As Reported by the Senate Insurance, 1
Commerce and Labor Committee 2
122nd General Assembly 5
Regular Session Sub. H. B. No. 374 6
1997-1998 7
REPRESENTATIVES VAN VYVEN-BRADING-CORBIN-GARCIA-HAINES- 9
MOTTLEY-NETZLEY-SCHURING-TAYLOR-TERWILLEGER-THOMAS-TIBERI- 10
LEWIS-HOTTINGER-MAIER-TAVARES-JERSE-METELSKY-REID-WESTON- 11
CLANCY-HOUSEHOLDER-LUCAS-VESPER-O'BRIEN-VERICH-SULZER-BENDER- 12
MOTTL-MYERS-OGG-CORE-OLMAN-OPFER-DAMSCHRODER-BRITTON-HARRIS- 13
LOGAN-PATTON-ROMAN-WINKLER-WILSON-CATES-ROBERTS-FORD-JONES- 14
JACOBSON-FOX-SALERNO-MILLER-COLONNA-BOYD-PRINGLE-SUTTON-MALLORY- 15
SENATORS CUPP-DiDONATO 16
17
A B I L L
To amend sections 1739.05, 1751.06, 1751.15, 19
1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 20
1751.65, 1751.67, 3901.21, 3901.49, 3901.491, 21
3901.50, 3901.501, 3923.021, 3923.122, 3923.26, 22
3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 24
3923.64, 3924.01, 3924.02, 3924.03, 3924.07 to
3924.11, 3924.111, 3924.12 to 3924.14, 3924.51, 26
3924.61 to 3924.64, 3924.66 to 3924.68, and 27
3924.73, to enact sections 1751.57, 1751.58, 28
3901.044, 3923.571, 3923.581, 3924.031, 3924.032, 30
3924.033, and 3924.27, and to repeal section 31
3941.53 of the Revised Code relative to the 32
implementation of the federal Health Insurance 33
Portability and Accountability Act of 1996 and 34
insurance coverage of follow-up care for a mother 35
and newborn, and to declare an emergency. 36
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 38
Section 1. That sections 1739.05, 1751.06, 1751.15, 40
2
1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 1751.67, 41
3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 43
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 45
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 46
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 47
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 49
and 3924.73 be amended and sections 1751.57, 1751.58, 3901.044, 50
3923.571, 3923.581, 3924.031, 3924.032, 3924.033, and 3924.27 of 51
the Revised Code be enacted to read as follows: 53
Sec. 1739.05. (A) A multiple employer welfare arrangement 62
that is created pursuant to sections 1739.01 to 1739.22 of the 63
Revised Code and that operates a group self-insurance program may 64
be established only if any of the following applies: 65
(1) The arrangement has and maintains a minimum enrollment 67
of three hundred employees of two or more employers. 68
(2) The arrangement has and maintains a minimum enrollment 70
of three hundred self-employed individuals. 71
(3) The arrangement has and maintains a minimum enrollment 73
of three hundred employees or self-employed individuals in any 74
combination of divisions (A)(1) and (2) of this section. 75
(B) A multiple employer welfare arrangement that is 77
created pursuant to sections 1739.01 to 1739.22 of the Revised 78
Code and that operates a group self-insurance program shall 79
comply with all laws applicable to self-funded programs in this 80
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 81
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 82
3923.301, and 3923.38, 3923.581, 3923.63, 3924.031, 3924.032, AND 85
3924.27 of the Revised Code. 86
(C) A multiple employer welfare arrangement created 88
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 89
solicit enrollments only through agents or solicitors licensed 90
pursuant to Chapter 3905. of the Revised Code to sell or solicit 91
sickness and accident insurance. 92
(D) A multiple employer welfare arrangement created 94
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pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 95
provide benefits only to individuals who are members, employees 96
of members, or the dependents of members or employees, or are 97
eligible for continuation of coverage under section 1751.53 or 98
3923.38 of the Revised Code or under Title X of the "Consolidated 99
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 100
U.S.C.A. 1161, as amended. 101
Sec. 1751.06. Upon obtaining a certificate of authority as 110
required under this chapter, a health insuring corporation may do 112
all of the following:
(A) Enroll individuals and their dependents in either of 114
the following circumstances: 115
(1) The individual resides OR LIVES in the approved 117
service area.
(2) The individual's place of employment is located in the 120
approved service area and the individual has agreed to receive 121
health care services in accordance with the evidence of coverage. 122
(B) Contract with providers and health care facilities for 124
the health care services to which enrollees are entitled under 125
the terms of the health insuring corporation's health care 126
contracts;
(C) Contract with insurance companies authorized to do 129
business in this state for insurance, indemnity, or reimbursement 130
against the cost of providing emergency and nonemergency health 131
care services for enrollees, subject to the provisions set forth 132
in this chapter and the limitations set forth in the Revised 134
Code;
(D) Contract with any person pursuant to the requirements 136
of division (A)(18) of section 1751.03 of the Revised Code for 137
managerial or administrative services, or for data processing, 138
actuarial analysis, billing services, or any other services 139
authorized by the superintendent of insurance. However, a health 141
insuring corporation shall not enter into a contract for any of 142
the services listed in this division with an insurance company 143
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that is not authorized to engage in the business of insurance in 144
this state.
(E) Accept from governmental agencies, private agencies, 146
corporations, associations, groups, individuals, or other 147
persons, payments covering all or part of the costs of planning, 148
development, construction, and the provision of health care 149
services;
(F) Purchase, lease, construct, renovate, operate, or 151
maintain health care facilities, and their ancillary equipment, 152
and any property necessary in the transaction of the business of 153
the health insuring corporation.;
(G) IN THE EMPLOYER GROUP MARKET, IMPOSE AN AFFILIATION 156
PERIOD OF NOT MORE THAN SIXTY DAYS, WHICH PERIOD BEGINS ON THE 157
INDIVIDUAL'S DATE OF ENROLLMENT AND RUNS CONCURRENTLY WITH ANY 158
WAITING PERIOD IMPOSED UNDER THE COVERAGE. FOR PURPOSES OF THIS 159
DIVISION, "AFFILIATION PERIOD" MEANS A PERIOD OF TIME WHICH, 160
UNDER THE TERMS OF THE COVERAGE OFFERED, MUST EXPIRE BEFORE THE 161
COVERAGE BECOMES EFFECTIVE. NO HEALTH CARE SERVICES OR BENEFITS 162
NEED TO BE PROVIDED DURING AN AFFILIATION PERIOD, AND NO PERIODIC 163
PREPAYMENTS CAN BE CHARGED FOR ANY COVERAGE DURING THAT PERIOD. 164
(H) IF A HEALTH INSURING CORPORATION OFFERS COVERAGE IN 167
THE SMALL EMPLOYER GROUP MARKET THROUGH A NETWORK PLAN, LIMIT OR 168
DENY THE COVERAGE IN ACCORDANCE WITH SECTION 3924.031 OF THE 170
REVISED CODE; 171
(I) REFUSE TO ISSUE COVERAGE IN THE SMALL EMPLOYER GROUP 174
MARKET PURSUANT TO SECTION 3924.032 OF THE REVISED CODE; 176
(J) ESTABLISH EMPLOYER CONTRIBUTION RULES OR GROUP 179
PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN CONNECTION 180
WITH A GROUP CONTRACT IN THE SMALL EMPLOYER GROUP MARKET, AS 181
PROVIDED IN DIVISION (E)(1) OF SECTION 3924.03 OF THE REVISED 184
CODE.
Nothing in this section shall be construed as prohibiting a 186
health insuring corporation without other commercial enrollment 187
from contracting solely with federal health care programs 188
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regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 190
authority of a health insuring corporation to perform those 191
functions not otherwise prohibited by law. 192
Sec. 1751.15. (A) After a health insuring corporation has 201
furnished, directly or indirectly, basic health care services for 202
a period of twenty-four months, and if it currently meets the 203
financial requirements set forth in section 1751.28 of the 204
Revised Code and had net income as reported to the superintendent 205
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 206
less than thirty days during its month of licensure FOR 208
INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 209
(B) During the open enrollment period described in 211
division (A) of this section, the health insuring corporation 212
shall accept applicants and their dependents in the order in 213
which they apply for enrollment and in accordance with any of the 214
following:
(1) Up to its capacity, as determined by the health 216
insuring corporation subject to review by the superintendent; 217
(2) If less than its capacity, one per cent of the health 219
insuring corporation's total number of subscribers residing in 220
this state as of the immediately preceding thirty-first day of 221
December. 222
(C) Where a health insuring corporation demonstrates to 224
the satisfaction of the superintendent that such open enrollment 225
would jeopardize its economic viability, the superintendent may 226
do any of the following:
(1) Waive the requirement for open enrollment; 228
(2) Impose a limit on the number of applicants and their 230
dependents that must be enrolled; 231
(3) Authorize such underwriting restrictions upon open 233
enrollment as are necessary to do any of the following: 234
(a) Preserve its financial stability; 236
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(b) Prevent excessive adverse selection; 238
(c) Avoid unreasonably high or unmarketable charges for 240
coverage of health care services. 241
(D)(1) A request to the superintendent under division (C) 244
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 245
documentation, including financial data. In reviewing the 246
request, the superintendent may consider various factors, 247
including the size of the health insuring corporation, the health 248
insuring corporation's net worth and profitability, the health 249
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 250
(2) Any action taken by the superintendent under division 252
(C) of this section shall be effective for a period of not more 254
than one year. At the expiration of such time, a new 255
demonstration of the health insuring corporation's need for the 256
restriction, limit, or waiver shall be made before a new 257
restriction, limit, or waiver is granted by the superintendent. 258
(3) Irrespective of the granting of any restriction, 260
limit, or waiver by the superintendent, a health insuring 261
corporation may reject an applicant or a dependent of the 262
applicant during its open enrollment period if the applicant or 263
dependent: 264
(a) Was eligible for and was covered under any 266
employer-sponsored health care coverage, or if employer-sponsored 267
health care coverage was available at the time of open 268
enrollment;
(b) Is eligible for conversion or continuation coverage 270
under state or federal law; 271
(c) Is eligible for medicare, and the health insuring 273
corporation does not have an agreement on appropriate payment 274
mechanisms with the governmental agency administering the 275
medicare program.
(E) A health insuring corporation shall not be required 277
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either to enroll applicants or their dependents who are confined 278
to a health care facility because of chronic illness, permanent 279
injury, or other infirmity that would cause economic impairment 280
to the health insuring corporation if such applicants or their 281
dependents were enrolled or to make the effective date of 282
benefits for applicants or their dependents enrolled under this 283
section earlier than ninety days after the date of enrollment. 284
(F) A health insuring corporation shall not be required to 286
cover the fees or costs, or both, for any basic health care 287
service related to a transplant of a body organ if the transplant 288
occurs within one year after the effective date of an enrollee's 289
coverage under this section. This limitation on coverage does 290
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 291
(G) Each health insuring corporation required to hold an 293
open enrollment pursuant to division (A) of this section shall 294
file with the superintendent, not later than sixty days prior to 295
the commencement of the proposed open enrollment period, the 296
following documents:
(1) The proposed public notice of open enrollment; 298
(2) The evidence of coverage approved pursuant to section 300
1751.11 of the Revised Code that will be used during open 302
enrollment;
(3) The contractual periodic prepayment and premium rate 304
approved pursuant to section 1751.12 of the Revised Code that 305
will be applicable during open enrollment; 306
(4) Any solicitation document approved pursuant to section 309
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 310
(5) A list of the proposed dates of publication of the 312
public notice, and the names of the newspapers in which the 313
notice will appear; 314
(6) Any request for a restriction, limit, or waiver with 316
respect to the open enrollment period, along with any supporting 317
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documentation. 318
(H)(1) An open enrollment period shall not satisfy the 320
requirements of this section unless the health insuring 321
corporation provides adequate public notice in accordance with 322
divisions (H)(2) and (3) of this section. No public notice shall 323
be used until the form of the public notice has been filed by the 324
health insuring corporation with the superintendent. If the 325
superintendent does not disapprove the public notice within sixty 326
days after it is filed, it shall be deemed approved, unless the 327
superintendent sooner gives approval for the public notice. If 328
the superintendent determines within this sixty-day period that 329
the public notice fails to meet the requirements of this section, 330
the superintendent shall so notify the health insuring 331
corporation and it shall be unlawful for the health insuring 332
corporation to use the public notice. Such disapproval shall be 333
effected by a written order, which shall state the grounds for 334
disapproval and shall be issued in accordance with Chapter 119. 335
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 337
section shall be published in at least one newspaper of general 338
circulation in each county in the health insuring corporation's 339
service area, at least once in each of the two weeks immediately 340
preceding the month in which the open enrollment is to occur and 341
in each week of that month, or until the enrollment limitation is 342
reached, whichever occurs first. The notice published during the 343
last week of open enrollment shall appear not less than five days 344
before the end of the open enrollment period. It shall be at 345
least two newspaper columns wide or two and one-half inches wide, 347
whichever is larger. The first two lines of the text shall be 348
published in not less than twelve-point, boldface type. The 349
remainder of the text of the notice shall be published in not 350
less than eight-point type. The entire public notice shall be 351
surrounded by a continuous black line not less than one-eighth of 352
an inch wide.
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(3) The following information shall be included in the 354
public notice provided under division (H)(2) of this section: 355
(a) The dates that open enrollment will be held and the 357
date coverage obtained under the open enrollment will become 358
effective;
(b) Notice that an applicant or the applicant's dependents 360
will not be denied coverage during open enrollment because of a 361
preexisting health condition, but that some limitations and 362
restrictions may apply;
(c) The address where a person may obtain an application; 364
(d) The telephone number that a person may call to request 366
an application or to ask questions; 368
(e) The date the first payment will be due; 370
(f) The actual rates or range of rates that will be 372
applicable for applicants; 373
(g) Any limitation granted by the superintendent on the 376
number of applications that will be accepted by the health 377
insuring corporation.
(4) Within thirty days after the end of an open enrollment 380
period, the health insuring corporation shall submit to the 381
superintendent proof of publication for the public notices, and 382
shall report the total number of applicants and their dependents 383
enrolled during the open enrollment period. 384
(I)(1) No health insuring corporation may employ any 386
scheme, plan, or device that restricts the ability of any person 387
to enroll during open enrollment. 388
(2) No health insuring corporation may require enrollment 390
to be made in person. Every health insuring corporation shall 391
permit application for coverage by mail. A representative of the 393
health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 394
operations of the health insuring corporation and to answer any 395
questions the applicant may have. Every health insuring 396
corporation shall make open enrollment applications and 397
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solicitation documents readily available to any potential 398
applicant who requests such material. 399
(J) An application postmarked on the last day of an open 401
enrollment period shall qualify as a valid application, 402
regardless of the date on which it is received by the health 403
insuring corporation.
(K) This section does not apply to any health insuring 405
corporation that offers only supplemental health care services or 407
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 408
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 409
U.S.C.A. 301, as amended, and that has no other commercial 410
enrollment, or to any health insuring corporation that offers 411
plans only through other federal health care programs regulated 412
by federal regulatory bodies and that has no other commercial 413
enrollment.
(L) EACH HEALTH INSURING CORPORATION SHALL ACCEPT 416
FEDERALLY ELIGIBLE INDIVIDUALS FOR OPEN ENROLLMENT COVERAGE AS 417
PROVIDED IN SECTION 3923.581 OF THE REVISED CODE. A HEALTH 419
INSURING CORPORATION MAY REINSURE COVERAGE OF ANY FEDERALLY 420
ELIGIBLE INDIVIDUAL ACQUIRED UNDER THAT SECTION WITH THE OPEN 421
ENROLLMENT REINSURANCE PROGRAM IN ACCORDANCE WITH DIVISION (G) OF 423
SECTION 3924.11 OF THE REVISED CODE. FIXED PERIODIC PREPAYMENT 426
RATES CHARGED FOR COVERAGE REINSURED BY THE PROGRAM SHALL BE 427
ESTABLISHED IN ACCORDANCE WITH SECTION 3924.12 OF THE REVISED 429
CODE.
(M) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 432
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 434
148.103. 435
Sec. 1751.16. (A) Except as provided in division (F) of 444
this section, every group contract issued by a health insuring 445
corporation shall provide an option for conversion to an 446
individual contract issued on a direct-payment basis to any 447
subscriber covered by the group contract who terminates 448
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employment or membership in the group, unless: 449
(1) Termination of the conversion option or contract is 451
based upon nonpayment of premium after reasonable notice in 452
writing has been given by the health insuring corporation to the 453
subscriber. 454
(2) The subscriber is, or is eligible to be, covered for 456
benefits at least comparable to the group contract under any of 457
the following: 458
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 460
(1935), 42 U.S.C.A. 301, as amended; 461
(b) Any act of congress or law under this or any other 463
state of the United States providing coverage at least comparable 464
to the benefits under division (A)(2)(a) of this section; 465
(c) Any policy of insurance or health care plan providing 467
coverage at least comparable to the benefits under division 468
(A)(2)(a) of this section. 469
(B)(1) The direct-payment contract offered by the health 471
insuring corporation pursuant to division (A) of this section 473
shall provide benefits comparable to the benefits being provided 474
by any of the individual contracts then being issued to 475
individual subscribers by the health insuring corporation. The 476
contract may contain a coordination of benefits provision as 477
approved by the superintendent of insurance THE FOLLOWING: 479
(a) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 482
ELIGIBLE INDIVIDUAL, BENEFITS COMPARABLE TO BENEFITS IN ANY OF 483
THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO INDIVIDUAL 484
SUBSCRIBERS BY THE HEALTH INSURING CORPORATION; 485
(b) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 488
BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 489
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 490
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 491
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (B)(1)(b) OF 493
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 494
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 495
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PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. THE 496
CONTRACTUAL PERIODIC PREPAYMENTS CHARGED FOR SUCH PLANS MAY NOT 497
EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE STANDARD 498
RATE CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH THE 499
ORGANIZATION IS CURRENTLY ACCEPTING NEW BUSINESS AND FOR WHICH 500
SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 501
(2) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 503
DIVISION (A) OF THIS SECTION MAY INCLUDE A COORDINATION OF 505
BENEFITS PROVISION AS APPROVED BY THE SUPERINTENDENT. 506
(3) FOR PURPOSES OF DIVISION (B) OF THIS SECTION 509
"FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS 510
DEFINED IN 45 C.F.R. 148.103. 513
(C) The option for conversion shall be available: 515
(1) Upon the death of the subscriber, to the surviving 517
spouse with respect to SUCH OF the spouse or AND dependents who 519
were AS ARE then covered by the group contract; 520
(2) To a child solely with respect to the child upon the 522
child's attaining the limiting age of coverage under the group 523
contract while covered as a dependent under the contract; 524
(3) Upon the divorce, dissolution, or annulment of the 526
marriage of the subscriber, to the divorced spouse, or, in the 527
event of annulment, to the former spouse of the subscriber. 529
(D) No health insuring corporation shall do any of the 531
following:
(1) Use USE age as the basis for refusing to renew a 533
converted contract; 534
(2) Require a subscriber to produce evidence of 536
insurability in order to exercise the option for conversion 537
provided by this section; 538
(3) Include preexisting condition limitations in a 540
converted contract. 541
(E) Written notice of the conversion option provided by 544
this section shall be given to the subscriber by the health 545
insuring corporation by mail. The notice shall be sent to the 546
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subscriber's address in the records of the employer upon receipt 547
of notice from the employer of the event giving rise to the 548
conversion option. If the subscriber has not received notice of 549
the conversion privilege at least fifteen days prior to the 550
expiration of the thirty-day conversion period, then the 551
subscriber shall have an additional period within which to 552
exercise the privilege. This additional period shall expire 553
fifteen days after the subscriber receives notice, but in no 554
event shall the period extend beyond sixty days after the 555
expiration of the thirty-day conversion period. 556
(F) This section does not apply to any group contract 558
offering only supplemental health care services or specialty 559
health care services.
Sec. 1751.18. (A)(1) No health insuring corporation shall 568
cancel or fail to renew the coverage of a subscriber or enrollee 569
because of the subscriber's or enrollee's ANY health status or 571
requirement STATUS-RELATED FACTOR IN RELATION TO THE SUBSCRIBER 572
OR ENROLLEE, THE SUBSCRIBER'S OR ENROLLEE'S REQUIREMENTS for 574
health care services, or for any other reason designated under 575
rules adopted by the superintendent of insurance. 576
(2) Unless otherwise required by state or federal law, no 578
health insuring corporation, or health care facility or provider 579
through which the health insuring corporation has made 580
arrangements to provide health care services, shall discriminate 581
against any individual with regard to enrollment, disenrollment, 582
or the quality of health care services rendered, on the basis of 583
the individual's race, color, sex, age, religion, state of 584
health, or status as a recipient of medicare or medical 585
assistance under Title XVIII or XIX of the "Social Security Act," 586
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, OR ANY HEALTH 588
STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL. However, a 589
health insuring corporation shall not be required to accept a 591
recipient of medicare or medical assistance, if an agreement has 592
not been reached on appropriate payment mechanisms between the 593
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health insuring corporation and the governmental agency 594
administering these programs. Further, except during a period of 595
open enrollment under section 1751.15 of the Revised Code, a 596
health insuring corporation may reject an applicant for nongroup 597
enrollment on the basis of the state of ANY health of 598
STATUS-RELATED FACTOR IN RELATION TO the applicant. 600
(B) A health insuring corporation may cancel or decide not 603
to renew the coverage of a subscriber or AN enrollee for any of 604
the following reasons:
(1) Failure of the subscriber or enrollee to pay, or to 606
have paid on the subscriber's or enrollee's behalf, the required 607
premium rate or other charge; 608
(2) Fraud or forgery; 610
(3) Any material misrepresentation on the application for 612
coverage; 613
(4) The subscriber's or enrollee's permitting the use of 615
an identification card or similar documents by another person, 616
allowing that person to receive services for which that person is 618
not entitled;
(5) The subscriber's or enrollee's inability to establish 620
or maintain a provider-patient relationship with any provider 621
associated with the health insuring corporation, which inability 622
may include the subscriber's or enrollee's disruptive or abusive 623
behavior toward providers or the staff of the health care plan IF 625
THE ENROLLEE HAS PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES 626
FRAUD OR INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE 628
TERMS OF THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS
NOT BASED, EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH 629
STATUS-RELATED FACTOR IN RELATION TO THE ENROLLEE. 630
(C) A subscriber or AN enrollee may appeal any action or 632
decision of the A health insuring corporation under division (B) 636
of this section TAKEN PURSUANT TO SECTION 2742(b) TO (e) OF THE 639
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 640
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 642
15
AMENDED. To appeal, the subscriber or enrollee may submit a 645
written complaint to the health insuring corporation pursuant to 646
section 1751.19 of the Revised Code. The subscriber or enrollee 647
may, within thirty days after receiving a written response from 648
the health insuring corporation, appeal the health insuring 649
corporation's action or decision to the superintendent. 650
(D) AS USED IN THIS SECTION, "HEALTH STATUS-RELATED 652
FACTOR" MEANS ANY OF THE FOLLOWING: 653
(1) HEALTH STATUS; 655
(2) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 658
ILLNESSES;
(3) CLAIMS EXPERIENCE; 660
(4) RECEIPT OF HEALTH CARE; 662
(5) MEDICAL HISTORY; 664
(6) GENETIC INFORMATION; 666
(7) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 669
OUT OF ACTS OF DOMESTIC VIOLENCE;
(8) DISABILITY. 671
Sec. 1751.57. (A) THE FOLLOWING CONDITIONS APPLY TO ALL 673
INDIVIDUAL HEALTH INSURING CORPORATION CONTRACTS: 674
(1) EXCEPT AS PROVIDED IN SECTION 2742(b) TO (e) OF THE 678
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 683
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 688
AMENDED, A HEALTH INSURING CORPORATION THAT PROVIDES INDIVIDUAL 689
COVERAGE TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN FORCE SUCH 690
COVERAGE AT THE OPTION OF THE INDIVIDUAL. 691
(2) SUCH INDIVIDUAL CONTRACTS ARE SUBJECT TO SECTIONS 2743 693
AND 2747 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 697
ACT OF 1996." 698
(3) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 702
SHALL APPLY TO HEALTH INSURING CORPORATION CONTRACTS OFFERED IN 703
THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO HEALTH 704
BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 705
(B) IN ACCORDANCE WITH 45 C.F.R. 148.102, THIS SECTION 710
16
ALSO APPLIES TO ALL GROUP HEALTH INSURING CORPORATION CONTRACTS 711
THAT ARE NOT SOLD IN CONNECTION WITH AN EMPLOYMENT-RELATED GROUP 712
HEALTH CARE PLAN AND THAT PROVIDE MORE THAN SHORT-TERM, LIMITED 713
DURATION COVERAGE.
Sec. 1751.58. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2721 716
OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 720
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-21, 726
AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP HEALTH 727
INSURING CORPORATION CONTRACTS THAT ARE SOLD IN CONNECTION WITH 728
AN EMPLOYMENT-RELATED GROUP HEALTH CARE PLAN AND THAT ARE NOT 729
SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 731
(A) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 735
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 739
A HEALTH INSURING CORPORATION OFFERS COVERAGE IN THE SMALL OR 740
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE 741
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT 742
THE OPTION OF THE CONTRACT HOLDER. 743
(B) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISION (E)(1) OF 746
SECTION 3924.03 AND SECTIONS 3924.033 AND 3924.27 OF THE REVISED 747
CODE. 748
(C) SUCH GROUP CONTRACTS SHALL PROVIDE FOR THE SPECIAL 751
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 754
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 757
Sec. 1751.59. (A) No individual or group health insuring 766
corporation policy, contract, or agreement providing THAT MAKES 767
family coverage AVAILABLE may be delivered, issued for delivery, 769
or renewed in this state, unless the policy, contract, or
agreement covers adopted children of the subscriber on the same 770
basis as other dependents. 771
(B) The coverage required by this section is subject to 773
the requirements and restrictions set forth in section 3924.51 of 774
the Revised Code. Coverage for dependent children living outside 776
the health insuring corporation's approved service area must be 777
provided if a court order requires the subscriber to provide 778
17
health care coverage.
Sec. 1751.61. (A) Each individual or group evidence of 788
coverage that is delivered, issued for delivery, or renewed by a 789
health insuring corporation in this state, and that provides 790
MAKES coverage AVAILABLE for family members of a subscriber, also 792
shall provide that coverage applicable to children is payable 793
from the moment of birth with respect to a newly born child of 794
the subscriber or subscriber's spouse. 795
(B) Coverage for a newly born child is effective for a 797
period of thirty-one days from the date of birth. 798
(C) To continue coverage for a newly born child beyond the 800
thirty-one day period described in division (B) of this section, 801
the subscriber shall notify the health insuring corporation 802
within that period.
(D) If payment of a specific premium rate is required to 804
provide coverage under this section for an additional child, the 805
evidence of coverage may require the subscriber to make this 806
payment to the health insuring corporation within the thirty-one 807
day period described in division (B) of this section in order to 808
continue the coverage beyond that period. 809
Sec. 1751.64. (A) As used in this section, "genetic 819
screening or testing" means a laboratory test of a person's genes 820
or chromosomes for abnormalities, defects, or deficiencies, 821
including carrier status, that are linked to physical or mental 822
disorders or impairments, or that indicate a susceptibility to 823
illness, disease, or other disorders, whether physical or mental, 824
which test is a direct test for abnormalities, defects, or 825
deficiencies, and not an indirect manifestation of genetic 826
disorders.
(B) No health insuring corporation, in processing an 829
application for coverage for health care services under an 830
individual or group health insuring corporation policy, contract, 831
or agreement or in determining insurability under such a policy, 832
contract, or agreement, shall do any of the following: 833
18
(1) Require an individual seeking coverage to submit to 835
genetic screening or testing; 836
(2) Take into consideration, other than in accordance with 839
division (F) of this section, the results of genetic screening or 840
testing;
(3) Make any inquiry to determine the results of genetic 842
screening or testing; 843
(4) Make a decision adverse to the applicant based on 845
entries in medical records or other reports of genetic screening 846
or testing. 847
(C) In developing and asking questions regarding medical 850
histories of applicants for coverage under an individual or group 851
health insuring corporation policy, contract, or agreement, no 852
health insuring corporation shall ask for the results of genetic 853
screening or testing or ask questions designed to ascertain the 854
results of genetic screening or testing. 855
(D) No health insuring corporation shall cancel or refuse 858
to issue or renew coverage for health care services based on the 859
results of genetic screening or testing. 860
(E) No health insuring corporation shall deliver, issue 863
for delivery, or renew an individual or group policy, contract, 864
or agreement in this state that limits benefits based on the 865
results of genetic screening or testing. 866
(F) A health insuring corporation may consider the results 869
of genetic screening or testing if the results are voluntarily 870
submitted by an applicant for coverage or renewal of coverage and 871
the results are favorable to the applicant. 872
(G) A violation of this section is an unfair and deceptive 875
act or practice in the business of insurance under sections 876
3901.19 to 3901.26 of the Revised Code. 878
Sec. 1751.65. (A) As used in this section, "genetic 888
screening or testing" means a laboratory test of a person's genes 889
or chromosomes for abnormalities, defects, or deficiencies, 890
including carrier status, that are linked to physical or mental 891
19
disorders or impairments, or that indicate a susceptibility to 892
illness, disease, or other disorders, whether physical or mental, 893
which test is a direct test for abnormalities, defects, or 894
deficiencies, and not an indirect manifestation of genetic 895
disorders. 896
(B) Upon the repeal of section 1751.64 of the Revised 899
Code, no health insuring corporation shall do either of the 901
following:
(1) Consider, in a manner adverse to an applicant or 903
insured, any information obtained from genetic screening or 904
testing conducted prior to the repeal of section 1751.64 of the 905
Revised Code in processing an application for coverage for health 908
care services under an individual or group policy, contract, or 909
agreement or in determining insurability under such a policy, 910
contract, or agreement; 911
(2) Inquire, directly or indirectly, into the results of 913
genetic screening or testing conducted prior to the repeal of 914
section 1751.64 of the Revised Code, or use such information, in 917
whole or in part, to cancel, refuse to issue or renew, or limit 918
benefits under, an individual or group policy, contract, or 919
agreement.
(C) Any health insuring corporation that has engaged in, 922
is engaged in, or is about to engage in a violation of division 923
(B) of this section is subject to the jurisdiction of the 925
superintendent of insurance under section 3901.04 of the Revised 926
Code.
Sec. 1751.67. (A) Each individual or group health 935
insuring corporation policy, contract, or agreement delivered, 936
issued for delivery, or renewed in this state that provides 937
maternity benefits shall provide coverage of inpatient care and 938
follow-up care for a mother and her newborn as follows: 939
(1) The policy, contract, or agreement shall cover a 941
minimum of forty-eight hours of inpatient care following a normal 943
vaginal delivery and a minimum of ninety-six hours of inpatient 944
20
care following a cesarean delivery. Services covered as 945
inpatient care shall include medical, educational, and any other 946
services that are consistent with the inpatient care recommended 947
in the protocols and guidelines developed by national 948
organizations that represent pediatric, obstetric, and nursing 949
professionals.
(2) The policy, contract, or agreement shall cover a 951
physician-directed source of follow-up care. Services covered as 953
follow-up care shall include physical assessment of the mother 954
and newborn, parent education, assistance and training in breast 955
or bottle feeding, assessment of the home support system,
performance of any medically necessary and appropriate clinical 956
tests, and any other services that are consistent with the 957
follow-up care recommended in the protocols and guidelines 958
developed by national organizations that represent pediatric, 959
obstetric, and nursing professionals. The coverage shall apply 960
to services provided in a medical setting or through home health 961
care visits. The coverage shall apply to a home health care 962
visit only if the provider who conducts the visit is 963
knowledgeable and experienced in maternity and newborn care. 964
When a decision is made in accordance with division (B) of 967
this section to discharge a mother or newborn prior to the
expiration of the applicable number of hours of inpatient care 968
required to be covered, the coverage of follow-up care shall 969
apply to all follow-up care that is provided within forty-eight 970
SEVENTY-TWO hours after discharge. When a mother or newborn 971
receives at least the number of hours of inpatient care required 973
to be covered, the coverage of follow-up care shall apply to 974
follow-up care that is determined to be medically necessary by 975
the provider responsible for discharging the mother or newborn. 976
(B) Any decision to shorten the length of inpatient stay 978
to less than that specified under division (A)(1) of this section 980
shall be made by the physician attending the mother or newborn, 981
except that if a nurse-midwife is attending the mother in 982
21
collaboration with a physician, the decision may be made by the 983
nurse-midwife. Decisions regarding early discharge shall be made 984
only after conferring with the mother or a person responsible for 985
the mother or newborn. For purposes of this division, a person 986
responsible for the mother or newborn may include a parent, 987
guardian, or any other person with authority to make medical 988
decisions for the mother or newborn.
(C)(1) No health insuring corporation may do either of the 990
following:
(a) Terminate the participation of a provider or health 992
care facility in an individual or group health care plan solely 993
for making recommendations for inpatient or follow-up care for a 994
particular mother or newborn that are consistent with the care 995
required to be covered by this section; 996
(b) Establish or offer monetary or other financial 998
incentives for the purpose of encouraging a person to decline the 1,000
inpatient or follow-up care required to be covered by this
section. 1,001
(2) Whoever violates division (C)(1)(a) or (b) of this 1,003
section has engaged in an unfair and deceptive act or practice in 1,004
the business of insurance under sections 3901.19 to 3901.26 of 1,005
the Revised Code.
(D) This section does not do any of the following: 1,007
(1) Require a policy, contract, or agreement to cover 1,009
inpatient or follow-up care that is not received in accordance 1,010
with the policy's, contract's, or agreement's terms pertaining to 1,011
the providers and facilities from which an individual is 1,012
authorized to receive health care services; 1,013
(2) Require a mother or newborn to stay in a hospital or 1,015
other inpatient setting for a fixed period of time following 1,016
delivery;
(3) Require a child to be delivered in a hospital or other 1,018
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 1,020
22
authority to practice nurse-midwifery in accordance with Chapter 1,021
4723. of the Revised Code; 1,022
(5) Establish minimum standards of medical diagnosis, 1,024
care, or treatment for inpatient or follow-up care for a mother 1,025
or newborn. A deviation from the care required to be covered 1,026
under this section shall not, solely on the basis of this 1,027
section, give rise to a medical claim or to derivative claims for 1,028
relief, as those terms are defined in section 2305.11 of the 1,029
Revised Code.
Sec. 3901.044. THE SUPERINTENDENT OF INSURANCE MAY ADOPT 1,032
RULES IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE THAT 1,035
THE SUPERINTENDENT CONSIDERS NECESSARY AND ADVISABLE FOR THE 1,036
PURPOSE OF IMPLEMENTING THE "HEALTH INSURANCE PORTABILITY AND 1,040
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 1,045
42 U.S.C.A. 300gg, AS AMENDED, AND ANY REGULATION ADOPTED 1,047
THEREUNDER. 1,048
Sec. 3901.21. The following are hereby defined as unfair 1,057
and deceptive acts or practices in the business of insurance: 1,058
(A) Making, issuing, circulating, or causing or permitting 1,060
to be made, issued, or circulated, or preparing with intent to so 1,061
use, any estimate, illustration, circular, or statement 1,062
misrepresenting the terms of any policy issued or to be issued or 1,063
the benefits or advantages promised thereby or the dividends or 1,064
share of the surplus to be received thereon, or making any false 1,065
or misleading statements as to the dividends or share of surplus 1,066
previously paid on similar policies, or making any misleading 1,067
representation or any misrepresentation as to the financial 1,068
condition of any insurer as shown by the last preceding verified 1,069
statement made by it to the insurance department of this state, 1,070
or as to the legal reserve system upon which any life insurer 1,071
operates, or using any name or title of any policy or class of 1,072
policies misrepresenting the true nature thereof, or making any 1,073
misrepresentation or incomplete comparison to any person for the 1,074
purpose of inducing or tending to induce such person to purchase, 1,075
23
amend, lapse, forfeit, change, or surrender insurance. 1,076
Any written statement concerning the premiums for a policy 1,078
which refers to the net cost after credit for an assumed 1,079
dividend, without an accurate written statement of the gross 1,080
premiums, cash values, and dividends based on the insurer's 1,081
current dividend scale, which are used to compute the net cost 1,082
for such policy, and a prominent warning that the rate of 1,083
dividend is not guaranteed, is a misrepresentation for the 1,084
purposes of this division. 1,085
(B) Making, publishing, disseminating, circulating, or 1,087
placing before the public or causing, directly or indirectly, to 1,088
be made, published, disseminated, circulated, or placed before 1,089
the public, in a newspaper, magazine, or other publication, or in 1,090
the form of a notice, circular, pamphlet, letter, or poster, or 1,091
over any radio station, or in any other way, or preparing with 1,092
intent to so use, an advertisement, announcement, or statement 1,093
containing any assertion, representation, or statement, with 1,094
respect to the business of insurance or with respect to any 1,095
person in the conduct of his THE PERSON'S insurance business, 1,096
which is untrue, deceptive, or misleading. 1,097
(C) Making, publishing, disseminating, or circulating, 1,099
directly or indirectly, or aiding, abetting, or encouraging the 1,100
making, publishing, disseminating, or circulating, or preparing 1,101
with intent to so use, any statement, pamphlet, circular, 1,102
article, or literature, which is false as to the financial 1,103
condition of an insurer and which is calculated to injure any 1,104
person engaged in the business of insurance. 1,105
(D) Filing with any supervisory or other public official, 1,107
or making, publishing, disseminating, circulating, or delivering 1,108
to any person, or placing before the public, or causing directly 1,109
or indirectly to be made, published, disseminated, circulated, 1,110
delivered to any person, or placed before the public, any false 1,111
statement of financial condition of an insurer. 1,112
Making any false entry in any book, report, or statement of 1,114
24
any insurer with intent to deceive any agent or examiner lawfully 1,115
appointed to examine into its condition or into any of its 1,116
affairs, or any public official to whom such insurer is required 1,117
by law to report, or who has authority by law to examine into its 1,118
condition or into any of its affairs, or, with like intent, 1,119
willfully omitting to make a true entry of any material fact 1,120
pertaining to the business of such insurer in any book, report, 1,121
or statement of such insurer, or mutilating, destroying, 1,122
suppressing, withholding, or concealing any of its records. 1,123
(E) Issuing or delivering or permitting agents, officers, 1,125
or employees to issue or deliver agency company stock or other 1,126
capital stock or benefit certificates or shares in any common-law 1,127
corporation or securities or any special or advisory board 1,128
contracts or other contracts of any kind promising returns and 1,129
profits as an inducement to insurance. 1,130
(F) Making or permitting any unfair discrimination among 1,132
individuals of the same class and equal expectation of life in 1,133
the rates charged for any contract of life insurance or of life 1,134
annuity or in the dividends or other benefits payable thereon, or 1,135
in any other of the terms and conditions of such contract. 1,136
(G)(1) Except as otherwise expressly provided by law, 1,138
knowingly permitting or offering to make or making any contract 1,139
of life insurance, life annuity or accident and health insurance, 1,140
or agreement as to such contract other than as plainly expressed 1,141
in the contract issued thereon, or paying or allowing, or giving 1,142
or offering to pay, allow, or give, directly or indirectly, as 1,143
inducement to such insurance, or annuity, any rebate of premiums 1,144
payable on the contract, or any special favor or advantage in the 1,145
dividends or other benefits thereon, or any valuable 1,146
consideration or inducement whatever not specified in the 1,147
contract; or giving, or selling, or purchasing, or offering to 1,148
give, sell, or purchase, as inducement to such insurance or 1,149
annuity or in connection therewith, any stocks, bonds, or other 1,150
securities, or other obligations of any insurance company or 1,151
25
other corporation, association, or partnership, or any dividends 1,152
or profits accrued thereon, or anything of value whatsoever not 1,153
specified in the contract. 1,154
(2) Nothing in division (F) or division (G)(1) of this 1,156
section shall be construed as prohibiting any of the following 1,157
practices: (a) in the case of any contract of life insurance or 1,158
life annuity, paying bonuses to policyholders or otherwise 1,159
abating their premiums in whole or in part out of surplus 1,160
accumulated from nonparticipating insurance, provided that any 1,161
such bonuses or abatement of premiums shall be fair and equitable 1,162
to policyholders and for the best interests of the company and 1,163
its policyholders; (b) in the case of life insurance policies 1,164
issued on the industrial debit plan, making allowance to 1,165
policyholders who have continuously for a specified period made 1,166
premium payments directly to an office of the insurer in an 1,167
amount which fairly represents the saving in collection expenses; 1,168
(c) readjustment of the rate of premium for a group insurance 1,169
policy based on the loss or expense experience thereunder, at the 1,170
end of the first or any subsequent policy year of insurance 1,171
thereunder, which may be made retroactive only for such policy 1,172
year. 1,173
(H) Making, issuing, circulating, or causing or permitting 1,175
to be made, issued, or circulated, or preparing with intent to so 1,176
use, any statement to the effect that a policy of life insurance 1,177
is, is the equivalent of, or represents shares of capital stock 1,178
or any rights or options to subscribe for or otherwise acquire 1,179
any such shares in the life insurance company issuing that policy 1,180
or any other company. 1,181
(I) Making, issuing, circulating, or causing or permitting 1,183
to be made, issued or circulated, or preparing with intent to so 1,184
issue, any statement to the effect that payments to a 1,185
policyholder of the principal amounts of a pure endowment are 1,186
other than payments of a specific benefit for which specific 1,187
premiums have been paid. 1,188
26
(J) Making, issuing, circulating, or causing or permitting 1,190
to be made, issued, or circulated, or preparing with intent to so 1,191
use, any statement to the effect that any insurance company was 1,192
required to change a policy form or related material to comply 1,193
with Title XXXIX of the Revised Code or any regulation of the 1,194
superintendent of insurance, for the purpose of inducing or 1,195
intending to induce any policyholder or prospective policyholder 1,196
to purchase, amend, lapse, forfeit, change, or surrender 1,197
insurance. 1,198
(K) Aiding or abetting another to violate this section. 1,200
(L) Refusing to issue any policy of insurance, or 1,202
canceling or declining to renew such policy because of the sex or 1,203
marital status of the applicant, prospective insured, insured, or 1,204
policyholder. 1,205
(M) Making or permitting any unfair discrimination between 1,207
individuals of the same class and of essentially the same hazard 1,208
in the amount of premium, policy fees, or rates charged for any 1,209
policy or contract of insurance, other than life insurance, or in 1,210
the benefits payable thereunder, or in underwriting standards and 1,211
practices or eligibility requirements, or in any of the terms or 1,212
conditions of such contract, or in any other manner whatever. 1,213
(N) Refusing to make available disability income insurance 1,215
solely because the applicant's principal occupation is that of 1,216
managing a household. 1,217
(O) Refusing, when offering maternity benefits under any 1,219
individual or group sickness and accident insurance policy, to 1,220
make maternity benefits available to the policyholder for the 1,221
individual or individuals to be covered under any comparable 1,222
policy to be issued for delivery in this state, including family 1,223
members if the policy otherwise provides coverage for family 1,224
members. Nothing in this division shall be construed to prohibit 1,225
an insurer from imposing a reasonable waiting period for such 1,226
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE 1,227
POLICY, but in no event shall such waiting period exceed two 1,228
27
hundred seventy days. 1,229
(P) Using, or permitting to be used, a pattern settlement 1,231
as the basis of any offer of settlement. As used in this 1,232
division, "pattern settlement" means a method by which liability 1,233
is routinely imputed to a claimant without an investigation of 1,234
the particular occurrence upon which the claim is based and by 1,235
using a predetermined formula for the assignment of liability 1,236
arising out of occurrences of a similar nature. Nothing in this 1,237
division shall be construed to prohibit an insurer from 1,238
determining a claimant's liability by applying formulas or 1,239
guidelines to the facts and circumstances disclosed by the 1,240
insurer's investigation of the particular occurrence upon which a 1,241
claim is based. 1,242
(Q) Refusing to insure, or refusing to continue to insure, 1,244
or limiting the amount, extent, or kind of life or sickness and 1,245
accident insurance or annuity coverage available to an 1,246
individual, or charging an individual a different rate for the 1,247
same coverage solely because of blindness or partial blindness. 1,248
With respect to all other conditions, including the underlying 1,249
cause of blindness or partial blindness, persons who are blind or 1,250
partially blind shall be subject to the same standards of sound 1,251
actuarial principles or actual or reasonably anticipated 1,252
actuarial experience as are sighted persons. Refusal to insure 1,253
includes, but is not limited to, denial by an insurer of 1,254
disability insurance coverage on the grounds that the policy 1,255
defines "disability" as being presumed in the event that the 1,256
eyesight of the insured is lost. However, an insurer may exclude 1,257
from coverage disabilities consisting solely of blindness or 1,258
partial blindness when such conditions existed at the time the 1,259
policy was issued. To the extent that the provisions of this 1,260
division may appear to conflict with any provision of section 1,261
3999.16 of the Revised Code, this division applies. 1,262
(R)(1) Directly or indirectly offering to sell, selling, 1,264
or delivering, issuing for delivery, renewing, or using or 1,265
28
otherwise marketing any policy of insurance or insurance product 1,266
in connection with or in any way related to the grant of a 1,267
student loan guaranteed in whole or in part by an agency or 1,268
commission of this state or the United States, except insurance 1,269
that is required under federal or state law as a condition for 1,270
obtaining such a loan and the premium for which is included in 1,271
the fees and charges applicable to the loan; or, in the case of 1,272
an insurer or insurance agent, knowingly permitting any lender 1,273
making such loans to engage in such acts or practices in 1,274
connection with the insurer's or agent's insurance business. 1,275
(2) Except in the case of a violation of division (G) of 1,277
this section, division (R)(1) of this section does not apply to 1,278
either of the following: 1,279
(a) Acts or practices of an insurer, its agents, 1,281
representatives, or employees in connection with the grant of a 1,282
guaranteed student loan to its insured or the insured's spouse or 1,283
dependent children where such acts or practices take place more 1,284
than ninety days after the effective date of the insurance; 1,285
(b) Acts or practices of an insurer, its agents, 1,287
representatives, or employees in connection with the 1,288
solicitation, processing, or issuance of an insurance policy or 1,289
product covering the student loan borrower or his THE BORROWER'S 1,290
spouse or dependent children, where such acts or practices take 1,291
place more than one hundred eighty days after the date on which 1,292
the borrower is notified that the student loan was approved. 1,293
(S) Denying coverage, under any health insurance or health 1,295
care policy, contract, or plan providing family coverage, to any 1,296
natural or adopted child of the named insured or subscriber 1,297
solely on the basis that the child does not reside in the 1,298
household of the named insured or subscriber. 1,299
(T)(1) Using any underwriting standard or engaging in any 1,301
other act or practice that, directly or indirectly, due solely to 1,302
the actual or expected ANY health condition of STATUS-RELATED 1,304
FACTOR IN RELATION TO one or more individuals, does either of the 1,305
29
following:
(a) Terminates or fails to renew an existing individual 1,307
policy, contract, or plan of health benefits, or a health benefit 1,308
plan issued to a small AN employer as those terms are defined in 1,309
section 3924.01 of the Revised Code, for which an individual 1,310
would otherwise be eligible;
(b) With respect to a health benefit plan issued to a 1,312
small AN employer, as those terms are defined in section 3924.01 1,313
of the Revised Code, excludes or causes the exclusion of an 1,315
individual from coverage under an existing employer-provided 1,316
policy, contract, or plan of health benefits, except that an 1,317
insurer may exclude, on the basis of health status, a late 1,318
enrollee as defined in section 3924.01 of the Revised Code. 1,319
(2) The superintendent of insurance may adopt rules in 1,321
accordance with Chapter 119. of the Revised Code for purposes of 1,322
implementing division (T)(1) of this section. 1,323
(3) FOR PURPOSES OF DIVISION (T)(1) OF THIS SECTION, 1,327
"HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING: 1,328
(a) HEALTH STATUS; 1,330
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,333
ILLNESSES;
(c) CLAIMS EXPERIENCE; 1,335
(d) RECEIPT OF HEALTH CARE; 1,337
(e) MEDICAL HISTORY; 1,339
(f) GENETIC INFORMATION; 1,341
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,344
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 1,346
(U) With respect to a health benefit plan issued to a 1,348
small employer, as those terms are defined in section 3924.01 of 1,349
the Revised Code, negligently or willfully placing coverage for 1,350
adverse risks with a certain carrier, as defined in section 1,351
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 1,353
30
or practice that, directly or indirectly, causes or results in 1,354
the placing of coverage for adverse risks with another carrier, 1,355
as defined in section 3924.01 of the Revised Code. 1,356
(W) Failing to comply with section 3923.23, 3923.231, 1,358
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 1,359
in any unfair, discriminatory reimbursement practice. 1,360
(X) Intentionally establishing an unfair premium for, or 1,362
misrepresenting the cost of, any insurance policy financed under 1,363
a premium finance agreement of an insurance premium finance 1,364
company. 1,365
With respect to private passenger automobile insurance, no 1,367
insurer shall charge different premium rates to persons residing 1,368
within the limits of any municipal corporation based solely on 1,369
the location of the residence of the insured within those limits. 1,370
The enumeration in sections 3901.19 to 3901.26 of the 1,372
Revised Code of specific unfair or deceptive acts or practices in 1,373
the business of insurance is not exclusive or restrictive or 1,374
intended to limit the powers of the superintendent of insurance 1,375
to adopt rules to implement this section, or to take action under 1,376
other sections of the Revised Code. 1,377
This section does not prohibit the sale of shares of any 1,379
investment company registered under the "Investment Company Act 1,380
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 1,381
policies, annuities, or other contracts described in section 1,382
3907.15 of the Revised Code. 1,383
As used in this section, "estimate," "statement," 1,385
"representation," "misrepresentation," "advertisement," or 1,386
"announcement" includes oral or written occurrences. 1,387
Sec. 3901.49. (A) As used in this section: 1,398
(1) "Genetic screening or testing" means a laboratory test 1,400
of a person's genes or chromosomes for abnormalities, defects, or 1,401
deficiencies, including carrier status, that are linked to 1,402
physical or mental disorders or impairments, or that indicate a 1,403
susceptibility to illness, disease, or other disorders, whether 1,404
31
physical or mental, which test is a direct test for 1,405
abnormalities, defects, or deficiencies, and not an indirect 1,406
manifestation of genetic disorders. 1,407
(2) "Insurer" means any person authorized under Title 1,409
XXXIX of the Revised Code to engage in the business of sickness 1,410
and accident insurance. 1,411
(3) "Sickness and accident insurance" means sickness and 1,413
accident insurance under Chapter 3923. of the Revised Code 1,414
excluding disability income insurance and excluding supplemental 1,415
policies of sickness and accident insurance. 1,416
(B) No insurer, in processing an application for an 1,418
individual or group policy of sickness and accident insurance or 1,419
in determining insurability under such a policy, shall do any of 1,420
the following: 1,421
(1) Require an individual seeking coverage to submit to 1,423
genetic screening or testing; 1,424
(2) Take into consideration, other than in accordance with 1,426
division (F) of this section, the results of genetic screening or 1,427
testing; 1,428
(3) Make any inquiry to determine the results of genetic 1,430
screening or testing; 1,431
(4) Make a decision adverse to the applicant based on 1,433
entries in medical records or other reports of genetic screening 1,434
or testing. 1,435
(C) In developing and asking questions regarding medical 1,437
histories of applicants for sickness and accident insurance, no 1,438
insurer shall ask for the results of genetic screening or testing 1,439
or ask questions designed to ascertain the results of genetic 1,440
screening or testing. 1,441
(D) No insurer shall cancel or refuse to issue or renew 1,443
coverage under a sickness and accident insurance policy based on 1,444
the results of genetic screening or testing. 1,445
(E) No insurer shall deliver, issue for delivery, or renew 1,447
an individual or group policy of sickness and accident insurance 1,448
32
in this state that limits benefits based on the results of 1,449
genetic screening or testing. 1,450
(F) An insurer may consider the results of genetic 1,452
screening or testing if the results are voluntarily submitted by 1,453
an applicant for coverage or renewal of coverage and the results 1,454
are favorable to the applicant. 1,455
(G) A violation of this section is an unfair and deceptive 1,457
act or practice in the business of insurance under sections 1,458
3901.19 to 3901.26 of the Revised Code. 1,459
Sec. 3901.491. (A) As used in this section: 1,468
(1) "Genetic screening or testing" means a laboratory test 1,470
of a person's genes or chromosomes for abnormalities, defects, or 1,471
deficiencies, including carrier status, that are linked to 1,472
physical or mental disorders or impairments, or that indicate a 1,473
susceptibility to illness, disease, or other disorders, whether 1,474
physical or mental, which test is a direct test for 1,475
abnormalities, defects, or deficiencies, and not an indirect 1,476
manifestation of genetic disorders. 1,477
(2) "Insurer" means any person authorized under Title 1,479
XXXIX of the Revised Code to engage in the business of sickness 1,480
and accident insurance. 1,481
(3) "Sickness and accident insurance" means sickness and 1,483
accident insurance under Chapter 3923. of the Revised Code 1,484
excluding disability income insurance and excluding supplemental 1,485
policies of sickness and accident insurance. 1,486
(B) Upon the repeal of section 3901.49 of the Revised Code 1,488
by Sub. H.B. No. 71 of the 120th general assembly, no insurer 1,489
shall do either of the following: 1,490
(1) Consider, in a manner adverse to an applicant or 1,492
insured, any information obtained from genetic screening or 1,493
testing conducted prior to the repeal of section 3901.49 of the 1,494
Revised Code in processing an application for an individual or 1,495
group policy of sickness and accident insurance, or in 1,496
determining insurability under such a policy; 1,497
33
(2) Inquire, directly or indirectly, into the results of 1,499
genetic screening or testing conducted prior to the repeal of 1,500
section 3901.49 of the Revised Code, or use such information, in 1,501
whole or in part, to cancel, refuse to issue or renew, or limit 1,502
benefits under, a sickness and accident insurance policy. 1,503
(C) Any insurer that has engaged in, is engaged in, or is 1,505
about to engage in a violation of division (B) of this section is 1,506
subject to the jurisdiction of the superintendent of insurance 1,507
under section 3901.04 of the Revised Code. 1,508
Sec. 3901.50. (A) As used in this section: 1,519
(1) "Genetic screening or testing" means a laboratory test 1,521
of a person's genes or chromosomes for abnormalities, defects, or 1,522
deficiencies, including carrier status, that are linked to 1,523
physical or mental disorders or impairments, or that indicate a 1,524
susceptibility to illness, disease, or other disorders, whether 1,525
physical or mental, which test is a direct test for 1,526
abnormalities, defects, or deficiencies, and not an indirect 1,527
manifestation of genetic disorders. 1,528
(2) "Self-insurer" means any government entity providing 1,530
coverage for health care services on a self-insurance basis. 1,531
(B) No self-insurer, in processing an application for 1,533
coverage under a plan of self-insurance or in determining 1,534
insurability under such a plan, shall do any of the following: 1,535
(1) Require an individual seeking coverage to submit to 1,537
genetic screening or testing; 1,538
(2) Take into consideration, other than in accordance with 1,540
division (F) of this section, the results of genetic screening or 1,541
testing; 1,542
(3) Make any inquiry to determine the results of genetic 1,544
screening or testing; 1,545
(4) Make a decision adverse to the applicant based on 1,547
entries in medical records or other reports of genetic screening 1,548
or testing. 1,549
(C) In developing and asking questions regarding medical 1,551
34
histories of applicants for coverage under a plan of 1,552
self-insurance, no self-insurer shall ask for the results of 1,553
genetic screening or testing or ask questions designed to 1,554
ascertain the results of genetic screening or testing. 1,555
(D) No self-insurer shall cancel or refuse to provide or 1,557
renew coverage for health care services based on the results of 1,558
genetic screening or testing. 1,559
(E) No self-insurer shall establish or modify a plan of 1,561
self-insurance in this state that limits benefits based on the 1,562
results of genetic screening or testing. 1,563
(F) A self-insurer may consider the results of genetic 1,565
screening or testing if the results are voluntarily submitted by 1,566
an applicant for coverage or renewal of coverage and the results 1,567
are favorable to the applicant. 1,568
(G) A violation of this section is an unfair and deceptive 1,570
act or practice in the business of insurance under sections 1,571
3901.19 to 3901.26 of the Revised Code. 1,572
Sec. 3901.501. (A) As used in this section: 1,581
(1) "Genetic screening or testing" means a laboratory test 1,583
of a person's genes or chromosomes for abnormalities, defects, or 1,584
deficiencies, including carrier status, that are linked to 1,585
physical or mental disorders or impairments, or that indicate a 1,586
susceptibility to illness, disease, or other disorders, whether 1,587
physical or mental, which test is a direct test for 1,588
abnormalities, defects, or deficiencies, and not an indirect 1,589
manifestation of genetic disorders. 1,590
(2) "Self-insurer" means any government entity providing 1,592
coverage for health care services on a self-insurance basis. 1,593
(B) Upon the repeal of section 3901.50 of the Revised Code 1,595
by Sub. H.B. No. 71 of the 120th general assembly, no 1,596
self-insurer shall do either of the following: 1,597
(1) Consider, in a manner adverse to an applicant or 1,599
insured, any information obtained from genetic screening or 1,600
testing conducted prior to the repeal of section 3901.50 of the 1,601
35
Revised Code in processing an application for coverage under a 1,602
plan of self-insurance or in determining insurability under such 1,603
a plan; 1,604
(2) Inquire, directly or indirectly, into the results of 1,606
genetic screening or testing conducted prior to the repeal of 1,607
section 3901.50 of the Revised Code, or use such information, in 1,608
whole or in part, to cancel, refuse to provide or renew, or limit 1,609
benefits under, a plan of self-insurance. 1,610
(C) Any self-insurer that has engaged in, is engaged in, 1,612
or is about to engage in a violation of division (B) of this 1,613
section is subject to the jurisdiction of the superintendent of 1,614
insurance under section 3901.04 of the Revised Code. 1,615
Sec. 3923.021. (A) As used in this section, "benefits 1,624
provided are not unreasonable in relation to the premium charged" 1,625
means the rates were calculated in accordance with sound 1,626
actuarial principles. 1,627
(B) With respect to any filing, made pursuant to section 1,629
3923.02 of the Revised Code, of any premium rates for any 1,630
individual policy of sickness and accident insurance or for any 1,631
indorsement or rider pertaining thereto, the superintendent of 1,632
insurance may, within thirty days after filing: 1,633
(1) Disapprove such filing if he finds AFTER FINDING that 1,635
the benefits provided are unreasonable in relation to the premium 1,637
charged. Such disapproval shall be effected by written order of 1,638
the superintendent, a copy of which shall be mailed to the 1,639
insurer that has made the filing. In the order, the 1,640
superintendent shall specify the reasons for his THE disapproval 1,641
and state that a hearing will be held within fifteen days after 1,643
requested in writing by the insurer. If a hearing is so 1,644
requested, the superintendent shall also give such public notice 1,645
as he THE SUPERINTENDENT considers appropriate. The 1,647
superintendent, within fifteen days after the commencement of any 1,648
hearing, shall issue a written order, a copy of which shall be 1,649
mailed to the insurer that has made the filing, either affirming 1,650
36
his THE prior disapproval or approving such filing if he finds 1,652
AFTER FINDING that the benefits provided are not unreasonable in 1,653
relation to the premium charged. 1,654
(2) Set a date for a public hearing to commence no later 1,656
than forty days after the filing. The superintendent shall give 1,657
the insurer making the filing twenty days' written notice of the 1,658
hearing and shall give such public notice as he THE 1,659
SUPERINTENDENT considers appropriate. The superintendent, within 1,661
twenty days after the commencement of a hearing, shall issue a 1,662
written order, a copy of which shall be mailed to the insurer 1,663
that has made the filing, either approving such filing if he THE 1,664
SUPERINTENDENT finds that the benefits provided are not 1,666
unreasonable in relation to the premium charged, or disapproving 1,667
such filing if he THE SUPERINTENDENT finds that the benefits 1,668
provided are unreasonable in relation to the premium charged. 1,669
This division does not apply to any insurer organized or 1,670
transacting the business of insurance under Chapter 3907. or 1,671
3909. of the Revised Code. 1,672
(3) Take no action, in which case such filing shall be 1,674
deemed to be approved and shall become effective upon the 1,675
thirty-first day after such filing, unless the superintendent has 1,676
previously given to the insurer his A written approval. 1,677
(C) At any time after any filing has been approved 1,679
pursuant to this section, the superintendent may, after a hearing 1,680
of which at least twenty days' written notice has been given to 1,681
the insurer that has made such filing and for which such public 1,682
notice as he THE SUPERINTENDENT considers appropriate has been 1,683
given, withdraw approval of such filing if he finds AFTER FINDING 1,685
that the benefits provided are unreasonable in relation to the 1,687
premium charged. Such withdrawal of approval shall be effected 1,688
by written order of the superintendent, a copy of which shall be 1,689
mailed to the insurer that has made the filing, which shall state 1,690
the ground for such withdrawal and the date, not less than forty 1,691
days after the date of such order, when the withdrawal or 1,692
37
approval shall become effective. 1,693
(D) The superintendent may retain at the insurer's expense 1,695
such attorneys, actuaries, accountants, and other experts not 1,696
otherwise a part of the superintendent's staff as shall be 1,697
reasonably necessary to assist in the preparation for and conduct 1,698
of any public hearing under this section. The expense for 1,699
retaining such experts and the expenses of the department of 1,700
insurance incurred in connection with such public hearing shall 1,701
be assessed against the insurer in an amount not to exceed one 1,702
one-hundredth of one per cent of the sum of premiums earned plus 1,703
net realized investment gain or loss of such insurer as reflected 1,704
in the most current annual statement on file with the 1,705
superintendent. Any person retained shall be under the direction 1,706
and control of the superintendent and shall act in a purely 1,707
advisory capacity. 1,708
(E) This section does not apply to any filing of any 1,710
premium rate or rating formula for individual sickness and 1,711
accident insurance policies offered in accordance with division 1,712
(M)(L) of section 3923.58 of the Revised Code, or for any 1,713
amendment thereto. 1,714
Sec. 3923.122. (A) Every policy of group sickness and 1,724
accident insurance providing hospital, surgical, or medical 1,725
expense coverage for other than specific diseases or accidents 1,726
only, and delivered, issued for delivery, or renewed in this 1,727
state on or after January 1, 1976, shall include a provision 1,728
giving each insured the option to convert to THE FOLLOWING: 1,729
(1) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 1,732
ELIGIBLE INDIVIDUAL, any of the individual policies of hospital, 1,733
surgical, or medical expense insurance then being issued by the 1,734
insurer with benefit limits not to exceed those in effect under 1,735
the group policy;
(2) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 1,737
BASIC OR STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 1,738
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 1,739
38
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 1,740
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (A)(2) OF 1,741
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 1,742
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 1,743
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 1,744
(B) An option for conversion to an individual policy shall 1,746
be available without evidence of insurability to every insured, 1,747
including any person eligible under division (D) of this section, 1,748
who terminates his employment or membership in the group holding 1,749
the policy after having been continuously insured thereunder for 1,750
at least one year. 1,751
Upon receipt of the insured's written application and upon 1,753
payment of at least the first quarterly premium not later than 1,754
thirty-one days after the termination of coverage under the group 1,755
policy, the insurer shall issue a converted policy on a form then 1,756
available for conversion. The premium shall be in accordance 1,757
with the insurer's table of premium rates in effect on the later 1,758
of the following dates: 1,759
(1) The effective date of the converted policy; 1,761
(2) The date of application therefor; and shall be 1,763
applicable to the class of risk to which each person covered 1,765
belongs and to the form and amount of the policy at his THE
PERSON'S then attained age. HOWEVER, PREMIUMS CHARGED FEDERALLY 1,767
ELIGIBLE INDIVIDUALS MAY NOT EXCEED AN AMOUNT THAT IS TWO TIMES 1,769
THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER INDIVIDUAL OF 1,770
A GROUP TO WHICH THE INSURER IS CURRENTLY ACCEPTING NEW BUSINESS 1,771
AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 1,772
At the election of the insurer, a separate converted policy 1,774
may be issued to cover any dependent of an employee or member of 1,775
the group. 1,776
Except as provided in division (H) of this section, any 1,778
converted policy shall become effective as of the day following 1,779
the date of termination of insurance under the group policy. 1,780
Any probationary or waiting period set forth in the 1,782
39
converted policy is deemed to commence on the effective date of 1,783
the insured's coverage under the group policy. 1,784
(C) No insurer shall be required to issue a converted 1,786
policy to any person who is, or is eligible to be, covered for 1,787
benefits at least comparable to the group policy under: 1,788
(1) Title XVIII of the Social Security Act, as amended or 1,790
superseded; 1,791
(2) Any act of congress or law under this or any other 1,793
state of the United States that duplicates coverage offered under 1,794
division (C)(1) of this section; 1,795
(3) Any policy that duplicates coverage offered under 1,797
division (C)(1) of this section; 1,798
(4) Any other group sickness and accident insurance 1,800
providing hospital, surgical, or medical expense coverage for 1,801
other than specific diseases or accidents only. 1,802
(D) The option for conversion shall be available: 1,804
(1) Upon the death of the employee or member, to the 1,806
surviving spouse with respect to such of the spouse and 1,807
dependents as are then covered by the group policy; 1,808
(2) To a child solely with respect to himself THE CHILD 1,810
upon his attaining the limiting age of coverage under the group 1,812
policy while covered as a dependent thereunder; 1,813
(3) Upon the divorce, dissolution, or annulment of the 1,815
marriage of the employee or member, to the divorced spouse, or 1,816
former spouse in the event of annulment, of such employee or 1,817
member, or upon the legal separation of the spouse from such 1,818
employee or member, to the spouse. 1,819
Persons possessing the option for conversion pursuant to 1,821
this division shall be considered members for the purposes of 1,822
division (H) of this section. 1,823
(E) If coverage is continued under a group policy on an 1,825
employee following his retirement prior to the time he THE 1,826
EMPLOYEE is, or is eligible to be, covered by Title XVIII of the 1,828
Social Security Act, he THE EMPLOYEE may elect, in lieu of the 1,829
40
continuance of group insurance, to have the same conversion 1,831
rights as would apply had his THE EMPLOYEE'S insurance terminated 1,833
at retirement by reason of termination of employment. 1,834
(F) If the insurer and the group policyholder agree upon 1,836
one or more additional plans of benefits to be available for 1,837
converted policies, the applicant for the converted policy may 1,838
elect such a plan in lieu of a converted policy. 1,839
(G) The converted policy may contain provisions for 1,841
avoiding duplication of benefits provided pursuant to divisions 1,842
(C)(1), (2), (3), and (4) of this section or provided under any 1,843
other insured or noninsured plan or program. 1,844
(H) If an employee or member becomes entitled to obtain a 1,846
converted policy pursuant to this section, and if the employee or 1,847
member has not received notice of the conversion privilege at 1,848
least fifteen days prior to the expiration of the thirty-one-day 1,849
conversion period provided in division (B) of this section, then 1,850
the employee or member has an additional period within which to 1,851
exercise the privilege. This additional period shall expire 1,852
fifteen days after the employee or member receives notice, but in 1,853
no event shall the period extend beyond sixty days after the 1,854
expiration of the thirty-one-day conversion period. 1,855
Written notice presented to the employee or member, or 1,857
mailed by the policyholder to the last known address of the 1,858
employee or member as indicated on its records, constitutes 1,859
notice for the purpose of this division. In the case of a person 1,860
who is eligible for a converted policy under division (D) (2) or 1,861
(D)(3) of this section, a policyholder shall not be responsible 1,862
for presenting or mailing such notice, unless such policyholder 1,863
has actual knowledge of the person's eligibility for a converted 1,864
policy. 1,865
If an additional period is allowed by an employee or member 1,867
for the exercise of a conversion privilege, and if written 1,868
application for the converted policy, accompanied by at least the 1,869
first quarterly premium, is made after the expiration of the 1,870
41
thirty-one-day conversion period, but within the additional 1,871
period allowed an employee or member in accordance with this 1,872
division, the effective date of the converted policy shall be the 1,873
date of application. 1,874
(I) The converted policy may provide: 1,876
(1) That any hospital, surgical, or medical expense 1,878
benefits otherwise payable with respect to any person may be 1,879
reduced by the amount of any such benefits payable under the 1,880
group policy for the same loss after termination of coverage; 1,881
(2) For termination of coverage on any person who is, or 1,883
is eligible to be, covered pursuant to division (C) of this 1,884
section; 1,885
(3) That the insurer may request information in advance of 1,887
any premium due date of the policy as to whether the insured is, 1,888
or is eligible to be, covered pursuant to division (C) of this 1,889
section. If the insured is, or is eligible to be, covered, and 1,890
he THE INSURED fails to furnish the details of his THE INSURED'S 1,892
coverage or eligibility to the insurer within thirty-one days 1,893
after the date of the request, the benefits payable under the 1,894
converted policy may be based on the hospital, surgical, or 1,895
medical expenses actually incurred after excluding expenses to 1,896
the extent of the amount of benefits for which the insured is, or 1,897
is eligible to be, covered pursuant to division (C) of this 1,898
section.
(J) The converted policy may contain: 1,900
(1) Any exclusion, reduction, or limitation contained in 1,902
the group policy or customarily used in individual policies 1,903
issued by the insurer; 1,904
(2) Any provision permitted in this section; 1,906
(3) Any other provision not prohibited by law. 1,908
Any provision required or permitted in this section may be 1,910
made a part of any converted policy by means of an endorsement or 1,911
rider. 1,912
(K) The time limit specified in a converted policy for 1,914
42
certain defenses with respect to any person who was covered by a 1,915
group policy shall commence on the effective date of such 1,916
person's coverage under the group policy. 1,917
(L) No insurer shall use deterioration of health as the 1,919
basis for refusing to renew a converted policy. 1,920
(M) No insurer shall use age as the basis for refusing to 1,922
renew a converted policy. 1,923
(N) A converted policy made available pursuant to this 1,925
section shall, if delivery of the policy is to be made in this 1,926
state, comply with this section. If delivery of a converted 1,927
policy is to be made in another state, it may be on a form 1,928
offered by the insurer in the jurisdiction where the delivery is 1,929
to be made and which provides benefits substantially in 1,930
compliance with those required in a policy delivered in this 1,931
state. 1,932
(O) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 1,935
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 1,937
148.103. 1,938
Sec. 3923.26. Every certificate furnished by an insurer in 1,947
connection with, or pursuant to any provision of, any group 1,948
POLICY OR CERTIFICATE OF sickness and accident insurance policy 1,949
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE 1,950
providing coverage on an expense-incurred basis, and every 1,952
individual POLICY OF sickness and accident insurance policy 1,954
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE which 1,955
provides coverage on an expense-incurred basis, either of which 1,956
provides MAKES coverage AVAILABLE for family members of the 1,959
insured, shall, as to such family members' coverage, also provide 1,960
that any sickness and accident insurance benefits applicable for 1,961
children shall be payable with respect to a newly born child of 1,962
the insured from the moment of birth.
The coverage for newly born children shall consist of 1,964
coverage of injury or sickness, including the necessary care and 1,965
treatment of medically diagnosed congenital defects and birth 1,966
43
abnormalities. 1,967
If payment of a specific premium is required to provide 1,969
coverage for an additional child, the certificate or policy may 1,970
require that notification of birth of a newly born child and 1,971
payment of the required premium must be furnished to the insurer 1,972
within thirty-one days after the date of birth in order to have 1,973
the coverage continue beyond such period. 1,974
The requirements of this section apply to all such 1,976
individual or group sickness and accident insurance policies 1,977
delivered or issued for delivery in this state on or after 1,978
January 1, 1975, and all such individual or group sickness and 1,979
accident insurance policies renewed in this state on or after 1,980
January 1, 1978. 1,981
Sec. 3923.40. No individual or group policy of sickness 1,990
and accident insurance providing THAT MAKES family coverage 1,991
AVAILABLE may be delivered, issued for delivery, or renewed in 1,993
this state on or after January 1, 1989, unless the policy covers
adopted children of the insured on the same basis as other 1,994
dependents.
The coverage required by this section is subject to the 1,996
requirements and restrictions set forth in section 3924.51 of the 1,997
Revised Code. 1,998
Sec. 3923.57. Notwithstanding any provision of this 2,007
chapter, every individual policy of sickness and accident 2,008
insurance that is delivered, issued for delivery, or renewed in 2,009
this state is subject to the following conditions, as applicable: 2,010
(A) Pre-existing conditions provisions shall not exclude 2,012
or limit coverage for a period beyond twelve months following the 2,013
policyholder's effective date of coverage and may only relate to 2,014
conditions during the six months immediately preceding the 2,015
effective date of coverage. 2,016
(B) In determining whether a pre-existing conditions 2,018
provision applies to a policyholder or dependent, each policy 2,019
shall credit the time the policyholder or dependent was covered 2,020
44
under a previous policy, contract, or plan if the previous 2,022
coverage was continuous to a date not more than thirty days prior 2,024
to the effective date of the new coverage, exclusive of any 2,025
applicable service waiting period under the policy. 2,026
(C) Any such policy shall be renewable with respect to the 2,028
policyholder, or dependents of the policyholder, at the option of 2,029
the policyholder, except for any of the following reasons: 2,030
(1) Nonpayment of the required premiums by the 2,032
policyholder; 2,033
(2) Fraud or misrepresentation of the policyholder; 2,035
(3) When the insurer ceases to do the business of 2,037
individual sickness and accident insurance in this state, 2,038
provided that all of the following conditions are met: 2,039
(a) Notice of the decision to cease doing the business of 2,041
individual sickness and accident insurance is provided to the 2,042
department of insurance and the policyholder. 2,043
(b) An individual policy shall not be canceled by the 2,045
insurer for ninety days after the date of the notice required 2,047
under division (C)(3)(a) of this section unless the business has 2,048
been sold to another insurer. 2,049
(c) An insurer that ceases to do the business of 2,051
individual sickness and accident insurance in this state shall 2,052
not resume such business in this state for a period of five years 2,053
from the date of the notice required under division (C)(3)(a) of 2,054
this section (1) EXCEPT AS OTHERWISE PROVIDED IN DIVISION (C) OF 2,056
THIS SECTION, AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND 2,057
ACCIDENT INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR 2,058
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 2,059
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF AN 2,062
INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE OF 2,063
THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR CONTRIBUTIONS 2,066
IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE INSURER HAS NOT 2,067
RECEIVED TIMELY PREMIUM PAYMENTS.
45
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE THAT 2,070
CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION OF 2,071
MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN THE 2,074
INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION (D) OF THIS SECTION 2,075
AND THE APPLICABLE LAWS OF THIS STATE. 2,076
(d) IF THE INSURER OFFERS COVERAGE IN THE MARKET THROUGH A 2,079
NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES, LIVES, OR WORKS 2,080
IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE INSURER IS 2,081
AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT SUCH COVERAGE 2,082
IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY HEALTH 2,083
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e) IF THE COVERAGE IS MADE AVAILABLE IN THE INDIVIDUAL 2,086
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS, THE 2,087
MEMBERSHIP OF THE INDIVIDUAL IN THE ASSOCIATION, ON THE BASIS OF 2,088
WHICH THE COVERAGE IS PROVIDED, CEASES; PROVIDED, HOWEVER, THAT 2,089
SUCH COVERAGE IS TERMINATED UNDER DIVISION (C)(2)(e) OF THIS 2,092
SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH STATUS-RELATED 2,093
FACTOR OF COVERED INDIVIDUALS.
(3) AN INSURER MAY CANCEL OR DECIDE NOT TO RENEW THE 2,095
COVERAGE OF A DEPENDENT OF AN INDIVIDUAL IF THE DEPENDENT HAS 2,096
PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES FRAUD OR MADE AN 2,097
INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS OF 2,098
THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT BASED, 2,099
EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH STATUS-RELATED 2,100
FACTOR IN RELATION TO THE DEPENDENT.
(D)(1) IF AN INSURER DECIDES TO DISCONTINUE OFFERING A 2,103
PARTICULAR TYPE OF HEALTH INSURANCE COVERAGE OFFERED IN THE 2,104
INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE MAY BE DISCONTINUED BY 2,105
THE INSURER IF THE INSURER DOES ALL OF THE FOLLOWING: 2,106
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED COVERAGE 2,109
OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT LEAST 2,110
NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF THE 2,111
COVERAGE;
46
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE OF THIS 2,114
TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER INDIVIDUAL 2,115
HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY THE INSURER 2,116
FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF 2,119
THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE UNDER DIVISION 2,121
(D)(1)(b) OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY 2,122
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF 2,123
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE. 2,124
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL 2,126
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS STATE, 2,128
HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE INSURER ONLY 2,129
IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE DEPARTMENT OF 2,132
INSURANCE AND TO EACH INDIVIDUAL OF THE DISCONTINUATION AT LEAST 2,133
ONE HUNDRED EIGHTY DAYS PRIOR TO THE DATE OF THE EXPIRATION OF 2,134
THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED FOR DELIVERY 2,137
IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND COVERAGE UNDER 2,138
THAT HEALTH INSURANCE IN THAT MARKET IS NOT RENEWED. 2,139
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION 2,142
(D)(2) OF THIS SECTION IN THE INDIVIDUAL MARKET, THE INSURER 2,143
SHALL NOT PROVIDE FOR THE ISSUANCE OF ANY HEALTH INSURANCE 2,144
COVERAGE IN THE MARKET AND THIS STATE DURING THE FIVE-YEAR PERIOD 2,145
BEGINNING ON THE DATE OF THE DISCONTINUATION OF THE LAST HEALTH 2,146
INSURANCE COVERAGE NOT SO RENEWED. 2,147
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 2,150
section, both of the following apply:
(1) The benefit structure of any such policy may be 2,153
changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new 2,154
individual insureds. 2,155
(2) Any such policy may be rescinded for fraud, material 2,157
misrepresentation, or concealment by an applicant, policyholder, 2,158
47
or dependent AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, 2,160
MODIFY THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO 2,161
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS 2,162
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM 2,163
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM. 2,164
(F) SUCH POLICIES ARE SUBJECT TO SECTIONS 2743 AND 2747 OF 2,167
THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 2,171
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-43 2,177
AND 300gg-47, AS AMENDED. 2,178
(G) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 2,182
SHALL APPLY TO SICKNESS AND ACCIDENT INSURANCE POLICIES OFFERED 2,183
IN THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO 2,184
HEALTH BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 2,185
IN ACCORDANCE WITH 45 C.F.R. 148.102, DIVISIONS (C) TO (G) 2,190
OF THIS SECTION ALSO APPLY TO ALL GROUP SICKNESS AND ACCIDENT 2,191
INSURANCE POLICIES THAT ARE NOT SOLD IN CONNECTION WITH AN 2,192
EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT PROVIDE MORE THAN 2,193
SHORT-TERM, LIMITED DURATION COVERAGE. 2,194
IN APPLYING DIVISIONS (C) TO (G) OF THIS SECTION WITH 2,198
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY AN 2,200
INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH ONE 2,201
OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER. 2,202
FOR PURPOSES OF THIS SECTION, ANY POLICY ISSUED PURSUANT TO 2,204
DIVISION (C) OF SECTION 3923.13 OF THE REVISED CODE IN CONNECTION 2,207
WITH A PUBLIC OR PRIVATE COLLEGE OR UNIVERSITY STUDENT HEALTH
INSURANCE PROGRAM IS CONSIDERED TO BE ISSUED TO A BONA FIDE 2,208
ASSOCIATION AND IS NOT SUBJECT TO DIVISIONS (C) TO (G) OF THIS 2,210
SECTION.
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS THE 2,213
SAME MEANING AS IN SECTION 3924.03 OF THE REVISED CODE, AND 2,215
"HEALTH STATUS-RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME 2,216
MEANINGS AS IN SECTION 3924.031 OF THE REVISED CODE. 2,218
This section does not apply to any policy that provides 2,220
48
coverage for specific diseases or accidents only, or to any 2,221
hospital indemnity, medicare supplement, long-term care, 2,222
disability income, one-time-limited-duration policy of no longer 2,223
than six months, or other policy that offers only supplemental 2,224
benefits. 2,225
Sec. 3923.571. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2,227
2721 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 2,232
OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 2,238
300gg-21, AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP 2,239
POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE SOLD IN
CONNECTION WITH AN EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT 2,240
ARE NOT SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 2,241
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF 2,243
DIVISION (A) OF SECTION 3924.03 AND SECTION 3924.033 OF THE 2,245
REVISED CODE.
(B)(1) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 2,249
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 2,253
AN INSURER OFFERS COVERAGE IN THE SMALL OR LARGE GROUP MARKET IN 2,254
CONNECTION WITH A GROUP POLICY, THE INSURER SHALL RENEW OR 2,255
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE 2,256
POLICYHOLDER.
(2) AN INSURER MAY CANCEL OR DECIDE NOT TO RENEW THE 2,258
COVERAGE OF AN EMPLOYEE OR OF A DEPENDENT OF AN EMPLOYEE IF THE 2,259
EMPLOYEE OR DEPENDENT, AS APPLICABLE, HAS PERFORMED AN ACT OR 2,260
PRACTICE THAT CONSTITUTES FRAUD OR MADE AN INTENTIONAL 2,261
MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS OF THE
COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT BASED, 2,262
EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH STATUS-RELATED 2,263
FACTOR IN RELATION TO THE EMPLOYEE OR DEPENDENT. 2,264
AS USED IN DIVISION (B)(2) OF THIS SECTION, "HEALTH 2,267
STATUS-RELATED FACTOR" HAS THE SAME MEANING AS IN SECTION
3924.031 OF THE REVISED CODE. 2,269
(C)(1) NO SUCH POLICY, OR INSURER OFFERING HEALTH 2,271
INSURANCE COVERAGE IN CONNECTION WITH SUCH A POLICY, SHALL 2,273
49
REQUIRE ANY INDIVIDUAL, AS A CONDITION OF COVERAGE OR CONTINUED 2,274
COVERAGE UNDER THE POLICY, TO PAY A PREMIUM OR CONTRIBUTION THAT 2,275
IS GREATER THAN THE PREMIUM OR CONTRIBUTION FOR A SIMILARLY 2,276
SITUATED INDIVIDUAL COVERED UNDER THE POLICY ON THE BASIS OF ANY 2,277
HEALTH STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO 2,278
AN INDIVIDUAL COVERED UNDER THE POLICY AS A DEPENDENT OF THE 2,279
INDIVIDUAL. 2,280
(2) NOTHING IN DIVISION (C)(1) OF THIS SECTION SHALL BE 2,283
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 2,284
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY, 2,285
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM 2,286
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE 2,287
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO 2,288
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION. 2,289
(D) SUCH POLICIES SHALL PROVIDE FOR THE SPECIAL ENROLLMENT 2,292
PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH INSURANCE 2,296
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 2,298
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 2,307
of the Revised Code: 2,308
(1) "Case characteristics," "eligible employee," "health 2,310
HEALTH benefit plan," "late enrollee," AND "MEWA," and 2,312
"pre-existing conditions provision" have the same meanings as in 2,313
section 3924.01 of the Revised Code. 2,314
(2) "Insurer" means any sickness and accident insurance 2,316
company authorized to issue health benefit plans DO BUSINESS in 2,317
this state, or MEWA authorized to issue insured health benefit 2,319
plans in this state. "Insurer" does not include any health 2,320
insuring corporation that is owned or operated by an insurer. 2,322
(3) "Small employer" means any person, firm, corporation, 2,324
or partnership actively engaged in business whose total employed 2,325
work force, on at least fifty per cent of its working days during 2,326
the preceding year, consisted of at least two unrelated eligible 2,327
employees but no more than twenty-five eligible employees, the 2,328
majority of whom were employed within this state. In determining 2,329
50
the number of eligible employees, companies that are affiliated 2,330
companies or that are eligible to file a combined tax return for 2,331
purposes of state taxation shall be considered one employer. In 2,332
determining whether the members of an association are small 2,333
employers, each member of the association shall be considered as 2,334
a separate person, firm, corporation, or partnership. 2,335
(4) "Small employer group" means any group consisting of 2,337
all of the eligible employees of a small employer, except those 2,338
employees who are covered, or are eligible for coverage, under 2,339
any other private or public health benefits arrangement, 2,340
including the medicare program established under Title XVIII of 2,341
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 2,342
as amended, or any other act of congress or law of this or any 2,343
other state of the United States that provides benefits 2,344
comparable to the benefits provided under this section 2,345
PRE-EXISTING CONDITIONS PROVISION" MEANS A POLICY PROVISION THAT 2,348
EXCLUDES OR LIMITS COVERAGE FOR CHARGES OR EXPENSES INCURRED 2,349
DURING A SPECIFIED PERIOD FOLLOWING THE INSURED'S EFFECTIVE DATE 2,350
OF COVERAGE AS TO A CONDITION WHICH, DURING A SPECIFIED PERIOD 2,351
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE, HAD 2,352
MANIFESTED ITSELF IN SUCH A MANNER AS WOULD CAUSE AN ORDINARILY 2,353
PRUDENT PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,354
TREATMENT OR FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,355
TREATMENT WAS RECOMMENDED OR RECEIVED, OR A PREGNANCY EXISTING ON 2,356
THE EFFECTIVE DATE OF COVERAGE.
(B) Beginning in January of each year, insurers IN THE 2,359
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 2,360
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 2,362
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 2,363
3923.122 OF THE REVISED CODE, shall accept applicants for open 2,367
enrollment coverage, as set forth in divisions (B)(1) and (2) of 2,368
this section DIVISION, in the order in which they apply for 2,370
coverage and subject to the limitation set forth in division (G) 2,371
of this section:. INSURERS
51
(1) Insurers in the business of issuing health benefit 2,373
plans to small employer groups shall accept small employer groups 2,374
for which coverage is not otherwise available and for whom 2,375
coverage had not been terminated by the employer or by an 2,376
insurer, health maintenance organization, or health insuring 2,378
corporation during the preceding twelve-month period;
(2) Insurers in the business of issuing individual 2,380
policies of sickness and accident insurance as contemplated by 2,381
section 3923.021 of the Revised Code, except individual policies 2,382
issued pursuant to section 3923.122 of the Revised Code, shall 2,383
either accept individuals pursuant to the open enrollment 2,384
requirements of section 3941.53 of the Revised Code, if subject 2,385
to that section, or accept for coverage pursuant to this section 2,387
individuals to whom both of the following conditions apply: 2,388
(a)(1) The individual is not applying for coverage as an 2,390
employee of an employer, as a member of an association, or as a 2,391
member of any other group. 2,392
(b)(2) The individual is not covered, and is not eligible 2,394
for coverage, under any other private or public health benefits 2,395
arrangement, including the medicare program established under 2,396
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,397
U.S.C.A. 301, as amended, or any other act of congress or law of 2,398
this or any other state of the United States that provides 2,399
benefits comparable to the benefits provided under this section, 2,400
any medicare supplement policy, or any conversion or continuation 2,401
of coverage policy under state or federal law. 2,402
(C) An insurer shall offer to any individual or small 2,404
employer group accepted under this section the small employer 2,406
health care plan established by the board of directors of the 2,407
Ohio small employer health reinsurance program under division (A) 2,409
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 2,410
plan in benefit plan design and scope of covered services. 2,411
An insurer may offer other health benefit plans in addition 2,413
52
to, but not in lieu of, the plan required to be offered under 2,414
this division. These additional health benefit plans shall 2,415
provide, at a minimum, the coverage provided by the small 2,416
employer health care plan or any health benefit plan that is 2,417
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 2,418
For purposes of this division, the superintendent of 2,420
insurance shall determine whether a health benefit plan is 2,421
substantially similar to the small employer health care plan in 2,422
benefit plan design and scope of covered services. 2,423
(D) Health benefit plans issued under this section may 2,425
establish pre-existing conditions provisions that exclude or 2,426
limit coverage for a period of up to twelve months following the 2,427
individual's effective date of coverage and that may relate only 2,428
to conditions during the six months immediately preceding the 2,429
effective date of coverage. However, an insurer may exclude a 2,430
late enrollee for a period of up to eighteen months following the 2,431
individual's date of application for coverage. 2,432
(E) Premiums charged to groups or individuals under this 2,434
section may not exceed an amount that is two and one-half times 2,435
the highest rate charged any other group with similar case 2,436
characteristics or any other individual to which the insurer is 2,437
currently accepting new business, and for which similar 2,438
copayments and deductibles are applied. 2,439
(F) In offering health benefit plans under this section, 2,441
an insurer may require the purchase of health benefit plans that 2,442
condition the reimbursement of health services upon the use of a 2,443
specific network of providers. 2,444
(G)(1) In no event shall an insurer be required to accept 2,446
annually under this section either individuals or small employer 2,447
groups that WHO, in the aggregate, would cause the insurer to 2,448
have a total number of new insureds that is more than one-half 2,450
per cent of its total number of insured individuals in this state 2,451
per year, as contemplated by section 3923.021 of the Revised 2,452
53
Code, and small group certificate holders of health benefit plans 2,453
in this state per year, calculated as of the immediately 2,455
preceding thirty-first day of December and excluding the 2,456
insurer's medicare supplement policies and conversion or 2,457
continuation of coverage policies under state or federal law and 2,458
any policies described in division (N)(M) of this section. If an 2,459
insurer is subject to, and elects to operate under, the 2,461
individual open enrollment requirements of section 3941.53 of the 2,462
Revised Code, in no event shall the insurer be required to accept 2,463
annually under this section small employer groups that would 2,464
cause the insurer to have a total number of new insureds that is 2,465
more than one-half per cent of its total number of small group 2,466
certificate holders calculated as set forth in division (G)(1) of 2,467
this section.
(2) An officer of the insurer shall certify to the 2,469
department of insurance when it has met the enrollment limit set 2,470
forth in division (G)(1) of this section. Upon providing such 2,471
certification, the insurer shall be relieved of its open 2,472
enrollment requirement under this section for the remainder of 2,473
the calendar year. 2,474
(H) An insurer shall not be required to accept under this 2,476
section applicants who, at the time of enrollment, are confined 2,477
to a health care facility because of chronic illness, permanent 2,478
injury, or other infirmity that would cause economic impairment 2,479
to the insurer if the applicants were accepted, or to make the 2,480
effective date of benefits for individuals or groups accepted 2,481
under this section earlier than ninety days after the date of 2,482
acceptance. 2,483
(I) The requirements of this section do not apply to any 2,485
insurer that is currently in a state of supervision, insolvency, 2,486
or liquidation. If an insurer demonstrates to the satisfaction 2,487
of the superintendent that the requirements of this section would 2,489
place the insurer in a state of supervision, insolvency, or 2,490
liquidation, the superintendent may waive or modify the 2,491
54
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 2,493
a period of not more than one year. At the expiration of such 2,494
time, a new showing of need for a waiver or modification by the 2,495
insurer shall be made before a new waiver or modification is 2,496
issued or imposed.
(J) No hospital, health care facility, or health care 2,498
practitioner, and no person who employs any health care 2,499
practitioner, shall balance bill any individual or dependent of 2,500
an individual or any eligible employee or dependent of an 2,502
employee for any health care supplies or services provided to the
individual or dependent or the eligible employee or dependent, 2,503
who is insured under a policy or enrolled under a health benefit 2,505
plan issued under this section. The hospital, health care 2,506
facility, or health care practitioner, or any person that employs 2,507
the health care practitioner, shall accept payments made to it by 2,508
the insurer under the terms of the policy or contract insuring or 2,510
covering such individual as payment in full for such health care 2,511
supplies or services. 2,512
As used in this division, "hospital" has the same meaning 2,514
as in section 3727.01 of the Revised Code; "health care 2,515
practitioner" has the same meaning as in section 4769.01 of the 2,516
Revised Code; and "balance bill" means charging or collecting an 2,517
amount in excess of the amount reimbursable or payable under the 2,518
policy or health care service contract issued to an individual or 2,519
group under this section for such health care supply or service. 2,520
"Balance bill" does not include charging for or collecting 2,521
copayments or deductibles required by the policy or contract. 2,522
(K) An insurer shall pay an agent a commission in the 2,524
amount of five per cent of the premium charged for initial 2,525
placement or for otherwise securing the issuance of a policy or 2,526
contract issued to an individual or small employer group under 2,527
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 2,528
55
adopt, in accordance with Chapter 119. of the Revised Code, such 2,529
rules as are necessary to enforce this division. 2,530
(L) Except as otherwise provided in this section, sections 2,532
3924.01 to 3924.06 of the Revised Code apply to all health 2,533
benefit plans issued under this section. 2,534
(M) Individuals accepted for coverage under this section 2,536
may be issued contracts and certificates subject to the 2,537
requirements of section 3923.12 of the Revised Code. The 2,538
coverage issued to such individuals is not subject to the 2,539
requirements of section 3923.021 of the Revised Code. 2,540
(N)(M) This section does not apply to any policy that 2,542
provides coverage for specific diseases or accidents only, or to 2,544
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 2,546
than six months, or other policy that offers only supplemental 2,547
benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION: 2,549
(1) "CARRIER," "HEALTH BENEFIT PLAN," "MEWA," AND 2,551
"PRE-EXISTING CONDITIONS PROVISION" HAVE THE SAME MEANINGS AS IN 2,553
SECTION 3924.01 OF THE REVISED CODE.
(2) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE 2,555
INDIVIDUAL AS DEFINED IN 45 C.F.R. 148.103. 2,556
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 2,557
FOLLOWING:
(a) HEALTH STATUS; 2,559
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 2,561
ILLNESSES; 2,562
(c) CLAIMS EXPERIENCE; 2,564
(d) RECEIPT OF HEALTH CARE; 2,566
(e) MEDICAL HISTORY; 2,568
(f) GENETIC INFORMATION; 2,570
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 2,572
OUT OF ACTS OF DOMESTIC VIOLENCE; 2,573
(h) DISABILITY. 2,575
56
(4) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR 2,577
CASE CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE 2,578
APPLICABLE CARRIER FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF 2,579
THE APPLICABLE BASE PREMIUM RATE AND THE CORRESPONDING HIGHEST 2,580
PREMIUM RATE.
(5) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 2,582
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 2,583
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 2,584
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 2,585
UNDER CONTRACT WITH THE CARRIER.
(B) BEGINNING IN JANUARY OF EACH YEAR, CARRIERS IN THE 2,587
BUSINESS OF ISSUING HEALTH BENEFIT PLANS TO INDIVIDUALS OR 2,588
NONEMPLOYER GROUPS SHALL ACCEPT FEDERALLY ELIGIBLE INDIVIDUALS 2,589
FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS SECTION, IN THE 2,590
ORDER IN WHICH THEY APPLY FOR COVERAGE AND SUBJECT TO THE 2,591
LIMITATION SET FORTH IN DIVISION (J) OF THIS SECTION. 2,592
(C) NO CARRIER SHALL DO EITHER OF THE FOLLOWING: 2,594
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT 2,596
OF, SUCH INDIVIDUALS; 2,597
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH 2,599
COVERAGE.
(D) A CARRIER SHALL OFFER TO FEDERALLY ELIGIBLE 2,601
INDIVIDUALS THE BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD 2,602
OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS 2,603
SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT 2,605
DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF THIS 2,606
DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER 2,607
A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 2,608
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY 2,610
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED 2,611
ANY OTHER INDIVIDUAL TO WHICH THE CARRIER IS CURRENTLY ACCEPTING 2,612
NEW BUSINESS, AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES 2,613
ARE APPLIED.
57
(F) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE 2,615
INDIVIDUAL MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 2,616
OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY 2,618
APPLY FOR SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE 2,619
SERVICE AREA OF THE NETWORK PLAN; 2,621
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 2,623
COVERAGE TO FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS 2,624
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,625
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 2,627
SERVICES ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE 2,628
CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS AND 2,629
INDIVIDUALS.
(b) THE CARRIER IS APPLYING DIVISION (F)(2) OF THIS 2,631
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT 2,632
REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS. 2,633
(G) A CARRIER THAT, PURSUANT TO DIVISION (F)(2) OF THIS 2,636
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF 2,637
A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET 2,638
WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS 2,639
AFTER THE DATE THE COVERAGE IS DENIED. 2,640
(H) A CARRIER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO 2,642
FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS DEMONSTRATED 2,643
BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,644
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 2,646
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 2,647
(2) THE CARRIER IS APPLYING DIVISION (H) OF THIS SECTION 2,649
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE 2,650
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND 2,651
WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 2,652
THOSE INDIVIDUALS.
(I) A CARRIER THAT, PURSUANT TO DIVISION (H) OF THIS 2,654
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY 2,655
ELIGIBLE INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 2,656
58
INDIVIDUAL MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY 2,657
DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE CARRIER 2,659
HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER HAS 2,660
SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER. 2,661
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 2,664
SECTION, A CARRIER SHALL NOT BE REQUIRED TO ACCEPT ANNUALLY UNDER 2,666
THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS WHO, IN THE 2,667
AGGREGATE, WOULD CAUSE THE CARRIER TO HAVE A TOTAL NUMBER OF NEW 2,668
INSUREDS THAT IS MORE THAN ONE-HALF PER CENT OF ITS TOTAL NUMBER 2,669
OF INSURED INDIVIDUALS AND NONEMPLOYER GROUPS IN THIS STATE PER 2,670
YEAR, CALCULATED AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY
OF DECEMBER AND EXCLUDING THE CARRIER'S MEDICARE SUPPLEMENT 2,672
POLICIES AND CONVERSION OR CONTINUATION OF COVERAGE POLICIES 2,674
UNDER STATE OR FEDERAL LAW AND ANY POLICIES DESCRIBED IN DIVISION 2,675
(M) OF SECTION 3923.58 OF THE REVISED CODE. 2,676
(2) AN OFFICER OF THE CARRIER SHALL CERTIFY TO THE 2,678
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET 2,679
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH 2,680
CERTIFICATION, THE CARRIER SHALL BE RELIEVED OF ITS OPEN 2,681
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF 2,682
THE CALENDAR YEAR UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, 2,684
ALL THE CARRIERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET 2,685
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,687
SECTION. IN THAT EVENT, CARRIERS SHALL AGAIN ACCEPT APPLICANTS 2,688
FOR OPEN ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO 2,689
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,691
SECTION.
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 2,693
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 2,694
(L) THE REQUIREMENTS OF THIS SECTION DO NOT APPLY TO ANY 2,696
HEALTH BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 2,697
OF THE REVISED CODE.
Sec. 3923.59. Any insurer may reinsure coverage of any 2,706
59
individual, small employer group, or member of that NONEMPLOYER 2,707
group acquired under section 3923.58 OR 3923.581 of the Revised 2,710
Code with the Ohio small employer health OPEN ENROLLMENT 2,711
reinsurance program in accordance with division (G) of section 2,713
3924.11 of the Revised Code. Premium rates charged for coverage 2,714
reinsured by the program shall be established in accordance with 2,715
section 3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the 2,724
Revised Code, each individual or group policy of sickness and 2,726
accident insurance delivered, issued for delivery, or renewed in 2,727
this state that provides maternity benefits shall provide
coverage of inpatient care and follow-up care for a mother and 2,728
her newborn as follows:
(1) The policy shall cover a minimum of forty-eight hours 2,731
of inpatient care following a normal vaginal delivery and a 2,732
minimum of ninety-six hours of inpatient care following a 2,733
cesarean delivery. Services covered as inpatient care shall 2,734
include medical, educational, and any other services that are 2,735
consistent with the inpatient care recommended in the protocols 2,736
and guidelines developed by national organizations that represent 2,737
pediatric, obstetric, and nursing professionals. 2,738
(2) The policy shall cover a physician-directed source of 2,740
follow-up care. Services covered as follow-up care shall include 2,741
physical assessment of the mother and newborn, parent education, 2,742
assistance and training in breast or bottle feeding, assessment 2,743
of the home support system, performance of any medically 2,744
necessary and appropriate clinical tests, and any other services 2,745
that are consistent with the follow-up care recommended in the 2,746
protocols and guidelines developed by national organizations that 2,748
represent pediatric, obstetric, and nursing professionals. The 2,749
coverage shall apply to services provided in a medical setting or 2,750
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,751
conducts the visit is knowledgeable and experienced in maternity 2,752
60
and newborn care.
When a decision is made in accordance with division (B) of 2,754
this section to discharge a mother or newborn prior to the 2,755
expiration of the applicable number of hours of inpatient care 2,756
required to be covered, the coverage of follow-up care shall 2,757
apply to all follow-up care that is provided within forty-eight 2,758
SEVENTY-TWO hours after discharge. When a mother or newborn 2,759
receives at least the number of hours of inpatient care required 2,760
to be covered, the coverage of follow-up care shall apply to 2,761
follow-up care that is determined to be medically necessary by 2,762
the health care professionals responsible for discharging the 2,763
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,766
to less than that specified under division (A)(1) of this section 2,768
shall be made by the physician attending the mother or newborn, 2,769
except that if a nurse-midwife is attending the mother in 2,770
collaboration with a physician, the decision may be made by the 2,771
nurse-midwife. Decisions regarding early discharge shall be made 2,772
only after conferring with the mother or a person responsible for 2,773
the mother or newborn. For purposes of this division, a person 2,774
responsible for the mother or newborn may include a parent, 2,775
guardian, or any other person with authority to make medical 2,776
decisions for the mother or newborn.
(C)(1) No sickness and accident insurer may do either of 2,779
the following:
(a) Terminate the participation of a health care 2,782
professional or health care facility as a provider under a
sickness and accident insurance policy solely for making 2,783
recommendations for inpatient or follow-up care for a particular 2,784
mother or newborn that are consistent with the care required to 2,785
be covered by this section; 2,786
(b) Establish or offer monetary or other financial 2,789
incentives for the purpose of encouraging a person to decline the 2,790
inpatient or follow-up care required to be covered by this 2,791
61
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,795
section has engaged in an unfair and deceptive act or practice in 2,796
the business of insurance under sections 3901.19 to 3901.26 of 2,797
the Revised Code. 2,799
(D) This section does not do any of the following: 2,802
(1) Require a policy to cover inpatient or follow-up care 2,805
that is not received in accordance with the policy's terms 2,806
pertaining to the health care professionals and facilities from 2,807
which an individual is authorized to receive health care 2,808
services.;
(2) Require a mother or newborn to stay in a hospital or 2,811
other inpatient setting for a fixed period of time following
delivery; 2,812
(3) Require a child to be delivered in a hospital or other 2,815
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,817
authority to practice nurse-midwifery in accordance with Chapter 2,819
4723. of the Revised Code; 2,821
(5) Establish minimum standards of medical diagnosis, care 2,824
or treatment for inpatient or follow-up care for a mother or 2,825
newborn. A deviation from the care required to be covered under 2,826
this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those 2,827
terms are defined in section 2305.11 of the Revised Code. 2,830
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the 2,839
Revised Code, each public employee benefit plan established or 2,841
modified in this state that provides maternity benefits shall 2,842
provide coverage of inpatient care and follow-up care for a 2,843
mother and her newborn as follows: 2,844
(1) The plan shall cover a minimum of forty-eight hours of 2,846
inpatient care following a normal vaginal delivery and a minimum 2,848
of ninety-six hours of inpatient care following a cesarean 2,849
delivery. Services covered as inpatient care shall include 2,850
62
medical, educational, and any other services that are consistent 2,851
with the inpatient care recommended in the protocols and 2,852
guidelines developed by national organizations that represent 2,853
pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of 2,855
follow-up care. Services covered as follow-up care shall include 2,856
physical assessment of the mother and newborn, parent education, 2,857
assistance and training in breast or bottle feeding, assessment 2,858
of the home support system, performance of any medically 2,859
necessary and appropriate clinical tests, and any other services 2,860
that are consistent with the follow-up care recommended in the 2,861
protocols and guidelines developed by national organizations that 2,863
represent pediatric, obstetric, and nursing professionals. The 2,864
coverage shall apply to services provided in a medical setting or 2,865
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,866
conducts the visit is knowledgeable and experienced in maternity 2,867
and newborn care.
When a decision is made in accordance with division (B) of 2,869
this section to discharge a mother or newborn prior to the 2,870
expiration of the applicable number of hours of inpatient care 2,871
required to be covered, the coverage of follow-up care shall 2,872
apply to all follow-up care that is provided within forty-eight 2,873
SEVENTY-TWO hours after discharge. When a mother or newborn 2,874
receives at least the number of hours of inpatient care required 2,875
to be covered, the coverage of follow-up care shall apply to 2,876
follow-up care that is determined to be medically necessary by 2,877
the health care professionals responsible for discharging the 2,878
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,881
to less than that specified under division (A)(1) of this section 2,883
shall be made by the physician attending the mother or newborn, 2,884
except that if a nurse-midwife is attending the mother in 2,885
collaboration with a physician, the decision may be made by the 2,886
63
nurse-midwife. Decisions regarding early discharge shall be made 2,887
only after conferring with the mother or a person responsible for 2,888
the mother or newborn. For purposes of this division, a person 2,889
responsible for the mother or newborn may include a parent, 2,890
guardian, or any other person with authority to make medical 2,891
decisions for the mother or newborn.
(C)(1) No public employer who offers an employee benefit 2,894
plan may do either of the following: 2,895
(a) Terminate the participation of a health care 2,898
professional or health care facility as a provider under the plan 2,899
solely for making recommendations for inpatient or follow-up care 2,900
for a particular mother or newborn that are consistent with the 2,901
care required to be covered by this section; 2,902
(b) Establish or offer monetary or other financial 2,905
incentives for the purpose of encouraging a person to decline the 2,906
inpatient or follow-up care required to be covered by this 2,907
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,911
section has engaged in an unfair and deceptive act or practice in 2,912
the business of insurance under sections 3901.19 to 3901.26 of 2,913
the Revised Code. 2,915
(D) This section does not do any of the following: 2,918
(1) Require a plan to cover inpatient or follow-up care 2,921
that is not received in accordance with the plan's terms 2,922
pertaining to the health care professionals and facilities from 2,923
which an individual is authorized to receive health care 2,924
services.;
(2) Require a mother or newborn to stay in a hospital or 2,927
other inpatient setting for a fixed period of time following
delivery; 2,928
(3) Require a child to be delivered in a hospital or other 2,931
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,933
authority to practice nurse-midwifery in accordance with Chapter 2,935
64
4723. of the Revised Code; 2,937
(5) Establish minimum standards of medical diagnosis, 2,939
care, or treatment for inpatient or follow-up care for a mother 2,940
or newborn. A deviation from the care required to be covered 2,941
under this section shall not, solely on the basis of this 2,942
section, give rise to a medical claim or derivative medical 2,943
claim, as those terms are defined in section 2305.11 of the 2,944
Revised Code. 2,946
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 2,955
the Revised Code: 2,956
(A) "Actuarial certification" means a written statement 2,958
prepared by a member of the American academy of actuaries, or by 2,959
any other person acceptable to the superintendent of insurance, 2,960
that states that, based upon the person's examination, a carrier 2,961
offering health benefit plans to small employers is in compliance 2,962
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 2,963
certification" shall include a review of the appropriate records 2,964
of, and the actuarial assumptions and methods used by, the 2,965
carrier relative to establishing premium rates for the health 2,966
benefit plans. 2,967
(B) "Adjusted average market premium price" means the 2,969
average market premium price as determined by the board of 2,971
directors of the Ohio small employer health reinsurance program 2,972
either on the basis of the arithmetic mean of all carriers' 2,973
premium rates for an SEHC plan sold to groups with similar case 2,974
characteristics by all carriers selling SEHC plans in the state, 2,976
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 2,978
plan that is issued by a carrier and that covers at least two but 2,979
no more than fifty employees of a small employer, the lowest 2,981
premium rate for a new or existing business prescribed by the 2,982
carrier for the same or similar coverage under a plan or 2,983
arrangement covering any small employer with similar case 2,984
characteristics.
65
(D) "Carrier" means any sickness and accident insurance 2,986
company or health insuring corporation authorized to issue health 2,989
benefit plans in this state or a MEWA. A sickness and accident 2,991
insurance company that owns or operates a health insuring 2,992
corporation, either as a separate corporation or as a line of 2,994
business, shall be considered as a separate carrier from that 2,995
health insuring corporation for purposes of sections 3924.01 to 2,997
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 2,999
employer, the geographic area in which the employees work; the 3,000
age and sex of the individual employees and their dependents; the 3,001
appropriate industry classification as determined by the carrier; 3,002
the number of employees and dependents; and such other objective 3,003
criteria as may be established by the carrier. "Case 3,004
characteristics" does not include claims experience, health 3,005
status, or duration of coverage from the date of issue. 3,006
(F) "Dependent" means the spouse or child of an eligible 3,008
employee, subject to applicable terms of the health benefits plan 3,009
covering the employee. 3,010
(G) "Eligible employee" means an employee who works a 3,012
normal work week of twenty-five or more hours. "Eligible 3,013
employee" does not include a temporary or substitute employee, or 3,015
a seasonal employee who works only part of the calendar year on 3,016
the basis of natural or suitable times or circumstances. 3,017
(H) "Financially impaired" means a program member that, 3,019
after April 14, 1993, is not insolvent but is determined by the 3,022
superintendent to be potentially unable to fulfill its 3,023
contractual obligations, or is placed under an order of 3,024
rehabilitation or conservation by a court of competent 3,025
jurisdiction or under an order of supervision by the 3,026
superintendent.
(I) "Health benefit plan" means any hospital or medical 3,028
expense policy or certificate or any health plan provided by a 3,030
carrier, that is delivered, issued for delivery, renewed, or used 3,032
66
in this state on or after the date occurring six months after 3,033
November 24, 1995. "Health benefit plan" does not include 3,035
policies covering only accident, credit, dental, disability 3,036
income, long-term care, hospital indemnity, medicare supplement, 3,037
specified disease, or vision care; coverage under a 3,038
one-time-limited-duration policy of no longer than six months; 3,040
coverage issued as a supplement to liability insurance; insurance 3,041
arising out of a workers' compensation or similar law; automobile 3,042
medical-payment insurance; or insurance under which benefits are 3,043
payable with or without regard to fault and which is statutorily 3,044
required to be contained in any liability insurance policy or 3,045
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 3,047
period immediately following any service waiting period 3,048
established by an employer. 3,049
(K)(I) "Late enrollee" means an eligible employee or 3,051
dependent who requests enrollment ENROLLS in a small employer's 3,052
health benefit plan following OTHER THAN DURING the initial 3,054
enrollment FIRST period provided under the terms of the first 3,056
plan for IN which the employee or dependent was IS eligible 3,057
through the small employer, unless any of the following apply: 3,059
(1) The individual: 3,061
(a) Was covered under another health benefit plan at the 3,064
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 3,066
coverage under another health benefit plan was the reason for 3,069
declining enrollment;
(c) Has lost coverage under another health benefit plan as 3,072
a result of the termination of employment, a reduction of hours 3,073
worked per week, the termination of the other plan's coverage, 3,074
death of a spouse, or divorce; and 3,075
(d) Requests enrollment within thirty days after the 3,077
termination of coverage under another health benefit plan. 3,078
(2) The individual is employed by an employer who offers 3,080
67
multiple health benefit plans and the individual elects a 3,081
different health benefit plan during an open enrollment period. 3,082
(3) A court has ordered coverage to be provided for a 3,084
spouse or minor child under a covered employee's plan and a 3,085
request for enrollment is made within thirty days after issuance 3,086
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 3,088
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,091
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. 3,097
NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg, AS AMENDED. 3,100
(L)(J) "MEWA" means any "multiple employer welfare 3,102
arrangement" as defined in section 3 of the "Federal Employee 3,103
Retirement Income Security Act of 1974," 88 Stat. 832, 29 3,104
U.S.C.A. 1001, as amended, except for any arrangement which is 3,105
fully insured as defined in division (b)(6)(D) of section 514 of 3,106
that act. 3,107
(M)(K) "Midpoint rate" means, for small employers with 3,109
similar case characteristics and plan designs and as determined 3,110
by the applicable carrier for a rating period, the arithmetic 3,111
average of the applicable base premium rate and the corresponding 3,112
highest premium rate. 3,113
(N)(L) "Pre-existing conditions provision" means a policy 3,115
provision that excludes or limits coverage for charges or 3,117
expenses incurred during a specified period following the 3,118
insured's effective ENROLLMENT date of coverage as to a condition 3,120
which, during a specified period immediately preceding the 3,121
effective date of coverage, had manifested itself in such a 3,122
manner as would cause an ordinarily prudent person to seek 3,123
medical advice, diagnosis, care, or treatment or for which 3,124
medical advice, diagnosis, care, or treatment was recommended or 3,125
received, or DURING a pregnancy existing on SPECIFIED PERIOD 3,127
IMMEDIATELY PRECEDING the effective ENROLLMENT date of coverage. 3,128
GENETIC INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN 3,130
THE ABSENCE OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH 3,131
INFORMATION.
68
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, 3,133
WITH RESPECT TO AN INDIVIDUAL COVERED UNDER A GROUP HEALTH 3,134
BENEFIT PLAN, THE DATE OF ENROLLMENT OF THE INDIVIDUAL IN THE 3,135
PLAN OR, IF EARLIER, THE FIRST DAY OF THE WAITING PERIOD FOR SUCH 3,137
ENROLLMENT.
(O)(M) "Service waiting period" means the period of time 3,139
after employment begins before an eligible employee may enroll in 3,141
IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any 3,142
applicable health benefit plan offered by the small employer.
(P)(N)(1) "Small employer" means any person, firm, 3,145
corporation, partnership, or association actively engaged in 3,146
business whose total, IN CONNECTION WITH A GROUP HEALTH BENEFIT 3,147
PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN YEAR, AN 3,148
EMPLOYER WHO employed work force consisted of, on at least fifty 3,149
per cent of its working days during the preceding year, AN 3,150
AVERAGE OF at least two but no more than fifty eligible 3,152
employees, the majority of whom were employed within the state ON 3,153
BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND WHO EMPLOYS 3,154
AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN YEAR.
(2) In determining the number of eligible employees for 3,156
FOR purposes of division (P)(N)(1) of this section, companies 3,157
which are affiliated companies or which are eligible to file a 3,159
combined tax return for purposes of state taxation ALL PERSONS 3,161
TREATED AS A SINGLE EMPLOYER UNDER SUBSECTION (b), (c), (m), OR 3,163
(o) OF SECTION 414 OF THE "INTERNAL REVENUE CODE OF 1986," 100 3,167
STAT. 2085, 26 U.S.C.A. 1, AS AMENDED, shall be considered one 3,170
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE 3,171
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF 3,172
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED 3,173
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS REASONABLY 3,175
EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN THE CURRENT 3,176
CALENDAR YEAR. ANY REFERENCE IN DIVISION (N) OF THIS SECTION TO 3,177
AN "EMPLOYER" INCLUDES ANY PREDECESSOR OF THE EMPLOYER. Except 3,179
as otherwise specifically provided, provisions of sections 3,180
69
3924.01 to 3924.14 of the Revised Code that apply to a small 3,181
employer that has a health benefit plan shall continue to apply 3,182
until the plan anniversary following the date the employer no 3,183
longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small employer health 3,186
care plan, which is a health benefit plan for small INDIVIDUALS 3,187
AND employers established by the board in accordance with section 3,189
3924.10 of the Revised Code. 3,190
Sec. 3924.02. (A) An individual or group health benefit 3,199
plan is subject to sections 3924.01 to 3924.14 of the Revised 3,200
Code if it provides health care benefits covering at least two 3,202
but no more than fifty employees of a small employer, and if it 3,203
meets either of the following conditions: 3,204
(1) Any portion of the premium or benefits is paid by a 3,206
small employer, or any covered individual is reimbursed, whether 3,207
through wage adjustments or otherwise, by a small employer for 3,208
any portion of the premium. 3,209
(2) The health benefit plan is treated by the employer or 3,211
any of the covered individuals as part of a plan or program for 3,212
purposes of section 106 or 162 of the "Internal Revenue Code of 3,213
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,214
(B) Notwithstanding division (A) of this section, 3,216
divisions (D), (E)(2), (F), AND (G) to (J) of section 3924.03 of 3,218
the Revised Code and section 3924.04 of the Revised Code do not 3,220
apply to health benefit policies that are not sold to owners of 3,221
small businesses as an employment benefit plan. Such policies 3,222
shall clearly state that they are not being sold as an employment 3,223
benefit plan and that the owner of the business is not 3,224
responsible, either directly or indirectly, for paying the 3,225
premium or benefits.
(C) Every health benefit plan offered or delivered by a 3,227
carrier, other than a health insuring corporation, to a small 3,229
employer is subject to sections 3923.23, 3923.231, 3923.232, 3,230
3923.233, and 3923.234 of the Revised Code and any other 3,231
70
provision of the Revised Code that requires the reimbursement, 3,232
utilization, or consideration of a specific category of a 3,233
licensed or certified health care practitioner. 3,234
(D) Except as expressly provided in sections 3924.01 to 3,236
3924.14 of the Revised Code, no health benefit plan offered to a 3,237
small employer is subject to any of the following: 3,238
(1) Any law that would inhibit any carrier from 3,240
contracting with providers or groups of providers with respect to 3,241
health care services or benefits; 3,242
(2) Any law that would impose any restriction on the 3,244
ability to negotiate with providers regarding the level or method 3,245
of reimbursing care or services provided under the health benefit 3,246
plan; 3,247
(3) Any law that would require any carrier to either 3,249
include a specific provider or class of provider when contracting 3,250
for health care services or benefits, or to exclude any class of 3,251
provider that is generally authorized by statute to provide such 3,252
care. 3,253
Sec. 3924.03. Health EXCEPT AS OTHERWISE PROVIDED IN 3,262
SECTION 2721 OF THE "HEALTH INSURANCE PORTABILITY AND 3,267
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 3,272
42 U.S.C.A. 300gg-21, AS AMENDED, HEALTH benefit plans covering 3,274
small employers are subject to the following conditions, as 3,275
applicable:
(A)(1) Pre-existing conditions provisions shall not 3,277
exclude or limit coverage for a period beyond twelve months, OR 3,278
EIGHTEEN MONTHS IN THE CASE OF A LATE ENROLLEE, following the 3,279
individual's effective ENROLLMENT date of coverage and may only 3,280
relate to conditions during A PHYSICAL OR MENTAL CONDITION, 3,282
REGARDLESS OF THE CAUSE OF THE CONDITION, FOR WHICH MEDICAL 3,284
ADVICE, DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED 3,285
WITHIN the six months immediately preceding the effective 3,287
ENROLLMENT date of coverage.
DIVISION (A)(1) OF THIS SECTION IS SUBJECT TO THE 3,290
71
EXCEPTIONS SET FORTH IN SECTION 2701(d) OF THE "HEALTH INSURANCE 3,293
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,296
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION 3,298
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF 3,299
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR 3,300
DEPENDENT AS OF THE ENROLLMENT DATE. 3,301
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE COUNTED, 3,304
WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A GROUP HEALTH 3,305
BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE ENROLLMENT 3,306
DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL OF WHICH THE 3,307
INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE COVERAGE. 3,308
SUBSECTIONS (c)(2) TO (4) AND (e) OF SECTION 2701 OF THE "HEALTH 3,310
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996" APPLY WITH 3,314
RESPECT TO CREDITING PREVIOUS COVERAGE. 3,315
(4) AS USED IN DIVISION (A) OF THIS SECTION: 3,318
(a) "CREDITABLE COVERAGE" HAS THE SAME MEANING AS IN 3,321
SECTION 2701(c)(1) OF THE "HEALTH INSURANCE PORTABILITY AND 3,325
ACCOUNTABILITY ACT OF 1996." 3,326
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN INDIVIDUAL 3,329
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF ENROLLMENT 3,330
OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE FIRST DAY OF 3,331
THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions 3,333
provision applies to an eligible employee or dependent, all 3,334
health benefit plans shall credit the time the person was covered 3,335
under a previous employer-based health benefit plan provided by a 3,336
carrier if the previous coverage was continuous to a date not 3,338
more than thirty days prior to the effective date of the new 3,340
coverage, exclusive of any applicable service waiting period 3,341
under the plan. 3,342
(C) Any such health benefit plan shall be renewable with 3,344
respect to all eligible employees or dependents at the option of 3,345
the policyholder, contract holder, or small employer, except for 3,346
any of the following reasons: 3,347
72
(1) Nonpayment of the required premiums by the 3,349
policyholder, contract holder, or employer; 3,350
(2) Fraud or misrepresentation of the policyholder, 3,352
contract holder, or employer or, with respect to coverage of 3,353
individual insureds, the insureds or their representatives ; 3,355
(3) When the total number of insured individuals covered 3,357
under all of the health benefit plans of any one employer is less 3,358
than the total number of individuals or percentage of individuals 3,359
required by participation requirements under any specific health 3,360
benefit plan of that employer; 3,361
(4) Noncompliance with any plan provision that has been 3,363
approved by the superintendent of insurance; 3,364
(5) When the carrier ceases doing business in the small 3,366
employer market, provided that all of the following conditions 3,367
are met: 3,368
(a) Notice of the decision to cease to do business in the 3,370
small employer market is provided to the department of insurance, 3,371
the board of directors of the Ohio small employer health 3,372
reinsurance program, the policyholder or contract holder, and the 3,373
employer. 3,374
(b) Health benefit plans subject to sections 3924.01 to 3,376
3924.14 of the Revised Code shall not be canceled by the carrier 3,377
for ninety days after the date of the notice required under 3,379
division (C)(5)(a) of this section unless the business has been 3,380
sold to another carrier or the cancellations are approved by the 3,381
superintendent. 3,382
(c) A carrier that ceases to do business in the small 3,384
employer marketplace is prohibited from re-entering the small 3,385
employer marketplace for a period of five years from the date of 3,386
the notice required under division (C)(5)(a) of this section. 3,387
(D) Notwithstanding division (C) of this section, any such 3,389
health benefit plan or any coverage provided to an individual 3,390
under such a plan may be rescinded for fraud, material 3,391
misrepresentation, or concealment by an applicant, employee, 3,392
73
dependent, or small employer. 3,393
(E) Every carrier doing business in the small employer 3,395
market may underwrite and rate small employer groups, as 3,396
permitted by sections 3924.01 to 3924.14 of the Revised Code, 3,397
using accepted underwriting and actuarial practices (1) EXCEPT 3,399
AS PROVIDED IN SECTION 2712(b) TO (e) OF THE "HEALTH INSURANCE 3,401
PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF A CARRIER OFFERS 3,403
COVERAGE IN THE SMALL EMPLOYER MARKET IN CONNECTION WITH A GROUP 3,404
HEALTH BENEFIT PLAN, THE CARRIER SHALL RENEW OR CONTINUE IN FORCE 3,405
SUCH COVERAGE AT THE OPTION OF THE PLAN SPONSOR OF THE PLAN. 3,406
(2) A CARRIER MAY CANCEL OR DECIDE NOT TO RENEW THE 3,408
COVERAGE OF ANY ELIGIBLE EMPLOYEE OR OF A DEPENDENT OF AN 3,409
ELIGIBLE EMPLOYEE IF THE EMPLOYEE OR DEPENDENT, AS APPLICABLE, 3,411
HAS PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES FRAUD OR MADE 3,412
AN INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS 3,413
OF THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT
BASED, EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH 3,414
STATUS-RELATED FACTOR IN RELATION TO THE EMPLOYEE OR DEPENDENT. 3,415
AS USED IN DIVISION (B)(2) OF THIS SECTION, "HEALTH 3,418
STATUS-RELATED FACTOR" HAS THE SAME MEANING AS IN SECTION
3924.031 OF THE REVISED CODE. 3,419
(F)(C) A carrier shall not exclude any eligible employee 3,421
or dependent, who would otherwise be covered under a health 3,422
benefit plan, on the basis of any actual or expected health 3,423
condition of the employee or dependent. However, a carrier may 3,424
exclude a late enrollee for a period of up to twenty-four months 3,425
or may, in the discretion of the carrier, extend coverage to the 3,426
late enrollee at any time during that period. A carrier also may 3,427
medically underwrite a late enrollee. 3,428
If, prior to the effective date of this amendment NOVEMBER 3,431
24, 1995, a carrier excluded an eligible employee or dependent, 3,432
other than a late enrollee, on the basis of an actual or expected 3,433
health condition, the carrier shall, upon the initial renewal of 3,434
the coverage on or after that date, extend coverage to the 3,435
74
employee or dependent if all other eligibility requirements are 3,436
met.
(G)(D) No health benefit plan issued by a carrier shall 3,439
limit or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 3,441
medical condition, or accident, except for pre-existing 3,442
conditions as permitted under division (A) of this section. If a 3,443
health benefit plan that is delivered or issued for delivery 3,445
prior to April 14, 1993, contains such limitations or exclusions, 3,447
by use of a rider or amendment applicable to a specific 3,448
individual, the plan shall eliminate the use of such riders or 3,449
amendments within eighteen months after April 14, 1993. 3,450
(H)(E)(1) EXCEPT AS PROVIDED IN SECTIONS 3924.031 AND 3,453
3924.032 OF THE REVISED CODE, AND SUBJECT TO SUCH RULES AS MAY BE 3,456
ADOPTED BY THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH 3,457
CHAPTER 119. OF THE REVISED CODE, A CARRIER SHALL OFFER AND MAKE 3,458
AVAILABLE EVERY HEALTH BENEFIT PLAN THAT IT IS ACTIVELY MARKETING 3,459
TO EVERY SMALL EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH 3,460
COVERAGE.
DIVISION (E)(1) OF THIS SECTION DOES NOT APPLY TO A HEALTH 3,463
BENEFIT PLAN THAT A CARRIER MAKES AVAILABLE IN THE SMALL EMPLOYER 3,464
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS. 3,465
DIVISION (E)(1) OF THIS SECTION SHALL NOT BE CONSTRUED TO 3,468
PRECLUDE A CARRIER FROM ESTABLISHING EMPLOYER CONTRIBUTION RULES 3,469
OR GROUP PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN 3,470
CONNECTION WITH A GROUP HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER 3,471
MARKET, AS ALLOWED UNDER THE LAW OF THIS STATE. AS USED IN 3,472
DIVISION (E)(1) OF THIS SECTION, "EMPLOYER CONTRIBUTION RULE" 3,474
MEANS A REQUIREMENT RELATING TO THE MINIMUM LEVEL OR AMOUNT OF 3,475
EMPLOYER CONTRIBUTION TOWARD THE PREMIUM FOR ENROLLMENT OF 3,476
EMPLOYEES AND DEPENDENTS AND "GROUP PARTICIPATION RULE" MEANS A 3,477
REQUIREMENT RELATING TO THE MINIMUM NUMBER OF EMPLOYEES OR 3,478
DEPENDENTS THAT MUST BE ENROLLED IN RELATION TO A SPECIFIED 3,479
PERCENTAGE OR NUMBER OF ELIGIBLE INDIVIDUALS OR EMPLOYEES OF AN 3,480
75
EMPLOYER.
(2) Each health benefit plan, at the time of initial group 3,482
enrollment, shall make coverage available to all the eligible 3,483
employees of a small employer without a service waiting period. 3,484
The decision of whether to impose a service waiting period shall 3,486
be made by the small employer. Such waiting periods shall not be 3,487
greater than ninety days. 3,488
(3) EACH HEALTH BENEFIT PLAN SHALL PROVIDE FOR THE SPECIAL 3,491
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,494
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,497
(I)(F) The benefit structure of any health benefit plan 3,500
may, AT THE TIME OF COVERAGE RENEWAL, be changed by the carrier 3,502
to make it consistent with the benefit structure contained in 3,503
health benefit plans being marketed to new small employer groups. 3,504
IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE SMALL EMPLOYER 3,506
MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW OF 3,508
THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL EMPLOYER 3,509
GROUP PLANS.
(J)(G) A carrier may obtain any facts and information 3,511
necessary to apply this section, or supply those facts and 3,512
information to any other third-party payer, without the consent 3,513
of the beneficiary. Each person claiming benefits under a health 3,514
benefit plan shall provide any facts and information necessary to 3,515
apply this section. 3,516
FOR PURPOSES OF THIS SECTION, "BONA FIDE ASSOCIATION" MEANS 3,519
AN ASSOCIATION THAT HAS BEEN ACTIVELY IN EXISTENCE FOR AT LEAST 3,520
FIVE YEARS; HAS BEEN FORMED AND MAINTAINED IN GOOD FAITH FOR 3,521
PURPOSES OTHER THAN OBTAINING INSURANCE; DOES NOT CONDITION 3,522
MEMBERSHIP IN THE ASSOCIATION ON ANY HEALTH STATUS-RELATED 3,523
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,525
RELATING TO AN INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; 3,526
MAKES HEALTH INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION 3,527
AVAILABLE TO ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED 3,528
76
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,531
RELATING TO SUCH MEMBERS OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE 3,532
THROUGH A MEMBER; DOES NOT MAKE HEALTH INSURANCE COVERAGE OFFERED 3,533
THROUGH THE ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A 3,534
MEMBER OF THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT 3,535
IMPOSED BY THE SUPERINTENDENT. TO MAINTAIN ITS STATUS AS A "BONA 3,536
FIDE ASSOCIATION," EACH ASSOCIATION SHALL ANNUALLY CERTIFY TO THE 3,537
SUPERINTENDENT THAT IT MEETS THE REQUIREMENTS OF THIS PARAGRAPH. 3,538
Sec. 3924.031. (A) AS USED IN THIS SECTION AND SECTION 3,541
3924.032 OF THE REVISED CODE: 3,543
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 3,545
FOLLOWING: 3,546
(a) HEALTH STATUS; 3,548
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 3,551
ILLNESSES;
(c) CLAIMS EXPERIENCE; 3,553
(d) RECEIPT OF HEALTH CARE; 3,555
(e) MEDICAL HISTORY; 3,557
(f) GENETIC INFORMATION; 3,559
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 3,562
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 3,564
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 3,566
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 3,567
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 3,568
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 3,570
UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE SMALL 3,573
EMPLOYER MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 3,574
OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH 3,576
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR 3,577
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN; 3,578
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 3,580
77
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH 3,581
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE: 3,582
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 3,585
SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL GROUPS 3,586
BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT 3,587
HOLDERS AND MEMBERS.
(b) THE CARRIER IS APPLYING DIVISION (B)(2) OF THIS 3,590
SECTION UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE 3,591
CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES 3,592
AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 3,593
SUCH EMPLOYEES AND DEPENDENTS. 3,594
(C) A CARRIER THAT, PURSUANT TO DIVISION (B)(2) OF THIS 3,598
SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE AREA 3,599
OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL EMPLOYER 3,600
MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY 3,601
DAYS AFTER THE DATE THE COVERAGE IS DENIED. 3,602
Sec. 3924.032. (A) A CARRIER MAY REFUSE TO ISSUE HEALTH 3,605
BENEFIT PLANS IN THE SMALL EMPLOYER MARKET IF THE CARRIER HAS 3,606
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT OF 3,607
INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 3,609
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 3,610
(2) THE CARRIER IS APPLYING DIVISION (A) OF THIS SECTION 3,613
UNIFORMLY TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS 3,614
STATE CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE 3,615
AND WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS 3,616
AND THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH 3,617
STATUS-RELATED FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS. 3,618
(B) A CARRIER THAT, PURSUANT TO DIVISION (A) OF THIS 3,622
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 3,623
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED 3,624
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE 3,625
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER 3,626
78
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL 3,627
COVERAGE, WHICHEVER IS LATER. 3,628
(C) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 3,631
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 3,632
Sec. 3924.033. (A) EACH CARRIER, IN CONNECTION WITH THE 3,635
OFFERING OF A HEALTH BENEFIT PLAN TO A SMALL EMPLOYER, SHALL 3,636
DISCLOSE TO THE EMPLOYER, AS PART OF ITS SOLICITATION AND SALES 3,637
MATERIALS, THAT THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,638
SECTION IS AVAILABLE UPON REQUEST. 3,639
(B) A CARRIER SHALL PROVIDE THE FOLLOWING INFORMATION TO A 3,642
SMALL EMPLOYER UPON REQUEST: 3,643
(1) THE PROVISIONS OF THE PLAN CONCERNING THE CARRIER'S 3,646
RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY AFFECT 3,647
CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO RENEWABILITY OF 3,650
COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY 3,652
PRE-EXISTING CONDITION EXCLUSION; 3,653
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL HEALTH 3,656
BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,660
SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER 3,661
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE 3,662
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT PLAN. 3,664
(D) NOTHING IN THIS SECTION REQUIRES A CARRIER TO DISCLOSE 3,667
ANY INFORMATION THAT IS BY LAW PROPRIETARY AND TRADE SECRET 3,668
INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit 3,677
entity to be known as the "Ohio small employer health reinsurance 3,679
program." Any carrier issuing health benefit plans in this state 3,680
on or after April 14, 1993, may be a member of the program. 3,681
(B) A carrier may elect to be a member of the program by 3,683
filing a written intention to participate with the superintendent 3,685
79
of insurance at least thirty days prior to the implementation of 3,686
the program. Any carrier that does not file a written intention 3,687
to participate within that time period may not participate for 3,688
three years after April 14, 1993, and may file an intention to 3,690
participate only at that time or on any subsequent three-year 3,691
anniversary date. However, the superintendent may permit a 3,692
carrier to participate in the program at other intervals for 3,693
reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A 3,695
CARRIER TO PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE 3,696
SHOWN. THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 3,697
CARRIERS SEEKING TO CHANGE THEIR STATUS UNDER THIS DIVISION. 3,698
Sec. 3924.08. (A) The board of directors of the Ohio 3,707
small employer health reinsurance program shall consist of nine 3,708
appointed members who shall serve staggered terms as determined 3,709
by the initial board for its members and by the plan of operation 3,710
of the program for members of subsequent boards. Within thirty 3,711
days after April 14, 1993, the members of the board shall be 3,712
appointed, as follows: 3,713
(1) The chairperson of the senate committee having 3,715
jurisdiction over insurance shall appoint the following members: 3,716
(a) Two member carriers that are small employer carriers; 3,718
(b) One member carrier that is a health maintenance 3,720
organization predominantly in the small employer market; 3,721
(c) One representative of providers of health care. 3,723
(2) The chairperson of the committee in the house of 3,725
representatives having jurisdiction over insurance shall appoint 3,726
the following members: 3,727
(a) One member carrier that is a small employer carrier; 3,729
(b) One member carrier whose principal health insurance 3,731
business is in the large employer market; 3,732
(c) One representative of an employer with fifty or fewer 3,734
employees; 3,735
(d) One representative of consumers in this state. 3,737
80
(3) The superintendent OF INSURANCE shall appoint a 3,739
representative of a member carrier operating in the small 3,741
employer market who is a fellow of the society of actuaries. 3,742
The superintendent, a member of the house of 3,744
representatives appointed by the speaker of the house of 3,745
representatives, and a member of the senate appointed by the 3,746
president of the senate, shall be ex-officio members of the 3,747
board. The membership of all boards subsequent to the initial 3,748
board shall reflect the distribution described in division (A) of 3,750
this section.
The chairperson of the initial board and each subsequent 3,752
board shall represent a small employer member carrier and shall 3,753
be elected by a majority of the voting members of the board. 3,754
Each chairperson shall serve for the maximum duration established 3,755
in the plan of operation. 3,756
(B) Within one hundred eighty days after the appointment 3,758
of the initial board, the board shall establish a plan of 3,759
operation and, thereafter, any amendments to the plan that are 3,760
necessary or suitable, to assure the fair, reasonable, and 3,761
equitable administration of the program. The board shall, 3,762
immediately upon adoption, provide to the superintendent copies 3,763
of the plan of operation and all subsequent amendments to it. 3,764
(C) The plan of operation shall establish rules, 3,766
conditions, and procedures for all of the following: 3,767
(1) The handling and accounting of assets and moneys of 3,769
the program and for an annual fiscal reporting to the 3,770
superintendent; 3,771
(2) Filling vacancies on the board; 3,773
(3) Selecting an administering insurer, which shall be a 3,775
carrier as defined in section 3924.01 of the Revised Code, and 3,776
setting forth the powers and duties of the administering insurer; 3,777
(4) Reinsuring risks in accordance with sections 3924.07 3,779
to 3924.14 of the Revised Code; 3,780
(5) Collecting assessments subject to section 3924.13 of 3,782
81
the Revised Code from all members to provide for claims reinsured 3,783
by the program and for administrative expenses incurred or 3,784
estimated to be incurred during the period for which the 3,785
assessment is made; 3,786
(6) Providing protection for carriers from the financial 3,788
risk associated with small employers that present poor credit 3,789
risks; 3,790
(7) Establishing standards for the coverage of small 3,792
employers that have a high turnover of employees; 3,793
(8) Establishing an appeals process for carriers to seek 3,795
relief when a carrier has experienced an unfair share of 3,796
administrative and credit risks; 3,797
(9) Establishing the adjusted average market premium 3,799
prices for use by the SEHC plan for INDIVIDUALS, FOR groups of 3,801
two to twenty-five employees, and for groups of twenty-six to 3,802
fifty employees that are offered in the state; 3,803
(10) Establishing participation standards at issue and 3,805
renewal for reinsured cases; 3,806
(11) Reinsuring risks and collecting assessments in 3,808
accordance with division (G) of section 3924.11 of the Revised 3,809
Code; 3,810
(12) Any additional matters as determined by the board. 3,812
Sec. 3924.09. The Ohio small employer health reinsurance 3,821
program shall have the general powers and authority granted under 3,822
the laws of the state to insurance companies licensed to transact 3,823
sickness and accident insurance, except the power to issue 3,824
insurance. The board of directors of the program also shall have 3,825
the specific authority to do all of the following: 3,826
(A) Enter into contracts as are necessary or proper to 3,828
carry out the provisions and purposes of sections 3924.07 to 3,829
3924.14 of the Revised Code, including the authority to enter 3,830
into contracts with similar programs of other states for the 3,831
joint performance of common functions, or with persons or other 3,832
organizations for the performance of administrative functions; 3,833
82
(B) Sue or be sued, including taking any legal actions 3,835
necessary or proper for recovery of any assessments for, on 3,836
behalf of, or against any program or board member; 3,837
(C) Take such legal action as is necessary to avoid the 3,839
payment of improper claims against the program; 3,840
(D) Design the SEHC plan which, when offered by a carrier, 3,842
is eligible for reinsurance and issue reinsurance policies in 3,843
accordance with the requirements of sections 3924.07 to 3924.14 3,844
of the Revised Code; 3,845
(E) Establish rules, conditions, and procedures pertaining 3,847
to the reinsurance of members' risks by the program; 3,848
(F) Establish appropriate rates, rate schedules, rate 3,850
adjustments, rate classifications, and any other actuarial 3,851
functions appropriate to the operation of the program; 3,852
(G) Assess members in accordance with division (G) of 3,855
section 3924.11 and the provisions of section 3924.13 of the 3,856
Revised Code, and make such advance interim assessments as may be 3,857
reasonable and necessary for organizational and interim operating 3,858
expenses. Any interim assessments shall be credited as offsets 3,859
against any regular assessments due following the close of the 3,860
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 3,862
other committees if necessary to provide technical assistance 3,863
with respect to the operation of the program, policy and other 3,864
contract design, and any other function within the authority of 3,865
the program; 3,866
(I) Borrow money to effect the purposes of the program. 3,868
Any notes or other evidence of indebtedness of the program not in 3,869
default shall be legal investments for carriers and may be 3,870
carried as admitted assets. 3,871
(J) Reinsure risks, collect assessments, and otherwise 3,873
carry out its duties under division (G) of section 3924.11 of the 3,874
Revised Code.; 3,875
(K) Study the operation of the Ohio small employer health 3,878
83
reinsurance program and the open enrollment reinsurance program 3,879
and, based on its findings, make legislative recommendations to 3,880
the general assembly for improvements in the effectiveness, 3,881
operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF 3,883
SECTIONS 1751.16, 3923.122, AND 3923.581 OF THE REVISED CODE. 3,884
Sec. 3924.10. (A) The board of directors of the Ohio 3,893
small employer health reinsurance program shall design the SEHC 3,894
plan which, when offered by a carrier, is eligible for 3,895
reinsurance under the program. The board shall establish the 3,896
form and level of coverage to be made available by carriers in 3,897
their SEHC plan. In designing the plan the board shall also 3,899
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 3,900
of coverage established by the board shall specify which 3,901
components of a health benefit plan offered by a small employer 3,902
carrier may be reinsured. The SEHC plan is subject to division 3,904
(C) of section 3924.02 of the Revised Code and to the provisions 3,905
in Chapters 1751., 3923., and any other chapter of the Revised 3,907
Code that require coverage or the offer of coverage of a health 3,908
care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 3,911
eighty days after its appointment. The plan may include cost 3,912
containment features including any of the following:
(1) Utilization review of health care services, including 3,914
review of the medical necessity of hospital and physician 3,915
services; 3,916
(2) Case management benefit alternatives; 3,918
(3) Selective contracting with hospitals, physicians, and 3,920
other health care providers; 3,921
(4) Reasonable benefit differentials applicable to 3,923
participating and nonparticipating providers; 3,924
(5) Employee assistance program options that provide 3,926
preventive and early intervention mental health and substance 3,927
84
abuse services; 3,928
(6) Other provisions for the cost-effective management of 3,930
the plan. 3,931
(C) An SEHC plan established for use by health insuring 3,934
corporations shall be consistent with the basic method of 3,936
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 3,938
insurance, in the form and manner prescribed by the 3,939
superintendent, that the SEHC plan filed by the carrier is in 3,941
substantial compliance with the provisions of the board SEHC 3,942
plan. Upon receipt by the superintendent of the certification, 3,943
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 3,945
date that the program becomes operational and as a condition of 3,946
transacting business in this state, renew coverage provided to 3,947
any individual or group under its SEHC plan. 3,948
(F) A carrier shall not be required to renew coverage 3,950
where the superintendent finds that renewal of coverage would 3,951
place the carrier in a financially impaired condition. The 3,952
superintendent shall determine when the carrier is no longer 3,953
financially impaired and is, therefore, subject to the guaranteed 3,954
renewability requirements. 3,955
Sec. 3924.11. Any member of the Ohio small employer health 3,964
reinsurance program may reinsure small employer groups or 3,965
individuals in accordance with the following conditions and 3,966
limitations: 3,967
(A) With respect to eligible employees and their 3,969
dependents who are hired subsequent to the commencement of the 3,970
employer's coverage by a carrier and who are not late enrollees, 3,971
and with respect to employees of an employer who are otherwise 3,972
eligible for insurance but were excluded by the carrier's 3,973
underwriting and who are not late enrollees, coverage may be 3,974
reinsured in either ANY of the following ways: 3,975
(1) Except in the case of late enrollees, within sixty 3,977
85
days after the commencement of their coverage under the plan; 3,978
(2) In the case of late enrollees WHO WERE NOT ELIGIBLE TO 3,981
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,982
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,985
ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 3,987
300gg-42, AS AMENDED, eighteen months after the date the late 3,989
enrollee becomes a member of the small employer's plan; 3,990
(3) IN THE CASE OF LATE ENROLLEES WHO WERE ELIGIBLE TO 3,992
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,994
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,997
ACT OF 1996," AS AMENDED, WITHIN SIXTY DAYS AFTER THE 3,998
COMMENCEMENT OF THEIR COVERAGE UNDER THE PLAN. 3,999
(B)(1) The carrier may reinsure either the entire eligible 4,002
group or any eligible individual, in accordance with the premium 4,004
rates established in section 3924.12 of the Revised Code, upon 4,006
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,009
dependents of an eligible employee, who were previously excluded 4,010
from group coverage for medical reasons, and shall reinsure such 4,011
employees or dependents within sixty days after the carrier is 4,012
required to include them in the group coverage.
(C) With respect to an SEHC plan, the program shall 4,015
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,017
the program shall reinsure the level of coverage provided up to, 4,018
but not exceeding, the level of coverage provided in an SEHC 4,019
plan. In the coverage provided to small employers, carriers 4,020
shall be required to use high-cost care management, hospital 4,021
precertification techniques, and other cost containment 4,022
mechanisms established by the program. 4,023
(E) A carrier may not reinsure existing business, except 4,025
pursuant to division (A) of this section. 4,026
(F) If an employer group is covered under a plan other 4,028
than an SEHC plan and the carrier chooses to reinsure the group 4,029
86
subsequent to the initial coverage period, or if a new individual 4,030
joins the group and the carrier wants to reinsure that 4,031
individual, the carrier shall not force the employer to change to 4,033
an SEHC plan. The carrier shall allow the employer to maintain 4,034
the same benefit plan and reinsure only that portion of the plan 4,035
that is consistent with an SEHC plan.
(G) With respect to coverage provided to a small employer 4,037
group or AN individual acquired under section 3923.58 OR A 4,038
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 3923.581 of 4,039
the Revised Code, the following conditions and limitations apply: 4,041
(1) Within sixty days after the commencement of the 4,044
initial coverage, any carrier may reinsure coverage of an entire 4,045
small employer group, or of eligible employees or dependents of 4,046
such group, or any SUCH AN individual acquired under section 4,047
3923.58 of the Revised Code with the OPEN ENROLLMENT REINSURANCE 4,049
program IN ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A 4,051
carrier may reinsure, within sixty days after the effective date 4,053
of coverage, an employee eligible for coverage under section 4,055
3923.58 of the Revised Code. Premium rates charged for coverage 4,056
reinsured by the program shall be established in accordance with 4,057
section 3924.12 of the Revised Code. 4,058
(2) The board of directors of the OHIO HEALTH REINSURANCE 4,061
program shall establish the open enrollment reinsurance fund for 4,062
coverage provided under section 3923.58 of the Revised Code AND, 4,063
WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, COVERAGE PROVIDED 4,065
UNDER SECTION 3923.581 OF THE REVISED CODE. The fund shall be 4,066
maintained separately from any reinsurance fund established for 4,067
small employer health care plans issued pursuant to sections
3924.07 to 3924.14 of the Revised Code. The board shall 4,068
calculate, on a retrospective basis, the amount needed for 4,069
maintenance of the open enrollment reinsurance fund and, on the 4,070
basis of that calculation, shall determine the amount to be 4,071
assessed each carrier that is required to provide open enrollment 4,072
coverage. 4,073
87
Assessments shall be apportioned by the board among all 4,075
carriers participating in the open enrollment reinsurance program 4,076
in proportion to their respective shares of the total premiums, 4,077
net of reinsurance premiums paid by a carrier for open enrollment 4,078
coverage and net of reinsurance premiums paid by the carrier for 4,079
all other small group and individual health benefit plans, earned 4,080
in this state from all health benefit plans covering small 4,081
employers and individuals that are issued by all such carriers 4,082
during the calendar year coinciding with or ending during the 4,083
fiscal year of the open enrollment program, or on any other 4,084
equitable basis reflecting coverage of small employers and 4,085
individuals in this state as may be provided in the plan of 4,086
operation adopted by the board. In no event shall the assessment 4,087
of any carrier under this section exceed, on an annual basis, 4,089
three per cent of its Ohio premiums for health benefit plans 4,090
covering small employers and individuals as reported on its most 4,091
recent annual statement filed with the superintendent of 4,092
insurance.
The board shall submit its determination of the amount of 4,094
the assessment to the superintendent for review of the accuracy 4,096
of the calculation of the assessment. Upon approval by the 4,097
superintendent, each carrier shall, within thirty days after 4,098
receipt of the notice of assessment, submit the assessment to the 4,099
board for purposes of the open enrollment reinsurance fund. 4,100
(3) If the assessments made and collected pursuant to 4,102
division (G)(2) of this section are not sufficient to pay the 4,103
claims reinsured under division (G) of this section and the 4,104
allocated administrative expenses, incurred or estimated to be 4,105
incurred during the period for which the assessment was made, the 4,106
secretary of the board shall immediately notify the 4,107
superintendent, and the superintendent shall suspend the 4,108
operation of open enrollment under section 3923.58 of the Revised 4,109
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER 4,110
SECTION 3923.581 OF THE REVISED CODE until the board has 4,111
88
collected in subsequent years through assessments made pursuant 4,112
to division (G)(2) of this section an amount sufficient to pay 4,113
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,115
under section 3923.58 of the Revised Code may elect not to 4,117
participate in the open enrollment reinsurance program under 4,118
division (G) of this section by filing an application with the 4,119
superintendent and obtaining the superintendent's approval. In 4,120
determining whether to approve an application, the superintendent 4,121
shall consider whether the carrier meets all of the following 4,122
standards: 4,123
(i) Demonstration by the carrier of a substantial and 4,125
established market presence; 4,126
(ii) Demonstrated experience in the small employer group 4,128
INDIVIDUAL market and history of rating and underwriting small 4,129
employer groups INDIVIDUAL PLANS; 4,131
(iii) Commitment to comply with the requirements of 4,133
section 3923.58 of the Revised Code; 4,134
(iv) Financial ability to assume and manage the risk of 4,136
enrolling open enrollment groups and individuals without the need 4,137
for, or protection of, reinsurance. 4,138
(b) A carrier whose application for nonparticipation has 4,140
been rejected by the superintendent may appeal the decision in 4,141
accordance with Chapter 119. of the Revised Code. A carrier that 4,142
has received approval of the superintendent not to participate in 4,143
the open enrollment reinsurance program shall, on or before the 4,144
first day of December, annually certify to the superintendent 4,145
that it continues to meet the standards described in division 4,146
(G)(4)(a) of this section. 4,147
(c) In any year subsequent to the year in which its 4,149
application not to participate has been approved, a carrier may 4,150
elect to participate in the open enrollment reinsurance program 4,151
by giving notice to the superintendent and board on or before the 4,152
thirty-first day of December. If, after a period of 4,153
89
nonparticipation, a carrier elects to participate in the open 4,154
enrollment reinsurance program, the carrier retains the risks it 4,155
assumed during the period when it was not participating. 4,156
(d) The superintendent may, at any time, authorize a 4,158
carrier to modify an election not to participate if the risk from 4,159
the carrier's open enrollment business jeopardizes the financial 4,160
condition of the carrier. If the superintendent authorizes the 4,161
carrier to again participate in the open enrollment reinsurance 4,162
program, the carrier shall retain the risks it assumed during the 4,163
period of nonparticipation. 4,164
(5) At the time of acquiring a small employer group, a 4,166
carrier shall determine whether to reinsure the entire group or 4,167
any individual pursuant to section 3924.12 of the Revised Code. 4,168
(6)(a) The open enrollment reinsurance program shall be 4,171
operated separately from the Ohio small employer health 4,172
reinsurance program.
(b) A carrier's election to participate in the open 4,174
enrollment reinsurance program under division (G) of this section 4,176
shall not be construed as an election to participate in the Ohio 4,177
small employer health reinsurance program under section 3924.07 4,178
of the Revised Code.
Sec. 3924.111. (A) The Ohio small employer health 4,189
reinsurance program shall not provide reinsurance for any 4,190
individual reinsured under the program until five thousand 4,191
dollars in benefit payments have been made by a member of the 4,192
program for services provided to that individual during a
calendar year, which payments would have been reimbursed through 4,193
the program but for the five-thousand-dollar deductible. The 4,194
member shall retain ten per cent of the next fifty thousand 4,195
dollars of benefit payments made during that calendar year, and 4,196
the program shall reinsure the remainder. However, a member's 4,197
maximum liability under this section with respect to any one 4,198
individual reinsured under the program shall not exceed ten 4,199
thousand dollars in any one calendar year. 4,200
90
(B) The board of directors of the Ohio small employer 4,203
health reinsurance program shall periodically review the 4,204
deductible amount and the maximum liability amount set forth in 4,205
division (A) of this section and, considering the rate of 4,206
inflation, adjust each amount as the board considers necessary. 4,207
Sec. 3924.12. (A) Except as provided in division (B) of 4,216
this section, premium rates charged for coverage reinsured by the 4,217
Ohio small employer health reinsurance program shall be 4,218
established as follows: 4,219
(1) For whole group reinsurance coverage, one and one-half 4,221
times the adjusted average market premium price established by 4,222
the program for that classification or group with similar 4,223
characteristics and coverage, with respect to the eligible 4,224
employees of a small employer and their dependents, all of whose 4,225
coverage is reinsured with the program, minus a ceding expense 4,226
factor determined by the board of directors of the program; 4,227
(2) For individual reinsurance coverage, five times the 4,229
adjusted average market premium price established by the program 4,230
for an individual in that classification or group with similar 4,231
characteristics and coverage, with respect to an eligible 4,232
employee or the employee's dependents, minus a ceding expense 4,234
factor determined by the board. 4,235
(B) Premium rates charged for reinsurance by the program 4,237
to a health insuring corporation that is approved by the 4,239
secretary of health and human services as a federally qualified 4,240
health maintenance organization pursuant to the "Social Security 4,241
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as 4,242
such is subject to requirements that limit the amount of risk 4,243
that may be ceded to the program, may be modified to reflect the 4,244
portion of risk that may be ceded to the program. 4,245
Sec. 3924.13. (A) Following the close of each calendar 4,254
year, the administering insurer of the Ohio small employer health 4,255
reinsurance program shall determine the net premiums, the program 4,256
expenses for administration, and the incurred losses, if any, for 4,257
91
the year, taking into account investment income and other 4,258
appropriate gains and losses. For purposes of this section, 4,259
health benefit plan premiums earned by MEWAs shall be established 4,260
by adding paid claim losses and administrative expenses of the 4,261
MEWA. Health benefit plan premiums and benefits paid by a 4,263
carrier that are less than an amount determined by the board of 4,264
directors of the program to justify the cost of collection shall 4,265
not be considered for purposes of determining assessments. For 4,266
purposes of this division, "net premiums" means health benefit 4,267
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 4,269
assessments of carriers in accordance with this division. 4,270
Assessments shall be apportioned by the board among all carriers 4,271
participating in the program in proportion to their respective 4,272
shares of the total premiums, net of reinsurance premiums paid 4,273
for coverage under this program earned in the state from health 4,274
benefit plans covering small employers that are issued by 4,275
participating members during the calendar year coinciding with or 4,276
ending during the fiscal year of the program, or on any other 4,277
equitable basis reflecting coverage of small employers as may be 4,278
provided in the plan of operation. An assessment shall be made 4,279
pursuant to this division against a health insuring corporation 4,280
that is approved by the secretary of health and human services as 4,283
a federally qualified health maintenance organization pursuant to 4,284
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 4,285
as amended, subject to an assessment adjustment formula adopted 4,286
by the board for such health insuring corporations that 4,287
recognizes the restrictions imposed on the entities by federal 4,289
law. The adjustment formula shall be adopted by the board prior 4,291
to the first anniversary of the program's operation. In no event 4,292
shall the assessment made pursuant to this division exceed, on an 4,293
annual basis, one per cent of the carrier's Ohio small employer 4,295
group premium as reported on its most recent annual statement 4,296
filed with the superintendent of insurance. If an excess is 4,297
92
actuarially projected, the superintendent may take any action 4,298
necessary to lower the assessment to the maximum level of one per 4,299
cent.
(C) If assessments exceed actual losses and administrative 4,301
expenses of the program, the excess shall be held at interest and 4,302
used by the board to offset future losses or to reduce program 4,303
premiums. As used in this division, "future losses" includes 4,304
reserves for incurred but not reported claims. 4,305
(D) Each carrier's proportion of participation in the 4,307
program shall be determined annually by the board based on annual 4,309
statements and other reports deemed necessary by the board and 4,310
filed by the carrier with the board. MEWAs shall report to the 4,311
board claims payments made and administrative expenses incurred 4,312
in this state on an annual basis on a form prescribed by the 4,313
superintendent.
(E) Provision shall be made in the plan of operation for 4,315
the imposition of an interest penalty for late payment of 4,316
assessments. 4,317
(F) A carrier may seek from the superintendent a 4,319
deferment, in whole or in part, from any assessment issued by the 4,320
board. The superintendent may defer, in whole or in part, the 4,321
assessment of a carrier if, in the opinion of the superintendent, 4,322
payment of the assessment would endanger the carrier's ability to 4,323
fulfill its contractual obligations. 4,324
(G) In the event an assessment against a carrier is 4,326
deferred in whole or in part, the amount by which the assessment 4,327
is deferred may be assessed against the other carriers in a 4,328
manner consistent with the basis for assessments set forth in 4,329
this section. In such event, the other carriers assessed shall 4,330
have a claim in the amount of the assessment against the carrier 4,331
receiving the deferment. The carrier receiving the deferment 4,332
shall remain liable to the program for the amount deferred. The 4,333
superintendent may attach appropriate conditions to any 4,334
deferment. 4,335
93
Sec. 3924.14. Neither the participation as members of the 4,344
Ohio small employer health reinsurance program or as members of 4,345
the board of directors of the program, the establishment of 4,347
rates, forms, or procedures for coverage issued by the program, 4,348
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 4,349
legal action or any criminal or civil liability or penalty 4,350
against the program, the board, or any of its members either 4,351
jointly or separately.
Sec. 3924.27. (A) AS USED IN THIS SECTION: 4,354
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE 4,356
THE SAME MEANINGS AS IN SECTION 3924.01 OF THE REVISED CODE. 4,357
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 4,359
FOLLOWING: 4,360
(a) HEALTH STATUS; 4,362
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 4,365
ILLNESSES;
(c) CLAIMS EXPERIENCE; 4,367
(d) RECEIPT OF HEALTH CARE; 4,369
(e) MEDICAL HISTORY; 4,371
(f) GENETIC INFORMATION; 4,373
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 4,376
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 4,378
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING 4,380
HEALTH INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH 4,381
BENEFIT PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF 4,382
ENROLLMENT OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A 4,383
PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR 4,384
CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE 4,385
PLAN ON THE BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION 4,386
TO THE INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS 4,387
A DEPENDENT OF THE INDIVIDUAL. 4,388
(C) NOTHING IN DIVISION (B) OF THIS SECTION SHALL BE 4,392
94
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 4,393
FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO PREVENT A 4,394
GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING GROUP HEALTH 4,395
INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM DISCOUNTS OR 4,396
REBATES OR MODIFYING OTHERWISE APPLICABLE COPAYMENTS OR 4,397
DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF HEALTH 4,398
PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section: 4,407
(1) "Child" means, in connection with any adoption or 4,409
placement for adoption of the child, an individual who has not 4,410
attained age eighteen as of the date of the adoption or placement 4,411
for adoption. 4,412
(2) "Health insurer" has the same meaning as in section 4,414
3924.41 of the Revised Code. 4,415
(3) "Placement for adoption" means the assumption and 4,417
retention by a person of a legal obligation for total or partial 4,418
support of a child in anticipation of the adoption of the child. 4,419
The child's placement with a person terminates upon the 4,420
termination of that legal obligation. 4,421
(B) If an individual or group health plan of a health 4,423
insurer provides MAKES coverage AVAILABLE for dependent children 4,425
of participants or beneficiaries, the plan shall provide benefits 4,426
to dependent children placed with participants or beneficiaries 4,427
for adoption under the same terms and conditions as apply to the 4,428
natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become 4,429
final. 4,430
(C) A health plan described in division (B) of this 4,432
section shall not restrict coverage under the plan of any 4,434
dependent child adopted by a participant or beneficiary, or 4,435
placed with a participant or beneficiary for adoption, solely on 4,436
the basis of a pre-existing condition of the child at the time 4,437
that the child would otherwise become eligible for coverage under 4,438
the plan, if the adoption or placement for adoption occurs while 4,439
95
the participant or beneficiary is eligible for coverage under the 4,440
plan.
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 4,449
the Revised Code: 4,450
(A) "Account holder" means the natural person who opens a 4,453
medical savings account or on whose behalf a medical savings 4,454
account is opened.
(B) "Eligible medical expense" means any expense for a 4,457
service rendered by a licensed health care provider or a 4,458
Christian Science practitioner, or for an article, device, or 4,459
drug prescribed by a licensed health care provider or provided by 4,460
a Christian Science practitioner, when intended for use in the 4,462
mitigation, treatment, or prevention of disease; ANY AMOUNT PAID 4,463
FOR TRANSPORTATION TO THE LOCATION AT WHICH SUCH A SERVICE IS 4,464
RENDERED; ANY AMOUNT PAID FOR LODGING NECESSITATED BY THE RECEIPT 4,465
OF CARE AT A NONLOCAL HOSPITAL; or premiums paid for 4,466
comprehensive sickness and accident insurance, coverage under a 4,468
health care plan of a health insuring corporation organized under 4,469
Chapter 1751. of the Revised Code, long-term care insurance as 4,471
defined in section 3923.41 of the Revised Code, Medicare MEDICARE 4,472
supplemental coverage as defined in section 3923.33 of the 4,474
Revised Code, or payments made pursuant to cost sharing 4,475
agreements under comprehensive sickness and accident plans. An 4,476
"eligible medical expense" does not include expenses otherwise 4,477
paid or reimbursed, including medical expenses paid or reimbursed 4,478
under an automobile or motor vehicle insurance policy, a workers' 4,479
compensation insurance policy or plan, or an employer-sponsored 4,480
health coverage policy, plan, or contract.
(C) "Qualified dependent" means a child of an account 4,483
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 4,486
twenty-three years of age and a full-time student at an
accredited college or university; 4,487
(2) The child is not self-sufficient due to physical or 4,489
96
mental disorders or impairments; 4,490
(3) The child is legally entitled to the provision of 4,492
proper or necessary subsistence, education, medical care, or 4,493
other care necessary for the child's health, guidance, or 4,494
well-being and is not otherwise emancipated, self-supporting, 4,495
married, or a member of the armed forces of the United States 4,497
DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE 4,498
"INTERNAL REVENUE CODE OF 1986," 100 STAT. 2085, 26 U.S.C.A. 1, 4,499
AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened 4,508
by or on behalf of any natural person, to pay the person's 4,509
eligible medical expenses and the eligible medical expenses of 4,510
that person's spouse or qualified dependent. A medical savings 4,511
account may be opened by or on behalf of a person only if that 4,514
person participates in a sickness or accident insurance plan, a 4,515
plan offered by a health insuring corporation organized under 4,516
Chapter 1751. of the Revised Code, or a self-funded, 4,517
employer-sponsored health benefit plan established pursuant to 4,518
the "Employee Retirement Income Security Act of 1974," 88 Stat. 4,519
832, 29 U.S.C.A. 1001, as amended. While the medical savings
account is open, the account holder shall continue to participate 4,520
in such a plan.
(B) A person who refuses to participate in a policy, plan, 4,523
or contract of health coverage that is funded by the person's 4,524
employer, and who receives additional monetary compensation by 4,525
virtue of refusing that coverage, may not open a medical savings 4,526
account unless the medical savings account also is sponsored by 4,527
the person's employer. 4,528
Sec. 3924.63. The owners of interest in a medical savings 4,538
account are the account holder, AND the account holder's spouse, 4,539
and qualified dependents. No medical savings account shall be 4,540
subject to garnishment or attachment. 4,542
Sec. 3924.64. (A) At the time a medical savings account 4,552
is opened, an administrator for the account shall be designated. 4,553
97
If an employer opens an account for an employee, the employer may 4,554
designate the administrator. If an account is opened by any 4,555
person other than an employer, or if an employer chooses not to 4,556
designate an administrator for an account opened for an employee, 4,557
the account holder shall designate the administrator. The 4,558
administrator shall manage the account in a fiduciary capacity 4,559
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 4,562
of the following:
(1) A federally or state-chartered bank, savings and loan 4,565
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 4,567
(3) An insurer authorized under Title XXXIX of the Revised 4,570
Code to engage in the business of sickness and accident 4,571
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 4,574
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 4,577
Revised Code;
(6) A certified public accountant; 4,579
(7) An employer that administers an employee benefit plan 4,582
subject to regulation under the "Employee Retirement Income 4,583
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 4,585
amended, or that maintains medical savings accounts for its 4,586
employees;
(8) Health insuring corporations organized under Chapter 4,589
1751. of the Revised Code.
(C) Each administrator shall send to the account holder, 4,592
at least annually, a statement setting forth the balance 4,593
remaining in the account holder's account and detailing the 4,594
activity in the account since the last statement was issued. 4,595
Upon an administrator's receipt of a written request from an 4,596
account holder for a current statement, the administrator shall 4,597
promptly send the statement to the account holder.
98
(D) When an account holder documents to the administrator 4,600
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 4,601
account holder, OR the account holder's spouse, or qualified 4,603
dependents, the administrator shall reimburse the account holder 4,604
for, or shall pay for, the eligible medical expense with funds 4,605
from the account holder's account, if sufficient funds are 4,606
available in the account holder's account. If there are not 4,607
sufficient funds in the account to fully reimburse the account 4,608
holder or pay the expenses, the administrator shall reimburse the 4,610
account holder or pay the expenses using whatever funds are in 4,611
the account. The reimbursement or payment shall be made within 4,612
thirty days of the administrator's receipt of the documentation. 4,613
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 4,614
expense does not count toward meeting the deductible or other 4,615
obligation for the receipt of benefits that is required by the 4,616
insurer or other third-party payer providing health coverage to 4,617
the account holder. The administrator shall keep a record of the 4,618
amounts disbursed from the account for documented eligible 4,619
medical expenses and of the dates on which the expenses were 4,620
incurred. This record shall be made available to any sickness 4,621
and accident insurer or other third-party payer providing health 4,622
coverage to the account holder, for use by the insurer or 4,623
third-party payer in determining whether the account holder has 4,624
met the deductible or other obligation required for the receipt 4,625
of benefits from the insurer or third-party payer. 4,626
(E) When an account is opened, the administrator shall 4,629
give written notice to the account holder of the date of the last 4,630
business day of the administrator's business year. 4,631
Sec. 3924.66. (A) In determining Ohio adjusted gross 4,640
income under Chapter 5747. of the Revised Code, an account holder 4,641
may deduct an amount equaling the total of the deposits that the 4,643
account holder, the account holder's spouse, or the account 4,644
99
holder's employer made to the account during the taxable year, to 4,645
the extent that the funds for the deposits have not otherwise 4,646
been deducted or excluded in determining the account holder's
federal adjusted gross income. The amount deducted by an account 4,648
holder for a taxable year shall not exceed three thousand 4,649
dollars. If two married persons each have an account, each 4,650
spouse may claim the deduction described in this section, and the 4,652
amount deducted by each spouse shall not exceed three thousand 4,653
dollars, whether the spouses file returns jointly or separately. 4,654
(B) The maximum deduction allowed under division (A) of 4,656
this section shall be adjusted annually by the department of 4,657
taxation to reflect increases in the consumer price index for all 4,658
items for all urban consumers for the north central region, as 4,659
published by the United States bureau of labor statistics. 4,660
(C) In determining Ohio adjusted gross income under 4,662
Chapter 5747. of the Revised Code, an account holder may deduct 4,663
the investment earnings of a medical savings account from the 4,664
account holder's federal adjusted gross income, to the extent 4,665
that these earnings have been included in the account holder's 4,666
federal adjusted gross income.
(D) In determining Ohio adjusted gross income under 4,668
Chapter 5747. of the Revised Code, an account holder shall add to 4,669
the account holder's federal adjusted gross income an amount 4,670
equal to the sum of the amounts described in divisions (D)(1) and 4,672
(2) of this section to the extent that those amounts were 4,673
included in the account holder's federal adjusted gross income 4,674
and previously deducted in determining the account holder's Ohio 4,676
adjusted gross income. In determining the extent to which 4,677
amounts withdrawn from the account shall be included in the 4,678
account holder's Ohio adjusted gross income, the tax commissioner 4,680
shall be guided by the provisions of sections 72 and 408 of the 4,681
Internal Revenue Code governing the determination of the amount 4,682
of withdrawals from an individual retirement account to be 4,683
included in federal gross income.
100
(1) Amounts withdrawn from the account during the taxable 4,686
year used for any purpose other than to reimburse the account 4,687
holder for, or to pay, the eligible medical expenses of the 4,688
account holder, OR the account holder's spouse, or qualified 4,690
dependents; 4,691
(2) Investment earnings during the taxable year on amounts 4,693
withdrawn from the account that are described in division (D)(1) 4,694
of this section. 4,695
(E) Amounts withdrawn from a medical savings account to 4,697
reimburse the account holder for, or to pay, the account holder's 4,698
eligible medical expenses, or the eligible medical expenses of 4,699
the account holder's spouse or qualified dependents, shall not be 4,701
included in the account holder's Ohio adjusted gross income in 4,702
determining taxes due under Chapter 5747. of the Revised Code. 4,703
(F) If a qualified dependent of an account holder becomes 4,706
ineligible to continue to participate in the account holder's 4,708
policy, plan, or contract of health coverage, the account holder 4,709
may withdraw funds from the account holder's account and use
those funds to pay the premium for the first year of a policy, 4,710
plan, or contract of health coverage for the qualified dependent 4,711
and to pay any deductible for the first year of that policy, 4,713
plan, or contract. Funds withdrawn and used for that purpose 4,714
shall not be included in the account holder's Ohio adjusted gross 4,715
income in determining taxes due under Chapter 5747. of the 4,716
Revised Code. 4,717
Sec. 3924.67. An account holder may withdraw funds from 4,727
the account holder's account at any time, for any purpose.
However, the administrator of a medical savings account shall not 4,728
disburse funds to an account holder during the year in which the 4,730
funds were deposited, except to reimburse the account holder for, 4,731
or pay for, a documented eligible medical expense of the account 4,732
holder, OR the account holder's spouse, or a qualified dependent. 4,733
Sec. 3924.68. (A) If an account holder, whose medical 4,743
savings account has been opened by the account holder's employer, 4,744
101
later ceases to be employed by that employer, the account holder 4,745
may, within sixty days of the account holder's final date of 4,746
employment, request in writing to the administrator of the 4,748
account that the administrator continue to administer the 4,749
account.
(1) If the administrator agrees to continue to administer 4,752
the account, funds in the account may continue to be used to pay 4,753
the eligible medical expenses of the account holder, AND the 4,754
account holder's spouse, and qualified dependents, pursuant to 4,755
sections 3924.61 to 3924.74 of the Revised Code. 4,757
If the account holder later becomes employed by a new 4,759
employer that opens a new medical savings account on the account 4,760
holder's behalf, the account holder may transfer any funds 4,762
remaining in the account opened by the account holder's former 4,763
employer to the account opened by the account holder's new 4,764
employer. For purposes of determining taxes due under Chapter 4,766
5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, 4,767
nor shall it be considered a deposit to a medical savings 4,768
account.
(2) If the administrator does not agree to continue to 4,771
administer the account, or if the account holder requests that 4,772
the account be closed, the administrator shall close the account 4,773
and mail a check or other negotiable instrument in the amount of 4,774
the account balance as of that date to the account holder. The 4,775
amount distributed shall be included in the account holder's Ohio 4,776
adjusted gross income in determining taxes due under Chapter 4,777
5747. of the Revised Code. 4,778
(B) Within sixty days of the account holder's final date 4,780
of employment, the account holder may transfer any funds 4,782
remaining in the account opened by the account holder's former 4,783
employer to another medical savings account owned by the account 4,784
holder. For purposes of determining taxes due under Chapter 4,785
5747,. of the Revised Code, this transfer of funds shall not be 4,786
102
considered a withdrawal of funds from a medical savings account, 4,787
nor shall it be considered a deposit to a medical savings
account. 4,788
(C) An administrator of an account opened by an employer 4,790
shall not close an account without the permission of the account 4,791
holder until at least sixty-one days after the account holder's 4,792
final date of employment. The employer shall notify the 4,793
administrator of the employee's final date of employment. 4,794
Sec. 3924.73. (A) As used in this section: 4,803
(1) "Health care insurer" means any person legally engaged 4,805
in the business of providing sickness and accident insurance 4,806
contracts in this state, a health insuring corporation organized 4,808
under Chapter 1751. of the Revised Code, or any legal entity that 4,809
is self-insured and provides health care benefits to its
employees or members. 4,810
(2) "Small employer" has the same meaning as in division 4,812
(P) of section 3924.01 of the Revised Code. 4,813
(B)(1) Subject to division (B)(2) of this section, nothing 4,816
in sections 3924.61 to 3924.74 of the Revised Code shall be 4,817
construed to limit the rights, privileges, or protections of 4,818
employees or small employers under sections 3924.01 to 3924.14 of 4,819
the Revised Code. 4,820
(2) If any account holder enrolls or applies to enroll in 4,822
a policy or contract offered by a health care insurer providing 4,823
sickness and accident coverage that is more comprehensive than, 4,824
and has a deductible amount that is less than, the coverage and 4,825
deductible amount of the policy under which the account holder 4,826
currently is enrolled, the health care insurer to which the 4,827
account holder applies may subject the account holder to the same 4,829
medical review, waiting periods, and underwriting requirements to 4,830
which the health care insurer generally subjects other enrollees 4,831
or applicants, unless the account holder enrolls or applies to 4,832
enroll during a designated period of open enrollment. 4,833
Section 2. That existing sections 1739.05, 1751.06, 4,835
103
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 4,836
1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 4,837
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 4,839
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 4,840
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 4,841
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 4,842
and 3924.73 and section 3941.53 of the Revised Code are hereby 4,843
repealed.
Section 3. The amendments to sections 1751.59, 1751.61, 4,845
3923.122, 3923.26, 3923.40, and 3924.51 of the Revised Code by 4,846
this act shall apply to contracts, evidences of coverage, 4,847
policies, and plans that are delivered, issued for delivery, 4,848
renewed, or established in this state on or after the effective 4,849
date of this section. 4,850
Section 4. The amendment of sections 1751.64, 3901.49, and 4,852
3901.50 of the Revised Code is not intended to supersede the 4,853
earlier repeal, with delayed effective dates, of those sections. 4,854
Section 5. This act is hereby declared to be an emergency 4,856
measure necessary for the immediate preservation of the public 4,857
peace, health, and safety. The reason for such necessity is that 4,858
Ohio must meet the federal deadline relative to the 4,859
implementation of the federal Health Insurance Portability and
Accountability Act of 1996. Ohio's failure to meet this deadline 4,860
could result in the federal government assuming regulation over 4,861
certain areas of health insurance, thereby disrupting the stable 4,862
health insurance market in Ohio that currently exists under Ohio 4,863
law. Meeting the federal deadline will protect the public health 4,865
and safety of the citizens of this state by ensuring the
stability of the health insurance market through the continued 4,866
regulation of this market by the state. Therefore, this act 4,867
shall go into immediate effect.