As Passed by the House 1
122nd General Assembly 4
Regular Session Am. 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-WESTON- 10
CLANCY-HOUSEHOLDER-LUCAS-VESPER-O'BRIEN-VERICH-SULZER-BENDER- 11
MOTTL-MYERS-OGG-CORE-OLMAN-OPFER-DAMSCHRODER-BRITTON-HARRIS- 12
LOGAN-PATTON-ROMAN-WINKLER-WILSON-CATES-ROBERTS-FORD-JONES- 13
JACOBSON-FOX-SALERNO-MILLER-COLONNA-BOYD-PRINGLE-SUTTON-MALLORY 14
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A B I L L
To amend sections 1739.05, 1751.06, 1751.14, 18
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 19
1751.64, 1751.65, 1751.67, 3901.21, 3901.49, 20
3901.491, 3901.50, 3901.501, 3923.021, 3923.122, 21
3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 22
3923.63, 3923.64, 3924.01, 3924.02, 3924.03, 23
3924.07 to 3924.11, 3924.111, 3924.12 to 3924.14, 25
3924.51, 3924.61 to 3924.64, 3924.66 to 3924.68, 26
and 3924.73, to enact sections 1751.57, 1751.58, 27
3901.044, 3923.571, 3923.581, 3924.031, 3924.032, 29
3924.033, and 3924.27, and to repeal section 30
3941.53 of the Revised Code relative to the 31
implementation of the federal Health Insurance 32
Portability and Accountability Act of 1996 and 33
insurance coverage of follow-up care for a mother 34
and newborn, and to declare an emergency. 35
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 37
Section 1. That sections 1739.05, 1751.06, 1751.14, 39
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 40
1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 42
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3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 44
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 45
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 46
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 48
and 3924.73 be amended and sections 1751.57, 1751.58, 3901.044, 49
3923.571, 3923.581, 3924.031, 3924.032, 3924.033, and 3924.27 of 50
the Revised Code be enacted to read as follows: 52
Sec. 1739.05. (A) A multiple employer welfare arrangement 61
that is created pursuant to sections 1739.01 to 1739.22 of the 62
Revised Code and that operates a group self-insurance program may 63
be established only if any of the following applies: 64
(1) The arrangement has and maintains a minimum enrollment 66
of three hundred employees of two or more employers. 67
(2) The arrangement has and maintains a minimum enrollment 69
of three hundred self-employed individuals. 70
(3) The arrangement has and maintains a minimum enrollment 72
of three hundred employees or self-employed individuals in any 73
combination of divisions (A)(1) and (2) of this section. 74
(B) A multiple employer welfare arrangement that is 76
created pursuant to sections 1739.01 to 1739.22 of the Revised 77
Code and that operates a group self-insurance program shall 78
comply with all laws applicable to self-funded programs in this 79
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 80
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 81
3923.301, and 3923.38, 3923.581, 3923.63, 3924.031, 3924.032, AND 84
3924.27 of the Revised Code. 85
(C) A multiple employer welfare arrangement created 87
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 88
solicit enrollments only through agents or solicitors licensed 89
pursuant to Chapter 3905. of the Revised Code to sell or solicit 90
sickness and accident insurance. 91
(D) A multiple employer welfare arrangement created 93
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 94
provide benefits only to individuals who are members, employees 95
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of members, or the dependents of members or employees, or are 96
eligible for continuation of coverage under section 1751.53 or 97
3923.38 of the Revised Code or under Title X of the "Consolidated 98
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 99
U.S.C.A. 1161, as amended. 100
Sec. 1751.06. Upon obtaining a certificate of authority as 109
required under this chapter, a health insuring corporation may do 111
all of the following:
(A) Enroll individuals and their dependents in either of 113
the following circumstances: 114
(1) The individual resides OR LIVES in the approved 116
service area.
(2) The individual's place of employment is located in the 119
approved service area and the individual has agreed to receive 120
health care services in accordance with the evidence of coverage. 121
(B) Contract with providers and health care facilities for 123
the health care services to which enrollees are entitled under 124
the terms of the health insuring corporation's health care 125
contracts;
(C) Contract with insurance companies authorized to do 128
business in this state for insurance, indemnity, or reimbursement 129
against the cost of providing emergency and nonemergency health 130
care services for enrollees, subject to the provisions set forth 131
in this chapter and the limitations set forth in the Revised 133
Code;
(D) Contract with any person pursuant to the requirements 135
of division (A)(18) of section 1751.03 of the Revised Code for 136
managerial or administrative services, or for data processing, 137
actuarial analysis, billing services, or any other services 138
authorized by the superintendent of insurance. However, a health 140
insuring corporation shall not enter into a contract for any of 141
the services listed in this division with an insurance company 142
that is not authorized to engage in the business of insurance in 143
this state.
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(E) Accept from governmental agencies, private agencies, 145
corporations, associations, groups, individuals, or other 146
persons, payments covering all or part of the costs of planning, 147
development, construction, and the provision of health care 148
services;
(F) Purchase, lease, construct, renovate, operate, or 150
maintain health care facilities, and their ancillary equipment, 151
and any property necessary in the transaction of the business of 152
the health insuring corporation.;
(G) IN THE EMPLOYER GROUP MARKET, IMPOSE AN AFFILIATION 155
PERIOD OF NOT MORE THAN SIXTY DAYS, WHICH PERIOD BEGINS ON THE 156
INDIVIDUAL'S DATE OF ENROLLMENT AND RUNS CONCURRENTLY WITH ANY 157
WAITING PERIOD IMPOSED UNDER THE COVERAGE. FOR PURPOSES OF THIS 158
DIVISION, "AFFILIATION PERIOD" MEANS A PERIOD OF TIME WHICH, 159
UNDER THE TERMS OF THE COVERAGE OFFERED, MUST EXPIRE BEFORE THE 160
COVERAGE BECOMES EFFECTIVE. NO HEALTH CARE SERVICES OR BENEFITS 161
NEED TO BE PROVIDED DURING AN AFFILIATION PERIOD, AND NO PERIODIC 162
PREPAYMENTS CAN BE CHARGED FOR ANY COVERAGE DURING THAT PERIOD. 163
(H) IF A HEALTH INSURING CORPORATION OFFERS COVERAGE IN 166
THE SMALL EMPLOYER GROUP MARKET THROUGH A NETWORK PLAN, LIMIT OR 167
DENY THE COVERAGE IN ACCORDANCE WITH SECTION 3924.031 OF THE 169
REVISED CODE; 170
(I) REFUSE TO ISSUE COVERAGE IN THE SMALL EMPLOYER GROUP 173
MARKET PURSUANT TO SECTION 3924.032 OF THE REVISED CODE; 175
(J) ESTABLISH EMPLOYER CONTRIBUTION RULES OR GROUP 178
PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN CONNECTION 179
WITH A GROUP CONTRACT IN THE SMALL EMPLOYER GROUP MARKET, AS 180
PROVIDED IN DIVISION (E)(1) OF SECTION 3924.03 OF THE REVISED 183
CODE.
Nothing in this section shall be construed as prohibiting a 185
health insuring corporation without other commercial enrollment 186
from contracting solely with federal health care programs 187
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 189
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authority of a health insuring corporation to perform those 190
functions not otherwise prohibited by law. 191
Sec. 1751.14. (A) Any policy, contract, or agreement for 201
health care services authorized by this chapter that is issued, 202
delivered, or renewed in this state and that provides that 203
coverage of an unmarried dependent child will terminate upon 204
attainment of the limiting age for dependent children specified 205
in the policy, contract, or agreement, shall also provide in 206
substance that attainment of the limiting age shall not operate 207
to terminate the coverage of the child if the child is and 208
continues to be both:
(1) Incapable of self-sustaining employment by reason of 210
mental retardation or physical handicap; 211
(2) Primarily dependent upon the subscriber for support 213
and maintenance. 214
(B) Proof of incapacity and dependence for purposes of 216
division (A) of this section shall be furnished to the health 217
insuring corporation within thirty-one days of the child's 219
attainment of the limiting age. Upon request, but not more 220
frequently than annually, the health insuring corporation may 221
require proof satisfactory to it of the continuance of such 222
incapacity and dependency.
(C) Nothing in this section shall be construed to require 225
a health insuring corporation to cover a dependent child who is 226
mentally retarded or physically handicapped if the policy, 227
contract, or agreement is underwritten on evidence of 228
insurability based on health factors set forth in the 229
application, or if the dependent child does not satisfy the 230
conditions of the policy, contract, or agreement as to any 231
requirement for evidence of insurability or any other provision 232
of the policy, contract, or agreement, satisfaction of which is 233
required for coverage thereunder to take effect. In any such 234
case, the terms of the policy, contract, or agreement shall apply 235
with regard to the coverage or exclusion of the dependent from 236
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such coverage.
(D) This section does not apply to any health insuring 239
corporation, policy, contract, or agreement offering only 240
supplemental health care services or specialty health care
services. 241
(E) THIS SECTION DOES NOT APPLY TO ANY GROUP HEALTH 244
INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT OR TO ANY 245
POLICY, CONTRACT, OR AGREEMENT WRITTEN UNDER SECTION 1751.15 OR 246
3923.581 OF THE REVISED CODE. 247
Sec. 1751.15. (A) After a health insuring corporation has 256
furnished, directly or indirectly, basic health care services for 257
a period of twenty-four months, and if it currently meets the 258
financial requirements set forth in section 1751.28 of the 259
Revised Code and had net income as reported to the superintendent 260
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 261
less than thirty days during its month of licensure FOR 263
INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 264
(B) During the open enrollment period described in 266
division (A) of this section, the health insuring corporation 267
shall accept applicants and their dependents in the order in 268
which they apply for enrollment and in accordance with any of the 269
following:
(1) Up to its capacity, as determined by the health 271
insuring corporation subject to review by the superintendent; 272
(2) If less than its capacity, one per cent of the health 274
insuring corporation's total number of subscribers residing in 275
this state as of the immediately preceding thirty-first day of 276
December. 277
(C) Where a health insuring corporation demonstrates to 279
the satisfaction of the superintendent that such open enrollment 280
would jeopardize its economic viability, the superintendent may 281
do any of the following:
(1) Waive the requirement for open enrollment; 283
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(2) Impose a limit on the number of applicants and their 285
dependents that must be enrolled; 286
(3) Authorize such underwriting restrictions upon open 288
enrollment as are necessary to do any of the following: 289
(a) Preserve its financial stability; 291
(b) Prevent excessive adverse selection; 293
(c) Avoid unreasonably high or unmarketable charges for 295
coverage of health care services. 296
(D)(1) A request to the superintendent under division (C) 299
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 300
documentation, including financial data. In reviewing the 301
request, the superintendent may consider various factors, 302
including the size of the health insuring corporation, the health 303
insuring corporation's net worth and profitability, the health 304
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 305
(2) Any action taken by the superintendent under division 307
(C) of this section shall be effective for a period of not more 309
than one year. At the expiration of such time, a new 310
demonstration of the health insuring corporation's need for the 311
restriction, limit, or waiver shall be made before a new 312
restriction, limit, or waiver is granted by the superintendent. 313
(3) Irrespective of the granting of any restriction, 315
limit, or waiver by the superintendent, a health insuring 316
corporation may reject an applicant or a dependent of the 317
applicant during its open enrollment period if the applicant or 318
dependent: 319
(a) Was eligible for and was covered under any 321
employer-sponsored health care coverage, or if employer-sponsored 322
health care coverage was available at the time of open 323
enrollment;
(b) Is eligible for conversion or continuation coverage 325
under state or federal law; 326
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(c) Is eligible for medicare, and the health insuring 328
corporation does not have an agreement on appropriate payment 329
mechanisms with the governmental agency administering the 330
medicare program.
(E) A health insuring corporation shall not be required 332
either to enroll applicants or their dependents who are confined 333
to a health care facility because of chronic illness, permanent 334
injury, or other infirmity that would cause economic impairment 335
to the health insuring corporation if such applicants or their 336
dependents were enrolled or to make the effective date of 337
benefits for applicants or their dependents enrolled under this 338
section earlier than ninety days after the date of enrollment. 339
(F) A health insuring corporation shall not be required to 341
cover the fees or costs, or both, for any basic health care 342
service related to a transplant of a body organ if the transplant 343
occurs within one year after the effective date of an enrollee's 344
coverage under this section. This limitation on coverage does 345
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 346
(G) Each health insuring corporation required to hold an 348
open enrollment pursuant to division (A) of this section shall 349
file with the superintendent, not later than sixty days prior to 350
the commencement of the proposed open enrollment period, the 351
following documents:
(1) The proposed public notice of open enrollment; 353
(2) The evidence of coverage approved pursuant to section 355
1751.11 of the Revised Code that will be used during open 357
enrollment;
(3) The contractual periodic prepayment and premium rate 359
approved pursuant to section 1751.12 of the Revised Code that 360
will be applicable during open enrollment; 361
(4) Any solicitation document approved pursuant to section 364
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 365
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(5) A list of the proposed dates of publication of the 367
public notice, and the names of the newspapers in which the 368
notice will appear; 369
(6) Any request for a restriction, limit, or waiver with 371
respect to the open enrollment period, along with any supporting 372
documentation. 373
(H)(1) An open enrollment period shall not satisfy the 375
requirements of this section unless the health insuring 376
corporation provides adequate public notice in accordance with 377
divisions (H)(2) and (3) of this section. No public notice shall 378
be used until the form of the public notice has been filed by the 379
health insuring corporation with the superintendent. If the 380
superintendent does not disapprove the public notice within sixty 381
days after it is filed, it shall be deemed approved, unless the 382
superintendent sooner gives approval for the public notice. If 383
the superintendent determines within this sixty-day period that 384
the public notice fails to meet the requirements of this section, 385
the superintendent shall so notify the health insuring 386
corporation and it shall be unlawful for the health insuring 387
corporation to use the public notice. Such disapproval shall be 388
effected by a written order, which shall state the grounds for 389
disapproval and shall be issued in accordance with Chapter 119. 390
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 392
section shall be published in at least one newspaper of general 393
circulation in each county in the health insuring corporation's 394
service area, at least once in each of the two weeks immediately 395
preceding the month in which the open enrollment is to occur and 396
in each week of that month, or until the enrollment limitation is 397
reached, whichever occurs first. The notice published during the 398
last week of open enrollment shall appear not less than five days 399
before the end of the open enrollment period. It shall be at 400
least two newspaper columns wide or two and one-half inches wide, 402
whichever is larger. The first two lines of the text shall be 403
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published in not less than twelve-point, boldface type. The 404
remainder of the text of the notice shall be published in not 405
less than eight-point type. The entire public notice shall be 406
surrounded by a continuous black line not less than one-eighth of 407
an inch wide.
(3) The following information shall be included in the 409
public notice provided under division (H)(2) of this section: 410
(a) The dates that open enrollment will be held and the 412
date coverage obtained under the open enrollment will become 413
effective;
(b) Notice that an applicant or the applicant's dependents 415
will not be denied coverage during open enrollment because of a 416
preexisting health condition, but that some limitations and 417
restrictions may apply;
(c) The address where a person may obtain an application; 419
(d) The telephone number that a person may call to request 421
an application or to ask questions; 423
(e) The date the first payment will be due; 425
(f) The actual rates or range of rates that will be 427
applicable for applicants; 428
(g) Any limitation granted by the superintendent on the 431
number of applications that will be accepted by the health 432
insuring corporation.
(4) Within thirty days after the end of an open enrollment 435
period, the health insuring corporation shall submit to the 436
superintendent proof of publication for the public notices, and 437
shall report the total number of applicants and their dependents 438
enrolled during the open enrollment period. 439
(I)(1) No health insuring corporation may employ any 441
scheme, plan, or device that restricts the ability of any person 442
to enroll during open enrollment. 443
(2) No health insuring corporation may require enrollment 445
to be made in person. Every health insuring corporation shall 446
permit application for coverage by mail. A representative of the 448
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health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 449
operations of the health insuring corporation and to answer any 450
questions the applicant may have. Every health insuring 451
corporation shall make open enrollment applications and 452
solicitation documents readily available to any potential 453
applicant who requests such material. 454
(J) An application postmarked on the last day of an open 456
enrollment period shall qualify as a valid application, 457
regardless of the date on which it is received by the health 458
insuring corporation.
(K) This section does not apply to any health insuring 460
corporation that offers only supplemental health care services or 462
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 463
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 464
U.S.C.A. 301, as amended, and that has no other commercial 465
enrollment, or to any health insuring corporation that offers 466
plans only through other federal health care programs regulated 467
by federal regulatory bodies and that has no other commercial 468
enrollment.
(L) EACH HEALTH INSURING CORPORATION SHALL ACCEPT 471
FEDERALLY ELIGIBLE INDIVIDUALS FOR OPEN ENROLLMENT COVERAGE AS 472
PROVIDED IN SECTION 3923.581 OF THE REVISED CODE. A HEALTH 474
INSURING CORPORATION MAY REINSURE COVERAGE OF ANY FEDERALLY 475
ELIGIBLE INDIVIDUAL ACQUIRED UNDER THAT SECTION WITH THE OPEN 476
ENROLLMENT REINSURANCE PROGRAM IN ACCORDANCE WITH DIVISION (G) OF 478
SECTION 3924.11 OF THE REVISED CODE. FIXED PERIODIC PREPAYMENT 481
RATES CHARGED FOR COVERAGE REINSURED BY THE PROGRAM SHALL BE 482
ESTABLISHED IN ACCORDANCE WITH SECTION 3924.12 OF THE REVISED 484
CODE.
(M) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 487
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 489
148.103. 490
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Sec. 1751.16. (A) Except as provided in division (F) of 499
this section, every group contract issued by a health insuring 500
corporation shall provide an option for conversion to an 501
individual contract issued on a direct-payment basis to any 502
subscriber covered by the group contract who terminates 503
employment or membership in the group, unless: 504
(1) Termination of the conversion option or contract is 506
based upon nonpayment of premium after reasonable notice in 507
writing has been given by the health insuring corporation to the 508
subscriber. 509
(2) The subscriber is, or is eligible to be, covered for 511
benefits at least comparable to the group contract under any of 512
the following: 513
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 515
(1935), 42 U.S.C.A. 301, as amended; 516
(b) Any act of congress or law under this or any other 518
state of the United States providing coverage at least comparable 519
to the benefits under division (A)(2)(a) of this section; 520
(c) Any policy of insurance or health care plan providing 522
coverage at least comparable to the benefits under division 523
(A)(2)(a) of this section. 524
(B)(1) The direct-payment contract offered by the health 526
insuring corporation pursuant to division (A) of this section 528
shall provide benefits comparable to the benefits being provided 529
by any of the individual contracts then being issued to 530
individual subscribers by the health insuring corporation. The 531
contract may contain a coordination of benefits provision as 532
approved by the superintendent of insurance THE FOLLOWING: 534
(a) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 537
ELIGIBLE INDIVIDUAL, BENEFITS COMPARABLE TO BENEFITS IN ANY OF 538
THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO INDIVIDUAL 539
SUBSCRIBERS BY THE HEALTH INSURING CORPORATION; 540
(b) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 543
BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 544
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THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 545
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 546
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (B)(1)(b) OF 548
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 549
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 550
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. THE 551
CONTRACTUAL PERIODIC PREPAYMENTS CHARGED FOR SUCH PLANS MAY NOT 552
EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE STANDARD 553
RATE CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH THE 554
ORGANIZATION IS CURRENTLY ACCEPTING NEW BUSINESS AND FOR WHICH 555
SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 556
(2) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 558
DIVISION (A) OF THIS SECTION MAY INCLUDE A COORDINATION OF 560
BENEFITS PROVISION AS APPROVED BY THE SUPERINTENDENT. 561
(3) FOR PURPOSES OF DIVISION (B) OF THIS SECTION 564
"FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS 565
DEFINED IN 45 C.F.R. 148.103. 568
(C) The option for conversion shall be available: 570
(1) Upon the death of the subscriber, to the surviving 572
spouse with respect to SUCH OF the spouse or AND dependents who 574
were AS ARE then covered by the group contract; 575
(2) To a child solely with respect to the child upon the 577
child's attaining the limiting age of coverage under the group 578
contract while covered as a dependent under the contract; 579
(3) Upon the divorce, dissolution, or annulment of the 581
marriage of the subscriber, to the divorced spouse, or, in the 582
event of annulment, to the former spouse of the subscriber. 584
(D) No health insuring corporation shall do any of the 586
following:
(1) Use USE age as the basis for refusing to renew a 588
converted contract; 589
(2) Require a subscriber to produce evidence of 591
insurability in order to exercise the option for conversion 592
provided by this section; 593
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(3) Include preexisting condition limitations in a 595
converted contract. 596
(E) Written notice of the conversion option provided by 599
this section shall be given to the subscriber by the health 600
insuring corporation by mail. The notice shall be sent to the 601
subscriber's address in the records of the employer upon receipt 602
of notice from the employer of the event giving rise to the 603
conversion option. If the subscriber has not received notice of 604
the conversion privilege at least fifteen days prior to the 605
expiration of the thirty-day conversion period, then the 606
subscriber shall have an additional period within which to 607
exercise the privilege. This additional period shall expire 608
fifteen days after the subscriber receives notice, but in no 609
event shall the period extend beyond sixty days after the 610
expiration of the thirty-day conversion period. 611
(F) This section does not apply to any group contract 613
offering only supplemental health care services or specialty 614
health care services.
Sec. 1751.18. (A)(1) No health insuring corporation shall 623
cancel or fail to renew the coverage of a subscriber or enrollee 624
because of the subscriber's or enrollee's ANY health status or 626
requirement STATUS-RELATED FACTOR IN RELATION TO THE SUBSCRIBER, 627
THE SUBSCRIBER'S REQUIREMENTS for health care services, or for 629
any other reason designated under rules adopted by the 630
superintendent of insurance. 631
(2) Unless otherwise required by state or federal law, no 633
health insuring corporation, or health care facility or provider 634
through which the health insuring corporation has made 635
arrangements to provide health care services, shall discriminate 636
against any individual with regard to enrollment, disenrollment, 637
or the quality of health care services rendered, on the basis of 638
the individual's race, color, sex, age, religion, state of 639
health, or status as a recipient of medicare or medical 640
assistance under Title XVIII or XIX of the "Social Security Act," 641
15
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, OR ANY HEALTH 643
STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL. However, a 644
health insuring corporation shall not be required to accept a 646
recipient of medicare or medical assistance, if an agreement has 647
not been reached on appropriate payment mechanisms between the 648
health insuring corporation and the governmental agency 649
administering these programs. Further, except during a period of 650
open enrollment under section 1751.15 of the Revised Code, a 651
health insuring corporation may reject an applicant for nongroup 652
enrollment on the basis of the state of ANY health of 653
STATUS-RELATED FACTOR IN RELATION TO the applicant. 655
(B) A health insuring corporation may cancel or decide not 658
to renew the coverage of a subscriber or enrollee for any of the 659
following reasons:
(1) Failure of the subscriber or enrollee to pay, or to 661
have paid on the subscriber's or enrollee's behalf, the required 662
premium rate or other charge; 663
(2) Fraud or forgery; 665
(3) Any material misrepresentation on the application for 667
coverage; 668
(4) The subscriber's or enrollee's permitting the use of 670
an identification card or similar documents by another person, 671
allowing that person to receive services for which that person is 673
not entitled;
(5) The subscriber's or enrollee's inability to establish 675
or maintain a provider-patient relationship with any provider 676
associated with the health insuring corporation, which inability 677
may include the subscriber's or enrollee's disruptive or abusive 678
behavior toward providers or the staff of the health care plan. 680
(C) A subscriber or enrollee may appeal any action or 682
decision of the A health insuring corporation under division (B) 685
of this section TAKEN PURSUANT TO SECTION 2742(b) TO (e) OF THE 688
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 689
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 691
16
AMENDED. To appeal, the subscriber or enrollee may submit a 694
written complaint to the health insuring corporation pursuant to 695
section 1751.19 of the Revised Code. The subscriber or enrollee 696
may, within thirty days after receiving a written response from 697
the health insuring corporation, appeal the health insuring 698
corporation's action or decision to the superintendent. 699
(C) AS USED IN THIS SECTION, "HEALTH STATUS-RELATED 701
FACTOR" MEANS ANY OF THE FOLLOWING: 702
(1) HEALTH STATUS; 704
(2) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 707
ILLNESSES;
(3) CLAIMS EXPERIENCE; 709
(4) RECEIPT OF HEALTH CARE; 711
(5) MEDICAL HISTORY; 713
(6) GENETIC INFORMATION; 715
(7) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 718
OUT OF ACTS OF DOMESTIC VIOLENCE;
(8) DISABILITY. 720
Sec. 1751.57. (A) THE FOLLOWING CONDITIONS APPLY TO ALL 722
INDIVIDUAL HEALTH INSURING CORPORATION CONTRACTS: 723
(1) EXCEPT AS PROVIDED IN SECTION 2742(b) TO (e) OF THE 727
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 732
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 737
AMENDED, A HEALTH INSURING CORPORATION THAT PROVIDES INDIVIDUAL 738
COVERAGE TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN FORCE SUCH 739
COVERAGE AT THE OPTION OF THE INDIVIDUAL. 740
(2) SUCH INDIVIDUAL CONTRACTS ARE SUBJECT TO SECTIONS 2743 742
AND 2747 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 746
ACT OF 1996." 747
(3) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 751
SHALL APPLY TO HEALTH INSURING CORPORATION CONTRACTS OFFERED IN 752
THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO HEALTH 753
BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 754
(B) IN ACCORDANCE WITH 45 C.F.R. 148.102, THIS SECTION 759
17
ALSO APPLIES TO ALL GROUP HEALTH INSURING CORPORATION CONTRACTS 760
THAT ARE NOT SOLD IN CONNECTION WITH AN EMPLOYMENT-RELATED GROUP 761
HEALTH CARE PLAN AND THAT PROVIDE MORE THAN SHORT-TERM, LIMITED 762
DURATION COVERAGE.
Sec. 1751.58. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2721 765
OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 769
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-21, 775
AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP HEALTH 776
INSURING CORPORATION CONTRACTS THAT ARE SOLD IN CONNECTION WITH 777
AN EMPLOYMENT-RELATED GROUP HEALTH CARE PLAN AND THAT ARE NOT 778
SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 780
(A) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 784
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 788
A HEALTH INSURING CORPORATION OFFERS COVERAGE IN THE SMALL OR 789
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE 790
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT 791
THE OPTION OF THE CONTRACT HOLDER. 792
(B) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISION (E)(1) OF 795
SECTION 3924.03 AND SECTIONS 3924.033 AND 3924.27 OF THE REVISED 796
CODE. 797
(C) SUCH GROUP CONTRACTS SHALL PROVIDE FOR THE SPECIAL 800
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 803
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 806
Sec. 1751.59. (A) No individual or group health insuring 815
corporation policy, contract, or agreement providing THAT MAKES 816
family coverage AVAILABLE may be delivered, issued for delivery, 818
or renewed in this state, unless the policy, contract, or
agreement covers adopted children of the subscriber on the same 819
basis as other dependents. 820
(B) The coverage required by this section is subject to 822
the requirements and restrictions set forth in section 3924.51 of 823
the Revised Code. Coverage for dependent children living outside 825
the health insuring corporation's approved service area must be 826
provided if a court order requires the subscriber to provide 827
18
health care coverage.
Sec. 1751.61. (A) Each individual or group evidence of 837
coverage that is delivered, issued for delivery, or renewed by a 838
health insuring corporation in this state, and that provides 839
MAKES coverage AVAILABLE for family members of a subscriber, also 841
shall provide that coverage applicable to children is payable 842
from the moment of birth with respect to a newly born child of 843
the subscriber or subscriber's spouse. 844
(B) Coverage for a newly born child is effective for a 846
period of thirty-one days from the date of birth. 847
(C) To continue coverage for a newly born child beyond the 849
thirty-one day period described in division (B) of this section, 850
the subscriber shall notify the health insuring corporation 851
within that period.
(D) If payment of a specific premium rate is required to 853
provide coverage under this section for an additional child, the 854
evidence of coverage may require the subscriber to make this 855
payment to the health insuring corporation within the thirty-one 856
day period described in division (B) of this section in order to 857
continue the coverage beyond that period. 858
Sec. 1751.64. (A) As used in this section, "genetic 868
screening or testing" means a laboratory test of a person's genes 869
or chromosomes for abnormalities, defects, or deficiencies, 870
including carrier status, that are linked to physical or mental 871
disorders or impairments, or that indicate a susceptibility to 872
illness, disease, or other disorders, whether physical or mental, 873
which test is a direct test for abnormalities, defects, or 874
deficiencies, and not an indirect manifestation of genetic 875
disorders.
(B) No health insuring corporation, in processing an 878
application for coverage for health care services under an 879
individual or group health insuring corporation policy, contract, 880
or agreement or in determining insurability under such a policy, 881
contract, or agreement, shall do any of the following: 882
19
(1) Require an individual seeking coverage to submit to 884
genetic screening or testing; 885
(2) Take into consideration, other than in accordance with 888
division (F) of this section, the results of genetic screening or 889
testing;
(3) Make any inquiry to determine the results of genetic 891
screening or testing; 892
(4) Make a decision adverse to the applicant based on 894
entries in medical records or other reports of genetic screening 895
or testing. 896
(C) In developing and asking questions regarding medical 899
histories of applicants for coverage under an individual or group 900
health insuring corporation policy, contract, or agreement, no 901
health insuring corporation shall ask for the results of genetic 902
screening or testing or ask questions designed to ascertain the 903
results of genetic screening or testing. 904
(D) No health insuring corporation shall cancel or refuse 907
to issue or renew coverage for health care services based on the 908
results of genetic screening or testing. 909
(E) No health insuring corporation shall deliver, issue 912
for delivery, or renew an individual or group policy, contract, 913
or agreement in this state that limits benefits based on the 914
results of genetic screening or testing. 915
(F) A health insuring corporation may consider the results 918
of genetic screening or testing if the results are voluntarily 919
submitted by an applicant for coverage or renewal of coverage and 920
the results are favorable to the applicant. 921
(G) A violation of this section is an unfair and deceptive 924
act or practice in the business of insurance under sections 925
3901.19 to 3901.26 of the Revised Code. 927
Sec. 1751.65. (A) As used in this section, "genetic 937
screening or testing" means a laboratory test of a person's genes 938
or chromosomes for abnormalities, defects, or deficiencies, 939
including carrier status, that are linked to physical or mental 940
20
disorders or impairments, or that indicate a susceptibility to 941
illness, disease, or other disorders, whether physical or mental, 942
which test is a direct test for abnormalities, defects, or 943
deficiencies, and not an indirect manifestation of genetic 944
disorders. 945
(B) Upon the repeal of section 1751.64 of the Revised 948
Code, no health insuring corporation shall do either of the 950
following:
(1) Consider, in a manner adverse to an applicant or 952
insured, any information obtained from genetic screening or 953
testing conducted prior to the repeal of section 1751.64 of the 954
Revised Code in processing an application for coverage for health 957
care services under an individual or group policy, contract, or 958
agreement or in determining insurability under such a policy, 959
contract, or agreement; 960
(2) Inquire, directly or indirectly, into the results of 962
genetic screening or testing conducted prior to the repeal of 963
section 1751.64 of the Revised Code, or use such information, in 966
whole or in part, to cancel, refuse to issue or renew, or limit 967
benefits under, an individual or group policy, contract, or 968
agreement.
(C) Any health insuring corporation that has engaged in, 971
is engaged in, or is about to engage in a violation of division 972
(B) of this section is subject to the jurisdiction of the 974
superintendent of insurance under section 3901.04 of the Revised 975
Code.
Sec. 1751.67. (A) Each individual or group health 984
insuring corporation policy, contract, or agreement delivered, 985
issued for delivery, or renewed in this state that provides 986
maternity benefits shall provide coverage of inpatient care and 987
follow-up care for a mother and her newborn as follows: 988
(1) The policy, contract, or agreement shall cover a 990
minimum of forty-eight SEVENTY-TWO hours of inpatient care 991
following a normal vaginal delivery and a minimum of ninety-six 993
21
hours of inpatient care following a cesarean delivery. Services 994
covered as inpatient care shall include medical, educational, and 995
any other services that are consistent with the inpatient care 996
recommended in the protocols and guidelines developed by national 997
organizations that represent pediatric, obstetric, and nursing 998
professionals.
(2) The policy, contract, or agreement shall cover a 1,000
physician-directed source of follow-up care. Services covered as 1,002
follow-up care shall include physical assessment of the mother 1,003
and newborn, parent education, assistance and training in breast 1,004
or bottle feeding, assessment of the home support system,
performance of any medically necessary and appropriate clinical 1,005
tests, and any other services that are consistent with the 1,006
follow-up care recommended in the protocols and guidelines 1,007
developed by national organizations that represent pediatric, 1,008
obstetric, and nursing professionals. The coverage shall apply 1,009
to services provided in a medical setting or through home health 1,010
care visits. The coverage shall apply to a home health care 1,011
visit only if the provider who conducts the visit is 1,012
knowledgeable and experienced in maternity and newborn care. 1,013
When a decision is made in accordance with division (B) of 1,016
this section to discharge a mother or newborn prior to the
expiration of the applicable number of hours of inpatient care 1,017
required to be covered, the coverage of follow-up care shall 1,018
apply to all follow-up care that is provided within forty-eight 1,019
hours after discharge. When a mother or newborn receives at 1,020
least the number of hours of inpatient care required to be 1,021
covered, the coverage of follow-up care shall apply to follow-up 1,022
care that is determined to be medically necessary by the provider 1,024
responsible for discharging the mother or newborn.
(B) Any decision to shorten the length of inpatient stay 1,026
to less than that specified under division (A)(1) of this section 1,028
shall be made by the physician attending the mother or newborn, 1,029
except that if a nurse-midwife is attending the mother in 1,030
22
collaboration with a physician, the decision may be made by the 1,031
nurse-midwife. Decisions regarding early discharge shall be made 1,032
only after conferring with the mother or a person responsible for 1,033
the mother or newborn. For purposes of this division, a person 1,034
responsible for the mother or newborn may include a parent, 1,035
guardian, or any other person with authority to make medical 1,036
decisions for the mother or newborn.
(C)(1) No health insuring corporation may do either of the 1,038
following:
(a) Terminate the participation of a provider or health 1,040
care facility in an individual or group health care plan solely 1,041
for making recommendations for inpatient or follow-up care for a 1,042
particular mother or newborn that are consistent with the care 1,043
required to be covered by this section; 1,044
(b) Establish or offer monetary or other financial 1,046
incentives for the purpose of encouraging a person to decline the 1,048
inpatient or follow-up care required to be covered by this
section. 1,049
(2) Whoever violates division (C)(1)(a) or (b) of this 1,051
section has engaged in an unfair and deceptive act or practice in 1,052
the business of insurance under sections 3901.19 to 3901.26 of 1,053
the Revised Code.
(D) This section does not do any of the following: 1,055
(1) Require a policy, contract, or agreement to cover 1,057
inpatient or follow-up care that is not received in accordance 1,058
with the policy's, contract's, or agreement's terms pertaining to 1,059
the providers and facilities from which an individual is 1,060
authorized to receive health care services; 1,061
(2) Require a mother or newborn to stay in a hospital or 1,063
other inpatient setting for a fixed period of time following 1,064
delivery;
(3) Require a child to be delivered in a hospital or other 1,066
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 1,068
23
authority to practice nurse-midwifery in accordance with Chapter 1,069
4723. of the Revised Code; 1,070
(5) Establish minimum standards of medical diagnosis, 1,072
care, or treatment for inpatient or follow-up care for a mother 1,073
or newborn. A deviation from the care required to be covered 1,074
under this section shall not, solely on the basis of this 1,075
section, give rise to a medical claim or to derivative claims for 1,076
relief, as those terms are defined in section 2305.11 of the 1,077
Revised Code.
Sec. 3901.044. THE SUPERINTENDENT OF INSURANCE MAY ADOPT 1,080
RULES IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE THAT 1,083
THE SUPERINTENDENT CONSIDERS NECESSARY AND ADVISABLE FOR THE 1,084
PURPOSE OF IMPLEMENTING THE "HEALTH INSURANCE PORTABILITY AND 1,088
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 1,093
42 U.S.C.A. 300gg, AS AMENDED, AND ANY REGULATION ADOPTED 1,095
THEREUNDER. 1,096
Sec. 3901.21. The following are hereby defined as unfair 1,105
and deceptive acts or practices in the business of insurance: 1,106
(A) Making, issuing, circulating, or causing or permitting 1,108
to be made, issued, or circulated, or preparing with intent to so 1,109
use, any estimate, illustration, circular, or statement 1,110
misrepresenting the terms of any policy issued or to be issued or 1,111
the benefits or advantages promised thereby or the dividends or 1,112
share of the surplus to be received thereon, or making any false 1,113
or misleading statements as to the dividends or share of surplus 1,114
previously paid on similar policies, or making any misleading 1,115
representation or any misrepresentation as to the financial 1,116
condition of any insurer as shown by the last preceding verified 1,117
statement made by it to the insurance department of this state, 1,118
or as to the legal reserve system upon which any life insurer 1,119
operates, or using any name or title of any policy or class of 1,120
policies misrepresenting the true nature thereof, or making any 1,121
misrepresentation or incomplete comparison to any person for the 1,122
purpose of inducing or tending to induce such person to purchase, 1,123
24
amend, lapse, forfeit, change, or surrender insurance. 1,124
Any written statement concerning the premiums for a policy 1,126
which refers to the net cost after credit for an assumed 1,127
dividend, without an accurate written statement of the gross 1,128
premiums, cash values, and dividends based on the insurer's 1,129
current dividend scale, which are used to compute the net cost 1,130
for such policy, and a prominent warning that the rate of 1,131
dividend is not guaranteed, is a misrepresentation for the 1,132
purposes of this division. 1,133
(B) Making, publishing, disseminating, circulating, or 1,135
placing before the public or causing, directly or indirectly, to 1,136
be made, published, disseminated, circulated, or placed before 1,137
the public, in a newspaper, magazine, or other publication, or in 1,138
the form of a notice, circular, pamphlet, letter, or poster, or 1,139
over any radio station, or in any other way, or preparing with 1,140
intent to so use, an advertisement, announcement, or statement 1,141
containing any assertion, representation, or statement, with 1,142
respect to the business of insurance or with respect to any 1,143
person in the conduct of his THE PERSON'S insurance business, 1,144
which is untrue, deceptive, or misleading. 1,145
(C) Making, publishing, disseminating, or circulating, 1,147
directly or indirectly, or aiding, abetting, or encouraging the 1,148
making, publishing, disseminating, or circulating, or preparing 1,149
with intent to so use, any statement, pamphlet, circular, 1,150
article, or literature, which is false as to the financial 1,151
condition of an insurer and which is calculated to injure any 1,152
person engaged in the business of insurance. 1,153
(D) Filing with any supervisory or other public official, 1,155
or making, publishing, disseminating, circulating, or delivering 1,156
to any person, or placing before the public, or causing directly 1,157
or indirectly to be made, published, disseminated, circulated, 1,158
delivered to any person, or placed before the public, any false 1,159
statement of financial condition of an insurer. 1,160
Making any false entry in any book, report, or statement of 1,162
25
any insurer with intent to deceive any agent or examiner lawfully 1,163
appointed to examine into its condition or into any of its 1,164
affairs, or any public official to whom such insurer is required 1,165
by law to report, or who has authority by law to examine into its 1,166
condition or into any of its affairs, or, with like intent, 1,167
willfully omitting to make a true entry of any material fact 1,168
pertaining to the business of such insurer in any book, report, 1,169
or statement of such insurer, or mutilating, destroying, 1,170
suppressing, withholding, or concealing any of its records. 1,171
(E) Issuing or delivering or permitting agents, officers, 1,173
or employees to issue or deliver agency company stock or other 1,174
capital stock or benefit certificates or shares in any common-law 1,175
corporation or securities or any special or advisory board 1,176
contracts or other contracts of any kind promising returns and 1,177
profits as an inducement to insurance. 1,178
(F) Making or permitting any unfair discrimination among 1,180
individuals of the same class and equal expectation of life in 1,181
the rates charged for any contract of life insurance or of life 1,182
annuity or in the dividends or other benefits payable thereon, or 1,183
in any other of the terms and conditions of such contract. 1,184
(G)(1) Except as otherwise expressly provided by law, 1,186
knowingly permitting or offering to make or making any contract 1,187
of life insurance, life annuity or accident and health insurance, 1,188
or agreement as to such contract other than as plainly expressed 1,189
in the contract issued thereon, or paying or allowing, or giving 1,190
or offering to pay, allow, or give, directly or indirectly, as 1,191
inducement to such insurance, or annuity, any rebate of premiums 1,192
payable on the contract, or any special favor or advantage in the 1,193
dividends or other benefits thereon, or any valuable 1,194
consideration or inducement whatever not specified in the 1,195
contract; or giving, or selling, or purchasing, or offering to 1,196
give, sell, or purchase, as inducement to such insurance or 1,197
annuity or in connection therewith, any stocks, bonds, or other 1,198
securities, or other obligations of any insurance company or 1,199
26
other corporation, association, or partnership, or any dividends 1,200
or profits accrued thereon, or anything of value whatsoever not 1,201
specified in the contract. 1,202
(2) Nothing in division (F) or division (G)(1) of this 1,204
section shall be construed as prohibiting any of the following 1,205
practices: (a) in the case of any contract of life insurance or 1,206
life annuity, paying bonuses to policyholders or otherwise 1,207
abating their premiums in whole or in part out of surplus 1,208
accumulated from nonparticipating insurance, provided that any 1,209
such bonuses or abatement of premiums shall be fair and equitable 1,210
to policyholders and for the best interests of the company and 1,211
its policyholders; (b) in the case of life insurance policies 1,212
issued on the industrial debit plan, making allowance to 1,213
policyholders who have continuously for a specified period made 1,214
premium payments directly to an office of the insurer in an 1,215
amount which fairly represents the saving in collection expenses; 1,216
(c) readjustment of the rate of premium for a group insurance 1,217
policy based on the loss or expense experience thereunder, at the 1,218
end of the first or any subsequent policy year of insurance 1,219
thereunder, which may be made retroactive only for such policy 1,220
year. 1,221
(H) Making, issuing, circulating, or causing or permitting 1,223
to be made, issued, or circulated, or preparing with intent to so 1,224
use, any statement to the effect that a policy of life insurance 1,225
is, is the equivalent of, or represents shares of capital stock 1,226
or any rights or options to subscribe for or otherwise acquire 1,227
any such shares in the life insurance company issuing that policy 1,228
or any other company. 1,229
(I) Making, issuing, circulating, or causing or permitting 1,231
to be made, issued or circulated, or preparing with intent to so 1,232
issue, any statement to the effect that payments to a 1,233
policyholder of the principal amounts of a pure endowment are 1,234
other than payments of a specific benefit for which specific 1,235
premiums have been paid. 1,236
27
(J) Making, issuing, circulating, or causing or permitting 1,238
to be made, issued, or circulated, or preparing with intent to so 1,239
use, any statement to the effect that any insurance company was 1,240
required to change a policy form or related material to comply 1,241
with Title XXXIX of the Revised Code or any regulation of the 1,242
superintendent of insurance, for the purpose of inducing or 1,243
intending to induce any policyholder or prospective policyholder 1,244
to purchase, amend, lapse, forfeit, change, or surrender 1,245
insurance. 1,246
(K) Aiding or abetting another to violate this section. 1,248
(L) Refusing to issue any policy of insurance, or 1,250
canceling or declining to renew such policy because of the sex or 1,251
marital status of the applicant, prospective insured, insured, or 1,252
policyholder. 1,253
(M) Making or permitting any unfair discrimination between 1,255
individuals of the same class and of essentially the same hazard 1,256
in the amount of premium, policy fees, or rates charged for any 1,257
policy or contract of insurance, other than life insurance, or in 1,258
the benefits payable thereunder, or in underwriting standards and 1,259
practices or eligibility requirements, or in any of the terms or 1,260
conditions of such contract, or in any other manner whatever. 1,261
(N) Refusing to make available disability income insurance 1,263
solely because the applicant's principal occupation is that of 1,264
managing a household. 1,265
(O) Refusing, when offering maternity benefits under any 1,267
individual or group sickness and accident insurance policy, to 1,268
make maternity benefits available to the policyholder for the 1,269
individual or individuals to be covered under any comparable 1,270
policy to be issued for delivery in this state, including family 1,271
members if the policy otherwise provides coverage for family 1,272
members. Nothing in this division shall be construed to prohibit 1,273
an insurer from imposing a reasonable waiting period for such 1,274
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE 1,275
POLICY, but in no event shall such waiting period exceed two 1,276
28
hundred seventy days. 1,277
(P) Using, or permitting to be used, a pattern settlement 1,279
as the basis of any offer of settlement. As used in this 1,280
division, "pattern settlement" means a method by which liability 1,281
is routinely imputed to a claimant without an investigation of 1,282
the particular occurrence upon which the claim is based and by 1,283
using a predetermined formula for the assignment of liability 1,284
arising out of occurrences of a similar nature. Nothing in this 1,285
division shall be construed to prohibit an insurer from 1,286
determining a claimant's liability by applying formulas or 1,287
guidelines to the facts and circumstances disclosed by the 1,288
insurer's investigation of the particular occurrence upon which a 1,289
claim is based. 1,290
(Q) Refusing to insure, or refusing to continue to insure, 1,292
or limiting the amount, extent, or kind of life or sickness and 1,293
accident insurance or annuity coverage available to an 1,294
individual, or charging an individual a different rate for the 1,295
same coverage solely because of blindness or partial blindness. 1,296
With respect to all other conditions, including the underlying 1,297
cause of blindness or partial blindness, persons who are blind or 1,298
partially blind shall be subject to the same standards of sound 1,299
actuarial principles or actual or reasonably anticipated 1,300
actuarial experience as are sighted persons. Refusal to insure 1,301
includes, but is not limited to, denial by an insurer of 1,302
disability insurance coverage on the grounds that the policy 1,303
defines "disability" as being presumed in the event that the 1,304
eyesight of the insured is lost. However, an insurer may exclude 1,305
from coverage disabilities consisting solely of blindness or 1,306
partial blindness when such conditions existed at the time the 1,307
policy was issued. To the extent that the provisions of this 1,308
division may appear to conflict with any provision of section 1,309
3999.16 of the Revised Code, this division applies. 1,310
(R)(1) Directly or indirectly offering to sell, selling, 1,312
or delivering, issuing for delivery, renewing, or using or 1,313
29
otherwise marketing any policy of insurance or insurance product 1,314
in connection with or in any way related to the grant of a 1,315
student loan guaranteed in whole or in part by an agency or 1,316
commission of this state or the United States, except insurance 1,317
that is required under federal or state law as a condition for 1,318
obtaining such a loan and the premium for which is included in 1,319
the fees and charges applicable to the loan; or, in the case of 1,320
an insurer or insurance agent, knowingly permitting any lender 1,321
making such loans to engage in such acts or practices in 1,322
connection with the insurer's or agent's insurance business. 1,323
(2) Except in the case of a violation of division (G) of 1,325
this section, division (R)(1) of this section does not apply to 1,326
either of the following: 1,327
(a) Acts or practices of an insurer, its agents, 1,329
representatives, or employees in connection with the grant of a 1,330
guaranteed student loan to its insured or the insured's spouse or 1,331
dependent children where such acts or practices take place more 1,332
than ninety days after the effective date of the insurance; 1,333
(b) Acts or practices of an insurer, its agents, 1,335
representatives, or employees in connection with the 1,336
solicitation, processing, or issuance of an insurance policy or 1,337
product covering the student loan borrower or his THE BORROWER'S 1,338
spouse or dependent children, where such acts or practices take 1,339
place more than one hundred eighty days after the date on which 1,340
the borrower is notified that the student loan was approved. 1,341
(S) Denying coverage, under any health insurance or health 1,343
care policy, contract, or plan providing family coverage, to any 1,344
natural or adopted child of the named insured or subscriber 1,345
solely on the basis that the child does not reside in the 1,346
household of the named insured or subscriber. 1,347
(T)(1) Using any underwriting standard or engaging in any 1,349
other act or practice that, directly or indirectly, due solely to 1,350
the actual or expected ANY health condition of STATUS-RELATED 1,352
FACTOR IN RELATION TO one or more individuals, does either of the 1,353
30
following:
(a) Terminates or fails to renew an existing individual 1,355
policy, contract, or plan of health benefits, or a health benefit 1,356
plan issued to a small AN employer as those terms are defined in 1,357
section 3924.01 of the Revised Code, for which an individual 1,358
would otherwise be eligible;
(b) With respect to a health benefit plan issued to a 1,360
small AN employer, as those terms are defined in section 3924.01 1,361
of the Revised Code, excludes or causes the exclusion of an 1,363
individual from coverage under an existing employer-provided 1,364
policy, contract, or plan of health benefits, except that an 1,365
insurer may exclude, on the basis of health status, a late 1,366
enrollee as defined in section 3924.01 of the Revised Code. 1,367
(2) The superintendent of insurance may adopt rules in 1,369
accordance with Chapter 119. of the Revised Code for purposes of 1,370
implementing division (T)(1) of this section. 1,371
(3) FOR PURPOSES OF DIVISION (T)(1) OF THIS SECTION, 1,375
"HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING: 1,376
(a) HEALTH STATUS; 1,378
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,381
ILLNESSES;
(c) CLAIMS EXPERIENCE; 1,383
(d) RECEIPT OF HEALTH CARE; 1,385
(e) MEDICAL HISTORY; 1,387
(f) GENETIC INFORMATION; 1,389
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,392
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 1,394
(U) With respect to a health benefit plan issued to a 1,396
small employer, as those terms are defined in section 3924.01 of 1,397
the Revised Code, negligently or willfully placing coverage for 1,398
adverse risks with a certain carrier, as defined in section 1,399
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 1,401
31
or practice that, directly or indirectly, causes or results in 1,402
the placing of coverage for adverse risks with another carrier, 1,403
as defined in section 3924.01 of the Revised Code. 1,404
(W) Failing to comply with section 3923.23, 3923.231, 1,406
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 1,407
in any unfair, discriminatory reimbursement practice. 1,408
(X) Intentionally establishing an unfair premium for, or 1,410
misrepresenting the cost of, any insurance policy financed under 1,411
a premium finance agreement of an insurance premium finance 1,412
company. 1,413
With respect to private passenger automobile insurance, no 1,415
insurer shall charge different premium rates to persons residing 1,416
within the limits of any municipal corporation based solely on 1,417
the location of the residence of the insured within those limits. 1,418
The enumeration in sections 3901.19 to 3901.26 of the 1,420
Revised Code of specific unfair or deceptive acts or practices in 1,421
the business of insurance is not exclusive or restrictive or 1,422
intended to limit the powers of the superintendent of insurance 1,423
to adopt rules to implement this section, or to take action under 1,424
other sections of the Revised Code. 1,425
This section does not prohibit the sale of shares of any 1,427
investment company registered under the "Investment Company Act 1,428
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 1,429
policies, annuities, or other contracts described in section 1,430
3907.15 of the Revised Code. 1,431
As used in this section, "estimate," "statement," 1,433
"representation," "misrepresentation," "advertisement," or 1,434
"announcement" includes oral or written occurrences. 1,435
Sec. 3901.49. (A) As used in this section: 1,446
(1) "Genetic screening or testing" means a laboratory test 1,448
of a person's genes or chromosomes for abnormalities, defects, or 1,449
deficiencies, including carrier status, that are linked to 1,450
physical or mental disorders or impairments, or that indicate a 1,451
susceptibility to illness, disease, or other disorders, whether 1,452
32
physical or mental, which test is a direct test for 1,453
abnormalities, defects, or deficiencies, and not an indirect 1,454
manifestation of genetic disorders. 1,455
(2) "Insurer" means any person authorized under Title 1,457
XXXIX of the Revised Code to engage in the business of sickness 1,458
and accident insurance. 1,459
(3) "Sickness and accident insurance" means sickness and 1,461
accident insurance under Chapter 3923. of the Revised Code 1,462
excluding disability income insurance and excluding supplemental 1,463
policies of sickness and accident insurance. 1,464
(B) No insurer, in processing an application for an 1,466
individual or group policy of sickness and accident insurance or 1,467
in determining insurability under such a policy, shall do any of 1,468
the following: 1,469
(1) Require an individual seeking coverage to submit to 1,471
genetic screening or testing; 1,472
(2) Take into consideration, other than in accordance with 1,474
division (F) of this section, the results of genetic screening or 1,475
testing; 1,476
(3) Make any inquiry to determine the results of genetic 1,478
screening or testing; 1,479
(4) Make a decision adverse to the applicant based on 1,481
entries in medical records or other reports of genetic screening 1,482
or testing. 1,483
(C) In developing and asking questions regarding medical 1,485
histories of applicants for sickness and accident insurance, no 1,486
insurer shall ask for the results of genetic screening or testing 1,487
or ask questions designed to ascertain the results of genetic 1,488
screening or testing. 1,489
(D) No insurer shall cancel or refuse to issue or renew 1,491
coverage under a sickness and accident insurance policy based on 1,492
the results of genetic screening or testing. 1,493
(E) No insurer shall deliver, issue for delivery, or renew 1,495
an individual or group policy of sickness and accident insurance 1,496
33
in this state that limits benefits based on the results of 1,497
genetic screening or testing. 1,498
(F) An insurer may consider the results of genetic 1,500
screening or testing if the results are voluntarily submitted by 1,501
an applicant for coverage or renewal of coverage and the results 1,502
are favorable to the applicant. 1,503
(G) A violation of this section is an unfair and deceptive 1,505
act or practice in the business of insurance under sections 1,506
3901.19 to 3901.26 of the Revised Code. 1,507
Sec. 3901.491. (A) As used in this section: 1,516
(1) "Genetic screening or testing" means a laboratory test 1,518
of a person's genes or chromosomes for abnormalities, defects, or 1,519
deficiencies, including carrier status, that are linked to 1,520
physical or mental disorders or impairments, or that indicate a 1,521
susceptibility to illness, disease, or other disorders, whether 1,522
physical or mental, which test is a direct test for 1,523
abnormalities, defects, or deficiencies, and not an indirect 1,524
manifestation of genetic disorders. 1,525
(2) "Insurer" means any person authorized under Title 1,527
XXXIX of the Revised Code to engage in the business of sickness 1,528
and accident insurance. 1,529
(3) "Sickness and accident insurance" means sickness and 1,531
accident insurance under Chapter 3923. of the Revised Code 1,532
excluding disability income insurance and excluding supplemental 1,533
policies of sickness and accident insurance. 1,534
(B) Upon the repeal of section 3901.49 of the Revised Code 1,536
by Sub. H.B. No. 71 of the 120th general assembly, no insurer 1,537
shall do either of the following: 1,538
(1) Consider, in a manner adverse to an applicant or 1,540
insured, any information obtained from genetic screening or 1,541
testing conducted prior to the repeal of section 3901.49 of the 1,542
Revised Code in processing an application for an individual or 1,543
group policy of sickness and accident insurance, or in 1,544
determining insurability under such a policy; 1,545
34
(2) Inquire, directly or indirectly, into the results of 1,547
genetic screening or testing conducted prior to the repeal of 1,548
section 3901.49 of the Revised Code, or use such information, in 1,549
whole or in part, to cancel, refuse to issue or renew, or limit 1,550
benefits under, a sickness and accident insurance policy. 1,551
(C) Any insurer that has engaged in, is engaged in, or is 1,553
about to engage in a violation of division (B) of this section is 1,554
subject to the jurisdiction of the superintendent of insurance 1,555
under section 3901.04 of the Revised Code. 1,556
Sec. 3901.50. (A) As used in this section: 1,567
(1) "Genetic screening or testing" means a laboratory test 1,569
of a person's genes or chromosomes for abnormalities, defects, or 1,570
deficiencies, including carrier status, that are linked to 1,571
physical or mental disorders or impairments, or that indicate a 1,572
susceptibility to illness, disease, or other disorders, whether 1,573
physical or mental, which test is a direct test for 1,574
abnormalities, defects, or deficiencies, and not an indirect 1,575
manifestation of genetic disorders. 1,576
(2) "Self-insurer" means any government entity providing 1,578
coverage for health care services on a self-insurance basis. 1,579
(B) No self-insurer, in processing an application for 1,581
coverage under a plan of self-insurance or in determining 1,582
insurability under such a plan, shall do any of the following: 1,583
(1) Require an individual seeking coverage to submit to 1,585
genetic screening or testing; 1,586
(2) Take into consideration, other than in accordance with 1,588
division (F) of this section, the results of genetic screening or 1,589
testing; 1,590
(3) Make any inquiry to determine the results of genetic 1,592
screening or testing; 1,593
(4) Make a decision adverse to the applicant based on 1,595
entries in medical records or other reports of genetic screening 1,596
or testing. 1,597
(C) In developing and asking questions regarding medical 1,599
35
histories of applicants for coverage under a plan of 1,600
self-insurance, no self-insurer shall ask for the results of 1,601
genetic screening or testing or ask questions designed to 1,602
ascertain the results of genetic screening or testing. 1,603
(D) No self-insurer shall cancel or refuse to provide or 1,605
renew coverage for health care services based on the results of 1,606
genetic screening or testing. 1,607
(E) No self-insurer shall establish or modify a plan of 1,609
self-insurance in this state that limits benefits based on the 1,610
results of genetic screening or testing. 1,611
(F) A self-insurer may consider the results of genetic 1,613
screening or testing if the results are voluntarily submitted by 1,614
an applicant for coverage or renewal of coverage and the results 1,615
are favorable to the applicant. 1,616
(G) A violation of this section is an unfair and deceptive 1,618
act or practice in the business of insurance under sections 1,619
3901.19 to 3901.26 of the Revised Code. 1,620
Sec. 3901.501. (A) As used in this section: 1,629
(1) "Genetic screening or testing" means a laboratory test 1,631
of a person's genes or chromosomes for abnormalities, defects, or 1,632
deficiencies, including carrier status, that are linked to 1,633
physical or mental disorders or impairments, or that indicate a 1,634
susceptibility to illness, disease, or other disorders, whether 1,635
physical or mental, which test is a direct test for 1,636
abnormalities, defects, or deficiencies, and not an indirect 1,637
manifestation of genetic disorders. 1,638
(2) "Self-insurer" means any government entity providing 1,640
coverage for health care services on a self-insurance basis. 1,641
(B) Upon the repeal of section 3901.50 of the Revised Code 1,643
by Sub. H.B. No. 71 of the 120th general assembly, no 1,644
self-insurer shall do either of the following: 1,645
(1) Consider, in a manner adverse to an applicant or 1,647
insured, any information obtained from genetic screening or 1,648
testing conducted prior to the repeal of section 3901.50 of the 1,649
36
Revised Code in processing an application for coverage under a 1,650
plan of self-insurance or in determining insurability under such 1,651
a plan; 1,652
(2) Inquire, directly or indirectly, into the results of 1,654
genetic screening or testing conducted prior to the repeal of 1,655
section 3901.50 of the Revised Code, or use such information, in 1,656
whole or in part, to cancel, refuse to provide or renew, or limit 1,657
benefits under, a plan of self-insurance. 1,658
(C) Any self-insurer that has engaged in, is engaged in, 1,660
or is about to engage in a violation of division (B) of this 1,661
section is subject to the jurisdiction of the superintendent of 1,662
insurance under section 3901.04 of the Revised Code. 1,663
Sec. 3923.021. (A) As used in this section, "benefits 1,672
provided are not unreasonable in relation to the premium charged" 1,673
means the rates were calculated in accordance with sound 1,674
actuarial principles. 1,675
(B) With respect to any filing, made pursuant to section 1,677
3923.02 of the Revised Code, of any premium rates for any 1,678
individual policy of sickness and accident insurance or for any 1,679
indorsement or rider pertaining thereto, the superintendent of 1,680
insurance may, within thirty days after filing: 1,681
(1) Disapprove such filing if he finds AFTER FINDING that 1,683
the benefits provided are unreasonable in relation to the premium 1,685
charged. Such disapproval shall be effected by written order of 1,686
the superintendent, a copy of which shall be mailed to the 1,687
insurer that has made the filing. In the order, the 1,688
superintendent shall specify the reasons for his THE disapproval 1,689
and state that a hearing will be held within fifteen days after 1,691
requested in writing by the insurer. If a hearing is so 1,692
requested, the superintendent shall also give such public notice 1,693
as he THE SUPERINTENDENT considers appropriate. The 1,695
superintendent, within fifteen days after the commencement of any 1,696
hearing, shall issue a written order, a copy of which shall be 1,697
mailed to the insurer that has made the filing, either affirming 1,698
37
his THE prior disapproval or approving such filing if he finds 1,700
AFTER FINDING that the benefits provided are not unreasonable in 1,701
relation to the premium charged. 1,702
(2) Set a date for a public hearing to commence no later 1,704
than forty days after the filing. The superintendent shall give 1,705
the insurer making the filing twenty days' written notice of the 1,706
hearing and shall give such public notice as he THE 1,707
SUPERINTENDENT considers appropriate. The superintendent, within 1,709
twenty days after the commencement of a hearing, shall issue a 1,710
written order, a copy of which shall be mailed to the insurer 1,711
that has made the filing, either approving such filing if he THE 1,712
SUPERINTENDENT finds that the benefits provided are not 1,714
unreasonable in relation to the premium charged, or disapproving 1,715
such filing if he THE SUPERINTENDENT finds that the benefits 1,716
provided are unreasonable in relation to the premium charged. 1,717
This division does not apply to any insurer organized or 1,718
transacting the business of insurance under Chapter 3907. or 1,719
3909. of the Revised Code. 1,720
(3) Take no action, in which case such filing shall be 1,722
deemed to be approved and shall become effective upon the 1,723
thirty-first day after such filing, unless the superintendent has 1,724
previously given to the insurer his A written approval. 1,725
(C) At any time after any filing has been approved 1,727
pursuant to this section, the superintendent may, after a hearing 1,728
of which at least twenty days' written notice has been given to 1,729
the insurer that has made such filing and for which such public 1,730
notice as he THE SUPERINTENDENT considers appropriate has been 1,731
given, withdraw approval of such filing if he finds AFTER FINDING 1,733
that the benefits provided are unreasonable in relation to the 1,735
premium charged. Such withdrawal of approval shall be effected 1,736
by written order of the superintendent, a copy of which shall be 1,737
mailed to the insurer that has made the filing, which shall state 1,738
the ground for such withdrawal and the date, not less than forty 1,739
days after the date of such order, when the withdrawal or 1,740
38
approval shall become effective. 1,741
(D) The superintendent may retain at the insurer's expense 1,743
such attorneys, actuaries, accountants, and other experts not 1,744
otherwise a part of the superintendent's staff as shall be 1,745
reasonably necessary to assist in the preparation for and conduct 1,746
of any public hearing under this section. The expense for 1,747
retaining such experts and the expenses of the department of 1,748
insurance incurred in connection with such public hearing shall 1,749
be assessed against the insurer in an amount not to exceed one 1,750
one-hundredth of one per cent of the sum of premiums earned plus 1,751
net realized investment gain or loss of such insurer as reflected 1,752
in the most current annual statement on file with the 1,753
superintendent. Any person retained shall be under the direction 1,754
and control of the superintendent and shall act in a purely 1,755
advisory capacity. 1,756
(E) This section does not apply to any filing of any 1,758
premium rate or rating formula for individual sickness and 1,759
accident insurance policies offered in accordance with division 1,760
(M)(L) of section 3923.58 of the Revised Code, or for any 1,761
amendment thereto. 1,762
Sec. 3923.122. (A) Every policy of group sickness and 1,772
accident insurance providing hospital, surgical, or medical 1,773
expense coverage for other than specific diseases or accidents 1,774
only, and delivered, issued for delivery, or renewed in this 1,775
state on or after January 1, 1976, shall include a provision 1,776
giving each insured the option to convert to THE FOLLOWING: 1,777
(1) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 1,780
ELIGIBLE INDIVIDUAL, any of the individual policies of hospital, 1,781
surgical, or medical expense insurance then being issued by the 1,782
insurer with benefit limits not to exceed those in effect under 1,783
the group policy;
(2) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 1,785
BASIC OR STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 1,786
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 1,787
39
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 1,788
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (A)(2) OF 1,789
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 1,790
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 1,791
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 1,792
(B) An option for conversion to an individual policy shall 1,794
be available without evidence of insurability to every insured, 1,795
including any person eligible under division (D) of this section, 1,796
who terminates his employment or membership in the group holding 1,797
the policy after having been continuously insured thereunder for 1,798
at least one year. 1,799
Upon receipt of the insured's written application and upon 1,801
payment of at least the first quarterly premium not later than 1,802
thirty-one days after the termination of coverage under the group 1,803
policy, the insurer shall issue a converted policy on a form then 1,804
available for conversion. The premium shall be in accordance 1,805
with the insurer's table of premium rates in effect on the later 1,806
of the following dates: 1,807
(1) The effective date of the converted policy; 1,809
(2) The date of application therefor; and shall be 1,811
applicable to the class of risk to which each person covered 1,813
belongs and to the form and amount of the policy at his THE
PERSON'S then attained age. HOWEVER, PREMIUMS CHARGED FEDERALLY 1,815
ELIGIBLE INDIVIDUALS MAY NOT EXCEED AN AMOUNT THAT IS TWO TIMES 1,817
THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER INDIVIDUAL OF 1,818
A GROUP TO WHICH THE INSURER IS CURRENTLY ACCEPTING NEW BUSINESS 1,819
AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 1,820
At the election of the insurer, a separate converted policy 1,822
may be issued to cover any dependent of an employee or member of 1,823
the group. 1,824
Except as provided in division (H) of this section, any 1,826
converted policy shall become effective as of the day following 1,827
the date of termination of insurance under the group policy. 1,828
Any probationary or waiting period set forth in the 1,830
40
converted policy is deemed to commence on the effective date of 1,831
the insured's coverage under the group policy. 1,832
(C) No insurer shall be required to issue a converted 1,834
policy to any person who is, or is eligible to be, covered for 1,835
benefits at least comparable to the group policy under: 1,836
(1) Title XVIII of the Social Security Act, as amended or 1,838
superseded; 1,839
(2) Any act of congress or law under this or any other 1,841
state of the United States that duplicates coverage offered under 1,842
division (C)(1) of this section; 1,843
(3) Any policy that duplicates coverage offered under 1,845
division (C)(1) of this section; 1,846
(4) Any other group sickness and accident insurance 1,848
providing hospital, surgical, or medical expense coverage for 1,849
other than specific diseases or accidents only. 1,850
(D) The option for conversion shall be available: 1,852
(1) Upon the death of the employee or member, to the 1,854
surviving spouse with respect to such of the spouse and 1,855
dependents as are then covered by the group policy; 1,856
(2) To a child solely with respect to himself THE CHILD 1,858
upon his attaining the limiting age of coverage under the group 1,860
policy while covered as a dependent thereunder; 1,861
(3) Upon the divorce, dissolution, or annulment of the 1,863
marriage of the employee or member, to the divorced spouse, or 1,864
former spouse in the event of annulment, of such employee or 1,865
member, or upon the legal separation of the spouse from such 1,866
employee or member, to the spouse. 1,867
Persons possessing the option for conversion pursuant to 1,869
this division shall be considered members for the purposes of 1,870
division (H) of this section. 1,871
(E) If coverage is continued under a group policy on an 1,873
employee following his retirement prior to the time he THE 1,874
EMPLOYEE is, or is eligible to be, covered by Title XVIII of the 1,876
Social Security Act, he THE EMPLOYEE may elect, in lieu of the 1,877
41
continuance of group insurance, to have the same conversion 1,879
rights as would apply had his THE EMPLOYEE'S insurance terminated 1,881
at retirement by reason of termination of employment. 1,882
(F) If the insurer and the group policyholder agree upon 1,884
one or more additional plans of benefits to be available for 1,885
converted policies, the applicant for the converted policy may 1,886
elect such a plan in lieu of a converted policy. 1,887
(G) The converted policy may contain provisions for 1,889
avoiding duplication of benefits provided pursuant to divisions 1,890
(C)(1), (2), (3), and (4) of this section or provided under any 1,891
other insured or noninsured plan or program. 1,892
(H) If an employee or member becomes entitled to obtain a 1,894
converted policy pursuant to this section, and if the employee or 1,895
member has not received notice of the conversion privilege at 1,896
least fifteen days prior to the expiration of the thirty-one-day 1,897
conversion period provided in division (B) of this section, then 1,898
the employee or member has an additional period within which to 1,899
exercise the privilege. This additional period shall expire 1,900
fifteen days after the employee or member receives notice, but in 1,901
no event shall the period extend beyond sixty days after the 1,902
expiration of the thirty-one-day conversion period. 1,903
Written notice presented to the employee or member, or 1,905
mailed by the policyholder to the last known address of the 1,906
employee or member as indicated on its records, constitutes 1,907
notice for the purpose of this division. In the case of a person 1,908
who is eligible for a converted policy under division (D) (2) or 1,909
(D)(3) of this section, a policyholder shall not be responsible 1,910
for presenting or mailing such notice, unless such policyholder 1,911
has actual knowledge of the person's eligibility for a converted 1,912
policy. 1,913
If an additional period is allowed by an employee or member 1,915
for the exercise of a conversion privilege, and if written 1,916
application for the converted policy, accompanied by at least the 1,917
first quarterly premium, is made after the expiration of the 1,918
42
thirty-one-day conversion period, but within the additional 1,919
period allowed an employee or member in accordance with this 1,920
division, the effective date of the converted policy shall be the 1,921
date of application. 1,922
(I) The converted policy may provide: 1,924
(1) That any hospital, surgical, or medical expense 1,926
benefits otherwise payable with respect to any person may be 1,927
reduced by the amount of any such benefits payable under the 1,928
group policy for the same loss after termination of coverage; 1,929
(2) For termination of coverage on any person who is, or 1,931
is eligible to be, covered pursuant to division (C) of this 1,932
section; 1,933
(3) That the insurer may request information in advance of 1,935
any premium due date of the policy as to whether the insured is, 1,936
or is eligible to be, covered pursuant to division (C) of this 1,937
section. If the insured is, or is eligible to be, covered, and 1,938
he THE INSURED fails to furnish the details of his THE INSURED'S 1,940
coverage or eligibility to the insurer within thirty-one days 1,941
after the date of the request, the benefits payable under the 1,942
converted policy may be based on the hospital, surgical, or 1,943
medical expenses actually incurred after excluding expenses to 1,944
the extent of the amount of benefits for which the insured is, or 1,945
is eligible to be, covered pursuant to division (C) of this 1,946
section.
(J) The converted policy may contain: 1,948
(1) Any exclusion, reduction, or limitation contained in 1,950
the group policy or customarily used in individual policies 1,951
issued by the insurer; 1,952
(2) Any provision permitted in this section; 1,954
(3) Any other provision not prohibited by law. 1,956
Any provision required or permitted in this section may be 1,958
made a part of any converted policy by means of an endorsement or 1,959
rider. 1,960
(K) The time limit specified in a converted policy for 1,962
43
certain defenses with respect to any person who was covered by a 1,963
group policy shall commence on the effective date of such 1,964
person's coverage under the group policy. 1,965
(L) No insurer shall use deterioration of health as the 1,967
basis for refusing to renew a converted policy. 1,968
(M) No insurer shall use age as the basis for refusing to 1,970
renew a converted policy. 1,971
(N) A converted policy made available pursuant to this 1,973
section shall, if delivery of the policy is to be made in this 1,974
state, comply with this section. If delivery of a converted 1,975
policy is to be made in another state, it may be on a form 1,976
offered by the insurer in the jurisdiction where the delivery is 1,977
to be made and which provides benefits substantially in 1,978
compliance with those required in a policy delivered in this 1,979
state. 1,980
(O) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 1,983
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 1,985
148.103. 1,986
Sec. 3923.26. Every certificate furnished by an insurer in 1,995
connection with, or pursuant to any provision of, any group 1,996
POLICY OR CERTIFICATE OF sickness and accident insurance policy 1,997
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE 1,998
providing coverage on an expense-incurred basis, and every 2,000
individual POLICY OF sickness and accident insurance policy 2,002
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE which 2,003
provides coverage on an expense-incurred basis, either of which 2,004
provides MAKES coverage AVAILABLE for family members of the 2,007
insured, shall, as to such family members' coverage, also provide 2,008
that any sickness and accident insurance benefits applicable for 2,009
children shall be payable with respect to a newly born child of 2,010
the insured from the moment of birth.
The coverage for newly born children shall consist of 2,012
coverage of injury or sickness, including the necessary care and 2,013
treatment of medically diagnosed congenital defects and birth 2,014
44
abnormalities. 2,015
If payment of a specific premium is required to provide 2,017
coverage for an additional child, the certificate or policy may 2,018
require that notification of birth of a newly born child and 2,019
payment of the required premium must be furnished to the insurer 2,020
within thirty-one days after the date of birth in order to have 2,021
the coverage continue beyond such period. 2,022
The requirements of this section apply to all such 2,024
individual or group sickness and accident insurance policies 2,025
delivered or issued for delivery in this state on or after 2,026
January 1, 1975, and all such individual or group sickness and 2,027
accident insurance policies renewed in this state on or after 2,028
January 1, 1978. 2,029
Sec. 3923.40. No individual or group policy of sickness 2,038
and accident insurance providing THAT MAKES family coverage 2,039
AVAILABLE may be delivered, issued for delivery, or renewed in 2,041
this state on or after January 1, 1989, unless the policy covers
adopted children of the insured on the same basis as other 2,042
dependents.
The coverage required by this section is subject to the 2,044
requirements and restrictions set forth in section 3924.51 of the 2,045
Revised Code. 2,046
Sec. 3923.57. Notwithstanding any provision of this 2,055
chapter, every individual policy of sickness and accident 2,056
insurance that is delivered, issued for delivery, or renewed in 2,057
this state is subject to the following conditions, as applicable: 2,058
(A) Pre-existing conditions provisions shall not exclude 2,060
or limit coverage for a period beyond twelve months following the 2,061
policyholder's effective date of coverage and may only relate to 2,062
conditions during the six months immediately preceding the 2,063
effective date of coverage. 2,064
(B) In determining whether a pre-existing conditions 2,066
provision applies to a policyholder or dependent, each policy 2,067
shall credit the time the policyholder or dependent was covered 2,068
45
under a previous policy, contract, or plan if the previous 2,070
coverage was continuous to a date not more than thirty days prior 2,072
to the effective date of the new coverage, exclusive of any 2,073
applicable service waiting period under the policy. 2,074
(C) Any such policy shall be renewable with respect to the 2,076
policyholder, or dependents of the policyholder, at the option of 2,077
the policyholder, except for any of the following reasons: 2,078
(1) Nonpayment of the required premiums by the 2,080
policyholder; 2,081
(2) Fraud or misrepresentation of the policyholder; 2,083
(3) When the insurer ceases to do the business of 2,085
individual sickness and accident insurance in this state, 2,086
provided that all of the following conditions are met: 2,087
(a) Notice of the decision to cease doing the business of 2,089
individual sickness and accident insurance is provided to the 2,090
department of insurance and the policyholder. 2,091
(b) An individual policy shall not be canceled by the 2,093
insurer for ninety days after the date of the notice required 2,095
under division (C)(3)(a) of this section unless the business has 2,096
been sold to another insurer. 2,097
(c) An insurer that ceases to do the business of 2,099
individual sickness and accident insurance in this state shall 2,100
not resume such business in this state for a period of five years 2,101
from the date of the notice required under division (C)(3)(a) of 2,102
this section (1) EXCEPT AS OTHERWISE PROVIDED IN DIVISION (C) OF 2,104
THIS SECTION, AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND 2,105
ACCIDENT INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR 2,106
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 2,107
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF AN 2,110
INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE OF 2,111
THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR CONTRIBUTIONS 2,114
IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE INSURER HAS NOT 2,115
RECEIVED TIMELY PREMIUM PAYMENTS.
46
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE THAT 2,118
CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION OF 2,119
MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN THE 2,122
INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION (D) OF THIS SECTION 2,123
AND THE APPLICABLE LAWS OF THIS STATE. 2,124
(d) IF THE INSURER OFFERS COVERAGE IN THE MARKET THROUGH A 2,127
NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES, LIVES, OR WORKS 2,128
IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE INSURER IS 2,129
AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT SUCH COVERAGE 2,130
IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY HEALTH 2,131
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e) IF THE COVERAGE IS MADE AVAILABLE IN THE INDIVIDUAL 2,134
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS, THE 2,135
MEMBERSHIP OF THE INDIVIDUAL IN THE ASSOCIATION, ON THE BASIS OF 2,136
WHICH THE COVERAGE IS PROVIDED, CEASES; PROVIDED, HOWEVER, THAT 2,137
SUCH COVERAGE IS TERMINATED UNDER DIVISION (C)(2)(e) OF THIS 2,140
SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH STATUS-RELATED 2,141
FACTOR OF COVERED INDIVIDUALS.
(D)(1) IF AN INSURER DECIDES TO DISCONTINUE OFFERING A 2,144
PARTICULAR TYPE OF HEALTH INSURANCE COVERAGE OFFERED IN THE 2,145
INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE MAY BE DISCONTINUED BY 2,146
THE INSURER IF THE INSURER DOES ALL OF THE FOLLOWING: 2,147
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED COVERAGE 2,150
OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT LEAST 2,151
NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF THE 2,152
COVERAGE;
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE OF THIS 2,155
TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER INDIVIDUAL 2,156
HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY THE INSURER 2,157
FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF 2,160
THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE UNDER DIVISION 2,162
(D)(1)(b) OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY 2,163
47
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF 2,164
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE. 2,165
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL 2,167
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS STATE, 2,169
HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE INSURER ONLY 2,170
IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE DEPARTMENT OF 2,173
INSURANCE AND TO EACH INDIVIDUAL OF THE DISCONTINUATION AT LEAST 2,174
ONE HUNDRED EIGHTY DAYS PRIOR TO THE DATE OF THE EXPIRATION OF 2,175
THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED FOR DELIVERY 2,178
IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND COVERAGE UNDER 2,179
THAT HEALTH INSURANCE IN THAT MARKET IS NOT RENEWED. 2,180
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION 2,183
(D)(2) OF THIS SECTION IN THE INDIVIDUAL MARKET, THE INSURER 2,184
SHALL NOT PROVIDE FOR THE ISSUANCE OF ANY HEALTH INSURANCE 2,185
COVERAGE IN THE MARKET AND THIS STATE DURING THE FIVE-YEAR PERIOD 2,186
BEGINNING ON THE DATE OF THE DISCONTINUATION OF THE LAST HEALTH 2,187
INSURANCE COVERAGE NOT SO RENEWED. 2,188
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 2,191
section, both of the following apply:
(1) The benefit structure of any such policy may be 2,194
changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new 2,195
individual insureds. 2,196
(2) Any such policy may be rescinded for fraud, material 2,198
misrepresentation, or concealment by an applicant, policyholder, 2,199
or dependent AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, 2,201
MODIFY THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO 2,202
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS 2,203
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM 2,204
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM. 2,205
(F) SUCH POLICIES ARE SUBJECT TO SECTIONS 2743 AND 2747 OF 2,208
THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 2,212
48
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-43 2,218
AND 300gg-47, AS AMENDED. 2,219
(G) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 2,223
SHALL APPLY TO SICKNESS AND ACCIDENT INSURANCE POLICIES OFFERED 2,224
IN THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO 2,225
HEALTH BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 2,226
IN ACCORDANCE WITH 45 C.F.R. 148.102, DIVISIONS (C) TO (G) 2,231
OF THIS SECTION ALSO APPLY TO ALL GROUP SICKNESS AND ACCIDENT 2,232
INSURANCE POLICIES THAT ARE NOT SOLD IN CONNECTION WITH AN 2,233
EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT PROVIDE MORE THAN 2,234
SHORT-TERM, LIMITED DURATION COVERAGE. 2,235
IN APPLYING DIVISIONS (C) TO (G) OF THIS SECTION WITH 2,239
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY AN 2,241
INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH ONE 2,242
OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER. 2,243
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS THE 2,246
SAME MEANING AS IN SECTION 3924.03 OF THE REVISED CODE, AND 2,247/1
"HEALTH STATUS-RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME 2,249
MEANINGS AS IN SECTION 3924.031 OF THE REVISED CODE. 2,251
This section does not apply to any policy that provides 2,253
coverage for specific diseases or accidents only, or to any 2,254
hospital indemnity, medicare supplement, long-term care, 2,255
disability income, one-time-limited-duration policy of no longer 2,256
than six months, or other policy that offers only supplemental 2,257
benefits. 2,258
Sec. 3923.571. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2,260
2721 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 2,265
OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 2,271
300gg-21, AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP 2,272
POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE SOLD IN
CONNECTION WITH AN EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT 2,273
ARE NOT SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 2,274
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF 2,276
49
DIVISION (A) OF SECTION 3924.03 AND SECTION 3924.033 OF THE 2,278
REVISED CODE.
(B) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 2,282
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 2,286
AN INSURER OFFERS COVERAGE IN THE SMALL OR LARGE GROUP MARKET IN 2,287
CONNECTION WITH A GROUP POLICY, THE INSURER SHALL RENEW OR 2,288
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE 2,289
POLICYHOLDER.
(C)(1) NO SUCH POLICY, OR INSURER OFFERING HEALTH 2,291
INSURANCE COVERAGE IN CONNECTION WITH SUCH A POLICY, SHALL 2,293
REQUIRE ANY INDIVIDUAL, AS A CONDITION OF COVERAGE OR CONTINUED 2,294
COVERAGE UNDER THE POLICY, TO PAY A PREMIUM OR CONTRIBUTION THAT 2,295
IS GREATER THAN THE PREMIUM OR CONTRIBUTION FOR A SIMILARLY 2,296
SITUATED INDIVIDUAL COVERED UNDER THE POLICY ON THE BASIS OF ANY 2,297
HEALTH STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO 2,298
AN INDIVIDUAL COVERED UNDER THE POLICY AS A DEPENDENT OF THE 2,299
INDIVIDUAL. 2,300
(2) NOTHING IN DIVISION (C)(1) OF THIS SECTION SHALL BE 2,303
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 2,304
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY, 2,305
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM 2,306
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE 2,307
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO 2,308
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION. 2,309
(D) SUCH POLICIES SHALL PROVIDE FOR THE SPECIAL ENROLLMENT 2,312
PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH INSURANCE 2,316
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 2,318
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 2,327
of the Revised Code: 2,328
(1) "Case characteristics," "eligible employee," "health 2,330
HEALTH benefit plan," "late enrollee," AND "MEWA," and 2,332
"pre-existing conditions provision" have the same meanings as in 2,333
section 3924.01 of the Revised Code. 2,334
(2) "Insurer" means any sickness and accident insurance 2,336
50
company authorized to issue health benefit plans DO BUSINESS in 2,337
this state, or MEWA authorized to issue insured health benefit 2,339
plans in this state. "Insurer" does not include any health 2,340
insuring corporation that is owned or operated by an insurer. 2,342
(3) "Small employer" means any person, firm, corporation, 2,344
or partnership actively engaged in business whose total employed 2,345
work force, on at least fifty per cent of its working days during 2,346
the preceding year, consisted of at least two unrelated eligible 2,347
employees but no more than twenty-five eligible employees, the 2,348
majority of whom were employed within this state. In determining 2,349
the number of eligible employees, companies that are affiliated 2,350
companies or that are eligible to file a combined tax return for 2,351
purposes of state taxation shall be considered one employer. In 2,352
determining whether the members of an association are small 2,353
employers, each member of the association shall be considered as 2,354
a separate person, firm, corporation, or partnership. 2,355
(4) "Small employer group" means any group consisting of 2,357
all of the eligible employees of a small employer, except those 2,358
employees who are covered, or are eligible for coverage, under 2,359
any other private or public health benefits arrangement, 2,360
including the medicare program established under Title XVIII of 2,361
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 2,362
as amended, or any other act of congress or law of this or any 2,363
other state of the United States that provides benefits 2,364
comparable to the benefits provided under this section 2,365
PRE-EXISTING CONDITIONS PROVISION" MEANS A POLICY PROVISION THAT 2,368
EXCLUDES OR LIMITS COVERAGE FOR CHARGES OR EXPENSES INCURRED 2,369
DURING A SPECIFIED PERIOD FOLLOWING THE INSURED'S EFFECTIVE DATE 2,370
OF COVERAGE AS TO A CONDITION WHICH, DURING A SPECIFIED PERIOD 2,371
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE, HAD 2,372
MANIFESTED ITSELF IN SUCH A MANNER AS WOULD CAUSE AN ORDINARILY 2,373
PRUDENT PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,374
TREATMENT OR FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,375
TREATMENT WAS RECOMMENDED OR RECEIVED, OR A PREGNANCY EXISTING ON 2,376
51
THE EFFECTIVE DATE OF COVERAGE.
(B) Beginning in January of each year, insurers IN THE 2,379
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 2,380
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 2,382
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 2,383
3923.122 OF THE REVISED CODE, shall accept applicants for open 2,387
enrollment coverage, as set forth in divisions (B)(1) and (2) of 2,388
this section DIVISION, in the order in which they apply for 2,390
coverage and subject to the limitation set forth in division (G) 2,391
of this section:. INSURERS
(1) Insurers in the business of issuing health benefit 2,393
plans to small employer groups shall accept small employer groups 2,394
for which coverage is not otherwise available and for whom 2,395
coverage had not been terminated by the employer or by an 2,396
insurer, health maintenance organization, or health insuring 2,398
corporation during the preceding twelve-month period;
(2) Insurers in the business of issuing individual 2,400
policies of sickness and accident insurance as contemplated by 2,401
section 3923.021 of the Revised Code, except individual policies 2,402
issued pursuant to section 3923.122 of the Revised Code, shall 2,403
either accept individuals pursuant to the open enrollment 2,404
requirements of section 3941.53 of the Revised Code, if subject 2,405
to that section, or accept for coverage pursuant to this section 2,407
individuals to whom both of the following conditions apply: 2,408
(a)(1) The individual is not applying for coverage as an 2,410
employee of an employer, as a member of an association, or as a 2,411
member of any other group. 2,412
(b)(2) The individual is not covered, and is not eligible 2,414
for coverage, under any other private or public health benefits 2,415
arrangement, including the medicare program established under 2,416
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,417
U.S.C.A. 301, as amended, or any other act of congress or law of 2,418
this or any other state of the United States that provides 2,419
benefits comparable to the benefits provided under this section, 2,420
52
any medicare supplement policy, or any conversion or continuation 2,421
of coverage policy under state or federal law. 2,422
(C) An insurer shall offer to any individual or small 2,424
employer group accepted under this section the small employer 2,426
health care plan established by the board of directors of the 2,427
Ohio small employer health reinsurance program under division (A) 2,429
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 2,430
plan in benefit plan design and scope of covered services. 2,431
An insurer may offer other health benefit plans in addition 2,433
to, but not in lieu of, the plan required to be offered under 2,434
this division. These additional health benefit plans shall 2,435
provide, at a minimum, the coverage provided by the small 2,436
employer health care plan or any health benefit plan that is 2,437
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 2,438
For purposes of this division, the superintendent of 2,440
insurance shall determine whether a health benefit plan is 2,441
substantially similar to the small employer health care plan in 2,442
benefit plan design and scope of covered services. 2,443
(D) Health benefit plans issued under this section may 2,445
establish pre-existing conditions provisions that exclude or 2,446
limit coverage for a period of up to twelve months following the 2,447
individual's effective date of coverage and that may relate only 2,448
to conditions during the six months immediately preceding the 2,449
effective date of coverage. However, an insurer may exclude a 2,450
late enrollee for a period of up to eighteen months following the 2,451
individual's date of application for coverage. 2,452
(E) Premiums charged to groups or individuals under this 2,454
section may not exceed an amount that is two and one-half times 2,455
the highest rate charged any other group with similar case 2,456
characteristics or any other individual to which the insurer is 2,457
currently accepting new business, and for which similar 2,458
copayments and deductibles are applied. 2,459
53
(F) In offering health benefit plans under this section, 2,461
an insurer may require the purchase of health benefit plans that 2,462
condition the reimbursement of health services upon the use of a 2,463
specific network of providers. 2,464
(G)(1) In no event shall an insurer be required to accept 2,466
annually under this section either individuals or small employer 2,467
groups that WHO, in the aggregate, would cause the insurer to 2,468
have a total number of new insureds that is more than one-half 2,470
per cent of its total number of insured individuals in this state 2,471
per year, as contemplated by section 3923.021 of the Revised 2,472
Code, and small group certificate holders of health benefit plans 2,473
in this state per year, calculated as of the immediately 2,475
preceding thirty-first day of December and excluding the 2,476
insurer's medicare supplement policies and conversion or 2,477
continuation of coverage policies under state or federal law and 2,478
any policies described in division (N)(M) of this section. If an 2,479
insurer is subject to, and elects to operate under, the 2,481
individual open enrollment requirements of section 3941.53 of the 2,482
Revised Code, in no event shall the insurer be required to accept 2,483
annually under this section small employer groups that would 2,484
cause the insurer to have a total number of new insureds that is 2,485
more than one-half per cent of its total number of small group 2,486
certificate holders calculated as set forth in division (G)(1) of 2,487
this section.
(2) An officer of the insurer shall certify to the 2,489
department of insurance when it has met the enrollment limit set 2,490
forth in division (G)(1) of this section. Upon providing such 2,491
certification, the insurer shall be relieved of its open 2,492
enrollment requirement under this section for the remainder of 2,493
the calendar year. 2,494
(H) An insurer shall not be required to accept under this 2,496
section applicants who, at the time of enrollment, are confined 2,497
to a health care facility because of chronic illness, permanent 2,498
injury, or other infirmity that would cause economic impairment 2,499
54
to the insurer if the applicants were accepted, or to make the 2,500
effective date of benefits for individuals or groups accepted 2,501
under this section earlier than ninety days after the date of 2,502
acceptance. 2,503
(I) The requirements of this section do not apply to any 2,505
insurer that is currently in a state of supervision, insolvency, 2,506
or liquidation. If an insurer demonstrates to the satisfaction 2,507
of the superintendent that the requirements of this section would 2,509
place the insurer in a state of supervision, insolvency, or 2,510
liquidation, the superintendent may waive or modify the 2,511
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 2,513
a period of not more than one year. At the expiration of such 2,514
time, a new showing of need for a waiver or modification by the 2,515
insurer shall be made before a new waiver or modification is 2,516
issued or imposed.
(J) No hospital, health care facility, or health care 2,518
practitioner, and no person who employs any health care 2,519
practitioner, shall balance bill any individual or dependent of 2,520
an individual or any eligible employee or dependent of an 2,522
employee for any health care supplies or services provided to the
individual or dependent or the eligible employee or dependent, 2,523
who is insured under a policy or enrolled under a health benefit 2,525
plan issued under this section. The hospital, health care 2,526
facility, or health care practitioner, or any person that employs 2,527
the health care practitioner, shall accept payments made to it by 2,528
the insurer under the terms of the policy or contract insuring or 2,530
covering such individual as payment in full for such health care 2,531
supplies or services. 2,532
As used in this division, "hospital" has the same meaning 2,534
as in section 3727.01 of the Revised Code; "health care 2,535
practitioner" has the same meaning as in section 4769.01 of the 2,536
Revised Code; and "balance bill" means charging or collecting an 2,537
amount in excess of the amount reimbursable or payable under the 2,538
55
policy or health care service contract issued to an individual or 2,539
group under this section for such health care supply or service. 2,540
"Balance bill" does not include charging for or collecting 2,541
copayments or deductibles required by the policy or contract. 2,542
(K) An insurer shall pay an agent a commission in the 2,544
amount of five per cent of the premium charged for initial 2,545
placement or for otherwise securing the issuance of a policy or 2,546
contract issued to an individual or small employer group under 2,547
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 2,548
adopt, in accordance with Chapter 119. of the Revised Code, such 2,549
rules as are necessary to enforce this division. 2,550
(L) Except as otherwise provided in this section, sections 2,552
3924.01 to 3924.06 of the Revised Code apply to all health 2,553
benefit plans issued under this section. 2,554
(M) Individuals accepted for coverage under this section 2,556
may be issued contracts and certificates subject to the 2,557
requirements of section 3923.12 of the Revised Code. The 2,558
coverage issued to such individuals is not subject to the 2,559
requirements of section 3923.021 of the Revised Code. 2,560
(N)(M) This section does not apply to any policy that 2,562
provides coverage for specific diseases or accidents only, or to 2,564
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 2,566
than six months, or other policy that offers only supplemental 2,567
benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION: 2,569
(1) "CARRIER," "HEALTH BENEFIT PLAN," "MEWA," AND 2,571
"PRE-EXISTING CONDITIONS PROVISION" HAVE THE SAME MEANINGS AS IN 2,573
SECTION 3924.01 OF THE REVISED CODE.
(2) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE 2,575
INDIVIDUAL AS DEFINED IN 45 C.F.R. 148.103. 2,576
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 2,577
FOLLOWING:
56
(a) HEALTH STATUS; 2,579
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 2,581
ILLNESSES; 2,582
(c) CLAIMS EXPERIENCE; 2,584
(d) RECEIPT OF HEALTH CARE; 2,586
(e) MEDICAL HISTORY; 2,588
(f) GENETIC INFORMATION; 2,590
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 2,592
OUT OF ACTS OF DOMESTIC VIOLENCE; 2,593
(h) DISABILITY. 2,595
(4) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR 2,597
CASE CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE 2,598
APPLICABLE CARRIER FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF 2,599
THE APPLICABLE BASE PREMIUM RATE AND THE CORRESPONDING HIGHEST 2,600
PREMIUM RATE.
(5) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 2,602
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 2,603
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 2,604
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 2,605
UNDER CONTRACT WITH THE CARRIER.
(B) BEGINNING IN JANUARY OF EACH YEAR, CARRIERS IN THE 2,607
BUSINESS OF ISSUING HEALTH BENEFIT PLANS TO INDIVIDUALS OR 2,608
NONEMPLOYER GROUPS SHALL ACCEPT FEDERALLY ELIGIBLE INDIVIDUALS 2,609
FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS SECTION, IN THE 2,610
ORDER IN WHICH THEY APPLY FOR COVERAGE AND SUBJECT TO THE 2,611
LIMITATION SET FORTH IN DIVISION (J) OF THIS SECTION. 2,612
(C) NO CARRIER SHALL DO EITHER OF THE FOLLOWING: 2,614
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT 2,616
OF, SUCH INDIVIDUALS; 2,617
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH 2,619
COVERAGE.
(D) A CARRIER SHALL OFFER TO FEDERALLY ELIGIBLE 2,621
INDIVIDUALS THE BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD 2,622
OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS 2,623
57
SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT 2,625
DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF THIS 2,626
DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER 2,627
A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 2,628
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY 2,630
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED 2,631
ANY OTHER INDIVIDUAL TO WHICH THE CARRIER IS CURRENTLY ACCEPTING 2,632
NEW BUSINESS, AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES 2,633
ARE APPLIED.
(F) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE 2,635
INDIVIDUAL MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 2,636
OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY 2,638
APPLY FOR SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE 2,639
SERVICE AREA OF THE NETWORK PLAN; 2,641
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 2,643
COVERAGE TO FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS 2,644
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,645
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 2,647
SERVICES ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE 2,648
CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS AND 2,649
INDIVIDUALS.
(b) THE CARRIER IS APPLYING DIVISION (F)(2) OF THIS 2,651
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT 2,652
REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS. 2,653
(G) A CARRIER THAT, PURSUANT TO DIVISION (F)(2) OF THIS 2,656
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF 2,657
A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET 2,658
WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS 2,659
AFTER THE DATE THE COVERAGE IS DENIED. 2,660
(H) A CARRIER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO 2,662
FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS DEMONSTRATED 2,663
BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,664
58
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 2,666
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 2,667
(2) THE CARRIER IS APPLYING DIVISION (H) OF THIS SECTION 2,669
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE 2,670
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND 2,671
WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 2,672
THOSE INDIVIDUALS.
(I) A CARRIER THAT, PURSUANT TO DIVISION (H) OF THIS 2,674
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY 2,675
ELIGIBLE INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 2,676
INDIVIDUAL MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY 2,677
DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE CARRIER 2,679
HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER HAS 2,680
SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER. 2,681
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 2,684
SECTION, A CARRIER SHALL NOT BE REQUIRED TO ACCEPT ANNUALLY UNDER 2,686
THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS WHO, IN THE 2,687
AGGREGATE, WOULD CAUSE THE CARRIER TO HAVE A TOTAL NUMBER OF NEW 2,688
INSUREDS THAT IS MORE THAN ONE-HALF PER CENT OF ITS TOTAL NUMBER 2,689
OF INSURED INDIVIDUALS AND NONEMPLOYER GROUPS IN THIS STATE PER 2,690
YEAR, CALCULATED AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY
OF DECEMBER AND EXCLUDING THE CARRIER'S MEDICARE SUPPLEMENT 2,692
POLICIES AND CONVERSION OR CONTINUATION OF COVERAGE POLICIES 2,694
UNDER STATE OR FEDERAL LAW AND ANY POLICIES DESCRIBED IN DIVISION 2,695
(M) OF SECTION 3923.58 OF THE REVISED CODE. 2,696
(2) AN OFFICER OF THE CARRIER SHALL CERTIFY TO THE 2,698
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET 2,699
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH 2,700
CERTIFICATION, THE CARRIER SHALL BE RELIEVED OF ITS OPEN 2,701
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF 2,702
THE CALENDAR YEAR UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, 2,704
ALL THE CARRIERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET 2,705
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,707
59
SECTION. IN THAT EVENT, CARRIERS SHALL AGAIN ACCEPT APPLICANTS 2,708
FOR OPEN ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO 2,709
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,711
SECTION.
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 2,713
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 2,714
(L) THE REQUIREMENTS OF THIS SECTION DO NOT APPLY TO ANY 2,716
HEALTH BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 2,717
OF THE REVISED CODE.
Sec. 3923.59. Any insurer may reinsure coverage of any 2,726
individual, small employer group, or member of that NONEMPLOYER 2,727
group acquired under section 3923.58 OR 3923.581 of the Revised 2,730
Code with the Ohio small employer health OPEN ENROLLMENT 2,731
reinsurance program in accordance with division (G) of section 2,733
3924.11 of the Revised Code. Premium rates charged for coverage 2,734
reinsured by the program shall be established in accordance with 2,735
section 3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the 2,744
Revised Code, each individual or group policy of sickness and 2,746
accident insurance delivered, issued for delivery, or renewed in 2,747
this state that provides maternity benefits shall provide
coverage of inpatient care and follow-up care for a mother and 2,748
her newborn as follows:
(1) The policy shall cover a minimum of forty-eight 2,751
SEVENTY-TWO hours of inpatient care following a normal vaginal 2,752
delivery and a minimum of ninety-six hours of inpatient care 2,754
following a cesarean delivery. Services covered as inpatient 2,755
care shall include medical, educational, and any other services 2,756
that are consistent with the inpatient care recommended in the 2,757
protocols and guidelines developed by national organizations that 2,758
represent pediatric, obstetric, and nursing professionals. 2,759
(2) The policy shall cover a physician-directed source of 2,761
follow-up care. Services covered as follow-up care shall include 2,762
physical assessment of the mother and newborn, parent education, 2,763
60
assistance and training in breast or bottle feeding, assessment 2,764
of the home support system, performance of any medically 2,765
necessary and appropriate clinical tests, and any other services 2,766
that are consistent with the follow-up care recommended in the 2,767
protocols and guidelines developed by national organizations that 2,769
represent pediatric, obstetric, and nursing professionals. The 2,770
coverage shall apply to services provided in a medical setting or 2,771
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,772
conducts the visit is knowledgeable and experienced in maternity 2,773
and newborn care.
When a decision is made in accordance with division (B) of 2,775
this section to discharge a mother or newborn prior to the 2,776
expiration of the applicable number of hours of inpatient care 2,777
required to be covered, the coverage of follow-up care shall 2,778
apply to all follow-up care that is provided within forty-eight 2,779
hours after discharge. When a mother or newborn receives at 2,781
least the number of hours of inpatient care required to be
covered, the coverage of follow-up care shall apply to follow-up 2,782
care that is determined to be medically necessary by the health 2,783
care professionals responsible for discharging the mother or 2,784
newborn.
(B) Any decision to shorten the length of inpatient stay 2,787
to less than that specified under division (A)(1) of this section 2,789
shall be made by the physician attending the mother or newborn, 2,790
except that if a nurse-midwife is attending the mother in 2,791
collaboration with a physician, the decision may be made by the 2,792
nurse-midwife. Decisions regarding early discharge shall be made 2,793
only after conferring with the mother or a person responsible for 2,794
the mother or newborn. For purposes of this division, a person 2,795
responsible for the mother or newborn may include a parent, 2,796
guardian, or any other person with authority to make medical 2,797
decisions for the mother or newborn.
(C)(1) No sickness and accident insurer may do either of 2,800
61
the following:
(a) Terminate the participation of a health care 2,803
professional or health care facility as a provider under a
sickness and accident insurance policy solely for making 2,804
recommendations for inpatient or follow-up care for a particular 2,805
mother or newborn that are consistent with the care required to 2,806
be covered by this section; 2,807
(b) Establish or offer monetary or other financial 2,810
incentives for the purpose of encouraging a person to decline the 2,811
inpatient or follow-up care required to be covered by this 2,812
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,816
section has engaged in an unfair and deceptive act or practice in 2,817
the business of insurance under sections 3901.19 to 3901.26 of 2,818
the Revised Code. 2,820
(D) This section does not do any of the following: 2,823
(1) Require a policy to cover inpatient or follow-up care 2,826
that is not received in accordance with the policy's terms 2,827
pertaining to the health care professionals and facilities from 2,828
which an individual is authorized to receive health care 2,829
services.;
(2) Require a mother or newborn to stay in a hospital or 2,832
other inpatient setting for a fixed period of time following
delivery; 2,833
(3) Require a child to be delivered in a hospital or other 2,836
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,838
authority to practice nurse-midwifery in accordance with Chapter 2,840
4723. of the Revised Code; 2,842
(5) Establish minimum standards of medical diagnosis, care 2,845
or treatment for inpatient or follow-up care for a mother or 2,846
newborn. A deviation from the care required to be covered under 2,847
this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those 2,848
62
terms are defined in section 2305.11 of the Revised Code. 2,851
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the 2,860
Revised Code, each public employee benefit plan established or 2,862
modified in this state that provides maternity benefits shall 2,863
provide coverage of inpatient care and follow-up care for a 2,864
mother and her newborn as follows: 2,865
(1) The plan shall cover a minimum of forty-eight hours of 2,867
inpatient care following a normal vaginal delivery and a minimum 2,869
of ninety-six hours of inpatient care following a cesarean 2,870
delivery. Services covered as inpatient care shall include 2,871
medical, educational, and any other services that are consistent 2,872
with the inpatient care recommended in the protocols and 2,873
guidelines developed by national organizations that represent 2,874
pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of 2,876
follow-up care. Services covered as follow-up care shall include 2,877
physical assessment of the mother and newborn, parent education, 2,878
assistance and training in breast or bottle feeding, assessment 2,879
of the home support system, performance of any medically 2,880
necessary and appropriate clinical tests, and any other services 2,881
that are consistent with the follow-up care recommended in the 2,882
protocols and guidelines developed by national organizations that 2,884
represent pediatric, obstetric, and nursing professionals. The 2,885
coverage shall apply to services provided in a medical setting or 2,886
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,887
conducts the visit is knowledgeable and experienced in maternity 2,888
and newborn care.
When a decision is made in accordance with division (B) of 2,890
this section to discharge a mother or newborn prior to the 2,891
expiration of the applicable number of hours of inpatient care 2,892
required to be covered, the coverage of follow-up care shall 2,893
apply to all follow-up care that is provided within forty-eight 2,894
SEVENTY-TWO hours after discharge. When a mother or newborn 2,895
63
receives at least the number of hours of inpatient care required 2,896
to be covered, the coverage of follow-up care shall apply to 2,897
follow-up care that is determined to be medically necessary by 2,898
the health care professionals responsible for discharging the 2,899
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,902
to less than that specified under division (A)(1) of this section 2,904
shall be made by the physician attending the mother or newborn, 2,905
except that if a nurse-midwife is attending the mother in 2,906
collaboration with a physician, the decision may be made by the 2,907
nurse-midwife. Decisions regarding early discharge shall be made 2,908
only after conferring with the mother or a person responsible for 2,909
the mother or newborn. For purposes of this division, a person 2,910
responsible for the mother or newborn may include a parent, 2,911
guardian, or any other person with authority to make medical 2,912
decisions for the mother or newborn.
(C)(1) No public employer who offers an employee benefit 2,915
plan may do either of the following: 2,916
(a) Terminate the participation of a health care 2,919
professional or health care facility as a provider under the plan 2,920
solely for making recommendations for inpatient or follow-up care 2,921
for a particular mother or newborn that are consistent with the 2,922
care required to be covered by this section; 2,923
(b) Establish or offer monetary or other financial 2,926
incentives for the purpose of encouraging a person to decline the 2,927
inpatient or follow-up care required to be covered by this 2,928
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,932
section has engaged in an unfair and deceptive act or practice in 2,933
the business of insurance under sections 3901.19 to 3901.26 of 2,934
the Revised Code. 2,936
(D) This section does not do any of the following: 2,939
(1) Require a plan to cover inpatient or follow-up care 2,942
that is not received in accordance with the plan's terms 2,943
64
pertaining to the health care professionals and facilities from 2,944
which an individual is authorized to receive health care 2,945
services.;
(2) Require a mother or newborn to stay in a hospital or 2,948
other inpatient setting for a fixed period of time following
delivery; 2,949
(3) Require a child to be delivered in a hospital or other 2,952
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,954
authority to practice nurse-midwifery in accordance with Chapter 2,956
4723. of the Revised Code; 2,958
(5) Establish minimum standards of medical diagnosis, 2,960
care, or treatment for inpatient or follow-up care for a mother 2,961
or newborn. A deviation from the care required to be covered 2,962
under this section shall not, solely on the basis of this 2,963
section, give rise to a medical claim or derivative medical 2,964
claim, as those terms are defined in section 2305.11 of the 2,965
Revised Code. 2,967
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 2,976
the Revised Code: 2,977
(A) "Actuarial certification" means a written statement 2,979
prepared by a member of the American academy of actuaries, or by 2,980
any other person acceptable to the superintendent of insurance, 2,981
that states that, based upon the person's examination, a carrier 2,982
offering health benefit plans to small employers is in compliance 2,983
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 2,984
certification" shall include a review of the appropriate records 2,985
of, and the actuarial assumptions and methods used by, the 2,986
carrier relative to establishing premium rates for the health 2,987
benefit plans. 2,988
(B) "Adjusted average market premium price" means the 2,990
average market premium price as determined by the board of 2,992
directors of the Ohio small employer health reinsurance program 2,993
either on the basis of the arithmetic mean of all carriers' 2,994
65
premium rates for an SEHC plan sold to groups with similar case 2,995
characteristics by all carriers selling SEHC plans in the state, 2,997
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 2,999
plan that is issued by a carrier and that covers at least two but 3,000
no more than fifty employees of a small employer, the lowest 3,002
premium rate for a new or existing business prescribed by the 3,003
carrier for the same or similar coverage under a plan or 3,004
arrangement covering any small employer with similar case 3,005
characteristics.
(D) "Carrier" means any sickness and accident insurance 3,007
company or health insuring corporation authorized to issue health 3,010
benefit plans in this state or a MEWA. A sickness and accident 3,012
insurance company that owns or operates a health insuring 3,013
corporation, either as a separate corporation or as a line of 3,015
business, shall be considered as a separate carrier from that 3,016
health insuring corporation for purposes of sections 3924.01 to 3,018
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 3,020
employer, the geographic area in which the employees work; the 3,021
age and sex of the individual employees and their dependents; the 3,022
appropriate industry classification as determined by the carrier; 3,023
the number of employees and dependents; and such other objective 3,024
criteria as may be established by the carrier. "Case 3,025
characteristics" does not include claims experience, health 3,026
status, or duration of coverage from the date of issue. 3,027
(F) "Dependent" means the spouse or child of an eligible 3,029
employee, subject to applicable terms of the health benefits plan 3,030
covering the employee. 3,031
(G) "Eligible employee" means an employee who works a 3,033
normal work week of twenty-five or more hours. "Eligible 3,034
employee" does not include a temporary or substitute employee, or 3,036
a seasonal employee who works only part of the calendar year on 3,037
the basis of natural or suitable times or circumstances. 3,038
66
(H) "Financially impaired" means a program member that, 3,040
after April 14, 1993, is not insolvent but is determined by the 3,043
superintendent to be potentially unable to fulfill its 3,044
contractual obligations, or is placed under an order of 3,045
rehabilitation or conservation by a court of competent 3,046
jurisdiction or under an order of supervision by the 3,047
superintendent.
(I) "Health benefit plan" means any hospital or medical 3,049
expense policy or certificate or any health plan provided by a 3,051
carrier, that is delivered, issued for delivery, renewed, or used 3,053
in this state on or after the date occurring six months after 3,054
November 24, 1995. "Health benefit plan" does not include 3,056
policies covering only accident, credit, dental, disability 3,057
income, long-term care, hospital indemnity, medicare supplement, 3,058
specified disease, or vision care; coverage under a 3,059
one-time-limited-duration policy of no longer than six months; 3,061
coverage issued as a supplement to liability insurance; insurance 3,062
arising out of a workers' compensation or similar law; automobile 3,063
medical-payment insurance; or insurance under which benefits are 3,064
payable with or without regard to fault and which is statutorily 3,065
required to be contained in any liability insurance policy or 3,066
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 3,068
period immediately following any service waiting period 3,069
established by an employer. 3,070
(K)(I) "Late enrollee" means an eligible employee or 3,072
dependent who requests enrollment ENROLLS in a small employer's 3,073
health benefit plan following OTHER THAN DURING the initial 3,075
enrollment FIRST period provided under the terms of the first 3,077
plan for IN which the employee or dependent was IS eligible 3,078
through the small employer, unless any of the following apply: 3,080
(1) The individual: 3,082
(a) Was covered under another health benefit plan at the 3,085
time the individual was eligible to enroll;
67
(b) States, at the time of the initial eligibility, that 3,087
coverage under another health benefit plan was the reason for 3,090
declining enrollment;
(c) Has lost coverage under another health benefit plan as 3,093
a result of the termination of employment, a reduction of hours 3,094
worked per week, the termination of the other plan's coverage, 3,095
death of a spouse, or divorce; and 3,096
(d) Requests enrollment within thirty days after the 3,098
termination of coverage under another health benefit plan. 3,099
(2) The individual is employed by an employer who offers 3,101
multiple health benefit plans and the individual elects a 3,102
different health benefit plan during an open enrollment period. 3,103
(3) A court has ordered coverage to be provided for a 3,105
spouse or minor child under a covered employee's plan and a 3,106
request for enrollment is made within thirty days after issuance 3,107
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 3,109
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,112
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. 3,118
NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg, AS AMENDED. 3,121
(L)(J) "MEWA" means any "multiple employer welfare 3,123
arrangement" as defined in section 3 of the "Federal Employee 3,124
Retirement Income Security Act of 1974," 88 Stat. 832, 29 3,125
U.S.C.A. 1001, as amended, except for any arrangement which is 3,126
fully insured as defined in division (b)(6)(D) of section 514 of 3,127
that act. 3,128
(M)(K) "Midpoint rate" means, for small employers with 3,130
similar case characteristics and plan designs and as determined 3,131
by the applicable carrier for a rating period, the arithmetic 3,132
average of the applicable base premium rate and the corresponding 3,133
highest premium rate. 3,134
(N)(L) "Pre-existing conditions provision" means a policy 3,136
provision that excludes or limits coverage for charges or 3,138
expenses incurred during a specified period following the 3,139
insured's effective ENROLLMENT date of coverage as to a condition 3,141
68
which, during a specified period immediately preceding the 3,142
effective date of coverage, had manifested itself in such a 3,143
manner as would cause an ordinarily prudent person to seek 3,144
medical advice, diagnosis, care, or treatment or for which 3,145
medical advice, diagnosis, care, or treatment was recommended or 3,146
received, or DURING a pregnancy existing on SPECIFIED PERIOD 3,148
IMMEDIATELY PRECEDING the effective ENROLLMENT date of coverage. 3,149
GENETIC INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN 3,151
THE ABSENCE OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH 3,152
INFORMATION.
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, 3,154
WITH RESPECT TO AN INDIVIDUAL COVERED UNDER A GROUP HEALTH 3,155
BENEFIT PLAN, THE DATE OF ENROLLMENT OF THE INDIVIDUAL IN THE 3,156
PLAN OR, IF EARLIER, THE FIRST DAY OF THE WAITING PERIOD FOR SUCH 3,158
ENROLLMENT.
(O)(M) "Service waiting period" means the period of time 3,160
after employment begins before an eligible employee may enroll in 3,162
IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any 3,163
applicable health benefit plan offered by the small employer.
(P)(N)(1) "Small employer" means any person, firm, 3,166
corporation, partnership, or association actively engaged in 3,167
business whose total, IN CONNECTION WITH A GROUP HEALTH BENEFIT 3,168
PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN YEAR, AN 3,169
EMPLOYER WHO employed work force consisted of, on at least fifty 3,170
per cent of its working days during the preceding year, AN 3,171
AVERAGE OF at least two but no more than fifty eligible 3,173
employees, the majority of whom were employed within the state ON 3,174
BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND WHO EMPLOYS 3,175
AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN YEAR.
(2) In determining the number of eligible employees for 3,177
FOR purposes of division (P)(N)(1) of this section, companies 3,178
which are affiliated companies or which are eligible to file a 3,180
combined tax return for purposes of state taxation ALL PERSONS 3,182
TREATED AS A SINGLE EMPLOYER UNDER SUBSECTION (b), (c), (m), OR 3,184
69
(o) OF SECTION 414 OF THE "INTERNAL REVENUE CODE OF 1986," 100 3,188
STAT. 2085, 26 U.S.C.A. 1, AS AMENDED, shall be considered one 3,191
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE 3,192
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF 3,193
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED 3,194
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS REASONABLY 3,196
EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN THE CURRENT 3,197
CALENDAR YEAR. ANY REFERENCE IN DIVISION (N) OF THIS SECTION TO 3,198
AN "EMPLOYER" INCLUDES ANY PREDECESSOR OF THE EMPLOYER. Except 3,200
as otherwise specifically provided, provisions of sections 3,201
3924.01 to 3924.14 of the Revised Code that apply to a small 3,202
employer that has a health benefit plan shall continue to apply 3,203
until the plan anniversary following the date the employer no 3,204
longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small employer health 3,207
care plan, which is a health benefit plan for small INDIVIDUALS 3,208
AND employers established by the board in accordance with section 3,210
3924.10 of the Revised Code. 3,211
Sec. 3924.02. (A) An individual or group health benefit 3,220
plan is subject to sections 3924.01 to 3924.14 of the Revised 3,221
Code if it provides health care benefits covering at least two 3,223
but no more than fifty employees of a small employer, and if it 3,224
meets either of the following conditions: 3,225
(1) Any portion of the premium or benefits is paid by a 3,227
small employer, or any covered individual is reimbursed, whether 3,228
through wage adjustments or otherwise, by a small employer for 3,229
any portion of the premium. 3,230
(2) The health benefit plan is treated by the employer or 3,232
any of the covered individuals as part of a plan or program for 3,233
purposes of section 106 or 162 of the "Internal Revenue Code of 3,234
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,235
(B) Notwithstanding division (A) of this section, 3,237
divisions (D), (E)(2), (F), AND (G) to (J) of section 3924.03 of 3,239
the Revised Code and section 3924.04 of the Revised Code do not 3,241
70
apply to health benefit policies that are not sold to owners of 3,242
small businesses as an employment benefit plan. Such policies 3,243
shall clearly state that they are not being sold as an employment 3,244
benefit plan and that the owner of the business is not 3,245
responsible, either directly or indirectly, for paying the 3,246
premium or benefits.
(C) Every health benefit plan offered or delivered by a 3,248
carrier, other than a health insuring corporation, to a small 3,250
employer is subject to sections 3923.23, 3923.231, 3923.232, 3,251
3923.233, and 3923.234 of the Revised Code and any other 3,252
provision of the Revised Code that requires the reimbursement, 3,253
utilization, or consideration of a specific category of a 3,254
licensed or certified health care practitioner. 3,255
(D) Except as expressly provided in sections 3924.01 to 3,257
3924.14 of the Revised Code, no health benefit plan offered to a 3,258
small employer is subject to any of the following: 3,259
(1) Any law that would inhibit any carrier from 3,261
contracting with providers or groups of providers with respect to 3,262
health care services or benefits; 3,263
(2) Any law that would impose any restriction on the 3,265
ability to negotiate with providers regarding the level or method 3,266
of reimbursing care or services provided under the health benefit 3,267
plan; 3,268
(3) Any law that would require any carrier to either 3,270
include a specific provider or class of provider when contracting 3,271
for health care services or benefits, or to exclude any class of 3,272
provider that is generally authorized by statute to provide such 3,273
care. 3,274
Sec. 3924.03. Health EXCEPT AS OTHERWISE PROVIDED IN 3,283
SECTION 2721 OF THE "HEALTH INSURANCE PORTABILITY AND 3,288
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 3,293
42 U.S.C.A. 300gg-21, AS AMENDED, HEALTH benefit plans covering 3,295
small employers are subject to the following conditions, as 3,296
applicable:
71
(A)(1) Pre-existing conditions provisions shall not 3,298
exclude or limit coverage for a period beyond twelve months, OR 3,299
EIGHTEEN MONTHS IN THE CASE OF A LATE ENROLLEE, following the 3,300
individual's effective ENROLLMENT date of coverage and may only 3,301
relate to conditions during A PHYSICAL OR MENTAL CONDITION, 3,303
REGARDLESS OF THE CAUSE OF THE CONDITION, FOR WHICH MEDICAL 3,305
ADVICE, DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED 3,306
WITHIN the six months immediately preceding the effective 3,308
ENROLLMENT date of coverage.
DIVISION (A)(1) OF THIS SECTION IS SUBJECT TO THE 3,311
EXCEPTIONS SET FORTH IN SECTION 2701(d) OF THE "HEALTH INSURANCE 3,314
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,317
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION 3,319
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF 3,320
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR 3,321
DEPENDENT AS OF THE ENROLLMENT DATE. 3,322
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE COUNTED, 3,325
WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A GROUP HEALTH 3,326
BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE ENROLLMENT 3,327
DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL OF WHICH THE 3,328
INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE COVERAGE. 3,329
SUBSECTIONS (c)(2) TO (4) AND (e) OF SECTION 2701 OF THE "HEALTH 3,331
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996" APPLY WITH 3,335
RESPECT TO CREDITING PREVIOUS COVERAGE. 3,336
(4) AS USED IN DIVISION (A) OF THIS SECTION: 3,339
(a) "CREDITABLE COVERAGE" HAS THE SAME MEANING AS IN 3,342
SECTION 2701(c)(1) OF THE "HEALTH INSURANCE PORTABILITY AND 3,346
ACCOUNTABILITY ACT OF 1996." 3,347
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN INDIVIDUAL 3,350
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF ENROLLMENT 3,351
OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE FIRST DAY OF 3,352
THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions 3,354
provision applies to an eligible employee or dependent, all 3,355
72
health benefit plans shall credit the time the person was covered 3,356
under a previous employer-based health benefit plan provided by a 3,357
carrier if the previous coverage was continuous to a date not 3,359
more than thirty days prior to the effective date of the new 3,361
coverage, exclusive of any applicable service waiting period 3,362
under the plan. 3,363
(C) Any such health benefit plan shall be renewable with 3,365
respect to all eligible employees or dependents at the option of 3,366
the policyholder, contract holder, or small employer, except for 3,367
any of the following reasons: 3,368
(1) Nonpayment of the required premiums by the 3,370
policyholder, contract holder, or employer; 3,371
(2) Fraud or misrepresentation of the policyholder, 3,373
contract holder, or employer or, with respect to coverage of 3,374
individual insureds, the insureds or their representatives ; 3,376
(3) When the total number of insured individuals covered 3,378
under all of the health benefit plans of any one employer is less 3,379
than the total number of individuals or percentage of individuals 3,380
required by participation requirements under any specific health 3,381
benefit plan of that employer; 3,382
(4) Noncompliance with any plan provision that has been 3,384
approved by the superintendent of insurance; 3,385
(5) When the carrier ceases doing business in the small 3,387
employer market, provided that all of the following conditions 3,388
are met: 3,389
(a) Notice of the decision to cease to do business in the 3,391
small employer market is provided to the department of insurance, 3,392
the board of directors of the Ohio small employer health 3,393
reinsurance program, the policyholder or contract holder, and the 3,394
employer. 3,395
(b) Health benefit plans subject to sections 3924.01 to 3,397
3924.14 of the Revised Code shall not be canceled by the carrier 3,398
for ninety days after the date of the notice required under 3,400
division (C)(5)(a) of this section unless the business has been 3,401
73
sold to another carrier or the cancellations are approved by the 3,402
superintendent. 3,403
(c) A carrier that ceases to do business in the small 3,405
employer marketplace is prohibited from re-entering the small 3,406
employer marketplace for a period of five years from the date of 3,407
the notice required under division (C)(5)(a) of this section. 3,408
(D) Notwithstanding division (C) of this section, any such 3,410
health benefit plan or any coverage provided to an individual 3,411
under such a plan may be rescinded for fraud, material 3,412
misrepresentation, or concealment by an applicant, employee, 3,413
dependent, or small employer. 3,414
(E) Every carrier doing business in the small employer 3,416
market may underwrite and rate small employer groups, as 3,417
permitted by sections 3924.01 to 3924.14 of the Revised Code, 3,418
using accepted underwriting and actuarial practices EXCEPT AS 3,419
PROVIDED IN SECTION 2712(b) TO (e) OF THE "HEALTH INSURANCE 3,425
PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF A CARRIER OFFERS 3,428
COVERAGE IN THE SMALL EMPLOYER MARKET IN CONNECTION WITH A GROUP 3,429
HEALTH BENEFIT PLAN, THE CARRIER SHALL RENEW OR CONTINUE IN FORCE 3,430
SUCH COVERAGE AT THE OPTION OF THE PLAN SPONSOR OF THE PLAN. 3,431
(F)(C) A carrier shall not exclude any eligible employee 3,433
or dependent, who would otherwise be covered under a health 3,434
benefit plan, on the basis of any actual or expected health 3,435
condition of the employee or dependent. However, a carrier may 3,436
exclude a late enrollee for a period of up to twenty-four months 3,437
or may, in the discretion of the carrier, extend coverage to the 3,438
late enrollee at any time during that period. A carrier also may 3,439
medically underwrite a late enrollee. 3,440
If, prior to the effective date of this amendment NOVEMBER 3,443
24, 1995, a carrier excluded an eligible employee or dependent, 3,444
other than a late enrollee, on the basis of an actual or expected 3,445
health condition, the carrier shall, upon the initial renewal of 3,446
the coverage on or after that date, extend coverage to the 3,447
employee or dependent if all other eligibility requirements are 3,448
74
met.
(G)(D) No health benefit plan issued by a carrier shall 3,451
limit or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 3,453
medical condition, or accident, except for pre-existing 3,454
conditions as permitted under division (A) of this section. If a 3,455
health benefit plan that is delivered or issued for delivery 3,457
prior to April 14, 1993, contains such limitations or exclusions, 3,459
by use of a rider or amendment applicable to a specific 3,460
individual, the plan shall eliminate the use of such riders or 3,461
amendments within eighteen months after April 14, 1993. 3,462
(H)(E)(1) EXCEPT AS PROVIDED IN SECTIONS 3924.031 AND 3,465
3924.032 OF THE REVISED CODE, AND SUBJECT TO SUCH RULES AS MAY BE 3,468
ADOPTED BY THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH 3,469
CHAPTER 119. OF THE REVISED CODE, A CARRIER SHALL OFFER EVERY 3,472
HEALTH BENEFIT PLAN THAT IT IS ACTIVELY MARKETING TO EVERY SMALL 3,473
EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH COVERAGE. 3,474
DIVISION (E)(1) OF THIS SECTION DOES NOT APPLY TO A HEALTH 3,477
BENEFIT PLAN THAT A CARRIER MAKES AVAILABLE IN THE SMALL EMPLOYER 3,478
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS. 3,479
DIVISION (E)(1) OF THIS SECTION SHALL NOT BE CONSTRUED TO 3,482
PRECLUDE A CARRIER FROM ESTABLISHING EMPLOYER CONTRIBUTION RULES 3,483
OR GROUP PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN 3,484
CONNECTION WITH A GROUP HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER 3,485
MARKET, AS ALLOWED UNDER THE LAW OF THIS STATE. AS USED IN 3,486
DIVISION (E)(1) OF THIS SECTION, "EMPLOYER CONTRIBUTION RULE" 3,488
MEANS A REQUIREMENT RELATING TO THE MINIMUM LEVEL OR AMOUNT OF 3,489
EMPLOYER CONTRIBUTION TOWARD THE PREMIUM FOR ENROLLMENT OF 3,490
EMPLOYEES AND DEPENDENTS AND "GROUP PARTICIPATION RULE" MEANS A 3,491
REQUIREMENT RELATING TO THE MINIMUM NUMBER OF EMPLOYEES OR 3,492
DEPENDENTS THAT MUST BE ENROLLED IN RELATION TO A SPECIFIED 3,493
PERCENTAGE OR NUMBER OF ELIGIBLE INDIVIDUALS OR EMPLOYEES OF AN 3,494
EMPLOYER.
(2) Each health benefit plan, at the time of initial group 3,496
75
enrollment, shall make coverage available to all the eligible 3,497
employees of a small employer without a service waiting period. 3,498
The decision of whether to impose a service waiting period shall 3,500
be made by the small employer. Such waiting periods shall not be 3,501
greater than ninety days. 3,502
(3) EACH HEALTH BENEFIT PLAN SHALL PROVIDE FOR THE SPECIAL 3,505
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,508
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,511
(I)(F) The benefit structure of any health benefit plan 3,514
may, AT THE TIME OF COVERAGE RENEWAL, be changed by the carrier 3,516
to make it consistent with the benefit structure contained in 3,517
health benefit plans being marketed to new small employer groups. 3,518
IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE SMALL EMPLOYER 3,520
MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW OF 3,522
THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL EMPLOYER 3,523
GROUP PLANS.
(J)(G) A carrier may obtain any facts and information 3,525
necessary to apply this section, or supply those facts and 3,526
information to any other third-party payer, without the consent 3,527
of the beneficiary. Each person claiming benefits under a health 3,528
benefit plan shall provide any facts and information necessary to 3,529
apply this section. 3,530
FOR PURPOSES OF THIS SECTION, "BONA FIDE ASSOCIATION" MEANS 3,533
AN ASSOCIATION THAT HAS BEEN ACTIVELY IN EXISTENCE FOR AT LEAST 3,534
FIVE YEARS; HAS BEEN FORMED AND MAINTAINED IN GOOD FAITH FOR 3,535
PURPOSES OTHER THAN OBTAINING INSURANCE; DOES NOT CONDITION 3,536
MEMBERSHIP IN THE ASSOCIATION ON ANY HEALTH STATUS-RELATED 3,537
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,539
RELATING TO AN INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; 3,540
MAKES HEALTH INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION 3,541
AVAILABLE TO ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED 3,542
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,545
RELATING TO SUCH MEMBERS OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE 3,546
76
THROUGH A MEMBER; DOES NOT MAKE HEALTH INSURANCE COVERAGE OFFERED 3,547
THROUGH THE ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A 3,548
MEMBER OF THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT 3,549
IMPOSED BY THE SUPERINTENDENT. TO MAINTAIN ITS STATUS AS A "BONA 3,550
FIDE ASSOCIATION," EACH ASSOCIATION SHALL ANNUALLY CERTIFY TO THE 3,551
SUPERINTENDENT THAT IT MEETS THE REQUIREMENTS OF THIS PARAGRAPH. 3,552
Sec. 3924.031. (A) AS USED IN THIS SECTION AND SECTION 3,555
3924.032 OF THE REVISED CODE: 3,557
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 3,559
FOLLOWING: 3,560
(a) HEALTH STATUS; 3,562
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 3,565
ILLNESSES;
(c) CLAIMS EXPERIENCE; 3,567
(d) RECEIPT OF HEALTH CARE; 3,569
(e) MEDICAL HISTORY; 3,571
(f) GENETIC INFORMATION; 3,573
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 3,576
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 3,578
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 3,580
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 3,581
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 3,582
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 3,584
UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE SMALL 3,587
EMPLOYER MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 3,588
OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH 3,590
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR 3,591
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN; 3,592
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 3,594
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH 3,595
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE: 3,596
77
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 3,599
SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL GROUPS 3,600
BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT 3,601
HOLDERS AND MEMBERS.
(b) THE CARRIER IS APPLYING DIVISION (B)(2) OF THIS 3,604
SECTION UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE 3,605
CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES 3,606
AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 3,607
SUCH EMPLOYEES AND DEPENDENTS. 3,608
(C) A CARRIER THAT, PURSUANT TO DIVISION (B)(2) OF THIS 3,612
SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE AREA 3,613
OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL EMPLOYER 3,614
MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY 3,615
DAYS AFTER THE DATE THE COVERAGE IS DENIED. 3,616
Sec. 3924.032. (A) A CARRIER MAY REFUSE TO ISSUE HEALTH 3,619
BENEFIT PLANS IN THE SMALL EMPLOYER MARKET IF THE CARRIER HAS 3,620
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT OF 3,621
INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 3,623
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 3,624
(2) THE CARRIER IS APPLYING DIVISION (A) OF THIS SECTION 3,627
UNIFORMLY TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS 3,628
STATE CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE 3,629
AND WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS 3,630
AND THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH 3,631
STATUS-RELATED FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS. 3,632
(B) A CARRIER THAT, PURSUANT TO DIVISION (A) OF THIS 3,636
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 3,637
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED 3,638
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE 3,639
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER 3,640
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL 3,641
COVERAGE, WHICHEVER IS LATER. 3,642
78
(C) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 3,645
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 3,646
Sec. 3924.033. (A) EACH CARRIER, IN CONNECTION WITH THE 3,649
OFFERING OF A HEALTH BENEFIT PLAN TO A SMALL EMPLOYER, SHALL 3,650
DISCLOSE TO THE EMPLOYER, AS PART OF ITS SOLICITATION AND SALES 3,651
MATERIALS, THAT THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,652
SECTION IS AVAILABLE UPON REQUEST. 3,653
(B) A CARRIER SHALL PROVIDE THE FOLLOWING INFORMATION TO A 3,656
SMALL EMPLOYER UPON REQUEST: 3,657
(1) THE PROVISIONS OF THE PLAN CONCERNING THE CARRIER'S 3,660
RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY AFFECT 3,661
CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO RENEWABILITY OF 3,664
COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY 3,666
PRE-EXISTING CONDITION EXCLUSION; 3,667
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL HEALTH 3,670
BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,674
SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER 3,675
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE 3,676
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT PLAN. 3,678
(D) NOTHING IN THIS SECTION REQUIRES A CARRIER TO DISCLOSE 3,681
ANY INFORMATION THAT IS BY LAW PROPRIETARY AND TRADE SECRET 3,682
INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit 3,691
entity to be known as the "Ohio small employer health reinsurance 3,693
program." Any carrier issuing health benefit plans in this state 3,694
on or after April 14, 1993, may be a member of the program. 3,695
(B) A carrier may elect to be a member of the program by 3,697
filing a written intention to participate with the superintendent 3,699
of insurance at least thirty days prior to the implementation of 3,700
the program. Any carrier that does not file a written intention 3,701
79
to participate within that time period may not participate for 3,702
three years after April 14, 1993, and may file an intention to 3,704
participate only at that time or on any subsequent three-year 3,705
anniversary date. However, the superintendent may permit a 3,706
carrier to participate in the program at other intervals for 3,707
reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A 3,709
CARRIER TO PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE 3,710
SHOWN. THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 3,711
CARRIERS SEEKING TO CHANGE THEIR STATUS UNDER THIS DIVISION. 3,712
Sec. 3924.08. (A) The board of directors of the Ohio 3,721
small employer health reinsurance program shall consist of nine 3,722
appointed members who shall serve staggered terms as determined 3,723
by the initial board for its members and by the plan of operation 3,724
of the program for members of subsequent boards. Within thirty 3,725
days after April 14, 1993, the members of the board shall be 3,726
appointed, as follows: 3,727
(1) The chairperson of the senate committee having 3,729
jurisdiction over insurance shall appoint the following members: 3,730
(a) Two member carriers that are small employer carriers; 3,732
(b) One member carrier that is a health maintenance 3,734
organization predominantly in the small employer market; 3,735
(c) One representative of providers of health care. 3,737
(2) The chairperson of the committee in the house of 3,739
representatives having jurisdiction over insurance shall appoint 3,740
the following members: 3,741
(a) One member carrier that is a small employer carrier; 3,743
(b) One member carrier whose principal health insurance 3,745
business is in the large employer market; 3,746
(c) One representative of an employer with fifty or fewer 3,748
employees; 3,749
(d) One representative of consumers in this state. 3,751
(3) The superintendent OF INSURANCE shall appoint a 3,753
representative of a member carrier operating in the small 3,755
80
employer market who is a fellow of the society of actuaries. 3,756
The superintendent, a member of the house of 3,758
representatives appointed by the speaker of the house of 3,759
representatives, and a member of the senate appointed by the 3,760
president of the senate, shall be ex-officio members of the 3,761
board. The membership of all boards subsequent to the initial 3,762
board shall reflect the distribution described in division (A) of 3,764
this section.
The chairperson of the initial board and each subsequent 3,766
board shall represent a small employer member carrier and shall 3,767
be elected by a majority of the voting members of the board. 3,768
Each chairperson shall serve for the maximum duration established 3,769
in the plan of operation. 3,770
(B) Within one hundred eighty days after the appointment 3,772
of the initial board, the board shall establish a plan of 3,773
operation and, thereafter, any amendments to the plan that are 3,774
necessary or suitable, to assure the fair, reasonable, and 3,775
equitable administration of the program. The board shall, 3,776
immediately upon adoption, provide to the superintendent copies 3,777
of the plan of operation and all subsequent amendments to it. 3,778
(C) The plan of operation shall establish rules, 3,780
conditions, and procedures for all of the following: 3,781
(1) The handling and accounting of assets and moneys of 3,783
the program and for an annual fiscal reporting to the 3,784
superintendent; 3,785
(2) Filling vacancies on the board; 3,787
(3) Selecting an administering insurer, which shall be a 3,789
carrier as defined in section 3924.01 of the Revised Code, and 3,790
setting forth the powers and duties of the administering insurer; 3,791
(4) Reinsuring risks in accordance with sections 3924.07 3,793
to 3924.14 of the Revised Code; 3,794
(5) Collecting assessments subject to section 3924.13 of 3,796
the Revised Code from all members to provide for claims reinsured 3,797
by the program and for administrative expenses incurred or 3,798
81
estimated to be incurred during the period for which the 3,799
assessment is made; 3,800
(6) Providing protection for carriers from the financial 3,802
risk associated with small employers that present poor credit 3,803
risks; 3,804
(7) Establishing standards for the coverage of small 3,806
employers that have a high turnover of employees; 3,807
(8) Establishing an appeals process for carriers to seek 3,809
relief when a carrier has experienced an unfair share of 3,810
administrative and credit risks; 3,811
(9) Establishing the adjusted average market premium 3,813
prices for use by the SEHC plan for INDIVIDUALS, FOR groups of 3,815
two to twenty-five employees, and for groups of twenty-six to 3,816
fifty employees that are offered in the state; 3,817
(10) Establishing participation standards at issue and 3,819
renewal for reinsured cases; 3,820
(11) Reinsuring risks and collecting assessments in 3,822
accordance with division (G) of section 3924.11 of the Revised 3,823
Code; 3,824
(12) Any additional matters as determined by the board. 3,826
Sec. 3924.09. The Ohio small employer health reinsurance 3,835
program shall have the general powers and authority granted under 3,836
the laws of the state to insurance companies licensed to transact 3,837
sickness and accident insurance, except the power to issue 3,838
insurance. The board of directors of the program also shall have 3,839
the specific authority to do all of the following: 3,840
(A) Enter into contracts as are necessary or proper to 3,842
carry out the provisions and purposes of sections 3924.07 to 3,843
3924.14 of the Revised Code, including the authority to enter 3,844
into contracts with similar programs of other states for the 3,845
joint performance of common functions, or with persons or other 3,846
organizations for the performance of administrative functions; 3,847
(B) Sue or be sued, including taking any legal actions 3,849
necessary or proper for recovery of any assessments for, on 3,850
82
behalf of, or against any program or board member; 3,851
(C) Take such legal action as is necessary to avoid the 3,853
payment of improper claims against the program; 3,854
(D) Design the SEHC plan which, when offered by a carrier, 3,856
is eligible for reinsurance and issue reinsurance policies in 3,857
accordance with the requirements of sections 3924.07 to 3924.14 3,858
of the Revised Code; 3,859
(E) Establish rules, conditions, and procedures pertaining 3,861
to the reinsurance of members' risks by the program; 3,862
(F) Establish appropriate rates, rate schedules, rate 3,864
adjustments, rate classifications, and any other actuarial 3,865
functions appropriate to the operation of the program; 3,866
(G) Assess members in accordance with division (G) of 3,869
section 3924.11 and the provisions of section 3924.13 of the 3,870
Revised Code, and make such advance interim assessments as may be 3,871
reasonable and necessary for organizational and interim operating 3,872
expenses. Any interim assessments shall be credited as offsets 3,873
against any regular assessments due following the close of the 3,874
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 3,876
other committees if necessary to provide technical assistance 3,877
with respect to the operation of the program, policy and other 3,878
contract design, and any other function within the authority of 3,879
the program; 3,880
(I) Borrow money to effect the purposes of the program. 3,882
Any notes or other evidence of indebtedness of the program not in 3,883
default shall be legal investments for carriers and may be 3,884
carried as admitted assets. 3,885
(J) Reinsure risks, collect assessments, and otherwise 3,887
carry out its duties under division (G) of section 3924.11 of the 3,888
Revised Code.; 3,889
(K) Study the operation of the Ohio small employer health 3,892
reinsurance program and the open enrollment reinsurance program 3,893
and, based on its findings, make legislative recommendations to 3,894
83
the general assembly for improvements in the effectiveness, 3,895
operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF 3,897
SECTIONS 1742.13, 3923.122, AND 3923.581 OF THE REVISED CODE. 3,898
Sec. 3924.10. (A) The board of directors of the Ohio 3,907
small employer health reinsurance program shall design the SEHC 3,908
plan which, when offered by a carrier, is eligible for 3,909
reinsurance under the program. The board shall establish the 3,910
form and level of coverage to be made available by carriers in 3,911
their SEHC plan. In designing the plan the board shall also 3,913
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 3,914
of coverage established by the board shall specify which 3,915
components of a health benefit plan offered by a small employer 3,916
carrier may be reinsured. The SEHC plan is subject to division 3,918
(C) of section 3924.02 of the Revised Code and to the provisions 3,919
in Chapters 1751., 3923., and any other chapter of the Revised 3,921
Code that require coverage or the offer of coverage of a health 3,922
care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 3,925
eighty days after its appointment. The plan may include cost 3,926
containment features including any of the following:
(1) Utilization review of health care services, including 3,928
review of the medical necessity of hospital and physician 3,929
services; 3,930
(2) Case management benefit alternatives; 3,932
(3) Selective contracting with hospitals, physicians, and 3,934
other health care providers; 3,935
(4) Reasonable benefit differentials applicable to 3,937
participating and nonparticipating providers; 3,938
(5) Employee assistance program options that provide 3,940
preventive and early intervention mental health and substance 3,941
abuse services; 3,942
(6) Other provisions for the cost-effective management of 3,944
84
the plan. 3,945
(C) An SEHC plan established for use by health insuring 3,948
corporations shall be consistent with the basic method of 3,950
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 3,952
insurance, in the form and manner prescribed by the 3,953
superintendent, that the SEHC plan filed by the carrier is in 3,955
substantial compliance with the provisions of the board SEHC 3,956
plan. Upon receipt by the superintendent of the certification, 3,957
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 3,959
date that the program becomes operational and as a condition of 3,960
transacting business in this state, renew coverage provided to 3,961
any individual or group under its SEHC plan. 3,962
(F) A carrier shall not be required to renew coverage 3,964
where the superintendent finds that renewal of coverage would 3,965
place the carrier in a financially impaired condition. The 3,966
superintendent shall determine when the carrier is no longer 3,967
financially impaired and is, therefore, subject to the guaranteed 3,968
renewability requirements. 3,969
Sec. 3924.11. Any member of the Ohio small employer health 3,978
reinsurance program may reinsure small employer groups or 3,979
individuals in accordance with the following conditions and 3,980
limitations: 3,981
(A) With respect to eligible employees and their 3,983
dependents who are hired subsequent to the commencement of the 3,984
employer's coverage by a carrier and who are not late enrollees, 3,985
and with respect to employees of an employer who are otherwise 3,986
eligible for insurance but were excluded by the carrier's 3,987
underwriting and who are not late enrollees, coverage may be 3,988
reinsured in either ANY of the following ways: 3,989
(1) Except in the case of late enrollees, within sixty 3,991
days after the commencement of their coverage under the plan; 3,992
(2) In the case of late enrollees WHO WERE NOT ELIGIBLE TO 3,995
85
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,996
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,999
ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 4,001
300gg-42, AS AMENDED, eighteen months after the date the late 4,003
enrollee becomes a member of the small employer's plan; 4,004
(3) IN THE CASE OF LATE ENROLLEES WHO WERE ELIGIBLE TO 4,006
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 4,008
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 4,011
ACT OF 1996," AS AMENDED, WITHIN SIXTY DAYS AFTER THE 4,012
COMMENCEMENT OF THEIR COVERAGE UNDER THE PLAN. 4,013
(B)(1) The carrier may reinsure either the entire eligible 4,016
group or any eligible individual, in accordance with the premium 4,018
rates established in section 3924.12 of the Revised Code, upon 4,020
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,023
dependents of an eligible employee, who were previously excluded 4,024
from group coverage for medical reasons, and shall reinsure such 4,025
employees or dependents within sixty days after the carrier is 4,026
required to include them in the group coverage.
(C) With respect to an SEHC plan, the program shall 4,029
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,031
the program shall reinsure the level of coverage provided up to, 4,032
but not exceeding, the level of coverage provided in an SEHC 4,033
plan. In the coverage provided to small employers, carriers 4,034
shall be required to use high-cost care management, hospital 4,035
precertification techniques, and other cost containment 4,036
mechanisms established by the program. 4,037
(E) A carrier may not reinsure existing business, except 4,039
pursuant to division (A) of this section. 4,040
(F) If an employer group is covered under a plan other 4,042
than an SEHC plan and the carrier chooses to reinsure the group 4,043
subsequent to the initial coverage period, or if a new individual 4,044
joins the group and the carrier wants to reinsure that 4,045
86
individual, the carrier shall not force the employer to change to 4,047
an SEHC plan. The carrier shall allow the employer to maintain 4,048
the same benefit plan and reinsure only that portion of the plan 4,049
that is consistent with an SEHC plan.
(G) With respect to coverage provided to a small employer 4,051
group or AN individual acquired under section 3923.58 OR A 4,052
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 3923.581 of 4,053
the Revised Code, the following conditions and limitations apply: 4,055
(1) Within sixty days after the commencement of the 4,058
initial coverage, any carrier may reinsure coverage of an entire 4,059
small employer group, or of eligible employees or dependents of 4,060
such group, or any SUCH AN individual acquired under section 4,061
3923.58 of the Revised Code with the OPEN ENROLLMENT REINSURANCE 4,063
program IN ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A 4,065
carrier may reinsure, within sixty days after the effective date 4,067
of coverage, an employee eligible for coverage under section 4,069
3923.58 of the Revised Code. Premium rates charged for coverage 4,070
reinsured by the program shall be established in accordance with 4,071
section 3924.12 of the Revised Code. 4,072
(2) The board of directors of the OHIO HEALTH REINSURANCE 4,075
program shall establish the open enrollment reinsurance fund for 4,076
coverage provided under section 3923.58 of the Revised Code AND, 4,077
WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, COVERAGE PROVIDED 4,079
UNDER SECTION 3923.581 OF THE REVISED CODE. The fund shall be 4,080
maintained separately from any reinsurance fund established for 4,081
small employer health care plans issued pursuant to sections
3924.07 to 3924.14 of the Revised Code. The board shall 4,082
calculate, on a retrospective basis, the amount needed for 4,083
maintenance of the open enrollment reinsurance fund and, on the 4,084
basis of that calculation, shall determine the amount to be 4,085
assessed each carrier that is required to provide open enrollment 4,086
coverage. 4,087
Assessments shall be apportioned by the board among all 4,089
carriers participating in the open enrollment reinsurance program 4,090
87
in proportion to their respective shares of the total premiums, 4,091
net of reinsurance premiums paid by a carrier for open enrollment 4,092
coverage and net of reinsurance premiums paid by the carrier for 4,093
all other small group and individual health benefit plans, earned 4,094
in this state from all health benefit plans covering small 4,095
employers and individuals that are issued by all such carriers 4,096
during the calendar year coinciding with or ending during the 4,097
fiscal year of the open enrollment program, or on any other 4,098
equitable basis reflecting coverage of small employers and 4,099
individuals in this state as may be provided in the plan of 4,100
operation adopted by the board. In no event shall the assessment 4,101
of any carrier under this section exceed, on an annual basis, 4,103
three per cent of its Ohio premiums for health benefit plans 4,104
covering small employers and individuals as reported on its most 4,105
recent annual statement filed with the superintendent of 4,106
insurance.
The board shall submit its determination of the amount of 4,108
the assessment to the superintendent for review of the accuracy 4,110
of the calculation of the assessment. Upon approval by the 4,111
superintendent, each carrier shall, within thirty days after 4,112
receipt of the notice of assessment, submit the assessment to the 4,113
board for purposes of the open enrollment reinsurance fund. 4,114
(3) If the assessments made and collected pursuant to 4,116
division (G)(2) of this section are not sufficient to pay the 4,117
claims reinsured under division (G) of this section and the 4,118
allocated administrative expenses, incurred or estimated to be 4,119
incurred during the period for which the assessment was made, the 4,120
secretary of the board shall immediately notify the 4,121
superintendent, and the superintendent shall suspend the 4,122
operation of open enrollment under section 3923.58 of the Revised 4,123
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER 4,124
SECTION 3923.581 OF THE REVISED CODE until the board has 4,125
collected in subsequent years through assessments made pursuant 4,126
to division (G)(2) of this section an amount sufficient to pay 4,127
88
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,129
under section 3923.58 of the Revised Code may elect not to 4,131
participate in the open enrollment reinsurance program under 4,132
division (G) of this section by filing an application with the 4,133
superintendent and obtaining the superintendent's approval. In 4,134
determining whether to approve an application, the superintendent 4,135
shall consider whether the carrier meets all of the following 4,136
standards: 4,137
(i) Demonstration by the carrier of a substantial and 4,139
established market presence; 4,140
(ii) Demonstrated experience in the small employer group 4,142
INDIVIDUAL market and history of rating and underwriting small 4,143
employer groups INDIVIDUAL PLANS; 4,145
(iii) Commitment to comply with the requirements of 4,147
section 3923.58 of the Revised Code; 4,148
(iv) Financial ability to assume and manage the risk of 4,150
enrolling open enrollment groups and individuals without the need 4,151
for, or protection of, reinsurance. 4,152
(b) A carrier whose application for nonparticipation has 4,154
been rejected by the superintendent may appeal the decision in 4,155
accordance with Chapter 119. of the Revised Code. A carrier that 4,156
has received approval of the superintendent not to participate in 4,157
the open enrollment reinsurance program shall, on or before the 4,158
first day of December, annually certify to the superintendent 4,159
that it continues to meet the standards described in division 4,160
(G)(4)(a) of this section. 4,161
(c) In any year subsequent to the year in which its 4,163
application not to participate has been approved, a carrier may 4,164
elect to participate in the open enrollment reinsurance program 4,165
by giving notice to the superintendent and board on or before the 4,166
thirty-first day of December. If, after a period of 4,167
nonparticipation, a carrier elects to participate in the open 4,168
enrollment reinsurance program, the carrier retains the risks it 4,169
89
assumed during the period when it was not participating. 4,170
(d) The superintendent may, at any time, authorize a 4,172
carrier to modify an election not to participate if the risk from 4,173
the carrier's open enrollment business jeopardizes the financial 4,174
condition of the carrier. If the superintendent authorizes the 4,175
carrier to again participate in the open enrollment reinsurance 4,176
program, the carrier shall retain the risks it assumed during the 4,177
period of nonparticipation. 4,178
(5) At the time of acquiring a small employer group, a 4,180
carrier shall determine whether to reinsure the entire group or 4,181
any individual pursuant to section 3924.12 of the Revised Code. 4,182
(6)(a) The open enrollment reinsurance program shall be 4,185
operated separately from the Ohio small employer health 4,186
reinsurance program.
(b) A carrier's election to participate in the open 4,188
enrollment reinsurance program under division (G) of this section 4,190
shall not be construed as an election to participate in the Ohio 4,191
small employer health reinsurance program under section 3924.07 4,192
of the Revised Code.
Sec. 3924.111. (A) The Ohio small employer health 4,203
reinsurance program shall not provide reinsurance for any 4,204
individual reinsured under the program until five thousand 4,205
dollars in benefit payments have been made by a member of the 4,206
program for services provided to that individual during a
calendar year, which payments would have been reimbursed through 4,207
the program but for the five-thousand-dollar deductible. The 4,208
member shall retain ten per cent of the next fifty thousand 4,209
dollars of benefit payments made during that calendar year, and 4,210
the program shall reinsure the remainder. However, a member's 4,211
maximum liability under this section with respect to any one 4,212
individual reinsured under the program shall not exceed ten 4,213
thousand dollars in any one calendar year. 4,214
(B) The board of directors of the Ohio small employer 4,217
health reinsurance program shall periodically review the 4,218
90
deductible amount and the maximum liability amount set forth in 4,219
division (A) of this section and, considering the rate of 4,220
inflation, adjust each amount as the board considers necessary. 4,221
Sec. 3924.12. (A) Except as provided in division (B) of 4,230
this section, premium rates charged for coverage reinsured by the 4,231
Ohio small employer health reinsurance program shall be 4,232
established as follows: 4,233
(1) For whole group reinsurance coverage, one and one-half 4,235
times the adjusted average market premium price established by 4,236
the program for that classification or group with similar 4,237
characteristics and coverage, with respect to the eligible 4,238
employees of a small employer and their dependents, all of whose 4,239
coverage is reinsured with the program, minus a ceding expense 4,240
factor determined by the board of directors of the program; 4,241
(2) For individual reinsurance coverage, five times the 4,243
adjusted average market premium price established by the program 4,244
for an individual in that classification or group with similar 4,245
characteristics and coverage, with respect to an eligible 4,246
employee or the employee's dependents, minus a ceding expense 4,248
factor determined by the board. 4,249
(B) Premium rates charged for reinsurance by the program 4,251
to a health insuring corporation that is approved by the 4,253
secretary of health and human services as a federally qualified 4,254
health maintenance organization pursuant to the "Social Security 4,255
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as 4,256
such is subject to requirements that limit the amount of risk 4,257
that may be ceded to the program, may be modified to reflect the 4,258
portion of risk that may be ceded to the program. 4,259
Sec. 3924.13. (A) Following the close of each calendar 4,268
year, the administering insurer of the Ohio small employer health 4,269
reinsurance program shall determine the net premiums, the program 4,270
expenses for administration, and the incurred losses, if any, for 4,271
the year, taking into account investment income and other 4,272
appropriate gains and losses. For purposes of this section, 4,273
91
health benefit plan premiums earned by MEWAs shall be established 4,274
by adding paid claim losses and administrative expenses of the 4,275
MEWA. Health benefit plan premiums and benefits paid by a 4,277
carrier that are less than an amount determined by the board of 4,278
directors of the program to justify the cost of collection shall 4,279
not be considered for purposes of determining assessments. For 4,280
purposes of this division, "net premiums" means health benefit 4,281
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 4,283
assessments of carriers in accordance with this division. 4,284
Assessments shall be apportioned by the board among all carriers 4,285
participating in the program in proportion to their respective 4,286
shares of the total premiums, net of reinsurance premiums paid 4,287
for coverage under this program earned in the state from health 4,288
benefit plans covering small employers that are issued by 4,289
participating members during the calendar year coinciding with or 4,290
ending during the fiscal year of the program, or on any other 4,291
equitable basis reflecting coverage of small employers as may be 4,292
provided in the plan of operation. An assessment shall be made 4,293
pursuant to this division against a health insuring corporation 4,294
that is approved by the secretary of health and human services as 4,297
a federally qualified health maintenance organization pursuant to 4,298
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 4,299
as amended, subject to an assessment adjustment formula adopted 4,300
by the board for such health insuring corporations that 4,301
recognizes the restrictions imposed on the entities by federal 4,303
law. The adjustment formula shall be adopted by the board prior 4,305
to the first anniversary of the program's operation. In no event 4,306
shall the assessment made pursuant to this division exceed, on an 4,307
annual basis, one per cent of the carrier's Ohio small employer 4,309
group premium as reported on its most recent annual statement 4,310
filed with the superintendent of insurance. If an excess is 4,311
actuarially projected, the superintendent may take any action 4,312
necessary to lower the assessment to the maximum level of one per 4,313
92
cent.
(C) If assessments exceed actual losses and administrative 4,315
expenses of the program, the excess shall be held at interest and 4,316
used by the board to offset future losses or to reduce program 4,317
premiums. As used in this division, "future losses" includes 4,318
reserves for incurred but not reported claims. 4,319
(D) Each carrier's proportion of participation in the 4,321
program shall be determined annually by the board based on annual 4,323
statements and other reports deemed necessary by the board and 4,324
filed by the carrier with the board. MEWAs shall report to the 4,325
board claims payments made and administrative expenses incurred 4,326
in this state on an annual basis on a form prescribed by the 4,327
superintendent.
(E) Provision shall be made in the plan of operation for 4,329
the imposition of an interest penalty for late payment of 4,330
assessments. 4,331
(F) A carrier may seek from the superintendent a 4,333
deferment, in whole or in part, from any assessment issued by the 4,334
board. The superintendent may defer, in whole or in part, the 4,335
assessment of a carrier if, in the opinion of the superintendent, 4,336
payment of the assessment would endanger the carrier's ability to 4,337
fulfill its contractual obligations. 4,338
(G) In the event an assessment against a carrier is 4,340
deferred in whole or in part, the amount by which the assessment 4,341
is deferred may be assessed against the other carriers in a 4,342
manner consistent with the basis for assessments set forth in 4,343
this section. In such event, the other carriers assessed shall 4,344
have a claim in the amount of the assessment against the carrier 4,345
receiving the deferment. The carrier receiving the deferment 4,346
shall remain liable to the program for the amount deferred. The 4,347
superintendent may attach appropriate conditions to any 4,348
deferment. 4,349
Sec. 3924.14. Neither the participation as members of the 4,358
Ohio small employer health reinsurance program or as members of 4,359
93
the board of directors of the program, the establishment of 4,361
rates, forms, or procedures for coverage issued by the program, 4,362
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 4,363
legal action or any criminal or civil liability or penalty 4,364
against the program, the board, or any of its members either 4,365
jointly or separately.
Sec. 3924.27. (A) AS USED IN THIS SECTION: 4,368
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE 4,370
THE SAME MEANINGS AS IN SECTION 3924.01 OF THE REVISED CODE. 4,371
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 4,373
FOLLOWING: 4,374
(a) HEALTH STATUS; 4,376
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 4,379
ILLNESSES;
(c) CLAIMS EXPERIENCE; 4,381
(d) RECEIPT OF HEALTH CARE; 4,383
(e) MEDICAL HISTORY; 4,385
(f) GENETIC INFORMATION; 4,387
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 4,390
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 4,392
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING 4,394
HEALTH INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH 4,395
BENEFIT PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF 4,396
ENROLLMENT OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A 4,397
PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR 4,398
CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE 4,399
PLAN ON THE BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION 4,400
TO THE INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS 4,401
A DEPENDENT OF THE INDIVIDUAL. 4,402
(C) NOTHING IN DIVISION (B) OF THIS SECTION SHALL BE 4,406
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 4,407
FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO PREVENT A 4,408
94
GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING GROUP HEALTH 4,409
INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM DISCOUNTS OR 4,410
REBATES OR MODIFYING OTHERWISE APPLICABLE COPAYMENTS OR 4,411
DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF HEALTH 4,412
PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section: 4,421
(1) "Child" means, in connection with any adoption or 4,423
placement for adoption of the child, an individual who has not 4,424
attained age eighteen as of the date of the adoption or placement 4,425
for adoption. 4,426
(2) "Health insurer" has the same meaning as in section 4,428
3924.41 of the Revised Code. 4,429
(3) "Placement for adoption" means the assumption and 4,431
retention by a person of a legal obligation for total or partial 4,432
support of a child in anticipation of the adoption of the child. 4,433
The child's placement with a person terminates upon the 4,434
termination of that legal obligation. 4,435
(B) If an individual or group health plan of a health 4,437
insurer provides MAKES coverage AVAILABLE for dependent children 4,439
of participants or beneficiaries, the plan shall provide benefits 4,440
to dependent children placed with participants or beneficiaries 4,441
for adoption under the same terms and conditions as apply to the 4,442
natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become 4,443
final. 4,444
(C) A health plan described in division (B) of this 4,446
section shall not restrict coverage under the plan of any 4,448
dependent child adopted by a participant or beneficiary, or 4,449
placed with a participant or beneficiary for adoption, solely on 4,450
the basis of a pre-existing condition of the child at the time 4,451
that the child would otherwise become eligible for coverage under 4,452
the plan, if the adoption or placement for adoption occurs while 4,453
the participant or beneficiary is eligible for coverage under the 4,454
plan.
95
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 4,463
the Revised Code: 4,464
(A) "Account holder" means the natural person who opens a 4,467
medical savings account or on whose behalf a medical savings 4,468
account is opened.
(B) "Eligible medical expense" means any expense for a 4,471
service rendered by a licensed health care provider or a 4,472
Christian Science practitioner, or for an article, device, or 4,473
drug prescribed by a licensed health care provider or provided by 4,474
a Christian Science practitioner, when intended for use in the 4,476
mitigation, treatment, or prevention of disease; ANY AMOUNT PAID 4,477
FOR TRANSPORTATION TO THE LOCATION AT WHICH SUCH A SERVICE IS 4,478
RENDERED; ANY AMOUNT PAID FOR LODGING NECESSITATED BY THE RECEIPT 4,479
OF CARE AT A NONLOCAL HOSPITAL; or premiums paid for 4,480
comprehensive sickness and accident insurance, coverage under a 4,482
health care plan of a health insuring corporation organized under 4,483
Chapter 1751. of the Revised Code, long-term care insurance as 4,485
defined in section 3923.41 of the Revised Code, Medicare MEDICARE 4,486
supplemental coverage as defined in section 3923.33 of the 4,488
Revised Code, or payments made pursuant to cost sharing 4,489
agreements under comprehensive sickness and accident plans. An 4,490
"eligible medical expense" does not include expenses otherwise 4,491
paid or reimbursed, including medical expenses paid or reimbursed 4,492
under an automobile or motor vehicle insurance policy, a workers' 4,493
compensation insurance policy or plan, or an employer-sponsored 4,494
health coverage policy, plan, or contract.
(C) "Qualified dependent" means a child of an account 4,497
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 4,500
twenty-three years of age and a full-time student at an
accredited college or university; 4,501
(2) The child is not self-sufficient due to physical or 4,503
mental disorders or impairments; 4,504
(3) The child is legally entitled to the provision of 4,506
96
proper or necessary subsistence, education, medical care, or 4,507
other care necessary for the child's health, guidance, or 4,508
well-being and is not otherwise emancipated, self-supporting, 4,509
married, or a member of the armed forces of the United States 4,511
DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE 4,512
"INTERNAL REVENUE CODE OF 1986," 100 STAT. 2085, 26 U.S.C.A. 1, 4,513
AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened 4,522
by or on behalf of any natural person, to pay the person's 4,523
eligible medical expenses and the eligible medical expenses of 4,524
that person's spouse or qualified dependent. A medical savings 4,525
account may be opened by or on behalf of a person only if that 4,528
person participates in a sickness or accident insurance plan, a 4,529
plan offered by a health insuring corporation organized under 4,530
Chapter 1751. of the Revised Code, or a self-funded, 4,531
employer-sponsored health benefit plan established pursuant to 4,532
the "Employee Retirement Income Security Act of 1974," 88 Stat. 4,533
832, 29 U.S.C.A. 1001, as amended. While the medical savings
account is open, the account holder shall continue to participate 4,534
in such a plan.
(B) A person who refuses to participate in a policy, plan, 4,537
or contract of health coverage that is funded by the person's 4,538
employer, and who receives additional monetary compensation by 4,539
virtue of refusing that coverage, may not open a medical savings 4,540
account unless the medical savings account also is sponsored by 4,541
the person's employer. 4,542
Sec. 3924.63. The owners of interest in a medical savings 4,552
account are the account holder, AND the account holder's spouse, 4,553
and qualified dependents. No medical savings account shall be 4,554
subject to garnishment or attachment. 4,556
Sec. 3924.64. (A) At the time a medical savings account 4,566
is opened, an administrator for the account shall be designated. 4,567
If an employer opens an account for an employee, the employer may 4,568
designate the administrator. If an account is opened by any 4,569
97
person other than an employer, or if an employer chooses not to 4,570
designate an administrator for an account opened for an employee, 4,571
the account holder shall designate the administrator. The 4,572
administrator shall manage the account in a fiduciary capacity 4,573
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 4,576
of the following:
(1) A federally or state-chartered bank, savings and loan 4,579
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 4,581
(3) An insurer authorized under Title XXXIX of the Revised 4,584
Code to engage in the business of sickness and accident 4,585
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 4,588
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 4,591
Revised Code;
(6) A certified public accountant; 4,593
(7) An employer that administers an employee benefit plan 4,596
subject to regulation under the "Employee Retirement Income 4,597
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 4,599
amended, or that maintains medical savings accounts for its 4,600
employees;
(8) Health insuring corporations organized under Chapter 4,603
1751. of the Revised Code.
(C) Each administrator shall send to the account holder, 4,606
at least annually, a statement setting forth the balance 4,607
remaining in the account holder's account and detailing the 4,608
activity in the account since the last statement was issued. 4,609
Upon an administrator's receipt of a written request from an 4,610
account holder for a current statement, the administrator shall 4,611
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 4,614
of the account the account holder's payment of, or the account
98
holder's obligation for, an eligible medical expense for the 4,615
account holder, OR the account holder's spouse, or qualified 4,617
dependents, the administrator shall reimburse the account holder 4,618
for, or shall pay for, the eligible medical expense with funds 4,619
from the account holder's account, if sufficient funds are 4,620
available in the account holder's account. If there are not 4,621
sufficient funds in the account to fully reimburse the account 4,622
holder or pay the expenses, the administrator shall reimburse the 4,624
account holder or pay the expenses using whatever funds are in 4,625
the account. The reimbursement or payment shall be made within 4,626
thirty days of the administrator's receipt of the documentation. 4,627
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 4,628
expense does not count toward meeting the deductible or other 4,629
obligation for the receipt of benefits that is required by the 4,630
insurer or other third-party payer providing health coverage to 4,631
the account holder. The administrator shall keep a record of the 4,632
amounts disbursed from the account for documented eligible 4,633
medical expenses and of the dates on which the expenses were 4,634
incurred. This record shall be made available to any sickness 4,635
and accident insurer or other third-party payer providing health 4,636
coverage to the account holder, for use by the insurer or 4,637
third-party payer in determining whether the account holder has 4,638
met the deductible or other obligation required for the receipt 4,639
of benefits from the insurer or third-party payer. 4,640
(E) When an account is opened, the administrator shall 4,643
give written notice to the account holder of the date of the last 4,644
business day of the administrator's business year. 4,645
Sec. 3924.66. (A) In determining Ohio adjusted gross 4,654
income under Chapter 5747. of the Revised Code, an account holder 4,655
may deduct an amount equaling the total of the deposits that the 4,657
account holder, the account holder's spouse, or the account 4,658
holder's employer made to the account during the taxable year, to 4,659
the extent that the funds for the deposits have not otherwise 4,660
99
been deducted or excluded in determining the account holder's
federal adjusted gross income. The amount deducted by an account 4,662
holder for a taxable year shall not exceed three thousand 4,663
dollars. If two married persons each have an account, each 4,664
spouse may claim the deduction described in this section, and the 4,666
amount deducted by each spouse shall not exceed three thousand 4,667
dollars, whether the spouses file returns jointly or separately. 4,668
(B) The maximum deduction allowed under division (A) of 4,670
this section shall be adjusted annually by the department of 4,671
taxation to reflect increases in the consumer price index for all 4,672
items for all urban consumers for the north central region, as 4,673
published by the United States bureau of labor statistics. 4,674
(C) In determining Ohio adjusted gross income under 4,676
Chapter 5747. of the Revised Code, an account holder may deduct 4,677
the investment earnings of a medical savings account from the 4,678
account holder's federal adjusted gross income, to the extent 4,679
that these earnings have been included in the account holder's 4,680
federal adjusted gross income.
(D) In determining Ohio adjusted gross income under 4,682
Chapter 5747. of the Revised Code, an account holder shall add to 4,683
the account holder's federal adjusted gross income an amount 4,684
equal to the sum of the amounts described in divisions (D)(1) and 4,686
(2) of this section to the extent that those amounts were 4,687
included in the account holder's federal adjusted gross income 4,688
and previously deducted in determining the account holder's Ohio 4,690
adjusted gross income. In determining the extent to which 4,691
amounts withdrawn from the account shall be included in the 4,692
account holder's Ohio adjusted gross income, the tax commissioner 4,694
shall be guided by the provisions of sections 72 and 408 of the 4,695
Internal Revenue Code governing the determination of the amount 4,696
of withdrawals from an individual retirement account to be 4,697
included in federal gross income.
(1) Amounts withdrawn from the account during the taxable 4,700
year used for any purpose other than to reimburse the account 4,701
100
holder for, or to pay, the eligible medical expenses of the 4,702
account holder, OR the account holder's spouse, or qualified 4,704
dependents; 4,705
(2) Investment earnings during the taxable year on amounts 4,707
withdrawn from the account that are described in division (D)(1) 4,708
of this section. 4,709
(E) Amounts withdrawn from a medical savings account to 4,711
reimburse the account holder for, or to pay, the account holder's 4,712
eligible medical expenses, or the eligible medical expenses of 4,713
the account holder's spouse or qualified dependents, shall not be 4,715
included in the account holder's Ohio adjusted gross income in 4,716
determining taxes due under Chapter 5747. of the Revised Code. 4,717
(F) If a qualified dependent of an account holder becomes 4,720
ineligible to continue to participate in the account holder's 4,722
policy, plan, or contract of health coverage, the account holder 4,723
may withdraw funds from the account holder's account and use
those funds to pay the premium for the first year of a policy, 4,724
plan, or contract of health coverage for the qualified dependent 4,725
and to pay any deductible for the first year of that policy, 4,727
plan, or contract. Funds withdrawn and used for that purpose 4,728
shall not be included in the account holder's Ohio adjusted gross 4,729
income in determining taxes due under Chapter 5747. of the 4,730
Revised Code. 4,731
Sec. 3924.67. An account holder may withdraw funds from 4,741
the account holder's account at any time, for any purpose.
However, the administrator of a medical savings account shall not 4,742
disburse funds to an account holder during the year in which the 4,744
funds were deposited, except to reimburse the account holder for, 4,745
or pay for, a documented eligible medical expense of the account 4,746
holder, OR the account holder's spouse, or a qualified dependent. 4,747
Sec. 3924.68. (A) If an account holder, whose medical 4,757
savings account has been opened by the account holder's employer, 4,758
later ceases to be employed by that employer, the account holder 4,759
may, within sixty days of the account holder's final date of 4,760
101
employment, request in writing to the administrator of the 4,762
account that the administrator continue to administer the 4,763
account.
(1) If the administrator agrees to continue to administer 4,766
the account, funds in the account may continue to be used to pay 4,767
the eligible medical expenses of the account holder, AND the 4,768
account holder's spouse, and qualified dependents, pursuant to 4,769
sections 3924.61 to 3924.74 of the Revised Code. 4,771
If the account holder later becomes employed by a new 4,773
employer that opens a new medical savings account on the account 4,774
holder's behalf, the account holder may transfer any funds 4,776
remaining in the account opened by the account holder's former 4,777
employer to the account opened by the account holder's new 4,778
employer. For purposes of determining taxes due under Chapter 4,780
5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, 4,781
nor shall it be considered a deposit to a medical savings 4,782
account.
(2) If the administrator does not agree to continue to 4,785
administer the account, or if the account holder requests that 4,786
the account be closed, the administrator shall close the account 4,787
and mail a check or other negotiable instrument in the amount of 4,788
the account balance as of that date to the account holder. The 4,789
amount distributed shall be included in the account holder's Ohio 4,790
adjusted gross income in determining taxes due under Chapter 4,791
5747. of the Revised Code. 4,792
(B) Within sixty days of the account holder's final date 4,794
of employment, the account holder may transfer any funds 4,796
remaining in the account opened by the account holder's former 4,797
employer to another medical savings account owned by the account 4,798
holder. For purposes of determining taxes due under Chapter 4,799
5747,. of the Revised Code, this transfer of funds shall not be 4,800
considered a withdrawal of funds from a medical savings account, 4,801
nor shall it be considered a deposit to a medical savings
102
account. 4,802
(C) An administrator of an account opened by an employer 4,804
shall not close an account without the permission of the account 4,805
holder until at least sixty-one days after the account holder's 4,806
final date of employment. The employer shall notify the 4,807
administrator of the employee's final date of employment. 4,808
Sec. 3924.73. (A) As used in this section: 4,817
(1) "Health care insurer" means any person legally engaged 4,819
in the business of providing sickness and accident insurance 4,820
contracts in this state, a health insuring corporation organized 4,822
under Chapter 1751. of the Revised Code, or any legal entity that 4,823
is self-insured and provides health care benefits to its
employees or members. 4,824
(2) "Small employer" has the same meaning as in division 4,826
(P) of section 3924.01 of the Revised Code. 4,827
(B)(1) Subject to division (B)(2) of this section, nothing 4,830
in sections 3924.61 to 3924.74 of the Revised Code shall be 4,831
construed to limit the rights, privileges, or protections of 4,832
employees or small employers under sections 3924.01 to 3924.14 of 4,833
the Revised Code. 4,834
(2) If any account holder enrolls or applies to enroll in 4,836
a policy or contract offered by a health care insurer providing 4,837
sickness and accident coverage that is more comprehensive than, 4,838
and has a deductible amount that is less than, the coverage and 4,839
deductible amount of the policy under which the account holder 4,840
currently is enrolled, the health care insurer to which the 4,841
account holder applies may subject the account holder to the same 4,843
medical review, waiting periods, and underwriting requirements to 4,844
which the health care insurer generally subjects other enrollees 4,845
or applicants, unless the account holder enrolls or applies to 4,846
enroll during a designated period of open enrollment. 4,847
Section 2. That existing sections 1739.05, 1751.06, 4,849
1751.14, 1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 4,850
1751.65, 1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 4,851
103
3923.021, 3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 4,853
3923.63, 3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 4,854
3924.09, 3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 4,855
3924.51, 3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 4,856
3924.68, and 3924.73 and section 3941.53 of the Revised Code are 4,858
hereby repealed. 4,859
Section 3. The amendments to sections 1751.59, 1751.61, 4,861
3923.122, 3923.26, 3923.40, and 3924.51 of the Revised Code by 4,862
this act shall apply to contracts, evidences of coverage, 4,863
policies, and plans that are delivered, issued for delivery, 4,864
renewed, or established in this state on or after the effective 4,865
date of this section. 4,866
Section 4. The amendment of sections 1751.64, 3901.49, and 4,868
3901.50 of the Revised Code is not intended to supersede the 4,869
earlier repeal, with delayed effective dates, of those sections. 4,870
Section 5. This act is hereby declared to be an emergency 4,872
measure necessary for the immediate preservation of the public 4,873
peace, health, and safety. The reason for such necessity is that 4,874
Ohio must meet the federal deadline relative to the 4,875
implementation of the federal Health Insurance Portability and
Accountability Act of 1996. Ohio's failure to meet this deadline 4,876
could result in the federal government assuming regulation over 4,877
certain areas of health insurance, thereby disrupting the stable 4,878
health insurance market in Ohio that currently exists under Ohio 4,879
law. Meeting the federal deadline will protect the public health 4,881
and safety of the citizens of this state by ensuring the
stability of the health insurance market through the continued 4,882
regulation of this market by the state. Therefore, this act 4,883
shall go into immediate effect.