminates 499
employment or membership in the group, unless: 500
(1) Termination of the conversion option or contract is 502
based upon nonpayment of premium after reasonable notice in 503
writing has been given by the health insuring corporation to the 504
subscriber. 505
(2) The subscriber is, or is eligible to be, covered for 507
benefits at least comparable to the group contract under any of 508
the following: 509
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 511
(1935), 42 U.S.C.A. 301, as amended; 512
(b) Any act of congress or law under this or any other 514
state of the United States providing coverage at least comparable 515
to the benefits under division (A)(2)(a) of this section; 516
(c) Any policy of insurance or health care plan providing 518
coverage at least comparable to the benefits under division 519
(A)(2)(a) of this section. 520
(B)(1) The direct-payment contract offered by the health 522
insuring corporation pursuant to division (A) of this section 524
shall provide benefits comparable to the benefits being provided 525
by any of the individual contracts then being issued to 526
individual subscribers by the health insuring corporation. The 527
contract may contain a coordination of benefits provision as 528
approved by the superintendent of insurance THE FOLLOWING: 530
(a) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 533
ELIGIBLE INDIVIDUAL, BENEFITS COMPARABLE TO BENEFITS IN ANY OF 534
THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO INDIVIDUAL 535
SUBSCRIBERS BY THE HEALTH INSURING CORPORATION; 536
(b) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 539
BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 540
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 541
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 542
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (B)(1)(b) OF 544
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 545
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WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 546
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. THE 547
CONTRACTUAL PERIODIC PREPAYMENTS CHARGED FOR SUCH PLANS MAY NOT 548
EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE STANDARD 549
RATE CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH THE 550
ORGANIZATION IS CURRENTLY ACCEPTING NEW BUSINESS AND FOR WHICH 551
SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 552
(2) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 554
DIVISION (A) OF THIS SECTION MAY INCLUDE A COORDINATION OF 556
BENEFITS PROVISION AS APPROVED BY THE SUPERINTENDENT. 557
(3) FOR PURPOSES OF DIVISION (B) OF THIS SECTION 560
"FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS 561
DEFINED IN 45 C.F.R. 148.103. 564
(C) The option for conversion shall be available: 566
(1) Upon the death of the subscriber, to the surviving 568
spouse with respect to SUCH OF the spouse or AND dependents who 570
were AS ARE then covered by the group contract; 571
(2) To a child solely with respect to the child upon the 573
child's attaining the limiting age of coverage under the group 574
contract while covered as a dependent under the contract; 575
(3) Upon the divorce, dissolution, or annulment of the 577
marriage of the subscriber, to the divorced spouse, or, in the 578
event of annulment, to the former spouse of the subscriber. 580
(D) No health insuring corporation shall do any of the 582
following:
(1) Use USE age as the basis for refusing to renew a 584
converted contract; 585
(2) Require a subscriber to produce evidence of 587
insurability in order to exercise the option for conversion 588
provided by this section; 589
(3) Include preexisting condition limitations in a 591
converted contract. 592
(E) Written notice of the conversion option provided by 595
this section shall be given to the subscriber by the health 596
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insuring corporation by mail. The notice shall be sent to the 597
subscriber's address in the records of the employer upon receipt 598
of notice from the employer of the event giving rise to the 599
conversion option. If the subscriber has not received notice of 600
the conversion privilege at least fifteen days prior to the 601
expiration of the thirty-day conversion period, then the 602
subscriber shall have an additional period within which to 603
exercise the privilege. This additional period shall expire 604
fifteen days after the subscriber receives notice, but in no 605
event shall the period extend beyond sixty days after the 606
expiration of the thirty-day conversion period. 607
(F) This section does not apply to any group contract 609
offering only supplemental health care services or specialty 610
health care services.
Sec. 1751.18. (A)(1) No health insuring corporation shall 619
cancel or fail to renew the coverage of a subscriber or enrollee 620
because of the subscriber's or enrollee's ANY health status or 622
requirement STATUS-RELATED FACTOR IN RELATION TO THE SUBSCRIBER, 623
THE SUBSCRIBER'S REQUIREMENTS for health care services, or for 625
any other reason designated under rules adopted by the 626
superintendent of insurance. 627
(2) Unless otherwise required by state or federal law, no 629
health insuring corporation, or health care facility or provider 630
through which the health insuring corporation has made 631
arrangements to provide health care services, shall discriminate 632
against any individual with regard to enrollment, disenrollment, 633
or the quality of health care services rendered, on the basis of 634
the individual's race, color, sex, age, religion, state of 635
health, or status as a recipient of medicare or medical 636
assistance under Title XVIII or XIX of the "Social Security Act," 637
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, OR ANY HEALTH 639
STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL. However, a 640
health insuring corporation shall not be required to accept a 642
recipient of medicare or medical assistance, if an agreement has 643
15
not been reached on appropriate payment mechanisms between the 644
health insuring corporation and the governmental agency 645
administering these programs. Further, except during a period of 646
open enrollment under section 1751.15 of the Revised Code, a 647
health insuring corporation may reject an applicant for nongroup 648
enrollment on the basis of the state of ANY health of 649
STATUS-RELATED FACTOR IN RELATION TO the applicant. 651
(B) A health insuring corporation may cancel or decide not 654
to renew the coverage of a subscriber or enrollee for any of the 655
following reasons:
(1) Failure of the subscriber or enrollee to pay, or to 657
have paid on the subscriber's or enrollee's behalf, the required 658
premium rate or other charge; 659
(2) Fraud or forgery; 661
(3) Any material misrepresentation on the application for 663
coverage; 664
(4) The subscriber's or enrollee's permitting the use of 666
an identification card or similar documents by another person, 667
allowing that person to receive services for which that person is 669
not entitled;
(5) The subscriber's or enrollee's inability to establish 671
or maintain a provider-patient relationship with any provider 672
associated with the health insuring corporation, which inability 673
may include the subscriber's or enrollee's disruptive or abusive 674
behavior toward providers or the staff of the health care plan. 676
(C) A subscriber or enrollee may appeal any action or 678
decision of the A health insuring corporation under division (B) 681
of this section TAKEN PURSUANT TO SECTION 2742(b) TO (e) OF THE 684
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 685
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 687
AMENDED. To appeal, the subscriber or enrollee may submit a 690
written complaint to the health insuring corporation pursuant to 691
section 1751.19 of the Revised Code. The subscriber or enrollee 692
may, within thirty days after receiving a written response from 693
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the health insuring corporation, appeal the health insuring 694
corporation's action or decision to the superintendent. 695
(C) AS USED IN THIS SECTION, "HEALTH STATUS-RELATED 697
FACTOR" MEANS ANY OF THE FOLLOWING: 698
(1) HEALTH STATUS; 700
(2) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 703
ILLNESSES;
(3) CLAIMS EXPERIENCE; 705
(4) RECEIPT OF HEALTH CARE; 707
(5) MEDICAL HISTORY; 709
(6) GENETIC INFORMATION; 711
(7) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 714
OUT OF ACTS OF DOMESTIC VIOLENCE;
(8) DISABILITY. 716
Sec. 1751.57. (A) THE FOLLOWING CONDITIONS APPLY TO ALL 718
INDIVIDUAL HEALTH INSURING CORPORATION CONTRACTS: 719
(1) EXCEPT AS PROVIDED IN SECTION 2742(b) TO (e) OF THE 723
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 728
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 733
AMENDED, A HEALTH INSURING CORPORATION THAT PROVIDES INDIVIDUAL 734
COVERAGE TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN FORCE SUCH 735
COVERAGE AT THE OPTION OF THE INDIVIDUAL. 736
(2) SUCH INDIVIDUAL CONTRACTS ARE SUBJECT TO SECTIONS 2743 738
AND 2747 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 742
ACT OF 1996." 743
(3) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 747
SHALL APPLY TO HEALTH INSURING CORPORATION CONTRACTS OFFERED IN 748
THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO HEALTH 749
BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 750
(B) IN ACCORDANCE WITH 45 C.F.R. 148.102, THIS SECTION 755
ALSO APPLIES TO ALL GROUP HEALTH INSURING CORPORATION CONTRACTS 756
THAT ARE NOT SOLD IN CONNECTION WITH AN EMPLOYMENT-RELATED GROUP 757
HEALTH CARE PLAN AND THAT PROVIDE MORE THAN SHORT-TERM, LIMITED 758
DURATION COVERAGE.
17
Sec. 1751.58. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2721 761
OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 765
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-21, 771
AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP HEALTH 772
INSURING CORPORATION CONTRACTS THAT ARE SOLD IN CONNECTION WITH 773
AN EMPLOYMENT-RELATED GROUP HEALTH CARE PLAN AND THAT ARE NOT 774
SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 776
(A) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 780
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 784
A HEALTH INSURING CORPORATION OFFERS COVERAGE IN THE SMALL OR 785
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE 786
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT 787
THE OPTION OF THE CONTRACT HOLDER. 788
(B) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISION (E)(1) OF 791
SECTION 3924.03 AND SECTIONS 3924.033 AND 3924.27 OF THE REVISED 792
CODE. 793
(C) SUCH GROUP CONTRACTS SHALL PROVIDE FOR THE SPECIAL 796
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 799
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 802
Sec. 1751.59. (A) No individual or group health insuring 811
corporation policy, contract, or agreement providing THAT MAKES 812
family coverage AVAILABLE may be delivered, issued for delivery, 814
or renewed in this state, unless the policy, contract, or
agreement covers adopted children of the subscriber on the same 815
basis as other dependents. 816
(B) The coverage required by this section is subject to 818
the requirements and restrictions set forth in section 3924.51 of 819
the Revised Code. Coverage for dependent children living outside 821
the health insuring corporation's approved service area must be 822
provided if a court order requires the subscriber to provide 823
health care coverage.
Sec. 1751.61. (A) Each individual or group evidence of 833
coverage that is delivered, issued for delivery, or renewed by a 834
health insuring corporation in this state, and that provides 835
18
MAKES coverage AVAILABLE for family members of a subscriber, also 837
shall provide that coverage applicable to children is payable 838
from the moment of birth with respect to a newly born child of 839
the subscriber or subscriber's spouse. 840
(B) Coverage for a newly born child is effective for a 842
period of thirty-one days from the date of birth. 843
(C) To continue coverage for a newly born child beyond the 845
thirty-one day period described in division (B) of this section, 846
the subscriber shall notify the health insuring corporation 847
within that period.
(D) If payment of a specific premium rate is required to 849
provide coverage under this section for an additional child, the 850
evidence of coverage may require the subscriber to make this 851
payment to the health insuring corporation within the thirty-one 852
day period described in division (B) of this section in order to 853
continue the coverage beyond that period. 854
Sec. 1751.64. (A) As used in this section, "genetic 864
screening or testing" means a laboratory test of a person's genes 865
or chromosomes for abnormalities, defects, or deficiencies, 866
including carrier status, that are linked to physical or mental 867
disorders or impairments, or that indicate a susceptibility to 868
illness, disease, or other disorders, whether physical or mental, 869
which test is a direct test for abnormalities, defects, or 870
deficiencies, and not an indirect manifestation of genetic 871
disorders.
(B) No health insuring corporation, in processing an 874
application for coverage for health care services under an 875
individual or group health insuring corporation policy, contract, 876
or agreement or in determining insurability under such a policy, 877
contract, or agreement, shall do any of the following: 878
(1) Require an individual seeking coverage to submit to 880
genetic screening or testing; 881
(2) Take into consideration, other than in accordance with 884
division (F) of this section, the results of genetic screening or 885
19
testing;
(3) Make any inquiry to determine the results of genetic 887
screening or testing; 888
(4) Make a decision adverse to the applicant based on 890
entries in medical records or other reports of genetic screening 891
or testing. 892
(C) In developing and asking questions regarding medical 895
histories of applicants for coverage under an individual or group 896
health insuring corporation policy, contract, or agreement, no 897
health insuring corporation shall ask for the results of genetic 898
screening or testing or ask questions designed to ascertain the 899
results of genetic screening or testing. 900
(D) No health insuring corporation shall cancel or refuse 903
to issue or renew coverage for health care services based on the 904
results of genetic screening or testing. 905
(E) No health insuring corporation shall deliver, issue 908
for delivery, or renew an individual or group policy, contract, 909
or agreement in this state that limits benefits based on the 910
results of genetic screening or testing. 911
(F) A health insuring corporation may consider the results 914
of genetic screening or testing if the results are voluntarily 915
submitted by an applicant for coverage or renewal of coverage and 916
the results are favorable to the applicant. 917
(G) A violation of this section is an unfair and deceptive 920
act or practice in the business of insurance under sections 921
3901.19 to 3901.26 of the Revised Code. 923
Sec. 1751.65. (A) As used in this section, "genetic 933
screening or testing" means a laboratory test of a person's genes 934
or chromosomes for abnormalities, defects, or deficiencies, 935
including carrier status, that are linked to physical or mental 936
disorders or impairments, or that indicate a susceptibility to 937
illness, disease, or other disorders, whether physical or mental, 938
which test is a direct test for abnormalities, defects, or 939
deficiencies, and not an indirect manifestation of genetic 940
20
disorders. 941
(B) Upon the repeal of section 1751.64 of the Revised 944
Code, no health insuring corporation shall do either of the 946
following:
(1) Consider, in a manner adverse to an applicant or 948
insured, any information obtained from genetic screening or 949
testing conducted prior to the repeal of section 1751.64 of the 950
Revised Code in processing an application for coverage for health 953
care services under an individual or group policy, contract, or 954
agreement or in determining insurability under such a policy, 955
contract, or agreement; 956
(2) Inquire, directly or indirectly, into the results of 958
genetic screening or testing conducted prior to the repeal of 959
section 1751.64 of the Revised Code, or use such information, in 962
whole or in part, to cancel, refuse to issue or renew, or limit 963
benefits under, an individual or group policy, contract, or 964
agreement.
(C) Any health insuring corporation that has engaged in, 967
is engaged in, or is about to engage in a violation of division 968
(B) of this section is subject to the jurisdiction of the 970
superintendent of insurance under section 3901.04 of the Revised 971
Code.
Sec. 1751.67. (A) Each individual or group health 980
insuring corporation policy, contract, or agreement delivered, 981
issued for delivery, or renewed in this state that provides 982
maternity benefits shall provide coverage of inpatient care and 983
follow-up care for a mother and her newborn as follows: 984
(1) The policy, contract, or agreement shall cover a 986
minimum of forty-eight SEVENTY-TWO hours of inpatient care 987
following a normal vaginal delivery and a minimum of ninety-six 989
hours of inpatient care following a cesarean delivery. Services 990
covered as inpatient care shall include medical, educational, and 991
any other services that are consistent with the inpatient care 992
recommended in the protocols and guidelines developed by national 993
21
organizations that represent pediatric, obstetric, and nursing 994
professionals.
(2) The policy, contract, or agreement shall cover a 996
physician-directed source of follow-up care. Services covered as 998
follow-up care shall include physical assessment of the mother 999
and newborn, parent education, assistance and training in breast 1,000
or bottle feeding, assessment of the home support system,
performance of any medically necessary and appropriate clinical 1,001
tests, and any other services that are consistent with the 1,002
follow-up care recommended in the protocols and guidelines 1,003
developed by national organizations that represent pediatric, 1,004
obstetric, and nursing professionals. The coverage shall apply 1,005
to services provided in a medical setting or through home health 1,006
care visits. The coverage shall apply to a home health care 1,007
visit only if the provider who conducts the visit is 1,008
knowledgeable and experienced in maternity and newborn care. 1,009
When a decision is made in accordance with division (B) of 1,012
this section to discharge a mother or newborn prior to the
expiration of the applicable number of hours of inpatient care 1,013
required to be covered, the coverage of follow-up care shall 1,014
apply to all follow-up care that is provided within forty-eight 1,015
hours after discharge. When a mother or newborn receives at 1,016
least the number of hours of inpatient care required to be 1,017
covered, the coverage of follow-up care shall apply to follow-up 1,018
care that is determined to be medically necessary by the provider 1,020
responsible for discharging the mother or newborn.
(B) Any decision to shorten the length of inpatient stay 1,022
to less than that specified under division (A)(1) of this section 1,024
shall be made by the physician attending the mother or newborn, 1,025
except that if a nurse-midwife is attending the mother in 1,026
collaboration with a physician, the decision may be made by the 1,027
nurse-midwife. Decisions regarding early discharge shall be made 1,028
only after conferring with the mother or a person responsible for 1,029
the mother or newborn. For purposes of this division, a person 1,030
22
responsible for the mother or newborn may include a parent, 1,031
guardian, or any other person with authority to make medical 1,032
decisions for the mother or newborn.
(C)(1) No health insuring corporation may do either of the 1,034
following:
(a) Terminate the participation of a provider or health 1,036
care facility in an individual or group health care plan solely 1,037
for making recommendations for inpatient or follow-up care for a 1,038
particular mother or newborn that are consistent with the care 1,039
required to be covered by this section; 1,040
(b) Establish or offer monetary or other financial 1,042
incentives for the purpose of encouraging a person to decline the 1,044
inpatient or follow-up care required to be covered by this
section. 1,045
(2) Whoever violates division (C)(1)(a) or (b) of this 1,047
section has engaged in an unfair and deceptive act or practice in 1,048
the business of insurance under sections 3901.19 to 3901.26 of 1,049
the Revised Code.
(D) This section does not do any of the following: 1,051
(1) Require a policy, contract, or agreement to cover 1,053
inpatient or follow-up care that is not received in accordance 1,054
with the policy's, contract's, or agreement's terms pertaining to 1,055
the providers and facilities from which an individual is 1,056
authorized to receive health care services; 1,057
(2) Require a mother or newborn to stay in a hospital or 1,059
other inpatient setting for a fixed period of time following 1,060
delivery;
(3) Require a child to be delivered in a hospital or other 1,062
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 1,064
authority to practice nurse-midwifery in accordance with Chapter 1,065
4723. of the Revised Code; 1,066
(5) Establish minimum standards of medical diagnosis, 1,068
care, or treatment for inpatient or follow-up care for a mother 1,069
23
or newborn. A deviation from the care required to be covered 1,070
under this section shall not, solely on the basis of this 1,071
section, give rise to a medical claim or to derivative claims for 1,072
relief, as those terms are defined in section 2305.11 of the 1,073
Revised Code.
Sec. 3901.044. THE SUPERINTENDENT OF INSURANCE MAY ADOPT 1,076
RULES IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE THAT 1,079
THE SUPERINTENDENT CONSIDERS NECESSARY AND ADVISABLE FOR THE 1,080
PURPOSE OF IMPLEMENTING THE "HEALTH INSURANCE PORTABILITY AND 1,084
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 1,089
42 U.S.C.A. 300gg, AS AMENDED, AND ANY REGULATION ADOPTED 1,091
THEREUNDER. 1,092
Sec. 3901.21. The following are hereby defined as unfair 1,101
and deceptive acts or practices in the business of insurance: 1,102
(A) Making, issuing, circulating, or causing or permitting 1,104
to be made, issued, or circulated, or preparing with intent to so 1,105
use, any estimate, illustration, circular, or statement 1,106
misrepresenting the terms of any policy issued or to be issued or 1,107
the benefits or advantages promised thereby or the dividends or 1,108
share of the surplus to be received thereon, or making any false 1,109
or misleading statements as to the dividends or share of surplus 1,110
previously paid on similar policies, or making any misleading 1,111
representation or any misrepresentation as to the financial 1,112
condition of any insurer as shown by the last preceding verified 1,113
statement made by it to the insurance department of this state, 1,114
or as to the legal reserve system upon which any life insurer 1,115
operates, or using any name or title of any policy or class of 1,116
policies misrepresenting the true nature thereof, or making any 1,117
misrepresentation or incomplete comparison to any person for the 1,118
purpose of inducing or tending to induce such person to purchase, 1,119
amend, lapse, forfeit, change, or surrender insurance. 1,120
Any written statement concerning the premiums for a policy 1,122
which refers to the net cost after credit for an assumed 1,123
dividend, without an accurate written statement of the gross 1,124
24
premiums, cash values, and dividends based on the insurer's 1,125
current dividend scale, which are used to compute the net cost 1,126
for such policy, and a prominent warning that the rate of 1,127
dividend is not guaranteed, is a misrepresentation for the 1,128
purposes of this division. 1,129
(B) Making, publishing, disseminating, circulating, or 1,131
placing before the public or causing, directly or indirectly, to 1,132
be made, published, disseminated, circulated, or placed before 1,133
the public, in a newspaper, magazine, or other publication, or in 1,134
the form of a notice, circular, pamphlet, letter, or poster, or 1,135
over any radio station, or in any other way, or preparing with 1,136
intent to so use, an advertisement, announcement, or statement 1,137
containing any assertion, representation, or statement, with 1,138
respect to the business of insurance or with respect to any 1,139
person in the conduct of his THE PERSON'S insurance business, 1,140
which is untrue, deceptive, or misleading. 1,141
(C) Making, publishing, disseminating, or circulating, 1,143
directly or indirectly, or aiding, abetting, or encouraging the 1,144
making, publishing, disseminating, or circulating, or preparing 1,145
with intent to so use, any statement, pamphlet, circular, 1,146
article, or literature, which is false as to the financial 1,147
condition of an insurer and which is calculated to injure any 1,148
person engaged in the business of insurance. 1,149
(D) Filing with any supervisory or other public official, 1,151
or making, publishing, disseminating, circulating, or delivering 1,152
to any person, or placing before the public, or causing directly 1,153
or indirectly to be made, published, disseminated, circulated, 1,154
delivered to any person, or placed before the public, any false 1,155
statement of financial condition of an insurer. 1,156
Making any false entry in any book, report, or statement of 1,158
any insurer with intent to deceive any agent or examiner lawfully 1,159
appointed to examine into its condition or into any of its 1,160
affairs, or any public official to whom such insurer is required 1,161
by law to report, or who has authority by law to examine into its 1,162
25
condition or into any of its affairs, or, with like intent, 1,163
willfully omitting to make a true entry of any material fact 1,164
pertaining to the business of such insurer in any book, report, 1,165
or statement of such insurer, or mutilating, destroying, 1,166
suppressing, withholding, or concealing any of its records. 1,167
(E) Issuing or delivering or permitting agents, officers, 1,169
or employees to issue or deliver agency company stock or other 1,170
capital stock or benefit certificates or shares in any common-law 1,171
corporation or securities or any special or advisory board 1,172
contracts or other contracts of any kind promising returns and 1,173
profits as an inducement to insurance. 1,174
(F) Making or permitting any unfair discrimination among 1,176
individuals of the same class and equal expectation of life in 1,177
the rates charged for any contract of life insurance or of life 1,178
annuity or in the dividends or other benefits payable thereon, or 1,179
in any other of the terms and conditions of such contract. 1,180
(G)(1) Except as otherwise expressly provided by law, 1,182
knowingly permitting or offering to make or making any contract 1,183
of life insurance, life annuity or accident and health insurance, 1,184
or agreement as to such contract other than as plainly expressed 1,185
in the contract issued thereon, or paying or allowing, or giving 1,186
or offering to pay, allow, or give, directly or indirectly, as 1,187
inducement to such insurance, or annuity, any rebate of premiums 1,188
payable on the contract, or any special favor or advantage in the 1,189
dividends or other benefits thereon, or any valuable 1,190
consideration or inducement whatever not specified in the 1,191
contract; or giving, or selling, or purchasing, or offering to 1,192
give, sell, or purchase, as inducement to such insurance or 1,193
annuity or in connection therewith, any stocks, bonds, or other 1,194
securities, or other obligations of any insurance company or 1,195
other corporation, association, or partnership, or any dividends 1,196
or profits accrued thereon, or anything of value whatsoever not 1,197
specified in the contract. 1,198
(2) Nothing in division (F) or division (G)(1) of this 1,200
26
section shall be construed as prohibiting any of the following 1,201
practices: (a) in the case of any contract of life insurance or 1,202
life annuity, paying bonuses to policyholders or otherwise 1,203
abating their premiums in whole or in part out of surplus 1,204
accumulated from nonparticipating insurance, provided that any 1,205
such bonuses or abatement of premiums shall be fair and equitable 1,206
to policyholders and for the best interests of the company and 1,207
its policyholders; (b) in the case of life insurance policies 1,208
issued on the industrial debit plan, making allowance to 1,209
policyholders who have continuously for a specified period made 1,210
premium payments directly to an office of the insurer in an 1,211
amount which fairly represents the saving in collection expenses; 1,212
(c) readjustment of the rate of premium for a group insurance 1,213
policy based on the loss or expense experience thereunder, at the 1,214
end of the first or any subsequent policy year of insurance 1,215
thereunder, which may be made retroactive only for such policy 1,216
year. 1,217
(H) Making, issuing, circulating, or causing or permitting 1,219
to be made, issued, or circulated, or preparing with intent to so 1,220
use, any statement to the effect that a policy of life insurance 1,221
is, is the equivalent of, or represents shares of capital stock 1,222
or any rights or options to subscribe for or otherwise acquire 1,223
any such shares in the life insurance company issuing that policy 1,224
or any other company. 1,225
(I) Making, issuing, circulating, or causing or permitting 1,227
to be made, issued or circulated, or preparing with intent to so 1,228
issue, any statement to the effect that payments to a 1,229
policyholder of the principal amounts of a pure endowment are 1,230
other than payments of a specific benefit for which specific 1,231
premiums have been paid. 1,232
(J) Making, issuing, circulating, or causing or permitting 1,234
to be made, issued, or circulated, or preparing with intent to so 1,235
use, any statement to the effect that any insurance company was 1,236
required to change a policy form or related material to comply 1,237
27
with Title XXXIX of the Revised Code or any regulation of the 1,238
superintendent of insurance, for the purpose of inducing or 1,239
intending to induce any policyholder or prospective policyholder 1,240
to purchase, amend, lapse, forfeit, change, or surrender 1,241
insurance. 1,242
(K) Aiding or abetting another to violate this section. 1,244
(L) Refusing to issue any policy of insurance, or 1,246
canceling or declining to renew such policy because of the sex or 1,247
marital status of the applicant, prospective insured, insured, or 1,248
policyholder. 1,249
(M) Making or permitting any unfair discrimination between 1,251
individuals of the same class and of essentially the same hazard 1,252
in the amount of premium, policy fees, or rates charged for any 1,253
policy or contract of insurance, other than life insurance, or in 1,254
the benefits payable thereunder, or in underwriting standards and 1,255
practices or eligibility requirements, or in any of the terms or 1,256
conditions of such contract, or in any other manner whatever. 1,257
(N) Refusing to make available disability income insurance 1,259
solely because the applicant's principal occupation is that of 1,260
managing a household. 1,261
(O) Refusing, when offering maternity benefits under any 1,263
individual or group sickness and accident insurance policy, to 1,264
make maternity benefits available to the policyholder for the 1,265
individual or individuals to be covered under any comparable 1,266
policy to be issued for delivery in this state, including family 1,267
members if the policy otherwise provides coverage for family 1,268
members. Nothing in this division shall be construed to prohibit 1,269
an insurer from imposing a reasonable waiting period for such 1,270
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE 1,271
POLICY, but in no event shall such waiting period exceed two 1,272
hundred seventy days. 1,273
(P) Using, or permitting to be used, a pattern settlement 1,275
as the basis of any offer of settlement. As used in this 1,276
division, "pattern settlement" means a method by which liability 1,277
28
is routinely imputed to a claimant without an investigation of 1,278
the particular occurrence upon which the claim is based and by 1,279
using a predetermined formula for the assignment of liability 1,280
arising out of occurrences of a similar nature. Nothing in this 1,281
division shall be construed to prohibit an insurer from 1,282
determining a claimant's liability by applying formulas or 1,283
guidelines to the facts and circumstances disclosed by the 1,284
insurer's investigation of the particular occurrence upon which a 1,285
claim is based. 1,286
(Q) Refusing to insure, or refusing to continue to insure, 1,288
or limiting the amount, extent, or kind of life or sickness and 1,289
accident insurance or annuity coverage available to an 1,290
individual, or charging an individual a different rate for the 1,291
same coverage solely because of blindness or partial blindness. 1,292
With respect to all other conditions, including the underlying 1,293
cause of blindness or partial blindness, persons who are blind or 1,294
partially blind shall be subject to the same standards of sound 1,295
actuarial principles or actual or reasonably anticipated 1,296
actuarial experience as are sighted persons. Refusal to insure 1,297
includes, but is not limited to, denial by an insurer of 1,298
disability insurance coverage on the grounds that the policy 1,299
defines "disability" as being presumed in the event that the 1,300
eyesight of the insured is lost. However, an insurer may exclude 1,301
from coverage disabilities consisting solely of blindness or 1,302
partial blindness when such conditions existed at the time the 1,303
policy was issued. To the extent that the provisions of this 1,304
division may appear to conflict with any provision of section 1,305
3999.16 of the Revised Code, this division applies. 1,306
(R)(1) Directly or indirectly offering to sell, selling, 1,308
or delivering, issuing for delivery, renewing, or using or 1,309
otherwise marketing any policy of insurance or insurance product 1,310
in connection with or in any way related to the grant of a 1,311
student loan guaranteed in whole or in part by an agency or 1,312
commission of this state or the United States, except insurance 1,313
29
that is required under federal or state law as a condition for 1,314
obtaining such a loan and the premium for which is included in 1,315
the fees and charges applicable to the loan; or, in the case of 1,316
an insurer or insurance agent, knowingly permitting any lender 1,317
making such loans to engage in such acts or practices in 1,318
connection with the insurer's or agent's insurance business. 1,319
(2) Except in the case of a violation of division (G) of 1,321
this section, division (R)(1) of this section does not apply to 1,322
either of the following: 1,323
(a) Acts or practices of an insurer, its agents, 1,325
representatives, or employees in connection with the grant of a 1,326
guaranteed student loan to its insured or the insured's spouse or 1,327
dependent children where such acts or practices take place more 1,328
than ninety days after the effective date of the insurance; 1,329
(b) Acts or practices of an insurer, its agents, 1,331
representatives, or employees in connection with the 1,332
solicitation, processing, or issuance of an insurance policy or 1,333
product covering the student loan borrower or his THE BORROWER'S 1,334
spouse or dependent children, where such acts or practices take 1,335
place more than one hundred eighty days after the date on which 1,336
the borrower is notified that the student loan was approved. 1,337
(S) Denying coverage, under any health insurance or health 1,339
care policy, contract, or plan providing family coverage, to any 1,340
natural or adopted child of the named insured or subscriber 1,341
solely on the basis that the child does not reside in the 1,342
household of the named insured or subscriber. 1,343
(T)(1) Using any underwriting standard or engaging in any 1,345
other act or practice that, directly or indirectly, due solely to 1,346
the actual or expected ANY health condition of STATUS-RELATED 1,348
FACTOR IN RELATION TO one or more individuals, does either of the 1,349
following:
(a) Terminates or fails to renew an existing individual 1,351
policy, contract, or plan of health benefits, or a health benefit 1,352
plan issued to a small AN employer as those terms are defined in 1,353
30
section 3924.01 of the Revised Code, for which an individual 1,354
would otherwise be eligible;
(b) With respect to a health benefit plan issued to a 1,356
small AN employer, as those terms are defined in section 3924.01 1,357
of the Revised Code, excludes or causes the exclusion of an 1,359
individual from coverage under an existing employer-provided 1,360
policy, contract, or plan of health benefits, except that an 1,361
insurer may exclude, on the basis of health status, a late 1,362
enrollee as defined in section 3924.01 of the Revised Code. 1,363
(2) The superintendent of insurance may adopt rules in 1,365
accordance with Chapter 119. of the Revised Code for purposes of 1,366
implementing division (T)(1) of this section. 1,367
(3) FOR PURPOSES OF DIVISION (T)(1) OF THIS SECTION, 1,371
"HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING: 1,372
(a) HEALTH STATUS; 1,374
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,377
ILLNESSES;
(c) CLAIMS EXPERIENCE; 1,379
(d) RECEIPT OF HEALTH CARE; 1,381
(e) MEDICAL HISTORY; 1,383
(f) GENETIC INFORMATION; 1,385
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,388
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 1,390
(U) With respect to a health benefit plan issued to a 1,392
small employer, as those terms are defined in section 3924.01 of 1,393
the Revised Code, negligently or willfully placing coverage for 1,394
adverse risks with a certain carrier, as defined in section 1,395
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 1,397
or practice that, directly or indirectly, causes or results in 1,398
the placing of coverage for adverse risks with another carrier, 1,399
as defined in section 3924.01 of the Revised Code. 1,400
(W) Failing to comply with section 3923.23, 3923.231, 1,402
31
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 1,403
in any unfair, discriminatory reimbursement practice. 1,404
(X) Intentionally establishing an unfair premium for, or 1,406
misrepresenting the cost of, any insurance policy financed under 1,407
a premium finance agreement of an insurance premium finance 1,408
company. 1,409
With respect to private passenger automobile insurance, no 1,411
insurer shall charge different premium rates to persons residing 1,412
within the limits of any municipal corporation based solely on 1,413
the location of the residence of the insured within those limits. 1,414
The enumeration in sections 3901.19 to 3901.26 of the 1,416
Revised Code of specific unfair or deceptive acts or practices in 1,417
the business of insurance is not exclusive or restrictive or 1,418
intended to limit the powers of the superintendent of insurance 1,419
to adopt rules to implement this section, or to take action under 1,420
other sections of the Revised Code. 1,421
This section does not prohibit the sale of shares of any 1,423
investment company registered under the "Investment Company Act 1,424
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 1,425
policies, annuities, or other contracts described in section 1,426
3907.15 of the Revised Code. 1,427
As used in this section, "estimate," "statement," 1,429
"representation," "misrepresentation," "advertisement," or 1,430
"announcement" includes oral or written occurrences. 1,431
Sec. 3901.49. (A) As used in this section: 1,442
(1) "Genetic screening or testing" means a laboratory test 1,444
of a person's genes or chromosomes for abnormalities, defects, or 1,445
deficiencies, including carrier status, that are linked to 1,446
physical or mental disorders or impairments, or that indicate a 1,447
susceptibility to illness, disease, or other disorders, whether 1,448
physical or mental, which test is a direct test for 1,449
abnormalities, defects, or deficiencies, and not an indirect 1,450
manifestation of genetic disorders. 1,451
(2) "Insurer" means any person authorized under Title 1,453
32
XXXIX of the Revised Code to engage in the business of sickness 1,454
and accident insurance. 1,455
(3) "Sickness and accident insurance" means sickness and 1,457
accident insurance under Chapter 3923. of the Revised Code 1,458
excluding disability income insurance and excluding supplemental 1,459
policies of sickness and accident insurance. 1,460
(B) No insurer, in processing an application for an 1,462
individual or group policy of sickness and accident insurance or 1,463
in determining insurability under such a policy, shall do any of 1,464
the following: 1,465
(1) Require an individual seeking coverage to submit to 1,467
genetic screening or testing; 1,468
(2) Take into consideration, other than in accordance with 1,470
division (F) of this section, the results of genetic screening or 1,471
testing; 1,472
(3) Make any inquiry to determine the results of genetic 1,474
screening or testing; 1,475
(4) Make a decision adverse to the applicant based on 1,477
entries in medical records or other reports of genetic screening 1,478
or testing. 1,479
(C) In developing and asking questions regarding medical 1,481
histories of applicants for sickness and accident insurance, no 1,482
insurer shall ask for the results of genetic screening or testing 1,483
or ask questions designed to ascertain the results of genetic 1,484
screening or testing. 1,485
(D) No insurer shall cancel or refuse to issue or renew 1,487
coverage under a sickness and accident insurance policy based on 1,488
the results of genetic screening or testing. 1,489
(E) No insurer shall deliver, issue for delivery, or renew 1,491
an individual or group policy of sickness and accident insurance 1,492
in this state that limits benefits based on the results of 1,493
genetic screening or testing. 1,494
(F) An insurer may consider the results of genetic 1,496
screening or testing if the results are voluntarily submitted by 1,497
33
an applicant for coverage or renewal of coverage and the results 1,498
are favorable to the applicant. 1,499
(G) A violation of this section is an unfair and deceptive 1,501
act or practice in the business of insurance under sections 1,502
3901.19 to 3901.26 of the Revised Code. 1,503
Sec. 3901.491. (A) As used in this section: 1,512
(1) "Genetic screening or testing" means a laboratory test 1,514
of a person's genes or chromosomes for abnormalities, defects, or 1,515
deficiencies, including carrier status, that are linked to 1,516
physical or mental disorders or impairments, or that indicate a 1,517
susceptibility to illness, disease, or other disorders, whether 1,518
physical or mental, which test is a direct test for 1,519
abnormalities, defects, or deficiencies, and not an indirect 1,520
manifestation of genetic disorders. 1,521
(2) "Insurer" means any person authorized under Title 1,523
XXXIX of the Revised Code to engage in the business of sickness 1,524
and accident insurance. 1,525
(3) "Sickness and accident insurance" means sickness and 1,527
accident insurance under Chapter 3923. of the Revised Code 1,528
excluding disability income insurance and excluding supplemental 1,529
policies of sickness and accident insurance. 1,530
(B) Upon the repeal of section 3901.49 of the Revised Code 1,532
by Sub. H.B. No. 71 of the 120th general assembly, no insurer 1,533
shall do either of the following: 1,534
(1) Consider, in a manner adverse to an applicant or 1,536
insured, any information obtained from genetic screening or 1,537
testing conducted prior to the repeal of section 3901.49 of the 1,538
Revised Code in processing an application for an individual or 1,539
group policy of sickness and accident insurance, or in 1,540
determining insurability under such a policy; 1,541
(2) Inquire, directly or indirectly, into the results of 1,543
genetic screening or testing conducted prior to the repeal of 1,544
section 3901.49 of the Revised Code, or use such information, in 1,545
whole or in part, to cancel, refuse to issue or renew, or limit 1,546
34
benefits under, a sickness and accident insurance policy. 1,547
(C) Any insurer that has engaged in, is engaged in, or is 1,549
about to engage in a violation of division (B) of this section is 1,550
subject to the jurisdiction of the superintendent of insurance 1,551
under section 3901.04 of the Revised Code. 1,552
Sec. 3901.50. (A) As used in this section: 1,563
(1) "Genetic screening or testing" means a laboratory test 1,565
of a person's genes or chromosomes for abnormalities, defects, or 1,566
deficiencies, including carrier status, that are linked to 1,567
physical or mental disorders or impairments, or that indicate a 1,568
susceptibility to illness, disease, or other disorders, whether 1,569
physical or mental, which test is a direct test for 1,570
abnormalities, defects, or deficiencies, and not an indirect 1,571
manifestation of genetic disorders. 1,572
(2) "Self-insurer" means any government entity providing 1,574
coverage for health care services on a self-insurance basis. 1,575
(B) No self-insurer, in processing an application for 1,577
coverage under a plan of self-insurance or in determining 1,578
insurability under such a plan, shall do any of the following: 1,579
(1) Require an individual seeking coverage to submit to 1,581
genetic screening or testing; 1,582
(2) Take into consideration, other than in accordance with 1,584
division (F) of this section, the results of genetic screening or 1,585
testing; 1,586
(3) Make any inquiry to determine the results of genetic 1,588
screening or testing; 1,589
(4) Make a decision adverse to the applicant based on 1,591
entries in medical records or other reports of genetic screening 1,592
or testing. 1,593
(C) In developing and asking questions regarding medical 1,595
histories of applicants for coverage under a plan of 1,596
self-insurance, no self-insurer shall ask for the results of 1,597
genetic screening or testing or ask questions designed to 1,598
ascertain the results of genetic screening or testing. 1,599
35
(D) No self-insurer shall cancel or refuse to provide or 1,601
renew coverage for health care services based on the results of 1,602
genetic screening or testing. 1,603
(E) No self-insurer shall establish or modify a plan of 1,605
self-insurance in this state that limits benefits based on the 1,606
results of genetic screening or testing. 1,607
(F) A self-insurer may consider the results of genetic 1,609
screening or testing if the results are voluntarily submitted by 1,610
an applicant for coverage or renewal of coverage and the results 1,611
are favorable to the applicant. 1,612
(G) A violation of this section is an unfair and deceptive 1,614
act or practice in the business of insurance under sections 1,615
3901.19 to 3901.26 of the Revised Code. 1,616
Sec. 3901.501. (A) As used in this section: 1,625
(1) "Genetic screening or testing" means a laboratory test 1,627
of a person's genes or chromosomes for abnormalities, defects, or 1,628
deficiencies, including carrier status, that are linked to 1,629
physical or mental disorders or impairments, or that indicate a 1,630
susceptibility to illness, disease, or other disorders, whether 1,631
physical or mental, which test is a direct test for 1,632
abnormalities, defects, or deficiencies, and not an indirect 1,633
manifestation of genetic disorders. 1,634
(2) "Self-insurer" means any government entity providing 1,636
coverage for health care services on a self-insurance basis. 1,637
(B) Upon the repeal of section 3901.50 of the Revised Code 1,639
by Sub. H.B. No. 71 of the 120th general assembly, no 1,640
self-insurer shall do either of the following: 1,641
(1) Consider, in a manner adverse to an applicant or 1,643
insured, any information obtained from genetic screening or 1,644
testing conducted prior to the repeal of section 3901.50 of the 1,645
Revised Code in processing an application for coverage under a 1,646
plan of self-insurance or in determining insurability under such 1,647
a plan; 1,648
(2) Inquire, directly or indirectly, into the results of 1,650
36
genetic screening or testing conducted prior to the repeal of 1,651
section 3901.50 of the Revised Code, or use such information, in 1,652
whole or in part, to cancel, refuse to provide or renew, or limit 1,653
benefits under, a plan of self-insurance. 1,654
(C) Any self-insurer that has engaged in, is engaged in, 1,656
or is about to engage in a violation of division (B) of this 1,657
section is subject to the jurisdiction of the superintendent of 1,658
insurance under section 3901.04 of the Revised Code. 1,659
Sec. 3923.021. (A) As used in this section, "benefits 1,668
provided are not unreasonable in relation to the premium charged" 1,669
means the rates were calculated in accordance with sound 1,670
actuarial principles. 1,671
(B) With respect to any filing, made pursuant to section 1,673
3923.02 of the Revised Code, of any premium rates for any 1,674
individual policy of sickness and accident insurance or for any 1,675
indorsement or rider pertaining thereto, the superintendent of 1,676
insurance may, within thirty days after filing: 1,677
(1) Disapprove such filing if he finds AFTER FINDING that 1,679
the benefits provided are unreasonable in relation to the premium 1,681
charged. Such disapproval shall be effected by written order of 1,682
the superintendent, a copy of which shall be mailed to the 1,683
insurer that has made the filing. In the order, the 1,684
superintendent shall specify the reasons for his THE disapproval 1,685
and state that a hearing will be held within fifteen days after 1,687
requested in writing by the insurer. If a hearing is so 1,688
requested, the superintendent shall also give such public notice 1,689
as he THE SUPERINTENDENT considers appropriate. The 1,691
superintendent, within fifteen days after the commencement of any 1,692
hearing, shall issue a written order, a copy of which shall be 1,693
mailed to the insurer that has made the filing, either affirming 1,694
his THE prior disapproval or approving such filing if he finds 1,696
AFTER FINDING that the benefits provided are not unreasonable in 1,697
relation to the premium charged. 1,698
(2) Set a date for a public hearing to commence no later 1,700
37
than forty days after the filing. The superintendent shall give 1,701
the insurer making the filing twenty days' written notice of the 1,702
hearing and shall give such public notice as he THE 1,703
SUPERINTENDENT considers appropriate. The superintendent, within 1,705
twenty days after the commencement of a hearing, shall issue a 1,706
written order, a copy of which shall be mailed to the insurer 1,707
that has made the filing, either approving such filing if he THE 1,708
SUPERINTENDENT finds that the benefits provided are not 1,710
unreasonable in relation to the premium charged, or disapproving 1,711
such filing if he THE SUPERINTENDENT finds that the benefits 1,712
provided are unreasonable in relation to the premium charged. 1,713
This division does not apply to any insurer organized or 1,714
transacting the business of insurance under Chapter 3907. or 1,715
3909. of the Revised Code. 1,716
(3) Take no action, in which case such filing shall be 1,718
deemed to be approved and shall become effective upon the 1,719
thirty-first day after such filing, unless the superintendent has 1,720
previously given to the insurer his A written approval. 1,721
(C) At any time after any filing has been approved 1,723
pursuant to this section, the superintendent may, after a hearing 1,724
of which at least twenty days' written notice has been given to 1,725
the insurer that has made such filing and for which such public 1,726
notice as he THE SUPERINTENDENT considers appropriate has been 1,727
given, withdraw approval of such filing if he finds AFTER FINDING 1,729
that the benefits provided are unreasonable in relation to the 1,731
premium charged. Such withdrawal of approval shall be effected 1,732
by written order of the superintendent, a copy of which shall be 1,733
mailed to the insurer that has made the filing, which shall state 1,734
the ground for such withdrawal and the date, not less than forty 1,735
days after the date of such order, when the withdrawal or 1,736
approval shall become effective. 1,737
(D) The superintendent may retain at the insurer's expense 1,739
such attorneys, actuaries, accountants, and other experts not 1,740
otherwise a part of the superintendent's staff as shall be 1,741
38
reasonably necessary to assist in the preparation for and conduct 1,742
of any public hearing under this section. The expense for 1,743
retaining such experts and the expenses of the department of 1,744
insurance incurred in connection with such public hearing shall 1,745
be assessed against the insurer in an amount not to exceed one 1,746
one-hundredth of one per cent of the sum of premiums earned plus 1,747
net realized investment gain or loss of such insurer as reflected 1,748
in the most current annual statement on file with the 1,749
superintendent. Any person retained shall be under the direction 1,750
and control of the superintendent and shall act in a purely 1,751
advisory capacity. 1,752
(E) This section does not apply to any filing of any 1,754
premium rate or rating formula for individual sickness and 1,755
accident insurance policies offered in accordance with division 1,756
(M)(L) of section 3923.58 of the Revised Code, or for any 1,757
amendment thereto. 1,758
Sec. 3923.122. (A) Every policy of group sickness and 1,768
accident insurance providing hospital, surgical, or medical 1,769
expense coverage for other than specific diseases or accidents 1,770
only, and delivered, issued for delivery, or renewed in this 1,771
state on or after January 1, 1976, shall include a provision 1,772
giving each insured the option to convert to THE FOLLOWING: 1,773
(1) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 1,776
ELIGIBLE INDIVIDUAL, any of the individual policies of hospital, 1,777
surgical, or medical expense insurance then being issued by the 1,778
insurer with benefit limits not to exceed those in effect under 1,779
the group policy;
(2) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 1,781
BASIC OR STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 1,782
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 1,783
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 1,784
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (A)(2) OF 1,785
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 1,786
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 1,787
39
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 1,788
(B) An option for conversion to an individual policy shall 1,790
be available without evidence of insurability to every insured, 1,791
including any person eligible under division (D) of this section, 1,792
who terminates his employment or membership in the group holding 1,793
the policy after having been continuously insured thereunder for 1,794
at least one year. 1,795
Upon receipt of the insured's written application and upon 1,797
payment of at least the first quarterly premium not later than 1,798
thirty-one days after the termination of coverage under the group 1,799
policy, the insurer shall issue a converted policy on a form then 1,800
available for conversion. The premium shall be in accordance 1,801
with the insurer's table of premium rates in effect on the later 1,802
of the following dates: 1,803
(1) The effective date of the converted policy; 1,805
(2) The date of application therefor; and shall be 1,807
applicable to the class of risk to which each person covered 1,809
belongs and to the form and amount of the policy at his THE
PERSON'S then attained age. HOWEVER, PREMIUMS CHARGED FEDERALLY 1,811
ELIGIBLE INDIVIDUALS MAY NOT EXCEED AN AMOUNT THAT IS TWO TIMES 1,813
THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER INDIVIDUAL OF 1,814
A GROUP TO WHICH THE INSURER IS CURRENTLY ACCEPTING NEW BUSINESS 1,815
AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 1,816
At the election of the insurer, a separate converted policy 1,818
may be issued to cover any dependent of an employee or member of 1,819
the group. 1,820
Except as provided in division (H) of this section, any 1,822
converted policy shall become effective as of the day following 1,823
the date of termination of insurance under the group policy. 1,824
Any probationary or waiting period set forth in the 1,826
converted policy is deemed to commence on the effective date of 1,827
the insured's coverage under the group policy. 1,828
(C) No insurer shall be required to issue a converted 1,830
policy to any person who is, or is eligible to be, covered for 1,831
40
benefits at least comparable to the group policy under: 1,832
(1) Title XVIII of the Social Security Act, as amended or 1,834
superseded; 1,835
(2) Any act of congress or law under this or any other 1,837
state of the United States that duplicates coverage offered under 1,838
division (C)(1) of this section; 1,839
(3) Any policy that duplicates coverage offered under 1,841
division (C)(1) of this section; 1,842
(4) Any other group sickness and accident insurance 1,844
providing hospital, surgical, or medical expense coverage for 1,845
other than specific diseases or accidents only. 1,846
(D) The option for conversion shall be available: 1,848
(1) Upon the death of the employee or member, to the 1,850
surviving spouse with respect to such of the spouse and 1,851
dependents as are then covered by the group policy; 1,852
(2) To a child solely with respect to himself OR HERSELF 1,854
upon his attaining the limiting age of coverage under the group 1,856
policy while covered as a dependent thereunder; 1,857
(3) Upon the divorce, dissolution, or annulment of the 1,859
marriage of the employee or member, to the divorced spouse, or 1,860
former spouse in the event of annulment, of such employee or 1,861
member, or upon the legal separation of the spouse from such 1,862
employee or member, to the spouse. 1,863
Persons possessing the option for conversion pursuant to 1,865
this division shall be considered members for the purposes of 1,866
division (H) of this section. 1,867
(E) If coverage is continued under a group policy on an 1,869
employee following his retirement prior to the time he THE 1,870
EMPLOYEE is, or is eligible to be, covered by Title XVIII of the 1,872
Social Security Act, he THE EMPLOYEE may elect, in lieu of the 1,873
continuance of group insurance, to have the same conversion 1,875
rights as would apply had his THE EMPLOYEE'S insurance terminated 1,877
at retirement by reason of termination of employment. 1,878
(F) If the insurer and the group policyholder agree upon 1,880
41
one or more additional plans of benefits to be available for 1,881
converted policies, the applicant for the converted policy may 1,882
elect such a plan in lieu of a converted policy. 1,883
(G) The converted policy may contain provisions for 1,885
avoiding duplication of benefits provided pursuant to divisions 1,886
(C)(1), (2), (3), and (4) of this section or provided under any 1,887
other insured or noninsured plan or program. 1,888
(H) If an employee or member becomes entitled to obtain a 1,890
converted policy pursuant to this section, and if the employee or 1,891
member has not received notice of the conversion privilege at 1,892
least fifteen days prior to the expiration of the thirty-one-day 1,893
conversion period provided in division (B) of this section, then 1,894
the employee or member has an additional period within which to 1,895
exercise the privilege. This additional period shall expire 1,896
fifteen days after the employee or member receives notice, but in 1,897
no event shall the period extend beyond sixty days after the 1,898
expiration of the thirty-one-day conversion period. 1,899
Written notice presented to the employee or member, or 1,901
mailed by the policyholder to the last known address of the 1,902
employee or member as indicated on its records, constitutes 1,903
notice for the purpose of this division. In the case of a person 1,904
who is eligible for a converted policy under division (D) (2) or 1,905
(D)(3) of this section, a policyholder shall not be responsible 1,906
for presenting or mailing such notice, unless such policyholder 1,907
has actual knowledge of the person's eligibility for a converted 1,908
policy. 1,909
If an additional period is allowed by an employee or member 1,911
for the exercise of a conversion privilege, and if written 1,912
application for the converted policy, accompanied by at least the 1,913
first quarterly premium, is made after the expiration of the 1,914
thirty-one-day conversion period, but within the additional 1,915
period allowed an employee or member in accordance with this 1,916
division, the effective date of the converted policy shall be the 1,917
date of application. 1,918
42
(I) The converted policy may provide: 1,920
(1) That any hospital, surgical, or medical expense 1,922
benefits otherwise payable with respect to any person may be 1,923
reduced by the amount of any such benefits payable under the 1,924
group policy for the same loss after termination of coverage; 1,925
(2) For termination of coverage on any person who is, or 1,927
is eligible to be, covered pursuant to division (C) of this 1,928
section; 1,929
(3) That the insurer may request information in advance of 1,931
any premium due date of the policy as to whether the insured is, 1,932
or is eligible to be, covered pursuant to division (C) of this 1,933
section. If the insured is, or is eligible to be, covered, and 1,934
he THE INSURED fails to furnish the details of his THE INSURED'S 1,936
coverage or eligibility to the insurer within thirty-one days 1,937
after the date of the request, the benefits payable under the 1,938
converted policy may be based on the hospital, surgical, or 1,939
medical expenses actually incurred after excluding expenses to 1,940
the extent of the amount of benefits for which the insured is, or 1,941
is eligible to be, covered pursuant to division (C) of this 1,942
section.
(J) The converted policy may contain: 1,944
(1) Any exclusion, reduction, or limitation contained in 1,946
the group policy or customarily used in individual policies 1,947
issued by the insurer; 1,948
(2) Any provision permitted in this section; 1,950
(3) Any other provision not prohibited by law. 1,952
Any provision required or permitted in this section may be 1,954
made a part of any converted policy by means of an endorsement or 1,955
rider. 1,956
(K) The time limit specified in a converted policy for 1,958
certain defenses with respect to any person who was covered by a 1,959
group policy shall commence on the effective date of such 1,960
person's coverage under the group policy. 1,961
(L) No insurer shall use deterioration of health as the 1,963
43
basis for refusing to renew a converted policy. 1,964
(M) No insurer shall use age as the basis for refusing to 1,966
renew a converted policy. 1,967
(N) A converted policy made available pursuant to this 1,969
section shall, if delivery of the policy is to be made in this 1,970
state, comply with this section. If delivery of a converted 1,971
policy is to be made in another state, it may be on a form 1,972
offered by the insurer in the jurisdiction where the delivery is 1,973
to be made and which provides benefits substantially in 1,974
compliance with those required in a policy delivered in this 1,975
state. 1,976
(O) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 1,979
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 1,981
148.103. 1,982
Sec. 3923.26. Every certificate furnished by an insurer in 1,991
connection with, or pursuant to any provision of, any group 1,992
POLICY OR CERTIFICATE OF sickness and accident insurance policy 1,993
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE 1,994
providing coverage on an expense incurred basis, and every 1,996
individual POLICY OF sickness and accident insurance policy 1,997
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE which 1,998
provides coverage on an expense incurred basis, either of which 1,999
provides MAKES coverage AVAILABLE for family members of the 2,001
insured, shall, as to such family members' coverage, also provide 2,002
that any sickness and accident insurance benefits applicable for 2,003
children shall be payable with respect to a newly born child of 2,004
the insured from the moment of birth.
The coverage for newly born children shall consist of 2,006
coverage of injury or sickness, including the necessary care and 2,007
treatment of medically diagnosed congenital defects and birth 2,008
abnormalities. 2,009
If payment of a specific premium is required to provide 2,011
coverage for an additional child, the certificate or policy may 2,012
require that notification of birth of a newly born child and 2,013
44
payment of the required premium must be furnished to the insurer 2,014
within thirty-one days after the date of birth in order to have 2,015
the coverage continue beyond such period. 2,016
The requirements of this section apply to all such 2,018
individual or group sickness and accident insurance policies 2,019
delivered or issued for delivery in this state on or after 2,020
January 1, 1975, and all such individual or group sickness and 2,021
accident insurance policies renewed in this state on or after 2,022
January 1, 1978. 2,023
Sec. 3923.40. No individual or group policy of sickness 2,032
and accident insurance providing THAT MAKES family coverage 2,033
AVAILABLE may be delivered, issued for delivery, or renewed in 2,035
this state on or after January 1, 1989, unless the policy covers
adopted children of the insured on the same basis as other 2,036
dependents.
The coverage required by this section is subject to the 2,038
requirements and restrictions set forth in section 3924.51 of the 2,039
Revised Code. 2,040
Sec. 3923.57. Notwithstanding any provision of this 2,049
chapter, every individual policy of sickness and accident 2,050
insurance that is delivered, issued for delivery, or renewed in 2,051
this state is subject to the following conditions, as applicable: 2,052
(A) Pre-existing conditions provisions shall not exclude 2,054
or limit coverage for a period beyond twelve months following the 2,055
policyholder's effective date of coverage and may only relate to 2,056
conditions during the six months immediately preceding the 2,057
effective date of coverage. 2,058
(B) In determining whether a pre-existing conditions 2,060
provision applies to a policyholder or dependent, each policy 2,061
shall credit the time the policyholder or dependent was covered 2,062
under a previous policy, contract, or plan if the previous 2,064
coverage was continuous to a date not more than thirty days prior 2,066
to the effective date of the new coverage, exclusive of any 2,067
applicable service waiting period under the policy. 2,068
45
(C) Any such policy shall be renewable with respect to the 2,070
policyholder, or dependents of the policyholder, at the option of 2,071
the policyholder, except for any of the following reasons: 2,072
(1) Nonpayment of the required premiums by the 2,074
policyholder; 2,075
(2) Fraud or misrepresentation of the policyholder; 2,077
(3) When the insurer ceases to do the business of 2,079
individual sickness and accident insurance in this state, 2,080
provided that all of the following conditions are met: 2,081
(a) Notice of the decision to cease doing the business of 2,083
individual sickness and accident insurance is provided to the 2,084
department of insurance and the policyholder. 2,085
(b) An individual policy shall not be canceled by the 2,087
insurer for ninety days after the date of the notice required 2,089
under division (C)(3)(a) of this section unless the business has 2,090
been sold to another insurer. 2,091
(c) An insurer that ceases to do the business of 2,093
individual sickness and accident insurance in this state shall 2,094
not resume such business in this state for a period of five years 2,095
from the date of the notice required under division (C)(3)(a) of 2,096
this section (1) EXCEPT AS OTHERWISE PROVIDED IN DIVISION (C) OF 2,098
THIS SECTION, AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND 2,099
ACCIDENT INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR 2,100
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 2,101
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF AN 2,104
INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE OF 2,105
THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR CONTRIBUTIONS 2,108
IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE INSURER HAS NOT 2,109
RECEIVED TIMELY PREMIUM PAYMENTS.
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE THAT 2,112
CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION OF 2,113
MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN THE 2,116
46
INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION (D) OF THIS SECTION 2,117
AND THE APPLICABLE LAWS OF THIS STATE. 2,118
(d) IF THE INSURER OFFERS COVERAGE IN THE MARKET THROUGH A 2,121
NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES, LIVES, OR WORKS 2,122
IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE INSURER IS 2,123
AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT SUCH COVERAGE 2,124
IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY HEALTH 2,125
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e) IF THE COVERAGE IS MADE AVAILABLE IN THE INDIVIDUAL 2,128
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS, THE 2,129
MEMBERSHIP OF THE INDIVIDUAL IN THE ASSOCIATION, ON THE BASIS OF 2,130
WHICH THE COVERAGE IS PROVIDED, CEASES; PROVIDED, HOWEVER, THAT 2,131
SUCH COVERAGE IS TERMINATED UNDER DIVISION (C)(2)(e) OF THIS 2,134
SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH STATUS-RELATED 2,135
FACTOR OF COVERED INDIVIDUALS.
(D)(1) IF AN INSURER DECIDES TO DISCONTINUE OFFERING A 2,138
PARTICULAR TYPE OF HEALTH INSURANCE COVERAGE OFFERED IN THE 2,139
INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE MAY BE DISCONTINUED BY 2,140
THE INSURER IF THE INSURER DOES ALL OF THE FOLLOWING: 2,141
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED COVERAGE 2,144
OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT LEAST 2,145
NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF THE 2,146
COVERAGE;
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE OF THIS 2,149
TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER INDIVIDUAL 2,150
HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY THE INSURER 2,151
FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF 2,154
THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE UNDER DIVISION 2,156
(D)(1)(b) OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY 2,157
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF 2,158
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE. 2,159
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL 2,161
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS STATE, 2,163
47
HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE INSURER ONLY 2,164
IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE DEPARTMENT OF 2,167
INSURANCE AND TO EACH INDIVIDUAL OF THE DISCONTINUATION AT LEAST 2,168
ONE HUNDRED EIGHTY DAYS PRIOR TO THE DATE OF THE EXPIRATION OF 2,169
THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED FOR DELIVERY 2,172
IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND COVERAGE UNDER 2,173
THAT HEALTH INSURANCE IN THAT MARKET IS NOT RENEWED. 2,174
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION 2,177
(D)(2) OF THIS SECTION IN THE INDIVIDUAL MARKET, THE INSURER 2,178
SHALL NOT PROVIDE FOR THE ISSUANCE OF ANY HEALTH INSURANCE 2,179
COVERAGE IN THE MARKET AND THIS STATE DURING THE FIVE-YEAR PERIOD 2,180
BEGINNING ON THE DATE OF THE DISCONTINUATION OF THE LAST HEALTH 2,181
INSURANCE COVERAGE NOT SO RENEWED. 2,182
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 2,185
section, both of the following apply:
(1) The benefit structure of any such policy may be 2,188
changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new 2,189
individual insureds. 2,190
(2) Any such policy may be rescinded for fraud, material 2,192
misrepresentation, or concealment by an applicant, policyholder, 2,193
or dependent AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, 2,195
MODIFY THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO 2,196
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS 2,197
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM 2,198
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM. 2,199
(F) SUCH POLICIES ARE SUBJECT TO SECTIONS 2743 AND 2747 OF 2,202
THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 2,206
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-43 2,212
AND 300gg-47, AS AMENDED. 2,213
(G) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 2,217
SHALL APPLY TO SICKNESS AND ACCIDENT INSURANCE POLICIES OFFERED 2,218
48
IN THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO 2,219
HEALTH BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 2,220
IN ACCORDANCE WITH 45 C.F.R. 148.102, DIVISIONS (C) TO (G) 2,225
OF THIS SECTION ALSO APPLY TO ALL GROUP SICKNESS AND ACCIDENT 2,226
INSURANCE POLICIES THAT ARE NOT SOLD IN CONNECTION WITH AN 2,227
EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT PROVIDE MORE THAN 2,228
SHORT-TERM, LIMITED DURATION COVERAGE. 2,229
IN APPLYING DIVISIONS (C) TO (G) OF THIS SECTION WITH 2,233
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY AN 2,235
INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH ONE 2,236
OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER. 2,237
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS THE 2,240
SAME MEANING AS IN SECTION 3924.03 OF THE REVISED CODE, AND 2,242
"HEALTH-STATUS RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME 2,243
MEANINGS AS IN SECTION 3924.031 OF THE REVISED CODE. 2,245
This section does not apply to any policy that provides 2,247
coverage for specific diseases or accidents only, or to any 2,248
hospital indemnity, medicare supplement, long-term care, 2,249
disability income, one-time-limited-duration policy of no longer 2,250
than six months, or other policy that offers only supplemental 2,251
benefits. 2,252
Sec. 3923.571. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2,254
2721 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 2,259
OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 2,265
300gg-21, AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP 2,266
POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE SOLD IN
CONNECTION WITH AN EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT 2,267
ARE NOT SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 2,268
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF 2,270
DIVISION (A) OF SECTION 3924.03 AND SECTION 3924.033 OF THE 2,272
REVISED CODE.
(B) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 2,276
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 2,280
49
AN INSURER OFFERS COVERAGE IN THE SMALL OR LARGE GROUP MARKET IN 2,281
CONNECTION WITH A GROUP POLICY, THE INSURER SHALL RENEW OR 2,282
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE 2,283
POLICYHOLDER.
(C)(1) NO SUCH POLICY, OR INSURER OFFERING HEALTH 2,285
INSURANCE COVERAGE IN CONNECTION WITH SUCH A POLICY, SHALL 2,287
REQUIRE ANY INDIVIDUAL, AS A CONDITION OF COVERAGE OR CONTINUED 2,288
COVERAGE UNDER THE POLICY, TO PAY A PREMIUM OR CONTRIBUTION THAT 2,289
IS GREATER THAN THE PREMIUM OR CONTRIBUTION FOR A SIMILARLY 2,290
SITUATED INDIVIDUAL COVERED UNDER THE POLICY ON THE BASIS OF ANY 2,291
HEALTH STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO 2,292
AN INDIVIDUAL COVERED UNDER THE POLICY AS A DEPENDENT OF THE 2,293
INDIVIDUAL. 2,294
(2) NOTHING IN DIVISION (C)(1) OF THIS SECTION SHALL BE 2,297
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 2,298
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY, 2,299
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM 2,300
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE 2,301
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO 2,302
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION. 2,303
(D) SUCH POLICIES SHALL PROVIDE FOR THE SPECIAL ENROLLMENT 2,306
PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH INSURANCE 2,310
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 2,312
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 2,321
of the Revised Code: 2,322
(1) "Case characteristics," "eligible employee," "health 2,324
HEALTH benefit plan," "late enrollee," AND "MEWA," and 2,326
"pre-existing conditions provision" have the same meanings as in 2,327
section 3924.01 of the Revised Code. 2,328
(2) "Insurer" means any sickness and accident insurance 2,330
company authorized to issue health benefit plans DO BUSINESS in 2,331
this state, or MEWA authorized to issue insured health benefit 2,333
plans in this state. "Insurer" does not include any health 2,334
insuring corporation that is owned or operated by an insurer. 2,336
50
(3) "Small employer" means any person, firm, corporation, 2,338
or partnership actively engaged in business whose total employed 2,339
work force, on at least fifty per cent of its working days during 2,340
the preceding year, consisted of at least two unrelated eligible 2,341
employees but no more than twenty-five eligible employees, the 2,342
majority of whom were employed within this state. In determining 2,343
the number of eligible employees, companies that are affiliated 2,344
companies or that are eligible to file a combined tax return for 2,345
purposes of state taxation shall be considered one employer. In 2,346
determining whether the members of an association are small 2,347
employers, each member of the association shall be considered as 2,348
a separate person, firm, corporation, or partnership. 2,349
(4) "Small employer group" means any group consisting of 2,351
all of the eligible employees of a small employer, except those 2,352
employees who are covered, or are eligible for coverage, under 2,353
any other private or public health benefits arrangement, 2,354
including the medicare program established under Title XVIII of 2,355
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 2,356
as amended, or any other act of congress or law of this or any 2,357
other state of the United States that provides benefits 2,358
comparable to the benefits provided under this section 2,359
PRE-EXISTING CONDITIONS PROVISION" MEANS A POLICY PROVISION THAT 2,362
EXCLUDES OR LIMITS COVERAGE FOR CHARGES OR EXPENSES INCURRED 2,363
DURING A SPECIFIED PERIOD FOLLOWING THE INSURED'S EFFECTIVE DATE 2,364
OF COVERAGE AS TO A CONDITION WHICH, DURING A SPECIFIED PERIOD 2,365
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE, HAD 2,366
MANIFESTED ITSELF IN SUCH A MANNER AS WOULD CAUSE AN ORDINARILY 2,367
PRUDENT PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,368
TREATMENT OR FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,369
TREATMENT WAS RECOMMENDED OR RECEIVED, OR A PREGNANCY EXISTING ON 2,370
THE EFFECTIVE DATE OF COVERAGE.
(B) Beginning in January of each year, insurers IN THE 2,373
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 2,374
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 2,376
51
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 2,377
3923.122 OF THE REVISED CODE, shall accept applicants for open 2,381
enrollment coverage, as set forth in divisions (B)(1) and (2) of 2,382
this section DIVISION, in the order in which they apply for 2,384
coverage and subject to the limitation set forth in division (G) 2,385
of this section:. INSURERS
(1) Insurers in the business of issuing health benefit 2,387
plans to small employer groups shall accept small employer groups 2,388
for which coverage is not otherwise available and for whom 2,389
coverage had not been terminated by the employer or by an 2,390
insurer, health maintenance organization, or health insuring 2,392
corporation during the preceding twelve-month period;
(2) Insurers in the business of issuing individual 2,394
policies of sickness and accident insurance as contemplated by 2,395
section 3923.021 of the Revised Code, except individual policies 2,396
issued pursuant to section 3923.122 of the Revised Code, shall 2,397
either accept individuals pursuant to the open enrollment 2,398
requirements of section 3941.53 of the Revised Code, if subject 2,399
to that section, or accept for coverage pursuant to this section 2,401
individuals to whom both of the following conditions apply: 2,402
(a)(1) The individual is not applying for coverage as an 2,404
employee of an employer, as a member of an association, or as a 2,405
member of any other group. 2,406
(b)(2) The individual is not covered, and is not eligible 2,408
for coverage, under any other private or public health benefits 2,409
arrangement, including the medicare program established under 2,410
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,411
U.S.C.A. 301, as amended, or any other act of congress or law of 2,412
this or any other state of the United States that provides 2,413
benefits comparable to the benefits provided under this section, 2,414
any medicare supplement policy, or any conversion or continuation 2,415
of coverage policy under state or federal law. 2,416
(C) An insurer shall offer to any individual or small 2,418
employer group accepted under this section the small employer 2,420
52
health care plan established by the board of directors of the 2,421
Ohio small employer health reinsurance program under division (A) 2,423
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 2,424
plan in benefit plan design and scope of covered services. 2,425
An insurer may offer other health benefit plans in addition 2,427
to, but not in lieu of, the plan required to be offered under 2,428
this division. These additional health benefit plans shall 2,429
provide, at a minimum, the coverage provided by the small 2,430
employer health care plan or any health benefit plan that is 2,431
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 2,432
For purposes of this division, the superintendent of 2,434
insurance shall determine whether a health benefit plan is 2,435
substantially similar to the small employer health care plan in 2,436
benefit plan design and scope of covered services. 2,437
(D) Health benefit plans issued under this section may 2,439
establish pre-existing conditions provisions that exclude or 2,440
limit coverage for a period of up to twelve months following the 2,441
individual's effective date of coverage and that may relate only 2,442
to conditions during the six months immediately preceding the 2,443
effective date of coverage. However, an insurer may exclude a 2,444
late enrollee for a period of up to eighteen months following the 2,445
individual's date of application for coverage. 2,446
(E) Premiums charged to groups or individuals under this 2,448
section may not exceed an amount that is two and one-half times 2,449
the highest rate charged any other group with similar case 2,450
characteristics or any other individual to which the insurer is 2,451
currently accepting new business, and for which similar 2,452
copayments and deductibles are applied. 2,453
(F) In offering health benefit plans under this section, 2,455
an insurer may require the purchase of health benefit plans that 2,456
condition the reimbursement of health services upon the use of a 2,457
specific network of providers. 2,458
53
(G)(1) In no event shall an insurer be required to accept 2,460
annually under this section either individuals or small employer 2,461
groups that WHO, in the aggregate, would cause the insurer to 2,462
have a total number of new insureds that is more than one-half 2,464
per cent of its total number of insured individuals in this state 2,465
per year, as contemplated by section 3923.021 of the Revised 2,466
Code, and small group certificate holders of health benefit plans 2,467
in this state per year, calculated as of the immediately 2,469
preceding thirty-first day of December and excluding the 2,470
insurer's medicare supplement policies and conversion or 2,471
continuation of coverage policies under state or federal law and 2,472
any policies described in division (N)(M) of this section. If an 2,473
insurer is subject to, and elects to operate under, the 2,475
individual open enrollment requirements of section 3941.53 of the 2,476
Revised Code, in no event shall the insurer be required to accept 2,477
annually under this section small employer groups that would 2,478
cause the insurer to have a total number of new insureds that is 2,479
more than one-half per cent of its total number of small group 2,480
certificate holders calculated as set forth in division (G)(1) of 2,481
this section.
(2) An officer of the insurer shall certify to the 2,483
department of insurance when it has met the enrollment limit set 2,484
forth in division (G)(1) of this section. Upon providing such 2,485
certification, the insurer shall be relieved of its open 2,486
enrollment requirement under this section for the remainder of 2,487
the calendar year. 2,488
(H) An insurer shall not be required to accept under this 2,490
section applicants who, at the time of enrollment, are confined 2,491
to a health care facility because of chronic illness, permanent 2,492
injury, or other infirmity that would cause economic impairment 2,493
to the insurer if the applicants were accepted, or to make the 2,494
effective date of benefits for individuals or groups accepted 2,495
under this section earlier than ninety days after the date of 2,496
acceptance. 2,497
54
(I) The requirements of this section do not apply to any 2,499
insurer that is currently in a state of supervision, insolvency, 2,500
or liquidation. If an insurer demonstrates to the satisfaction 2,501
of the superintendent that the requirements of this section would 2,503
place the insurer in a state of supervision, insolvency, or 2,504
liquidation, the superintendent may waive or modify the 2,505
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 2,507
a period of not more than one year. At the expiration of such 2,508
time, a new showing of need for a waiver or modification by the 2,509
insurer shall be made before a new waiver or modification is 2,510
issued or imposed.
(J) No hospital, health care facility, or health care 2,512
practitioner, and no person who employs any health care 2,513
practitioner, shall balance bill any individual or dependent of 2,514
an individual or any eligible employee or dependent of an 2,516
employee for any health care supplies or services provided to the
individual or dependent or the eligible employee or dependent, 2,517
who is insured under a policy or enrolled under a health benefit 2,519
plan issued under this section. The hospital, health care 2,520
facility, or health care practitioner, or any person that employs 2,521
the health care practitioner, shall accept payments made to it by 2,522
the insurer under the terms of the policy or contract insuring or 2,524
covering such individual as payment in full for such health care 2,525
supplies or services. 2,526
As used in this division, "hospital" has the same meaning 2,528
as in section 3727.01 of the Revised Code; "health care 2,529
practitioner" has the same meaning as in section 4769.01 of the 2,530
Revised Code; and "balance bill" means charging or collecting an 2,531
amount in excess of the amount reimbursable or payable under the 2,532
policy or health care service contract issued to an individual or 2,533
group under this section for such health care supply or service. 2,534
"Balance bill" does not include charging for or collecting 2,535
copayments or deductibles required by the policy or contract. 2,536
55
(K) An insurer shall pay an agent a commission in the 2,538
amount of five per cent of the premium charged for initial 2,539
placement or for otherwise securing the issuance of a policy or 2,540
contract issued to an individual or small employer group under 2,541
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 2,542
adopt, in accordance with Chapter 119. of the Revised Code, such 2,543
rules as are necessary to enforce this division. 2,544
(L) Except as otherwise provided in this section, sections 2,546
3924.01 to 3924.06 of the Revised Code apply to all health 2,547
benefit plans issued under this section. 2,548
(M) Individuals accepted for coverage under this section 2,550
may be issued contracts and certificates subject to the 2,551
requirements of section 3923.12 of the Revised Code. The 2,552
coverage issued to such individuals is not subject to the 2,553
requirements of section 3923.021 of the Revised Code. 2,554
(N)(M) This section does not apply to any policy that 2,556
provides coverage for specific diseases or accidents only, or to 2,558
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 2,560
than six months, or other policy that offers only supplemental 2,561
benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION: 2,563
(1) "CARRIER," "HEALTH BENEFIT PLAN," "MEWA," AND 2,565
"PRE-EXISTING CONDITIONS PROVISION" HAVE THE SAME MEANINGS AS IN 2,567
SECTION 3924.01 OF THE REVISED CODE.
(2) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE 2,569
INDIVIDUAL AS DEFINED IN 45 C.F.R. 148.103. 2,570
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 2,571
FOLLOWING:
(a) HEALTH STATUS; 2,573
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 2,575
ILLNESSES; 2,576
(c) CLAIMS EXPERIENCE; 2,578
56
(d) RECEIPT OF HEALTH CARE; 2,580
(e) MEDICAL HISTORY; 2,582
(f) GENETIC INFORMATION; 2,584
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 2,586
OUT OF ACTS OF DOMESTIC VIOLENCE; 2,587
(h) DISABILITY. 2,589
(4) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR 2,591
CASE CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE 2,592
APPLICABLE CARRIER FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF 2,593
THE APPLICABLE BASE PREMIUM RATE AND THE CORRESPONDING HIGHEST 2,594
PREMIUM RATE.
(5) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 2,596
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 2,597
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 2,598
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 2,599
UNDER CONTRACT WITH THE CARRIER.
(B) BEGINNING IN JANUARY OF EACH YEAR, CARRIERS IN THE 2,601
BUSINESS OF ISSUING HEALTH BENEFIT PLANS TO INDIVIDUALS OR 2,602
NONEMPLOYER GROUPS SHALL ACCEPT FEDERALLY ELIGIBLE INDIVIDUALS 2,603
FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS SECTION, IN THE 2,604
ORDER IN WHICH THEY APPLY FOR COVERAGE AND SUBJECT TO THE 2,605
LIMITATION SET FORTH IN DIVISION (J) OF THIS SECTION. 2,606
(C) NO CARRIER SHALL DO EITHER OF THE FOLLOWING: 2,608
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT 2,610
OF, SUCH INDIVIDUALS; 2,611
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH 2,613
COVERAGE.
(D) A CARRIER SHALL OFFER TO FEDERALLY ELIGIBLE 2,615
INDIVIDUALS THE BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD 2,616
OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS 2,617
SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT 2,619
DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF THIS 2,620
DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER 2,621
A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
57
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 2,622
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY 2,624
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED 2,625
ANY OTHER INDIVIDUAL TO WHICH THE CARRIER IS CURRENTLY ACCEPTING 2,626
NEW BUSINESS, AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES 2,627
ARE APPLIED.
(F) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE 2,629
INDIVIDUAL MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 2,630
OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY 2,632
APPLY FOR SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE 2,633
SERVICE AREA OF THE NETWORK PLAN; 2,635
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 2,637
COVERAGE TO FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS 2,638
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,639
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 2,641
SERVICES ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE 2,642
CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS AND 2,643
INDIVIDUALS.
(b) THE CARRIER IS APPLYING DIVISION (F)(2) OF THIS 2,645
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT 2,646
REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS. 2,647
(G) A CARRIER THAT, PURSUANT TO DIVISION (F)(2) OF THIS 2,650
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF 2,651
A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET 2,652
WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS 2,653
AFTER THE DATE THE COVERAGE IS DENIED. 2,654
(H) A CARRIER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO 2,656
FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS DEMONSTRATED 2,657
BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,658
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 2,660
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 2,661
(2) THE CARRIER IS APPLYING DIVISION (H) OF THIS SECTION 2,663
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE 2,664
58
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND 2,665
WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 2,666
THOSE INDIVIDUALS.
(I) A CARRIER THAT, PURSUANT TO DIVISION (H) OF THIS 2,668
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY 2,669
ELIGIBLE INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 2,670
INDIVIDUAL MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY 2,671
DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE CARRIER 2,673
HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER HAS 2,674
SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER. 2,675
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 2,678
SECTION, A CARRIER SHALL NOT BE REQUIRED TO ACCEPT ANNUALLY UNDER 2,680
THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS WHO, IN THE 2,681
AGGREGATE, WOULD CAUSE THE CARRIER TO HAVE A TOTAL NUMBER OF NEW 2,682
INSUREDS THAT IS MORE THAN ONE-HALF PER CENT OF ITS TOTAL NUMBER 2,683
OF INSURED INDIVIDUALS AND NONEMPLOYER GROUPS IN THIS STATE PER 2,684
YEAR, CALCULATED AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY
OF DECEMBER AND EXCLUDING THE CARRIER'S MEDICARE SUPPLEMENT 2,686
POLICIES AND CONVERSION OR CONTINUATION OF COVERAGE POLICIES 2,688
UNDER STATE OR FEDERAL LAW AND ANY POLICIES DESCRIBED IN DIVISION 2,689
(M) OF SECTION 3923.58 OF THE REVISED CODE. 2,690
(2) AN OFFICER OF THE CARRIER SHALL CERTIFY TO THE 2,692
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET 2,693
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH 2,694
CERTIFICATION, THE CARRIER SHALL BE RELIEVED OF ITS OPEN 2,695
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF 2,696
THE CALENDAR YEAR UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, 2,698
ALL THE CARRIERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET 2,699
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,701
SECTION. IN THAT EVENT, CARRIERS SHALL AGAIN ACCEPT APPLICANTS 2,702
FOR OPEN ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO 2,703
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,705
SECTION.
59
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 2,707
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 2,708
(L) THE REQUIREMENTS OF THIS SECTION DO NOT APPLY TO ANY 2,710
HEALTH BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 2,711
OF THE REVISED CODE.
Sec. 3923.59. Any insurer may reinsure coverage of any 2,720
individual, small employer group, or member of that NONEMPLOYER 2,721
group acquired under section 3923.58 OR 3923.581 of the Revised 2,724
Code with the Ohio small employer health OPEN ENROLLMENT 2,725
reinsurance program in accordance with division (G) of section 2,727
3924.11 of the Revised Code. Premium rates charged for coverage 2,728
reinsured by the program shall be established in accordance with 2,729
section 3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the 2,738
Revised Code, each individual or group policy of sickness and 2,740
accident insurance delivered, issued for delivery, or renewed in 2,741
this state that provides maternity benefits shall provide
coverage of inpatient care and follow-up care for a mother and 2,742
her newborn as follows:
(1) The policy shall cover a minimum of forty-eight 2,745
SEVENTY-TWO hours of inpatient care following a normal vaginal 2,746
delivery and a minimum of ninety-six hours of inpatient care 2,748
following a cesarean delivery. Services covered as inpatient 2,749
care shall include medical, educational, and any other services 2,750
that are consistent with the inpatient care recommended in the 2,751
protocols and guidelines developed by national organizations that 2,752
represent pediatric, obstetric, and nursing professionals. 2,753
(2) The policy shall cover a physician-directed source of 2,755
follow-up care. Services covered as follow-up care shall include 2,756
physical assessment of the mother and newborn, parent education, 2,757
assistance and training in breast or bottle feeding, assessment 2,758
of the home support system, performance of any medically 2,759
necessary and appropriate clinical tests, and any other services 2,760
that are consistent with the follow-up care recommended in the 2,761
60
protocols and guidelines developed by national organizations that 2,763
represent pediatric, obstetric, and nursing professionals. The 2,764
coverage shall apply to services provided in a medical setting or 2,765
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,766
conducts the visit is knowledgeable and experienced in maternity 2,767
and newborn care.
When a decision is made in accordance with division (B) of 2,769
this section to discharge a mother or newborn prior to the 2,770
expiration of the applicable number of hours of inpatient care 2,771
required to be covered, the coverage of follow-up care shall 2,772
apply to all follow-up care that is provided within forty-eight 2,773
hours after discharge. When a mother or newborn receives at 2,775
least the number of hours of inpatient care required to be
covered, the coverage of follow-up care shall apply to follow-up 2,776
care that is determined to be medically necessary by the health 2,777
care professionals responsible for discharging the mother or 2,778
newborn.
(B) Any decision to shorten the length of inpatient stay 2,781
to less than that specified under division (A)(1) of this section 2,783
shall be made by the physician attending the mother or newborn, 2,784
except that if a nurse-midwife is attending the mother in 2,785
collaboration with a physician, the decision may be made by the 2,786
nurse-midwife. Decisions regarding early discharge shall be made 2,787
only after conferring with the mother or a person responsible for 2,788
the mother or newborn. For purposes of this division, a person 2,789
responsible for the mother or newborn may include a parent, 2,790
guardian, or any other person with authority to make medical 2,791
decisions for the mother or newborn.
(C)(1) No sickness and accident insurer may do either of 2,794
the following:
(a) Terminate the participation of a health care 2,797
professional or health care facility as a provider under a
sickness and accident insurance policy solely for making 2,798
61
recommendations for inpatient or follow-up care for a particular 2,799
mother or newborn that are consistent with the care required to 2,800
be covered by this section; 2,801
(b) Establish or offer monetary or other financial 2,804
incentives for the purpose of encouraging a person to decline the 2,805
inpatient or follow-up care required to be covered by this 2,806
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,810
section has engaged in an unfair and deceptive act or practice in 2,811
the business of insurance under sections 3901.19 to 3901.26 of 2,812
the Revised Code. 2,814
(D) This section does not do any of the following: 2,817
(1) Require a policy to cover inpatient or follow-up care 2,820
that is not received in accordance with the policy's terms 2,821
pertaining to the health care professionals and facilities from 2,822
which an individual is authorized to receive health care 2,823
services.;
(2) Require a mother or newborn to stay in a hospital or 2,826
other inpatient setting for a fixed period of time following
delivery; 2,827
(3) Require a child to be delivered in a hospital or other 2,830
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,832
authority to practice nurse-midwifery in accordance with Chapter 2,834
4723. of the Revised Code; 2,836
(5) Establish minimum standards of medical diagnosis, care 2,839
or treatment for inpatient or follow-up care for a mother or 2,840
newborn. A deviation from the care required to be covered under 2,841
this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those 2,842
terms are defined in section 2305.11 of the Revised Code. 2,845
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the 2,854
Revised Code, each public employee benefit plan established or 2,856
modified in this state that provides maternity benefits shall 2,857
62
provide coverage of inpatient care and follow-up care for a 2,858
mother and her newborn as follows: 2,859
(1) The plan shall cover a minimum of forty-eight hours of 2,861
inpatient care following a normal vaginal delivery and a minimum 2,863
of ninety-six hours of inpatient care following a cesarean 2,864
delivery. Services covered as inpatient care shall include 2,865
medical, educational, and any other services that are consistent 2,866
with the inpatient care recommended in the protocols and 2,867
guidelines developed by national organizations that represent 2,868
pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of 2,870
follow-up care. Services covered as follow-up care shall include 2,871
physical assessment of the mother and newborn, parent education, 2,872
assistance and training in breast or bottle feeding, assessment 2,873
of the home support system, performance of any medically 2,874
necessary and appropriate clinical tests, and any other services 2,875
that are consistent with the follow-up care recommended in the 2,876
protocols and guidelines developed by national organizations that 2,878
represent pediatric, obstetric, and nursing professionals. The 2,879
coverage shall apply to services provided in a medical setting or 2,880
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,881
conducts the visit is knowledgeable and experienced in maternity 2,882
and newborn care.
When a decision is made in accordance with division (B) of 2,884
this section to discharge a mother or newborn prior to the 2,885
expiration of the applicable number of hours of inpatient care 2,886
required to be covered, the coverage of follow-up care shall 2,887
apply to all follow-up care that is provided within forty-eight 2,888
SEVENTY-TWO hours after discharge. When a mother or newborn 2,889
receives at least the number of hours of inpatient care required 2,890
to be covered, the coverage of follow-up care shall apply to 2,891
follow-up care that is determined to be medically necessary by 2,892
the health care professionals responsible for discharging the 2,893
63
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,896
to less than that specified under division (A)(1) of this section 2,898
shall be made by the physician attending the mother or newborn, 2,899
except that if a nurse-midwife is attending the mother in 2,900
collaboration with a physician, the decision may be made by the 2,901
nurse-midwife. Decisions regarding early discharge shall be made 2,902
only after conferring with the mother or a person responsible for 2,903
the mother or newborn. For purposes of this division, a person 2,904
responsible for the mother or newborn may include a parent, 2,905
guardian, or any other person with authority to make medical 2,906
decisions for the mother or newborn.
(C)(1) No public employer who offers an employee benefit 2,909
plan may do either of the following: 2,910
(a) Terminate the participation of a health care 2,913
professional or health care facility as a provider under the plan 2,914
solely for making recommendations for inpatient or follow-up care 2,915
for a particular mother or newborn that are consistent with the 2,916
care required to be covered by this section; 2,917
(b) Establish or offer monetary or other financial 2,920
incentives for the purpose of encouraging a person to decline the 2,921
inpatient or follow-up care required to be covered by this 2,922
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,926
section has engaged in an unfair and deceptive act or practice in 2,927
the business of insurance under sections 3901.19 to 3901.26 of 2,928
the Revised Code. 2,930
(D) This section does not do any of the following: 2,933
(1) Require a plan to cover inpatient or follow-up care 2,936
that is not received in accordance with the plan's terms 2,937
pertaining to the health care professionals and facilities from 2,938
which an individual is authorized to receive health care 2,939
services.;
(2) Require a mother or newborn to stay in a hospital or 2,942
64
other inpatient setting for a fixed period of time following
delivery; 2,943
(3) Require a child to be delivered in a hospital or other 2,946
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,948
authority to practice nurse-midwifery in accordance with Chapter 2,950
4723. of the Revised Code; 2,952
(5) Establish minimum standards of medical diagnosis, 2,954
care, or treatment for inpatient or follow-up care for a mother 2,955
or newborn. A deviation from the care required to be covered 2,956
under this section shall not, solely on the basis of this 2,957
section, give rise to a medical claim or derivative medical 2,958
claim, as those terms are defined in section 2305.11 of the 2,959
Revised Code. 2,961
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 2,970
the Revised Code: 2,971
(A) "Actuarial certification" means a written statement 2,973
prepared by a member of the American academy of actuaries, or by 2,974
any other person acceptable to the superintendent of insurance, 2,975
that states that, based upon the person's examination, a carrier 2,976
offering health benefit plans to small employers is in compliance 2,977
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 2,978
certification" shall include a review of the appropriate records 2,979
of, and the actuarial assumptions and methods used by, the 2,980
carrier relative to establishing premium rates for the health 2,981
benefit plans. 2,982
(B) "Adjusted average market premium price" means the 2,984
average market premium price as determined by the board of 2,986
directors of the Ohio small employer health reinsurance program 2,987
either on the basis of the arithmetic mean of all carriers' 2,988
premium rates for an SEHC plan sold to groups with similar case 2,989
characteristics by all carriers selling SEHC plans in the state, 2,991
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 2,993
65
plan that is issued by a carrier and that covers at least two but 2,994
no more than fifty employees of a small employer, the lowest 2,996
premium rate for a new or existing business prescribed by the 2,997
carrier for the same or similar coverage under a plan or 2,998
arrangement covering any small employer with similar case 2,999
characteristics.
(D) "Carrier" means any sickness and accident insurance 3,001
company or health insuring corporation authorized to issue health 3,004
benefit plans in this state or a MEWA. A sickness and accident 3,006
insurance company that owns or operates a health insuring 3,007
corporation, either as a separate corporation or as a line of 3,009
business, shall be considered as a separate carrier from that 3,010
health insuring corporation for purposes of sections 3924.01 to 3,012
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 3,014
employer, the geographic area in which the employees work; the 3,015
age and sex of the individual employees and their dependents; the 3,016
appropriate industry classification as determined by the carrier; 3,017
the number of employees and dependents; and such other objective 3,018
criteria as may be established by the carrier. "Case 3,019
characteristics" does not include claims experience, health 3,020
status, or duration of coverage from the date of issue. 3,021
(F) "Dependent" means the spouse or child of an eligible 3,023
employee, subject to applicable terms of the health benefits plan 3,024
covering the employee. 3,025
(G) "Eligible employee" means an employee who works a 3,027
normal work week of twenty-five or more hours. "Eligible 3,028
employee" does not include a temporary or substitute employee, or 3,030
a seasonal employee who works only part of the calendar year on 3,031
the basis of natural or suitable times or circumstances. 3,032
(H) "Financially impaired" means a program member that, 3,034
after April 14, 1993, is not insolvent but is determined by the 3,037
superintendent to be potentially unable to fulfill its 3,038
contractual obligations, or is placed under an order of 3,039
66
rehabilitation or conservation by a court of competent 3,040
jurisdiction or under an order of supervision by the 3,041
superintendent.
(I) "Health benefit plan" means any hospital or medical 3,043
expense policy or certificate or any health plan provided by a 3,045
carrier, that is delivered, issued for delivery, renewed, or used 3,047
in this state on or after the date occurring six months after 3,048
November 24, 1995. "Health benefit plan" does not include 3,050
policies covering only accident, credit, dental, disability 3,051
income, long-term care, hospital indemnity, medicare supplement, 3,052
specified disease, or vision care; coverage under a 3,053
one-time-limited-duration policy of no longer than six months; 3,055
coverage issued as a supplement to liability insurance; insurance 3,056
arising out of a workers' compensation or similar law; automobile 3,057
medical-payment insurance; or insurance under which benefits are 3,058
payable with or without regard to fault and which is statutorily 3,059
required to be contained in any liability insurance policy or 3,060
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 3,062
period immediately following any service waiting period 3,063
established by an employer. 3,064
(K)(I) "Late enrollee" means an eligible employee or 3,066
dependent who requests enrollment ENROLLS in a small employer's 3,067
health benefit plan following OTHER THAN DURING the initial 3,069
enrollment FIRST period provided under the terms of the first 3,071
plan for IN which the employee or dependent was IS eligible 3,072
through the small employer, unless any of the following apply: 3,074
(1) The individual: 3,076
(a) Was covered under another health benefit plan at the 3,079
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 3,081
coverage under another health benefit plan was the reason for 3,084
declining enrollment;
(c) Has lost coverage under another health benefit plan as 3,087
67
a result of the termination of employment, a reduction of hours 3,088
worked per week, the termination of the other plan's coverage, 3,089
death of a spouse, or divorce; and 3,090
(d) Requests enrollment within thirty days after the 3,092
termination of coverage under another health benefit plan. 3,093
(2) The individual is employed by an employer who offers 3,095
multiple health benefit plans and the individual elects a 3,096
different health benefit plan during an open enrollment period. 3,097
(3) A court has ordered coverage to be provided for a 3,099
spouse or minor child under a covered employee's plan and a 3,100
request for enrollment is made within thirty days after issuance 3,101
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 3,103
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,106
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. 3,112
NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg, AS AMENDED. 3,115
(L)(J) "MEWA" means any "multiple employer welfare 3,117
arrangement" as defined in section 3 of the "Federal Employee 3,118
Retirement Income Security Act of 1974," 88 Stat. 832, 29 3,119
U.S.C.A. 1001, as amended, except for any arrangement which is 3,120
fully insured as defined in division (b)(6)(D) of section 514 of 3,121
that act. 3,122
(M)(K) "Midpoint rate" means, for small employers with 3,124
similar case characteristics and plan designs and as determined 3,125
by the applicable carrier for a rating period, the arithmetic 3,126
average of the applicable base premium rate and the corresponding 3,127
highest premium rate. 3,128
(N)(L) "Pre-existing conditions provision" means a policy 3,130
provision that excludes or limits coverage for charges or 3,132
expenses incurred during a specified period following the 3,133
insured's effective ENROLLMENT date of coverage as to a condition 3,135
which, during a specified period immediately preceding the 3,136
effective date of coverage, had manifested itself in such a 3,137
manner as would cause an ordinarily prudent person to seek 3,138
medical advice, diagnosis, care, or treatment or for which 3,139
68
medical advice, diagnosis, care, or treatment was recommended or 3,140
received, or DURING a pregnancy existing on SPECIFIED PERIOD 3,142
IMMEDIATELY PRECEDING the effective ENROLLMENT date of coverage. 3,143
GENETIC INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN 3,145
THE ABSENCE OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH 3,146
INFORMATION.
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, 3,148
WITH RESPECT TO AN INDIVIDUAL COVERED UNDER A GROUP HEALTH 3,149
BENEFIT PLAN, THE DATE OF ENROLLMENT OF THE INDIVIDUAL IN THE 3,150
PLAN OR, IF EARLIER, THE FIRST DAY OF THE WAITING PERIOD FOR SUCH 3,152
ENROLLMENT.
(O)(M) "Service waiting period" means the period of time 3,154
after employment begins before an eligible employee may enroll in 3,156
IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any 3,157
applicable health benefit plan offered by the small employer.
(P)(N)(1) "Small employer" means any person, firm, 3,160
corporation, partnership, or association actively engaged in 3,161
business whose total, IN CONNECTION WITH A GROUP HEALTH BENEFIT 3,162
PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN YEAR, AN 3,163
EMPLOYER WHO employed work force consisted of, on at least fifty 3,164
per cent of its working days during the preceding year, AN 3,165
AVERAGE OF at least two but no more than fifty eligible 3,167
employees, the majority of whom were employed within the state ON 3,168
BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND WHO EMPLOYS 3,169
AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN YEAR.
(2) In determining the number of eligible employees for 3,171
FOR purposes of division (P)(N)(1) of this section, companies 3,172
which are affiliated companies or which are eligible to file a 3,174
combined tax return for purposes of state taxation ALL PERSONS 3,176
TREATED AS A SINGLE EMPLOYER UNDER SUBSECTION (b), (c), (m), OR 3,178
(o) OF SECTION 414 OF THE "INTERNAL REVENUE CODE OF 1986," 100 3,182
STAT. 2085, 26 U.S.C.A. 1, AS AMENDED, shall be considered one 3,185
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE 3,186
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF 3,187
69
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED 3,188
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS REASONABLY 3,190
EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN THE CURRENT 3,191
CALENDAR YEAR. ANY REFERENCE IN DIVISION (N) OF THIS SECTION TO 3,192
AN "EMPLOYER" INCLUDES ANY PREDECESSOR OF THE EMPLOYER. Except 3,194
as otherwise specifically provided, provisions of sections 3,195
3924.01 to 3924.14 of the Revised Code that apply to a small 3,196
employer that has a health benefit plan shall continue to apply 3,197
until the plan anniversary following the date the employer no 3,198
longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small employer health 3,201
care plan, which is a health benefit plan for small INDIVIDUALS 3,202
AND employers established by the board in accordance with section 3,204
3924.10 of the Revised Code. 3,205
Sec. 3924.02. (A) An individual or group health benefit 3,214
plan is subject to sections 3924.01 to 3924.14 of the Revised 3,215
Code if it provides health care benefits covering at least two 3,217
but no more than fifty employees of a small employer, and if it 3,218
meets either of the following conditions: 3,219
(1) Any portion of the premium or benefits is paid by a 3,221
small employer, or any covered individual is reimbursed, whether 3,222
through wage adjustments or otherwise, by a small employer for 3,223
any portion of the premium. 3,224
(2) The health benefit plan is treated by the employer or 3,226
any of the covered individuals as part of a plan or program for 3,227
purposes of section 106 or 162 of the "Internal Revenue Code of 3,228
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,229
(B) Notwithstanding division (A) of this section, 3,231
divisions (D), (E)(2), (F), AND (G) to (J) of section 3924.03 of 3,233
the Revised Code and section 3924.04 of the Revised Code do not 3,235
apply to health benefit policies that are not sold to owners of 3,236
small businesses as an employment benefit plan. Such policies 3,237
shall clearly state that they are not being sold as an employment 3,238
benefit plan and that the owner of the business is not 3,239
70
responsible, either directly or indirectly, for paying the 3,240
premium or benefits.
(C) Every health benefit plan offered or delivered by a 3,242
carrier, other than a health insuring corporation, to a small 3,244
employer is subject to sections 3923.23, 3923.231, 3923.232, 3,245
3923.233, and 3923.234 of the Revised Code and any other 3,246
provision of the Revised Code that requires the reimbursement, 3,247
utilization, or consideration of a specific category of a 3,248
licensed or certified health care practitioner. 3,249
(D) Except as expressly provided in sections 3924.01 to 3,251
3924.14 of the Revised Code, no health benefit plan offered to a 3,252
small employer is subject to any of the following: 3,253
(1) Any law that would inhibit any carrier from 3,255
contracting with providers or groups of providers with respect to 3,256
health care services or benefits; 3,257
(2) Any law that would impose any restriction on the 3,259
ability to negotiate with providers regarding the level or method 3,260
of reimbursing care or services provided under the health benefit 3,261
plan; 3,262
(3) Any law that would require any carrier to either 3,264
include a specific provider or class of provider when contracting 3,265
for health care services or benefits, or to exclude any class of 3,266
provider that is generally authorized by statute to provide such 3,267
care. 3,268
Sec. 3924.03. Health EXCEPT AS OTHERWISE PROVIDED IN 3,277
SECTION 2721 OF THE "HEALTH INSURANCE PORTABILITY AND 3,282
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 3,287
42 U.S.C.A. 300gg-21, AS AMENDED, HEALTH benefit plans covering 3,289
small employers are subject to the following conditions, as 3,290
applicable:
(A)(1) Pre-existing conditions provisions shall not 3,292
exclude or limit coverage for a period beyond twelve months, OR 3,293
EIGHTEEN MONTHS IN THE CASE OF A LATE ENROLLEE, following the 3,294
individual's effective ENROLLMENT date of coverage and may only 3,295
71
relate to conditions during A PHYSICAL OR MENTAL CONDITION, 3,297
REGARDLESS OF THE CAUSE OF THE CONDITION, FOR WHICH MEDICAL 3,299
ADVICE, DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED 3,300
WITHIN the six months immediately preceding the effective 3,302
ENROLLMENT date of coverage.
DIVISION (A)(1) OF THIS SECTION IS SUBJECT TO THE 3,305
EXCEPTIONS SET FORTH IN SECTION 2701(d) OF THE "HEALTH INSURANCE 3,308
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,311
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION 3,313
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF 3,314
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR 3,315
DEPENDENT AS OF THE ENROLLMENT DATE. 3,316
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE COUNTED, 3,319
WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A GROUP HEALTH 3,320
BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE ENROLLMENT 3,321
DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL OF WHICH THE 3,322
INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE COVERAGE. 3,323
SUBSECTIONS (c)(2) TO (4) AND (e) OF SECTION 2701 OF THE "HEALTH 3,325
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996" APPLY WITH 3,329
RESPECT TO CREDITING PREVIOUS COVERAGE. 3,330
(4) AS USED IN DIVISION (A) OF THIS SECTION: 3,333
(a) "CREDITABLE COVERAGE" HAS THE SAME MEANING AS IN 3,336
SECTION 2701(c)(1) OF THE "HEALTH INSURANCE PORTABILITY AND 3,340
ACCOUNTABILITY ACT OF 1996." 3,341
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN INDIVIDUAL 3,344
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF ENROLLMENT 3,345
OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE FIRST DAY OF 3,346
THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions 3,348
provision applies to an eligible employee or dependent, all 3,349
health benefit plans shall credit the time the person was covered 3,350
under a previous employer-based health benefit plan provided by a 3,351
carrier if the previous coverage was continuous to a date not 3,353
more than thirty days prior to the effective date of the new 3,355
72
coverage, exclusive of any applicable service waiting period 3,356
under the plan. 3,357
(C) Any such health benefit plan shall be renewable with 3,359
respect to all eligible employees or dependents at the option of 3,360
the policyholder, contract holder, or small employer, except for 3,361
any of the following reasons: 3,362
(1) Nonpayment of the required premiums by the 3,364
policyholder, contract holder, or employer; 3,365
(2) Fraud or misrepresentation of the policyholder, 3,367
contract holder, or employer or, with respect to coverage of 3,368
individual insureds, the insureds or their representatives ; 3,370
(3) When the total number of insured individuals covered 3,372
under all of the health benefit plans of any one employer is less 3,373
than the total number of individuals or percentage of individuals 3,374
required by participation requirements under any specific health 3,375
benefit plan of that employer; 3,376
(4) Noncompliance with any plan provision that has been 3,378
approved by the superintendent of insurance; 3,379
(5) When the carrier ceases doing business in the small 3,381
employer market, provided that all of the following conditions 3,382
are met: 3,383
(a) Notice of the decision to cease to do business in the 3,385
small employer market is provided to the department of insurance, 3,386
the board of directors of the Ohio small employer health 3,387
reinsurance program, the policyholder or contract holder, and the 3,388
employer. 3,389
(b) Health benefit plans subject to sections 3924.01 to 3,391
3924.14 of the Revised Code shall not be canceled by the carrier 3,392
for ninety days after the date of the notice required under 3,394
division (C)(5)(a) of this section unless the business has been 3,395
sold to another carrier or the cancellations are approved by the 3,396
superintendent. 3,397
(c) A carrier that ceases to do business in the small 3,399
employer marketplace is prohibited from re-entering the small 3,400
73
employer marketplace for a period of five years from the date of 3,401
the notice required under division (C)(5)(a) of this section. 3,402
(D) Notwithstanding division (C) of this section, any such 3,404
health benefit plan or any coverage provided to an individual 3,405
under such a plan may be rescinded for fraud, material 3,406
misrepresentation, or concealment by an applicant, employee, 3,407
dependent, or small employer. 3,408
(E) Every carrier doing business in the small employer 3,410
market may underwrite and rate small employer groups, as 3,411
permitted by sections 3924.01 to 3924.14 of the Revised Code, 3,412
using accepted underwriting and actuarial practices EXCEPT AS 3,413
PROVIDED IN SECTION 2712(b) TO (e) OF THE "HEALTH INSURANCE 3,419
PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF A CARRIER OFFERS 3,422
COVERAGE IN THE SMALL EMPLOYER MARKET IN CONNECTION WITH A GROUP 3,423
HEALTH BENEFIT PLAN, THE CARRIER SHALL RENEW OR CONTINUE IN FORCE 3,424
SUCH COVERAGE AT THE OPTION OF THE PLAN SPONSOR OF THE PLAN. 3,425
(F)(C) A carrier shall not exclude any eligible employee 3,427
or dependent, who would otherwise be covered under a health 3,428
benefit plan, on the basis of any actual or expected health 3,429
condition of the employee or dependent. However, a carrier may 3,430
exclude a late enrollee for a period of up to twenty-four months 3,431
or may, in the discretion of the carrier, extend coverage to the 3,432
late enrollee at any time during that period. A carrier also may 3,433
medically underwrite a late enrollee. 3,434
If, prior to the effective date of this amendment NOVEMBER 3,437
24, 1995, a carrier excluded an eligible employee or dependent, 3,438
other than a late enrollee, on the basis of an actual or expected 3,439
health condition, the carrier shall, upon the initial renewal of 3,440
the coverage on or after that date, extend coverage to the 3,441
employee or dependent if all other eligibility requirements are 3,442
met.
(G)(D) No health benefit plan issued by a carrier shall 3,445
limit or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 3,447
74
medical condition, or accident, except for pre-existing 3,448
conditions as permitted under division (A) of this section. If a 3,449
health benefit plan that is delivered or issued for delivery 3,451
prior to April 14, 1993, contains such limitations or exclusions, 3,453
by use of a rider or amendment applicable to a specific 3,454
individual, the plan shall eliminate the use of such riders or 3,455
amendments within eighteen months after April 14, 1993. 3,456
(H)(E)(1) EXCEPT AS PROVIDED IN SECTIONS 3924.031 AND 3,459
3924.032 OF THE REVISED CODE, AND SUBJECT TO SUCH RULES AS MAY BE 3,462
ADOPTED BY THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH 3,463
CHAPTER 119. OF THE REVISED CODE, A CARRIER SHALL OFFER EVERY 3,466
HEALTH BENEFIT PLAN THAT IT IS ACTIVELY MARKETING TO EVERY SMALL 3,467
EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH COVERAGE. 3,468
DIVISION (E)(1) OF THIS SECTION DOES NOT APPLY TO A HEALTH 3,471
BENEFIT PLAN THAT A CARRIER MAKES AVAILABLE IN THE SMALL EMPLOYER 3,472
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS. 3,473
DIVISION (E)(1) OF THIS SECTION SHALL NOT BE CONSTRUED TO 3,476
PRECLUDE A CARRIER FROM ESTABLISHING EMPLOYER CONTRIBUTION RULES 3,477
OR GROUP PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN 3,478
CONNECTION WITH A GROUP HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER 3,479
MARKET, AS ALLOWED UNDER THE LAW OF THIS STATE. AS USED IN 3,480
DIVISION (E)(1) OF THIS SECTION, "EMPLOYER CONTRIBUTION RULE" 3,482
MEANS A REQUIREMENT RELATING TO THE MINIMUM LEVEL OR AMOUNT OF 3,483
EMPLOYER CONTRIBUTION TOWARD THE PREMIUM FOR ENROLLMENT OF 3,484
EMPLOYEES AND DEPENDENTS AND "GROUP PARTICIPATION RULE" MEANS A 3,485
REQUIREMENT RELATING TO THE MINIMUM NUMBER OF EMPLOYEES OR 3,486
DEPENDENTS THAT MUST BE ENROLLED IN RELATION TO A SPECIFIED 3,487
PERCENTAGE OR NUMBER OF ELIGIBLE INDIVIDUALS OR EMPLOYEES OF AN 3,488
EMPLOYER.
(2) Each health benefit plan, at the time of initial group 3,490
enrollment, shall make coverage available to all the eligible 3,491
employees of a small employer without a service waiting period. 3,492
The decision of whether to impose a service waiting period shall 3,494
be made by the small employer. Such waiting periods shall not be 3,495
75
greater than ninety days. 3,496
(3) EACH HEALTH BENEFIT PLAN SHALL PROVIDE FOR THE SPECIAL 3,499
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,502
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,505
(I)(F) The benefit structure of any health benefit plan 3,508
may, AT THE TIME OF COVERAGE RENEWAL, be changed by the carrier 3,510
to make it consistent with the benefit structure contained in 3,511
health benefit plans being marketed to new small employer groups. 3,512
IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE SMALL EMPLOYER 3,514
MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW OF 3,516
THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL EMPLOYER 3,517
GROUP PLANS.
(J)(G) A carrier may obtain any facts and information 3,519
necessary to apply this section, or supply those facts and 3,520
information to any other third-party payer, without the consent 3,521
of the beneficiary. Each person claiming benefits under a health 3,522
benefit plan shall provide any facts and information necessary to 3,523
apply this section. 3,524
FOR PURPOSES OF THIS SECTION, "BONA FIDE ASSOCIATION" MEANS 3,527
AN ASSOCIATION THAT HAS BEEN ACTIVELY IN EXISTENCE FOR AT LEAST 3,528
FIVE YEARS; HAS BEEN FORMED AND MAINTAINED IN GOOD FAITH FOR 3,529
PURPOSES OTHER THAN OBTAINING INSURANCE; DOES NOT CONDITION 3,530
MEMBERSHIP IN THE ASSOCIATION ON ANY HEALTH STATUS-RELATED 3,531
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,533
RELATING TO AN INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; 3,534
MAKES HEALTH INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION 3,535
AVAILABLE TO ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED 3,536
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,539
RELATING TO SUCH MEMBERS OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE 3,540
THROUGH A MEMBER; DOES NOT MAKE HEALTH INSURANCE COVERAGE OFFERED 3,541
THROUGH THE ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A 3,542
MEMBER OF THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT 3,543
IMPOSED BY THE SUPERINTENDENT. TO MAINTAIN ITS STATUS AS A "BONA 3,544
76
FIDE ASSOCIATION," EACH ASSOCIATION SHALL ANNUALLY CERTIFY TO THE 3,545
SUPERINTENDENT THAT IT MEETS THE REQUIREMENTS OF THIS PARAGRAPH. 3,546
Sec. 3924.031. (A) AS USED IN THIS SECTION AND SECTION 3,549
3924.032 OF THE REVISED CODE: 3,551
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 3,553
FOLLOWING: 3,554
(a) HEALTH STATUS; 3,556
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 3,559
ILLNESSES;
(c) CLAIMS EXPERIENCE; 3,561
(d) RECEIPT OF HEALTH CARE; 3,563
(e) MEDICAL HISTORY; 3,565
(f) GENETIC INFORMATION; 3,567
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 3,570
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 3,572
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 3,574
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 3,575
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 3,576
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 3,578
UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE SMALL 3,581
EMPLOYER MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 3,582
OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH 3,584
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR 3,585
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN; 3,586
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 3,588
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH 3,589
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE: 3,590
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 3,593
SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL GROUPS 3,594
BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT 3,595
HOLDERS AND MEMBERS.
77
(b) THE CARRIER IS APPLYING DIVISION (B)(2) OF THIS 3,598
SECTION UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE 3,599
CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES 3,600
AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 3,601
SUCH EMPLOYEES AND DEPENDENTS. 3,602
(C) A CARRIER THAT, PURSUANT TO DIVISION (B)(2) OF THIS 3,606
SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE AREA 3,607
OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL EMPLOYER 3,608
MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY 3,609
DAYS AFTER THE DATE THE COVERAGE IS DENIED. 3,610
Sec. 3924.032. (A) A CARRIER MAY REFUSE TO ISSUE HEALTH 3,613
BENEFIT PLANS IN THE SMALL EMPLOYER MARKET IF THE CARRIER HAS 3,614
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT OF 3,615
INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 3,617
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 3,618
(2) THE CARRIER IS APPLYING DIVISION (A) OF THIS SECTION 3,621
UNIFORMLY TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS 3,622
STATE CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE 3,623
AND WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS 3,624
AND THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH 3,625
STATUS-RELATED FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS. 3,626
(B) A CARRIER THAT, PURSUANT TO DIVISION (A) OF THIS 3,630
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 3,631
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED 3,632
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE 3,633
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER 3,634
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL 3,635
COVERAGE, WHICHEVER IS LATER. 3,636
(C) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 3,639
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 3,640
Sec. 3924.033. (A) EACH CARRIER, IN CONNECTION WITH THE 3,643
OFFERING OF A HEALTH BENEFIT PLAN TO A SMALL EMPLOYER, SHALL 3,644
78
DISCLOSE TO THE EMPLOYER, AS PART OF ITS SOLICITATION AND SALES 3,645
MATERIALS, THAT THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,646
SECTION IS AVAILABLE UPON REQUEST. 3,647
(B) A CARRIER SHALL PROVIDE THE FOLLOWING INFORMATION TO A 3,650
SMALL EMPLOYER UPON REQUEST: 3,651
(1) THE PROVISIONS OF THE PLAN CONCERNING THE CARRIER'S 3,654
RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY AFFECT 3,655
CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO RENEWABILITY OF 3,658
COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY 3,660
PRE-EXISTING CONDITION EXCLUSION; 3,661
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL HEALTH 3,664
BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,668
SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER 3,669
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE 3,670
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT PLAN. 3,672
(D) NOTHING IN THIS SECTION REQUIRES A CARRIER TO DISCLOSE 3,675
ANY INFORMATION THAT IS BY LAW PROPRIETARY AND TRADE SECRET 3,676
INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit 3,685
entity to be known as the "Ohio small employer health reinsurance 3,687
program." Any carrier issuing health benefit plans in this state 3,688
on or after April 14, 1993, may be a member of the program. 3,689
(B) A carrier may elect to be a member of the program by 3,691
filing a written intention to participate with the superintendent 3,693
of insurance at least thirty days prior to the implementation of 3,694
the program. Any carrier that does not file a written intention 3,695
to participate within that time period may not participate for 3,696
three years after April 14, 1993, and may file an intention to 3,698
participate only at that time or on any subsequent three-year 3,699
anniversary date. However, the superintendent may permit a 3,700
79
carrier to participate in the program at other intervals for 3,701
reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A 3,703
CARRIER TO PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE 3,704
SHOWN. THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 3,705
CARRIERS SEEKING TO CHANGE THEIR STATUS UNDER THIS DIVISION. 3,706
Sec. 3924.08. (A) The board of directors of the Ohio 3,715
small employer health reinsurance program shall consist of nine 3,716
appointed members who shall serve staggered terms as determined 3,717
by the initial board for its members and by the plan of operation 3,718
of the program for members of subsequent boards. Within thirty 3,719
days after April 14, 1993, the members of the board shall be 3,720
appointed, as follows: 3,721
(1) The chairperson of the senate committee having 3,723
jurisdiction over insurance shall appoint the following members: 3,724
(a) Two member carriers that are small employer carriers; 3,726
(b) One member carrier that is a health maintenance 3,728
organization predominantly in the small employer market; 3,729
(c) One representative of providers of health care. 3,731
(2) The chairperson of the committee in the house of 3,733
representatives having jurisdiction over insurance shall appoint 3,734
the following members: 3,735
(a) One member carrier that is a small employer carrier; 3,737
(b) One member carrier whose principal health insurance 3,739
business is in the large employer market; 3,740
(c) One representative of an employer with fifty or fewer 3,742
employees; 3,743
(d) One representative of consumers in this state. 3,745
(3) The superintendent OF INSURANCE shall appoint a 3,747
representative of a member carrier operating in the small 3,749
employer market who is a fellow of the society of actuaries. 3,750
The superintendent, a member of the house of 3,752
representatives appointed by the speaker of the house of 3,753
representatives, and a member of the senate appointed by the 3,754
80
president of the senate, shall be ex-officio members of the 3,755
board. The membership of all boards subsequent to the initial 3,756
board shall reflect the distribution described in division (A) of 3,758
this section.
The chairperson of the initial board and each subsequent 3,760
board shall represent a small employer member carrier and shall 3,761
be elected by a majority of the voting members of the board. 3,762
Each chairperson shall serve for the maximum duration established 3,763
in the plan of operation. 3,764
(B) Within one hundred eighty days after the appointment 3,766
of the initial board, the board shall establish a plan of 3,767
operation and, thereafter, any amendments to the plan that are 3,768
necessary or suitable, to assure the fair, reasonable, and 3,769
equitable administration of the program. The board shall, 3,770
immediately upon adoption, provide to the superintendent copies 3,771
of the plan of operation and all subsequent amendments to it. 3,772
(C) The plan of operation shall establish rules, 3,774
conditions, and procedures for all of the following: 3,775
(1) The handling and accounting of assets and moneys of 3,777
the program and for an annual fiscal reporting to the 3,778
superintendent; 3,779
(2) Filling vacancies on the board; 3,781
(3) Selecting an administering insurer, which shall be a 3,783
carrier as defined in section 3924.01 of the Revised Code, and 3,784
setting forth the powers and duties of the administering insurer; 3,785
(4) Reinsuring risks in accordance with sections 3924.07 3,787
to 3924.14 of the Revised Code; 3,788
(5) Collecting assessments subject to section 3924.13 of 3,790
the Revised Code from all members to provide for claims reinsured 3,791
by the program and for administrative expenses incurred or 3,792
estimated to be incurred during the period for which the 3,793
assessment is made; 3,794
(6) Providing protection for carriers from the financial 3,796
risk associated with small employers that present poor credit 3,797
81
risks; 3,798
(7) Establishing standards for the coverage of small 3,800
employers that have a high turnover of employees; 3,801
(8) Establishing an appeals process for carriers to seek 3,803
relief when a carrier has experienced an unfair share of 3,804
administrative and credit risks; 3,805
(9) Establishing the adjusted average market premium 3,807
prices for use by the SEHC plan for INDIVIDUALS, FOR groups of 3,809
two to twenty-five employees, and for groups of twenty-six to 3,810
fifty employees that are offered in the state; 3,811
(10) Establishing participation standards at issue and 3,813
renewal for reinsured cases; 3,814
(11) Reinsuring risks and collecting assessments in 3,816
accordance with division (G) of section 3924.11 of the Revised 3,817
Code; 3,818
(12) Any additional matters as determined by the board. 3,820
Sec. 3924.09. The Ohio small employer health reinsurance 3,829
program shall have the general powers and authority granted under 3,830
the laws of the state to insurance companies licensed to transact 3,831
sickness and accident insurance, except the power to issue 3,832
insurance. The board of directors of the program also shall have 3,833
the specific authority to do all of the following: 3,834
(A) Enter into contracts as are necessary or proper to 3,836
carry out the provisions and purposes of sections 3924.07 to 3,837
3924.14 of the Revised Code, including the authority to enter 3,838
into contracts with similar programs of other states for the 3,839
joint performance of common functions, or with persons or other 3,840
organizations for the performance of administrative functions; 3,841
(B) Sue or be sued, including taking any legal actions 3,843
necessary or proper for recovery of any assessments for, on 3,844
behalf of, or against any program or board member; 3,845
(C) Take such legal action as is necessary to avoid the 3,847
payment of improper claims against the program; 3,848
(D) Design the SEHC plan which, when offered by a carrier, 3,850
82
is eligible for reinsurance and issue reinsurance policies in 3,851
accordance with the requirements of sections 3924.07 to 3924.14 3,852
of the Revised Code; 3,853
(E) Establish rules, conditions, and procedures pertaining 3,855
to the reinsurance of members' risks by the program; 3,856
(F) Establish appropriate rates, rate schedules, rate 3,858
adjustments, rate classifications, and any other actuarial 3,859
functions appropriate to the operation of the program; 3,860
(G) Assess members in accordance with division (G) of 3,863
section 3924.11 and the provisions of section 3924.13 of the 3,864
Revised Code, and make such advance interim assessments as may be 3,865
reasonable and necessary for organizational and interim operating 3,866
expenses. Any interim assessments shall be credited as offsets 3,867
against any regular assessments due following the close of the 3,868
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 3,870
other committees if necessary to provide technical assistance 3,871
with respect to the operation of the program, policy and other 3,872
contract design, and any other function within the authority of 3,873
the program; 3,874
(I) Borrow money to effect the purposes of the program. 3,876
Any notes or other evidence of indebtedness of the program not in 3,877
default shall be legal investments for carriers and may be 3,878
carried as admitted assets. 3,879
(J) Reinsure risks, collect assessments, and otherwise 3,881
carry out its duties under division (G) of section 3924.11 of the 3,882
Revised Code.; 3,883
(K) Study the operation of the Ohio small employer health 3,886
reinsurance program and the open enrollment reinsurance program 3,887
and, based on its findings, make legislative recommendations to 3,888
the general assembly for improvements in the effectiveness, 3,889
operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF 3,891
SECTIONS 1742.13, 3923.122, AND 3923.581 OF THE REVISED CODE. 3,892
83
Sec. 3924.10. (A) The board of directors of the Ohio 3,901
small employer health reinsurance program shall design the SEHC 3,902
plan which, when offered by a carrier, is eligible for 3,903
reinsurance under the program. The board shall establish the 3,904
form and level of coverage to be made available by carriers in 3,905
their SEHC plan. In designing the plan the board shall also 3,907
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 3,908
of coverage established by the board shall specify which 3,909
components of a health benefit plan offered by a small employer 3,910
carrier may be reinsured. The SEHC plan is subject to division 3,912
(C) of section 3924.02 of the Revised Code and to the provisions 3,913
in Chapters 1751., 3923., and any other chapter of the Revised 3,915
Code that require coverage or the offer of coverage of a health 3,916
care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 3,919
eighty days after its appointment. The plan may include cost 3,920
containment features including any of the following:
(1) Utilization review of health care services, including 3,922
review of the medical necessity of hospital and physician 3,923
services; 3,924
(2) Case management benefit alternatives; 3,926
(3) Selective contracting with hospitals, physicians, and 3,928
other health care providers; 3,929
(4) Reasonable benefit differentials applicable to 3,931
participating and nonparticipating providers; 3,932
(5) Employee assistance program options that provide 3,934
preventive and early intervention mental health and substance 3,935
abuse services; 3,936
(6) Other provisions for the cost-effective management of 3,938
the plan. 3,939
(C) An SEHC plan established for use by health insuring 3,942
corporations shall be consistent with the basic method of 3,944
operation of such corporations.
84
(D) Each carrier shall certify to the superintendent of 3,946
insurance, in the form and manner prescribed by the 3,947
superintendent, that the SEHC plan filed by the carrier is in 3,949
substantial compliance with the provisions of the board SEHC 3,950
plan. Upon receipt by the superintendent of the certification, 3,951
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 3,953
date that the program becomes operational and as a condition of 3,954
transacting business in this state, renew coverage provided to 3,955
any individual or group under its SEHC plan. 3,956
(F) A carrier shall not be required to renew coverage 3,958
where the superintendent finds that renewal of coverage would 3,959
place the carrier in a financially impaired condition. The 3,960
superintendent shall determine when the carrier is no longer 3,961
financially impaired and is, therefore, subject to the guaranteed 3,962
renewability requirements. 3,963
Sec. 3924.11. Any member of the Ohio small employer health 3,972
reinsurance program may reinsure small employer groups or 3,973
individuals in accordance with the following conditions and 3,974
limitations: 3,975
(A) With respect to eligible employees and their 3,977
dependents who are hired subsequent to the commencement of the 3,978
employer's coverage by a carrier and who are not late enrollees, 3,979
and with respect to employees of an employer who are otherwise 3,980
eligible for insurance but were excluded by the carrier's 3,981
underwriting and who are not late enrollees, coverage may be 3,982
reinsured in either ANY of the following ways: 3,983
(1) Except in the case of late enrollees, within sixty 3,985
days after the commencement of their coverage under the plan; 3,986
(2) In the case of late enrollees WHO WERE NOT ELIGIBLE TO 3,989
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,990
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,993
ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 3,995
300gg-42, AS AMENDED, eighteen months after the date the late 3,997
85
enrollee becomes a member of the small employer's plan; 3,998
(3) IN THE CASE OF LATE ENROLLEES WHO WERE ELIGIBLE TO 4,000
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 4,002
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 4,005
ACT OF 1996," AS AMENDED, WITHIN SIXTY DAYS AFTER THE 4,006
COMMENCEMENT OF THEIR COVERAGE UNDER THE PLAN. 4,007
(B)(1) The carrier may reinsure either the entire eligible 4,010
group or any eligible individual, in accordance with the premium 4,012
rates established in section 3924.12 of the Revised Code, upon 4,014
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,017
dependents of an eligible employee, who were previously excluded 4,018
from group coverage for medical reasons, and shall reinsure such 4,019
employees or dependents within sixty days after the carrier is 4,020
required to include them in the group coverage.
(C) With respect to an SEHC plan, the program shall 4,023
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,025
the program shall reinsure the level of coverage provided up to, 4,026
but not exceeding, the level of coverage provided in an SEHC 4,027
plan. In the coverage provided to small employers, carriers 4,028
shall be required to use high-cost care management, hospital 4,029
precertification techniques, and other cost containment 4,030
mechanisms established by the program. 4,031
(E) A carrier may not reinsure existing business, except 4,033
pursuant to division (A) of this section. 4,034
(F) If an employer group is covered under a plan other 4,036
than an SEHC plan and the carrier chooses to reinsure the group 4,037
subsequent to the initial coverage period, or if a new individual 4,038
joins the group and the carrier wants to reinsure that 4,039
individual, the carrier shall not force the employer to change to 4,041
an SEHC plan. The carrier shall allow the employer to maintain 4,042
the same benefit plan and reinsure only that portion of the plan 4,043
that is consistent with an SEHC plan.
86
(G) With respect to coverage provided to a small employer 4,045
group or AN individual acquired under section 3923.58 OR A 4,046
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 3923.581 of 4,047
the Revised Code, the following conditions and limitations apply: 4,049
(1) Within sixty days after the commencement of the 4,052
initial coverage, any carrier may reinsure coverage of an entire 4,053
small employer group, or of eligible employees or dependents of 4,054
such group, or any SUCH AN individual acquired under section 4,055
3923.58 of the Revised Code with the OPEN ENROLLMENT REINSURANCE 4,057
program IN ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A 4,059
carrier may reinsure, within sixty days after the effective date 4,061
of coverage, an employee eligible for coverage under section 4,063
3923.58 of the Revised Code. Premium rates charged for coverage 4,064
reinsured by the program shall be established in accordance with 4,065
section 3924.12 of the Revised Code. 4,066
(2) The board of directors of the OHIO HEALTH REINSURANCE 4,069
program shall establish the open enrollment reinsurance fund for 4,070
coverage provided under section 3923.58 of the Revised Code AND, 4,071
WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, COVERAGE PROVIDED 4,073
UNDER SECTION 3923.581 OF THE REVISED CODE. The fund shall be 4,074
maintained separately from any reinsurance fund established for 4,075
small employer health care plans issued pursuant to sections
3924.07 to 3924.14 of the Revised Code. The board shall 4,076
calculate, on a retrospective basis, the amount needed for 4,077
maintenance of the open enrollment reinsurance fund and, on the 4,078
basis of that calculation, shall determine the amount to be 4,079
assessed each carrier that is required to provide open enrollment 4,080
coverage. 4,081
Assessments shall be apportioned by the board among all 4,083
carriers participating in the open enrollment reinsurance program 4,084
in proportion to their respective shares of the total premiums, 4,085
net of reinsurance premiums paid by a carrier for open enrollment 4,086
coverage and net of reinsurance premiums paid by the carrier for 4,087
all other small group and individual health benefit plans, earned 4,088
87
in this state from all health benefit plans covering small 4,089
employers and individuals that are issued by all such carriers 4,090
during the calendar year coinciding with or ending during the 4,091
fiscal year of the open enrollment program, or on any other 4,092
equitable basis reflecting coverage of small employers and 4,093
individuals in this state as may be provided in the plan of 4,094
operation adopted by the board. In no event shall the assessment 4,095
of any carrier under this section exceed, on an annual basis, 4,097
three per cent of its Ohio premiums for health benefit plans 4,098
covering small employers and individuals as reported on its most 4,099
recent annual statement filed with the superintendent of 4,100
insurance.
The board shall submit its determination of the amount of 4,102
the assessment to the superintendent for review of the accuracy 4,104
of the calculation of the assessment. Upon approval by the 4,105
superintendent, each carrier shall, within thirty days after 4,106
receipt of the notice of assessment, submit the assessment to the 4,107
board for purposes of the open enrollment reinsurance fund. 4,108
(3) If the assessments made and collected pursuant to 4,110
division (G)(2) of this section are not sufficient to pay the 4,111
claims reinsured under division (G) of this section and the 4,112
allocated administrative expenses, incurred or estimated to be 4,113
incurred during the period for which the assessment was made, the 4,114
secretary of the board shall immediately notify the 4,115
superintendent, and the superintendent shall suspend the 4,116
operation of open enrollment under section 3923.58 of the Revised 4,117
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER 4,118
SECTION 3923.581 OF THE REVISED CODE until the board has 4,119
collected in subsequent years through assessments made pursuant 4,120
to division (G)(2) of this section an amount sufficient to pay 4,121
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,123
under section 3923.58 of the Revised Code may elect not to 4,125
participate in the open enrollment reinsurance program under 4,126
88
division (G) of this section by filing an application with the 4,127
superintendent and obtaining the superintendent's approval. In 4,128
determining whether to approve an application, the superintendent 4,129
shall consider whether the carrier meets all of the following 4,130
standards: 4,131
(i) Demonstration by the carrier of a substantial and 4,133
established market presence; 4,134
(ii) Demonstrated experience in the small employer group 4,136
INDIVIDUAL market and history of rating and underwriting small 4,137
employer groups INDIVIDUAL PLANS; 4,139
(iii) Commitment to comply with the requirements of 4,141
section 3923.58 of the Revised Code; 4,142
(iv) Financial ability to assume and manage the risk of 4,144
enrolling open enrollment groups and individuals without the need 4,145
for, or protection of, reinsurance. 4,146
(b) A carrier whose application for nonparticipation has 4,148
been rejected by the superintendent may appeal the decision in 4,149
accordance with Chapter 119. of the Revised Code. A carrier that 4,150
has received approval of the superintendent not to participate in 4,151
the open enrollment reinsurance program shall, on or before the 4,152
first day of December, annually certify to the superintendent 4,153
that it continues to meet the standards described in division 4,154
(G)(4)(a) of this section. 4,155
(c) In any year subsequent to the year in which its 4,157
application not to participate has been approved, a carrier may 4,158
elect to participate in the open enrollment reinsurance program 4,159
by giving notice to the superintendent and board on or before the 4,160
thirty-first day of December. If, after a period of 4,161
nonparticipation, a carrier elects to participate in the open 4,162
enrollment reinsurance program, the carrier retains the risks it 4,163
assumed during the period when it was not participating. 4,164
(d) The superintendent may, at any time, authorize a 4,166
carrier to modify an election not to participate if the risk from 4,167
the carrier's open enrollment business jeopardizes the financial 4,168
89
condition of the carrier. If the superintendent authorizes the 4,169
carrier to again participate in the open enrollment reinsurance 4,170
program, the carrier shall retain the risks it assumed during the 4,171
period of nonparticipation. 4,172
(5) At the time of acquiring a small employer group, a 4,174
carrier shall determine whether to reinsure the entire group or 4,175
any individual pursuant to section 3924.12 of the Revised Code. 4,176
(6)(a) The open enrollment reinsurance program shall be 4,179
operated separately from the Ohio small employer health 4,180
reinsurance program.
(b) A carrier's election to participate in the open 4,182
enrollment reinsurance program under division (G) of this section 4,184
shall not be construed as an election to participate in the Ohio 4,185
small employer health reinsurance program under section 3924.07 4,186
of the Revised Code.
Sec. 3924.111. (A) The Ohio small employer health 4,197
reinsurance program shall not provide reinsurance for any 4,198
individual reinsured under the program until five thousand 4,199
dollars in benefit payments have been made by a member of the 4,200
program for services provided to that individual during a
calendar year, which payments would have been reimbursed through 4,201
the program but for the five-thousand-dollar deductible. The 4,202
member shall retain ten per cent of the next fifty thousand 4,203
dollars of benefit payments made during that calendar year, and 4,204
the program shall reinsure the remainder. However, a member's 4,205
maximum liability under this section with respect to any one 4,206
individual reinsured under the program shall not exceed ten 4,207
thousand dollars in any one calendar year. 4,208
(B) The board of directors of the Ohio small employer 4,211
health reinsurance program shall periodically review the 4,212
deductible amount and the maximum liability amount set forth in 4,213
division (A) of this section and, considering the rate of 4,214
inflation, adjust each amount as the board considers necessary. 4,215
Sec. 3924.12. (A) Except as provided in division (B) of 4,224
90
this section, premium rates charged for coverage reinsured by the 4,225
Ohio small employer health reinsurance program shall be 4,226
established as follows: 4,227
(1) For whole group reinsurance coverage, one and one-half 4,229
times the adjusted average market premium price established by 4,230
the program for that classification or group with similar 4,231
characteristics and coverage, with respect to the eligible 4,232
employees of a small employer and their dependents, all of whose 4,233
coverage is reinsured with the program, minus a ceding expense 4,234
factor determined by the board of directors of the program; 4,235
(2) For individual reinsurance coverage, five times the 4,237
adjusted average market premium price established by the program 4,238
for an individual in that classification or group with similar 4,239
characteristics and coverage, with respect to an eligible 4,240
employee or the employee's dependents, minus a ceding expense 4,242
factor determined by the board. 4,243
(B) Premium rates charged for reinsurance by the program 4,245
to a health insuring corporation that is approved by the 4,247
secretary of health and human services as a federally qualified 4,248
health maintenance organization pursuant to the "Social Security 4,249
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as 4,250
such is subject to requirements that limit the amount of risk 4,251
that may be ceded to the program, may be modified to reflect the 4,252
portion of risk that may be ceded to the program. 4,253
Sec. 3924.13. (A) Following the close of each calendar 4,262
year, the administering insurer of the Ohio small employer health 4,263
reinsurance program shall determine the net premiums, the program 4,264
expenses for administration, and the incurred losses, if any, for 4,265
the year, taking into account investment income and other 4,266
appropriate gains and losses. For purposes of this section, 4,267
health benefit plan premiums earned by MEWAs shall be established 4,268
by adding paid claim losses and administrative expenses of the 4,269
MEWA. Health benefit plan premiums and benefits paid by a 4,271
carrier that are less than an amount determined by the board of 4,272
91
directors of the program to justify the cost of collection shall 4,273
not be considered for purposes of determining assessments. For 4,274
purposes of this division, "net premiums" means health benefit 4,275
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 4,277
assessments of carriers in accordance with this division. 4,278
Assessments shall be apportioned by the board among all carriers 4,279
participating in the program in proportion to their respective 4,280
shares of the total premiums, net of reinsurance premiums paid 4,281
for coverage under this program earned in the state from health 4,282
benefit plans covering small employers that are issued by 4,283
participating members during the calendar year coinciding with or 4,284
ending during the fiscal year of the program, or on any other 4,285
equitable basis reflecting coverage of small employers as may be 4,286
provided in the plan of operation. An assessment shall be made 4,287
pursuant to this division against a health insuring corporation 4,288
that is approved by the secretary of health and human services as 4,291
a federally qualified health maintenance organization pursuant to 4,292
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 4,293
as amended, subject to an assessment adjustment formula adopted 4,294
by the board for such health insuring corporations that 4,295
recognizes the restrictions imposed on the entities by federal 4,297
law. The adjustment formula shall be adopted by the board prior 4,299
to the first anniversary of the program's operation. In no event 4,300
shall the assessment made pursuant to this division exceed, on an 4,301
annual basis, one per cent of the carrier's Ohio small employer 4,303
group premium as reported on its most recent annual statement 4,304
filed with the superintendent of insurance. If an excess is 4,305
actuarially projected, the superintendent may take any action 4,306
necessary to lower the assessment to the maximum level of one per 4,307
cent.
(C) If assessments exceed actual losses and administrative 4,309
expenses of the program, the excess shall be held at interest and 4,310
used by the board to offset future losses or to reduce program 4,311
92
premiums. As used in this division, "future losses" includes 4,312
reserves for incurred but not reported claims. 4,313
(D) Each carrier's proportion of participation in the 4,315
program shall be determined annually by the board based on annual 4,317
statements and other reports deemed necessary by the board and 4,318
filed by the carrier with the board. MEWAs shall report to the 4,319
board claims payments made and administrative expenses incurred 4,320
in this state on an annual basis on a form prescribed by the 4,321
superintendent.
(E) Provision shall be made in the plan of operation for 4,323
the imposition of an interest penalty for late payment of 4,324
assessments. 4,325
(F) A carrier may seek from the superintendent a 4,327
deferment, in whole or in part, from any assessment issued by the 4,328
board. The superintendent may defer, in whole or in part, the 4,329
assessment of a carrier if, in the opinion of the superintendent, 4,330
payment of the assessment would endanger the carrier's ability to 4,331
fulfill its contractual obligations. 4,332
(G) In the event an assessment against a carrier is 4,334
deferred in whole or in part, the amount by which the assessment 4,335
is deferred may be assessed against the other carriers in a 4,336
manner consistent with the basis for assessments set forth in 4,337
this section. In such event, the other carriers assessed shall 4,338
have a claim in the amount of the assessment against the carrier 4,339
receiving the deferment. The carrier receiving the deferment 4,340
shall remain liable to the program for the amount deferred. The 4,341
superintendent may attach appropriate conditions to any 4,342
deferment. 4,343
Sec. 3924.14. Neither the participation as members of the 4,352
Ohio small employer health reinsurance program or as members of 4,353
the board of directors of the program, the establishment of 4,355
rates, forms, or procedures for coverage issued by the program, 4,356
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 4,357
93
legal action or any criminal or civil liability or penalty 4,358
against the program, the board, or any of its members either 4,359
jointly or separately.
Sec. 3924.27. (A) AS USED IN THIS SECTION: 4,362
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE 4,364
THE SAME MEANINGS AS IN SECTION 3924.01 OF THE REVISED CODE. 4,365
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 4,367
FOLLOWING: 4,368
(a) HEALTH STATUS; 4,370
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 4,373
ILLNESSES;
(c) CLAIMS EXPERIENCE; 4,375
(d) RECEIPT OF HEALTH CARE; 4,377
(e) MEDICAL HISTORY; 4,379
(f) GENETIC INFORMATION; 4,381
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 4,384
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 4,386
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING 4,388
HEALTH INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH 4,389
BENEFIT PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF 4,390
ENROLLMENT OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A 4,391
PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR 4,392
CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE 4,393
PLAN ON THE BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION 4,394
TO THE INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS 4,395
A DEPENDENT OF THE INDIVIDUAL. 4,396
(C) NOTHING IN DIVISION (B) OF THIS SECTION SHALL BE 4,400
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 4,401
FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO PREVENT A 4,402
GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING GROUP HEALTH 4,403
INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM DISCOUNTS OR 4,404
REBATES OR MODIFYING OTHERWISE APPLICABLE COPAYMENTS OR 4,405
DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF HEALTH 4,406
94
PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section: 4,415
(1) "Child" means, in connection with any adoption or 4,417
placement for adoption of the child, an individual who has not 4,418
attained age eighteen as of the date of the adoption or placement 4,419
for adoption. 4,420
(2) "Health insurer" has the same meaning as in section 4,422
3924.41 of the Revised Code. 4,423
(3) "Placement for adoption" means the assumption and 4,425
retention by a person of a legal obligation for total or partial 4,426
support of a child in anticipation of the adoption of the child. 4,427
The child's placement with a person terminates upon the 4,428
termination of that legal obligation. 4,429
(B) If an individual or group health plan of a health 4,431
insurer provides MAKES coverage AVAILABLE for dependent children 4,433
of participants or beneficiaries, the plan shall provide benefits 4,434
to dependent children placed with participants or beneficiaries 4,435
for adoption under the same terms and conditions as apply to the 4,436
natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become 4,437
final. 4,438
(C) A health plan described in division (B) of this 4,440
section shall not restrict coverage under the plan of any 4,442
dependent child adopted by a participant or beneficiary, or 4,443
placed with a participant or beneficiary for adoption, solely on 4,444
the basis of a pre-existing condition of the child at the time 4,445
that the child would otherwise become eligible for coverage under 4,446
the plan, if the adoption or placement for adoption occurs while 4,447
the participant or beneficiary is eligible for coverage under the 4,448
plan.
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 4,457
the Revised Code: 4,458
(A) "Account holder" means the natural person who opens a 4,461
medical savings account or on whose behalf a medical savings 4,462
95
account is opened.
(B) "Eligible medical expense" means any expense for a 4,465
service rendered by a licensed health care provider or a 4,466
Christian Science practitioner, or for an article, device, or 4,467
drug prescribed by a licensed health care provider or provided by 4,468
a Christian Science practitioner, when intended for use in the 4,470
mitigation, treatment, or prevention of disease; ANY AMOUNT PAID 4,471
FOR TRANSPORTATION TO THE LOCATION AT WHICH SUCH A SERVICE IS 4,472
RENDERED; ANY AMOUNT PAID FOR LODGING NECESSITATED BY THE RECEIPT 4,473
OF CARE AT A NONLOCAL HOSPITAL; or premiums paid for 4,474
comprehensive sickness and accident insurance, coverage under a 4,476
health care plan of a health insuring corporation organized under 4,477
Chapter 1751. of the Revised Code, long-term care insurance as 4,479
defined in section 3923.41 of the Revised Code, Medicare 4,480
supplemental coverage as defined in section 3923.33 of the 4,481
Revised Code, or payments made pursuant to cost sharing 4,482
agreements under comprehensive sickness and accident plans. An 4,483
"eligible medical expense" does not include expenses otherwise 4,484
paid or reimbursed, including medical expenses paid or reimbursed 4,485
under an automobile or motor vehicle insurance policy, a workers' 4,486
compensation insurance policy or plan, or an employer-sponsored 4,487
health coverage policy, plan, or contract.
(C) "Qualified dependent" means a child of an account 4,490
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 4,493
twenty-three years of age and a full-time student at an
accredited college or university; 4,494
(2) The child is not self-sufficient due to physical or 4,496
mental disorders or impairments; 4,497
(3) The child is legally entitled to the provision of 4,499
proper or necessary subsistence, education, medical care, or 4,500
other care necessary for the child's health, guidance, or 4,501
well-being and is not otherwise emancipated, self-supporting, 4,502
married, or a member of the armed forces of the United States 4,504
96
DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE 4,505
"INTERNAL REVENUE CODE OF 1986," 100 STAT. 2085, 26 U.S.C.A. 1, 4,506
AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened 4,515
by or on behalf of any natural person, to pay the person's 4,516
eligible medical expenses and the eligible medical expenses of 4,517
that person's spouse or qualified dependent. A medical savings 4,518
account may be opened by or on behalf of a person only if that 4,521
person participates in a sickness or accident insurance plan, a 4,522
plan offered by a health insuring corporation organized under 4,523
Chapter 1751. of the Revised Code, or a self-funded, 4,524
employer-sponsored health benefit plan established pursuant to 4,525
the "Employee Retirement Income Security Act of 1974," 88 Stat. 4,526
832, 29 U.S.C.A. 1001, as amended. While the medical savings
account is open, the account holder shall continue to participate 4,527
in such a plan.
(B) A person who refuses to participate in a policy, plan, 4,530
or contract of health coverage that is funded by the person's 4,531
employer, and who receives additional monetary compensation by 4,532
virtue of refusing that coverage, may not open a medical savings 4,533
account unless the medical savings account also is sponsored by 4,534
the person's employer. 4,535
Sec. 3924.63. The owners of interest in a medical savings 4,545
account are the account holder, AND the account holder's spouse, 4,546
and qualified dependents. No medical savings account shall be 4,547
subject to garnishment or attachment. 4,549
Sec. 3924.64. (A) At the time a medical savings account 4,559
is opened, an administrator for the account shall be designated. 4,560
If an employer opens an account for an employee, the employer may 4,561
designate the administrator. If an account is opened by any 4,562
person other than an employer, or if an employer chooses not to 4,563
designate an administrator for an account opened for an employee, 4,564
the account holder shall designate the administrator. The 4,565
administrator shall manage the account in a fiduciary capacity 4,566
97
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 4,569
of the following:
(1) A federally or state-chartered bank, savings and loan 4,572
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 4,574
(3) An insurer authorized under Title XXXIX of the Revised 4,577
Code to engage in the business of sickness and accident 4,578
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 4,581
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 4,584
Revised Code;
(6) A certified public accountant; 4,586
(7) An employer that administers an employee benefit plan 4,589
subject to regulation under the "Employee Retirement Income 4,590
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 4,592
amended, or that maintains medical savings accounts for its 4,593
employees;
(8) Health insuring corporations organized under Chapter 4,596
1751. of the Revised Code.
(C) Each administrator shall send to the account holder, 4,599
at least annually, a statement setting forth the balance 4,600
remaining in the account holder's account and detailing the 4,601
activity in the account since the last statement was issued. 4,602
Upon an administrator's receipt of a written request from an 4,603
account holder for a current statement, the administrator shall 4,604
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 4,607
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 4,608
account holder, OR the account holder's spouse, or qualified 4,610
dependents, the administrator shall reimburse the account holder 4,611
for, or shall pay for, the eligible medical expense with funds 4,612
98
from the account holder's account, if sufficient funds are 4,613
available in the account holder's account. If there are not 4,614
sufficient funds in the account to fully reimburse the account 4,615
holder or pay the expenses, the administrator shall reimburse the 4,617
account holder or pay the expenses using whatever funds are in 4,618
the account. The reimbursement or payment shall be made within 4,619
thirty days of the administrator's receipt of the documentation. 4,620
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 4,621
expense does not count toward meeting the deductible or other 4,622
obligation for the receipt of benefits that is required by the 4,623
insurer or other third-party payer providing health coverage to 4,624
the account holder. The administrator shall keep a record of the 4,625
amounts disbursed from the account for documented eligible 4,626
medical expenses and of the dates on which the expenses were 4,627
incurred. This record shall be made available to any sickness 4,628
and accident insurer or other third-party payer providing health 4,629
coverage to the account holder, for use by the insurer or 4,630
third-party payer in determining whether the account holder has 4,631
met the deductible or other obligation required for the receipt 4,632
of benefits from the insurer or third-party payer. 4,633
(E) When an account is opened, the administrator shall 4,636
give written notice to the account holder of the date of the last 4,637
business day of the administrator's business year. 4,638
Sec. 3924.66. (A) In determining Ohio adjusted gross 4,647
income under Chapter 5747. of the Revised Code, an account holder 4,648
may deduct an amount equaling the total of the deposits that the 4,650
account holder, the account holder's spouse, or the account 4,651
holder's employer made to the account during the taxable year, to 4,652
the extent that the funds for the deposits have not otherwise 4,653
been deducted or excluded in determining the account holder's
federal adjusted gross income. The amount deducted by an account 4,655
holder for a taxable year shall not exceed three thousand 4,656
dollars. If two married persons each have an account, each 4,657
99
spouse may claim the deduction described in this section, and the 4,659
amount deducted by each spouse shall not exceed three thousand 4,660
dollars, whether the spouses file returns jointly or separately. 4,661
(B) The maximum deduction allowed under division (A) of 4,663
this section shall be adjusted annually by the department of 4,664
taxation to reflect increases in the consumer price index for all 4,665
items for all urban consumers for the north central region, as 4,666
published by the United States bureau of labor statistics. 4,667
(C) In determining Ohio adjusted gross income under 4,669
Chapter 5747. of the Revised Code, an account holder may deduct 4,670
the investment earnings of a medical savings account from the 4,671
account holder's federal adjusted gross income, to the extent 4,672
that these earnings have been included in the account holder's 4,673
federal adjusted gross income.
(D) In determining Ohio adjusted gross income under 4,675
Chapter 5747. of the Revised Code, an account holder shall add to 4,676
the account holder's federal adjusted gross income an amount 4,677
equal to the sum of the amounts described in divisions (D)(1) and 4,679
(2) of this section to the extent that those amounts were 4,680
included in the account holder's federal adjusted gross income 4,681
and previously deducted in determining the account holder's Ohio 4,683
adjusted gross income. In determining the extent to which 4,684
amounts withdrawn from the account shall be included in the 4,685
account holder's Ohio adjusted gross income, the tax commissioner 4,687
shall be guided by the provisions of sections 72 and 408 of the 4,688
Internal Revenue Code governing the determination of the amount 4,689
of withdrawals from an individual retirement account to be 4,690
included in federal gross income.
(1) Amounts withdrawn from the account during the taxable 4,693
year used for any purpose other than to reimburse the account 4,694
holder for, or to pay, the eligible medical expenses of the 4,695
account holder, OR the account holder's spouse, or qualified 4,697
dependents; 4,698
(2) Investment earnings during the taxable year on amounts 4,700
100
withdrawn from the account that are described in division (D)(1) 4,701
of this section. 4,702
(E) Amounts withdrawn from a medical savings account to 4,704
reimburse the account holder for, or to pay, the account holder's 4,705
eligible medical expenses, or the eligible medical expenses of 4,706
the account holder's spouse or qualified dependents, shall not be 4,708
included in the account holder's Ohio adjusted gross income in 4,709
determining taxes due under Chapter 5747. of the Revised Code. 4,710
(F) If a qualified dependent of an account holder becomes 4,713
ineligible to continue to participate in the account holder's 4,715
policy, plan, or contract of health coverage, the account holder 4,716
may withdraw funds from the account holder's account and use
those funds to pay the premium for the first year of a policy, 4,717
plan, or contract of health coverage for the qualified dependent 4,718
and to pay any deductible for the first year of that policy, 4,720
plan, or contract. Funds withdrawn and used for that purpose 4,721
shall not be included in the account holder's Ohio adjusted gross 4,722
income in determining taxes due under Chapter 5747. of the 4,723
Revised Code. 4,724
Sec. 3924.67. An account holder may withdraw funds from 4,734
the account holder's account at any time, for any purpose.
However, the administrator of a medical savings account shall not 4,735
disburse funds to an account holder during the year in which the 4,737
funds were deposited, except to reimburse the account holder for, 4,738
or pay for, a documented eligible medical expense of the account 4,739
holder, OR the account holder's spouse, or a qualified dependent. 4,740
Sec. 3924.68. (A) If an account holder, whose medical 4,750
savings account has been opened by the account holder's employer, 4,751
later ceases to be employed by that employer, the account holder 4,752
may, within sixty days of the account holder's final date of 4,753
employment, request in writing to the administrator of the 4,755
account that the administrator continue to administer the 4,756
account.
(1) If the administrator agrees to continue to administer 4,759
101
the account, funds in the account may continue to be used to pay 4,760
the eligible medical expenses of the account holder, AND the 4,761
account holder's spouse, and qualified dependents, pursuant to 4,762
sections 3924.61 to 3924.74 of the Revised Code. 4,764
If the account holder later becomes employed by a new 4,766
employer that opens a new medical savings account on the account 4,767
holder's behalf, the account holder may transfer any funds 4,769
remaining in the account opened by the account holder's former 4,770
employer to the account opened by the account holder's new 4,771
employer. For purposes of determining taxes due under Chapter 4,773
5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, 4,774
nor shall it be considered a deposit to a medical savings 4,775
account.
(2) If the administrator does not agree to continue to 4,778
administer the account, or if the account holder requests that 4,779
the account be closed, the administrator shall close the account 4,780
and mail a check or other negotiable instrument in the amount of 4,781
the account balance as of that date to the account holder. The 4,782
amount distributed shall be included in the account holder's Ohio 4,783
adjusted gross income in determining taxes due under Chapter 4,784
5747. of the Revised Code. 4,785
(B) Within sixty days of the account holder's final date 4,787
of employment, the account holder may transfer any funds 4,789
remaining in the account opened by the account holder's former 4,790
employer to another medical savings account owned by the account 4,791
holder. For purposes of determining taxes due under Chapter 4,792
5747,. of the Revised Code, this transfer of funds shall not be 4,793
considered a withdrawal of funds from a medical savings account, 4,794
nor shall it be considered a deposit to a medical savings
account. 4,795
(C) An administrator of an account opened by an employer 4,797
shall not close an account without the permission of the account 4,798
holder until at least sixty-one days after the account holder's 4,799
102
final date of employment. The employer shall notify the 4,800
administrator of the employee's final date of employment. 4,801
Sec. 3924.73. (A) As used in this section: 4,810
(1) "Health care insurer" means any person legally engaged 4,812
in the business of providing sickness and accident insurance 4,813
contracts in this state, a health insuring corporation organized 4,815
under Chapter 1751. of the Revised Code, or any legal entity that 4,816
is self-insured and provides health care benefits to its
employees or members. 4,817
(2) "Small employer" has the same meaning as in division 4,819
(P) of section 3924.01 of the Revised Code. 4,820
(B)(1) Subject to division (B)(2) of this section, nothing 4,823
in sections 3924.61 to 3924.74 of the Revised Code shall be 4,824
construed to limit the rights, privileges, or protections of 4,825
employees or small employers under sections 3924.01 to 3924.14 of 4,826
the Revised Code. 4,827
(2) If any account holder enrolls or applies to enroll in 4,829
a policy or contract offered by a health care insurer providing 4,830
sickness and accident coverage that is more comprehensive than, 4,831
and has a deductible amount that is less than, the coverage and 4,832
deductible amount of the policy under which the account holder 4,833
currently is enrolled, the health care insurer to which the 4,834
account holder applies may subject the account holder to the same 4,836
medical review, waiting periods, and underwriting requirements to 4,837
which the health care insurer generally subjects other enrollees 4,838
or applicants, unless the account holder enrolls or applies to 4,839
enroll during a designated period of open enrollment. 4,840
Section 2. That existing sections 1739.05, 1751.06, 4,842
1751.14, 1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 4,843
1751.65, 1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 4,844
3923.021, 3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 4,846
3923.63, 3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 4,847
3924.09, 3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 4,848
3924.51, 3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 4,849
103
3924.68, and 3924.73 and section 3941.53 of the Revised Code are 4,851
hereby repealed. 4,852
Section 3. The amendments to sections 1751.59, 1751.61, 4,854
3923.122, 3923.26, 3923.40, and 3924.51 of the Revised Code by 4,855
this act shall apply to contracts, evidences of coverage, 4,856
policies, and plans that are delivered, issued for delivery, 4,857
renewed, or established in this state on or after the effective 4,858
date of this section. 4,859
Section 4. The amendment of sections 1751.64, 3901.49, and 4,861
3901.50 of the Revised Code is not intended to supersede the 4,862
earlier repeal, with delayed effective dates, of those sections. 4,863
Section 5. This act is hereby declared to be an emergency 4,865
measure necessary for the immediate preservation of the public 4,866
peace, health, and safety. The reason for such necessity is that 4,867
Ohio must meet the federal deadline relative to the 4,868
implementation of the federal Health Insurance Portability and
Accountability Act of 1996. Ohio's failure to meet this deadline 4,869
could result in the federal government assuming regulation over 4,870
certain areas of health insurance, thereby disrupting the stable 4,871
health insurance market in Ohio that currently exists under Ohio 4,872
law. Meeting the federal deadline will protect the public health 4,874
and safety of the citizens of this state by ensuring the
stability of the health insurance market through the continued 4,875
regulation of this market by the state. Therefore, this act 4,876
shall go into immediate effect.