As Passed by the Senate 1
122nd General Assembly 4
Regular Session Sub. H. B. No. 374 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-BRADING-CORBIN-GARCIA-HAINES- 8
MOTTLEY-NETZLEY-SCHURING-TAYLOR-TERWILLEGER-THOMAS-TIBERI- 9
LEWIS-HOTTINGER-MAIER-TAVARES-JERSE-METELSKY-REID-WESTON- 10
CLANCY-HOUSEHOLDER-LUCAS-VESPER-O'BRIEN-VERICH-SULZER-BENDER- 11
MOTTL-MYERS-OGG-CORE-OLMAN-OPFER-DAMSCHRODER-BRITTON-HARRIS- 12
LOGAN-PATTON-ROMAN-WINKLER-WILSON-CATES-ROBERTS-FORD-JONES- 13
JACOBSON-FOX-SALERNO-MILLER-COLONNA-BOYD-PRINGLE-SUTTON-MALLORY- 14
SENATORS CUPP-DiDONATO-GILLMOR-HOWARD-OELSLAGER-WATTS- 15
DRAKE-CARNES-KEARNS-GARDNER-LATTA-GAETH-ZALESKI-LATELL-B. JOHNSON- 16
DIX-BLESSING-FINAN-SUHADOLNIK 17
18
A B I L L
To amend sections 1739.05, 1751.06, 1751.15, 20
1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 21
1751.65, 1751.67, 3901.21, 3901.49, 3901.491, 22
3901.50, 3901.501, 3923.021, 3923.122, 3923.26, 23
3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 25
3923.64, 3924.01, 3924.02, 3924.03, 3924.07 to
3924.11, 3924.111, 3924.12 to 3924.14, 3924.51, 27
3924.61 to 3924.64, 3924.66 to 3924.68, and 28
3924.73, to enact sections 1751.57, 1751.58, 29
3901.044, 3923.571, 3923.581, 3924.031, 3924.032, 31
3924.033, and 3924.27, and to repeal section 32
3941.53 of the Revised Code relative to the 33
implementation of the federal Health Insurance 34
Portability and Accountability Act of 1996 and 35
insurance coverage of follow-up care for a mother 36
and newborn, and to declare an emergency. 37
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 39
2
Section 1. That sections 1739.05, 1751.06, 1751.15, 41
1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 1751.67, 42
3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 44
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 46
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 47
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 48
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 50
and 3924.73 be amended and sections 1751.57, 1751.58, 3901.044, 51
3923.571, 3923.581, 3924.031, 3924.032, 3924.033, and 3924.27 of 52
the Revised Code be enacted to read as follows: 54
Sec. 1739.05. (A) A multiple employer welfare arrangement 63
that is created pursuant to sections 1739.01 to 1739.22 of the 64
Revised Code and that operates a group self-insurance program may 65
be established only if any of the following applies: 66
(1) The arrangement has and maintains a minimum enrollment 68
of three hundred employees of two or more employers. 69
(2) The arrangement has and maintains a minimum enrollment 71
of three hundred self-employed individuals. 72
(3) The arrangement has and maintains a minimum enrollment 74
of three hundred employees or self-employed individuals in any 75
combination of divisions (A)(1) and (2) of this section. 76
(B) A multiple employer welfare arrangement that is 78
created pursuant to sections 1739.01 to 1739.22 of the Revised 79
Code and that operates a group self-insurance program shall 80
comply with all laws applicable to self-funded programs in this 81
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 82
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 83
3923.301, and 3923.38, 3923.581, 3923.63, 3924.031, 3924.032, AND 86
3924.27 of the Revised Code. 87
(C) A multiple employer welfare arrangement created 89
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 90
solicit enrollments only through agents or solicitors licensed 91
pursuant to Chapter 3905. of the Revised Code to sell or solicit 92
sickness and accident insurance. 93
3
(D) A multiple employer welfare arrangement created 95
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 96
provide benefits only to individuals who are members, employees 97
of members, or the dependents of members or employees, or are 98
eligible for continuation of coverage under section 1751.53 or 99
3923.38 of the Revised Code or under Title X of the "Consolidated 100
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 101
U.S.C.A. 1161, as amended. 102
Sec. 1751.06. Upon obtaining a certificate of authority as 111
required under this chapter, a health insuring corporation may do 113
all of the following:
(A) Enroll individuals and their dependents in either of 115
the following circumstances: 116
(1) The individual resides OR LIVES in the approved 118
service area.
(2) The individual's place of employment is located in the 121
approved service area and the individual has agreed to receive 122
health care services in accordance with the evidence of coverage. 123
(B) Contract with providers and health care facilities for 125
the health care services to which enrollees are entitled under 126
the terms of the health insuring corporation's health care 127
contracts;
(C) Contract with insurance companies authorized to do 130
business in this state for insurance, indemnity, or reimbursement 131
against the cost of providing emergency and nonemergency health 132
care services for enrollees, subject to the provisions set forth 133
in this chapter and the limitations set forth in the Revised 135
Code;
(D) Contract with any person pursuant to the requirements 137
of division (A)(18) of section 1751.03 of the Revised Code for 138
managerial or administrative services, or for data processing, 139
actuarial analysis, billing services, or any other services 140
authorized by the superintendent of insurance. However, a health 142
insuring corporation shall not enter into a contract for any of 143
4
the services listed in this division with an insurance company 144
that is not authorized to engage in the business of insurance in 145
this state.
(E) Accept from governmental agencies, private agencies, 147
corporations, associations, groups, individuals, or other 148
persons, payments covering all or part of the costs of planning, 149
development, construction, and the provision of health care 150
services;
(F) Purchase, lease, construct, renovate, operate, or 152
maintain health care facilities, and their ancillary equipment, 153
and any property necessary in the transaction of the business of 154
the health insuring corporation.;
(G) IN THE EMPLOYER GROUP MARKET, IMPOSE AN AFFILIATION 157
PERIOD OF NOT MORE THAN SIXTY DAYS, WHICH PERIOD BEGINS ON THE 158
INDIVIDUAL'S DATE OF ENROLLMENT AND RUNS CONCURRENTLY WITH ANY 159
WAITING PERIOD IMPOSED UNDER THE COVERAGE. FOR PURPOSES OF THIS 160
DIVISION, "AFFILIATION PERIOD" MEANS A PERIOD OF TIME WHICH, 161
UNDER THE TERMS OF THE COVERAGE OFFERED, MUST EXPIRE BEFORE THE 162
COVERAGE BECOMES EFFECTIVE. NO HEALTH CARE SERVICES OR BENEFITS 163
NEED TO BE PROVIDED DURING AN AFFILIATION PERIOD, AND NO PERIODIC 164
PREPAYMENTS CAN BE CHARGED FOR ANY COVERAGE DURING THAT PERIOD. 165
(H) IF A HEALTH INSURING CORPORATION OFFERS COVERAGE IN 168
THE SMALL EMPLOYER GROUP MARKET THROUGH A NETWORK PLAN, LIMIT OR 169
DENY THE COVERAGE IN ACCORDANCE WITH SECTION 3924.031 OF THE 171
REVISED CODE; 172
(I) REFUSE TO ISSUE COVERAGE IN THE SMALL EMPLOYER GROUP 175
MARKET PURSUANT TO SECTION 3924.032 OF THE REVISED CODE; 177
(J) ESTABLISH EMPLOYER CONTRIBUTION RULES OR GROUP 180
PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN CONNECTION 181
WITH A GROUP CONTRACT IN THE SMALL EMPLOYER GROUP MARKET, AS 182
PROVIDED IN DIVISION (E)(1) OF SECTION 3924.03 OF THE REVISED 185
CODE.
Nothing in this section shall be construed as prohibiting a 187
health insuring corporation without other commercial enrollment 188
5
from contracting solely with federal health care programs 189
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 191
authority of a health insuring corporation to perform those 192
functions not otherwise prohibited by law. 193
Sec. 1751.15. (A) After a health insuring corporation has 202
furnished, directly or indirectly, basic health care services for 203
a period of twenty-four months, and if it currently meets the 204
financial requirements set forth in section 1751.28 of the 205
Revised Code and had net income as reported to the superintendent 206
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 207
less than thirty days during its month of licensure FOR 209
INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS. 210
(B) During the open enrollment period described in 212
division (A) of this section, the health insuring corporation 213
shall accept applicants and their dependents in the order in 214
which they apply for enrollment and in accordance with any of the 215
following:
(1) Up to its capacity, as determined by the health 217
insuring corporation subject to review by the superintendent; 218
(2) If less than its capacity, one per cent of the health 220
insuring corporation's total number of subscribers residing in 221
this state as of the immediately preceding thirty-first day of 222
December. 223
(C) Where a health insuring corporation demonstrates to 225
the satisfaction of the superintendent that such open enrollment 226
would jeopardize its economic viability, the superintendent may 227
do any of the following:
(1) Waive the requirement for open enrollment; 229
(2) Impose a limit on the number of applicants and their 231
dependents that must be enrolled; 232
(3) Authorize such underwriting restrictions upon open 234
enrollment as are necessary to do any of the following: 235
6
(a) Preserve its financial stability; 237
(b) Prevent excessive adverse selection; 239
(c) Avoid unreasonably high or unmarketable charges for 241
coverage of health care services. 242
(D)(1) A request to the superintendent under division (C) 245
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 246
documentation, including financial data. In reviewing the 247
request, the superintendent may consider various factors, 248
including the size of the health insuring corporation, the health 249
insuring corporation's net worth and profitability, the health 250
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 251
(2) Any action taken by the superintendent under division 253
(C) of this section shall be effective for a period of not more 255
than one year. At the expiration of such time, a new 256
demonstration of the health insuring corporation's need for the 257
restriction, limit, or waiver shall be made before a new 258
restriction, limit, or waiver is granted by the superintendent. 259
(3) Irrespective of the granting of any restriction, 261
limit, or waiver by the superintendent, a health insuring 262
corporation may reject an applicant or a dependent of the 263
applicant during its open enrollment period if the applicant or 264
dependent: 265
(a) Was eligible for and was covered under any 267
employer-sponsored health care coverage, or if employer-sponsored 268
health care coverage was available at the time of open 269
enrollment;
(b) Is eligible for conversion or continuation coverage 271
under state or federal law; 272
(c) Is eligible for medicare, and the health insuring 274
corporation does not have an agreement on appropriate payment 275
mechanisms with the governmental agency administering the 276
medicare program.
7
(E) A health insuring corporation shall not be required 278
either to enroll applicants or their dependents who are confined 279
to a health care facility because of chronic illness, permanent 280
injury, or other infirmity that would cause economic impairment 281
to the health insuring corporation if such applicants or their 282
dependents were enrolled or to make the effective date of 283
benefits for applicants or their dependents enrolled under this 284
section earlier than ninety days after the date of enrollment. 285
(F) A health insuring corporation shall not be required to 287
cover the fees or costs, or both, for any basic health care 288
service related to a transplant of a body organ if the transplant 289
occurs within one year after the effective date of an enrollee's 290
coverage under this section. This limitation on coverage does 291
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 292
(G) Each health insuring corporation required to hold an 294
open enrollment pursuant to division (A) of this section shall 295
file with the superintendent, not later than sixty days prior to 296
the commencement of the proposed open enrollment period, the 297
following documents:
(1) The proposed public notice of open enrollment; 299
(2) The evidence of coverage approved pursuant to section 301
1751.11 of the Revised Code that will be used during open 303
enrollment;
(3) The contractual periodic prepayment and premium rate 305
approved pursuant to section 1751.12 of the Revised Code that 306
will be applicable during open enrollment; 307
(4) Any solicitation document approved pursuant to section 310
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 311
(5) A list of the proposed dates of publication of the 313
public notice, and the names of the newspapers in which the 314
notice will appear; 315
(6) Any request for a restriction, limit, or waiver with 317
8
respect to the open enrollment period, along with any supporting 318
documentation. 319
(H)(1) An open enrollment period shall not satisfy the 321
requirements of this section unless the health insuring 322
corporation provides adequate public notice in accordance with 323
divisions (H)(2) and (3) of this section. No public notice shall 324
be used until the form of the public notice has been filed by the 325
health insuring corporation with the superintendent. If the 326
superintendent does not disapprove the public notice within sixty 327
days after it is filed, it shall be deemed approved, unless the 328
superintendent sooner gives approval for the public notice. If 329
the superintendent determines within this sixty-day period that 330
the public notice fails to meet the requirements of this section, 331
the superintendent shall so notify the health insuring 332
corporation and it shall be unlawful for the health insuring 333
corporation to use the public notice. Such disapproval shall be 334
effected by a written order, which shall state the grounds for 335
disapproval and shall be issued in accordance with Chapter 119. 336
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 338
section shall be published in at least one newspaper of general 339
circulation in each county in the health insuring corporation's 340
service area, at least once in each of the two weeks immediately 341
preceding the month in which the open enrollment is to occur and 342
in each week of that month, or until the enrollment limitation is 343
reached, whichever occurs first. The notice published during the 344
last week of open enrollment shall appear not less than five days 345
before the end of the open enrollment period. It shall be at 346
least two newspaper columns wide or two and one-half inches wide, 348
whichever is larger. The first two lines of the text shall be 349
published in not less than twelve-point, boldface type. The 350
remainder of the text of the notice shall be published in not 351
less than eight-point type. The entire public notice shall be 352
surrounded by a continuous black line not less than one-eighth of 353
9
an inch wide.
(3) The following information shall be included in the 355
public notice provided under division (H)(2) of this section: 356
(a) The dates that open enrollment will be held and the 358
date coverage obtained under the open enrollment will become 359
effective;
(b) Notice that an applicant or the applicant's dependents 361
will not be denied coverage during open enrollment because of a 362
preexisting health condition, but that some limitations and 363
restrictions may apply;
(c) The address where a person may obtain an application; 365
(d) The telephone number that a person may call to request 367
an application or to ask questions; 369
(e) The date the first payment will be due; 371
(f) The actual rates or range of rates that will be 373
applicable for applicants; 374
(g) Any limitation granted by the superintendent on the 377
number of applications that will be accepted by the health 378
insuring corporation.
(4) Within thirty days after the end of an open enrollment 381
period, the health insuring corporation shall submit to the 382
superintendent proof of publication for the public notices, and 383
shall report the total number of applicants and their dependents 384
enrolled during the open enrollment period. 385
(I)(1) No health insuring corporation may employ any 387
scheme, plan, or device that restricts the ability of any person 388
to enroll during open enrollment. 389
(2) No health insuring corporation may require enrollment 391
to be made in person. Every health insuring corporation shall 392
permit application for coverage by mail. A representative of the 394
health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 395
operations of the health insuring corporation and to answer any 396
questions the applicant may have. Every health insuring 397
10
corporation shall make open enrollment applications and 398
solicitation documents readily available to any potential 399
applicant who requests such material. 400
(J) An application postmarked on the last day of an open 402
enrollment period shall qualify as a valid application, 403
regardless of the date on which it is received by the health 404
insuring corporation.
(K) This section does not apply to any health insuring 406
corporation that offers only supplemental health care services or 408
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 409
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 410
U.S.C.A. 301, as amended, and that has no other commercial 411
enrollment, or to any health insuring corporation that offers 412
plans only through other federal health care programs regulated 413
by federal regulatory bodies and that has no other commercial 414
enrollment.
(L) EACH HEALTH INSURING CORPORATION SHALL ACCEPT 417
FEDERALLY ELIGIBLE INDIVIDUALS FOR OPEN ENROLLMENT COVERAGE AS 418
PROVIDED IN SECTION 3923.581 OF THE REVISED CODE. A HEALTH 420
INSURING CORPORATION MAY REINSURE COVERAGE OF ANY FEDERALLY 421
ELIGIBLE INDIVIDUAL ACQUIRED UNDER THAT SECTION WITH THE OPEN 422
ENROLLMENT REINSURANCE PROGRAM IN ACCORDANCE WITH DIVISION (G) OF 424
SECTION 3924.11 OF THE REVISED CODE. FIXED PERIODIC PREPAYMENT 427
RATES CHARGED FOR COVERAGE REINSURED BY THE PROGRAM SHALL BE 428
ESTABLISHED IN ACCORDANCE WITH SECTION 3924.12 OF THE REVISED 430
CODE.
(M) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 433
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 435
148.103. 436
Sec. 1751.16. (A) Except as provided in division (F) of 445
this section, every group contract issued by a health insuring 446
corporation shall provide an option for conversion to an 447
individual contract issued on a direct-payment basis to any 448
11
subscriber covered by the group contract who terminates 449
employment or membership in the group, unless: 450
(1) Termination of the conversion option or contract is 452
based upon nonpayment of premium after reasonable notice in 453
writing has been given by the health insuring corporation to the 454
subscriber. 455
(2) The subscriber is, or is eligible to be, covered for 457
benefits at least comparable to the group contract under any of 458
the following: 459
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 461
(1935), 42 U.S.C.A. 301, as amended; 462
(b) Any act of congress or law under this or any other 464
state of the United States providing coverage at least comparable 465
to the benefits under division (A)(2)(a) of this section; 466
(c) Any policy of insurance or health care plan providing 468
coverage at least comparable to the benefits under division 469
(A)(2)(a) of this section. 470
(B)(1) The direct-payment contract offered by the health 472
insuring corporation pursuant to division (A) of this section 474
shall provide benefits comparable to the benefits being provided 475
by any of the individual contracts then being issued to 476
individual subscribers by the health insuring corporation. The 477
contract may contain a coordination of benefits provision as 478
approved by the superintendent of insurance THE FOLLOWING: 480
(a) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 483
ELIGIBLE INDIVIDUAL, BENEFITS COMPARABLE TO BENEFITS IN ANY OF 484
THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO INDIVIDUAL 485
SUBSCRIBERS BY THE HEALTH INSURING CORPORATION; 486
(b) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 489
BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 490
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 491
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 492
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (B)(1)(b) OF 494
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 495
12
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 496
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. THE 497
CONTRACTUAL PERIODIC PREPAYMENTS CHARGED FOR SUCH PLANS MAY NOT 498
EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE STANDARD 499
RATE CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH THE 500
ORGANIZATION IS CURRENTLY ACCEPTING NEW BUSINESS AND FOR WHICH 501
SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 502
(2) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 504
DIVISION (A) OF THIS SECTION MAY INCLUDE A COORDINATION OF 506
BENEFITS PROVISION AS APPROVED BY THE SUPERINTENDENT. 507
(3) FOR PURPOSES OF DIVISION (B) OF THIS SECTION 510
"FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS 511
DEFINED IN 45 C.F.R. 148.103. 514
(C) The option for conversion shall be available: 516
(1) Upon the death of the subscriber, to the surviving 518
spouse with respect to SUCH OF the spouse or AND dependents who 520
were AS ARE then covered by the group contract; 521
(2) To a child solely with respect to the child upon the 523
child's attaining the limiting age of coverage under the group 524
contract while covered as a dependent under the contract; 525
(3) Upon the divorce, dissolution, or annulment of the 527
marriage of the subscriber, to the divorced spouse, or, in the 528
event of annulment, to the former spouse of the subscriber. 530
(D) No health insuring corporation shall do any of the 532
following:
(1) Use USE age as the basis for refusing to renew a 534
converted contract; 535
(2) Require a subscriber to produce evidence of 537
insurability in order to exercise the option for conversion 538
provided by this section; 539
(3) Include preexisting condition limitations in a 541
converted contract. 542
(E) Written notice of the conversion option provided by 545
this section shall be given to the subscriber by the health 546
13
insuring corporation by mail. The notice shall be sent to the 547
subscriber's address in the records of the employer upon receipt 548
of notice from the employer of the event giving rise to the 549
conversion option. If the subscriber has not received notice of 550
the conversion privilege at least fifteen days prior to the 551
expiration of the thirty-day conversion period, then the 552
subscriber shall have an additional period within which to 553
exercise the privilege. This additional period shall expire 554
fifteen days after the subscriber receives notice, but in no 555
event shall the period extend beyond sixty days after the 556
expiration of the thirty-day conversion period. 557
(F) This section does not apply to any group contract 559
offering only supplemental health care services or specialty 560
health care services.
Sec. 1751.18. (A)(1) No health insuring corporation shall 569
cancel or fail to renew the coverage of a subscriber or enrollee 570
because of the subscriber's or enrollee's ANY health status or 572
requirement STATUS-RELATED FACTOR IN RELATION TO THE SUBSCRIBER 573
OR ENROLLEE, THE SUBSCRIBER'S OR ENROLLEE'S REQUIREMENTS for 575
health care services, or for any other reason designated under 576
rules adopted by the superintendent of insurance. 577
(2) Unless otherwise required by state or federal law, no 579
health insuring corporation, or health care facility or provider 580
through which the health insuring corporation has made 581
arrangements to provide health care services, shall discriminate 582
against any individual with regard to enrollment, disenrollment, 583
or the quality of health care services rendered, on the basis of 584
the individual's race, color, sex, age, religion, state of 585
health, or status as a recipient of medicare or medical 586
assistance under Title XVIII or XIX of the "Social Security Act," 587
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, OR ANY HEALTH 589
STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL. However, a 590
health insuring corporation shall not be required to accept a 592
recipient of medicare or medical assistance, if an agreement has 593
14
not been reached on appropriate payment mechanisms between the 594
health insuring corporation and the governmental agency 595
administering these programs. Further, except during a period of 596
open enrollment under section 1751.15 of the Revised Code, a 597
health insuring corporation may reject an applicant for nongroup 598
enrollment on the basis of the state of ANY health of 599
STATUS-RELATED FACTOR IN RELATION TO the applicant. 601
(B) A health insuring corporation may cancel or decide not 604
to renew the coverage of a subscriber or AN enrollee for any of 605
the following reasons:
(1) Failure of the subscriber or enrollee to pay, or to 607
have paid on the subscriber's or enrollee's behalf, the required 608
premium rate or other charge; 609
(2) Fraud or forgery; 611
(3) Any material misrepresentation on the application for 613
coverage; 614
(4) The subscriber's or enrollee's permitting the use of 616
an identification card or similar documents by another person, 617
allowing that person to receive services for which that person is 619
not entitled;
(5) The subscriber's or enrollee's inability to establish 621
or maintain a provider-patient relationship with any provider 622
associated with the health insuring corporation, which inability 623
may include the subscriber's or enrollee's disruptive or abusive 624
behavior toward providers or the staff of the health care plan IF 626
THE ENROLLEE HAS PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES 627
FRAUD OR INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE 629
TERMS OF THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS
NOT BASED, EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH 630
STATUS-RELATED FACTOR IN RELATION TO THE ENROLLEE. 631
(C) A subscriber or AN enrollee may appeal any action or 633
decision of the A health insuring corporation under division (B) 637
of this section TAKEN PURSUANT TO SECTION 2742(b) TO (e) OF THE 640
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 641
15
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 643
AMENDED. To appeal, the subscriber or enrollee may submit a 646
written complaint to the health insuring corporation pursuant to 647
section 1751.19 of the Revised Code. The subscriber or enrollee 648
may, within thirty days after receiving a written response from 649
the health insuring corporation, appeal the health insuring 650
corporation's action or decision to the superintendent. 651
(D) AS USED IN THIS SECTION, "HEALTH STATUS-RELATED 653
FACTOR" MEANS ANY OF THE FOLLOWING: 654
(1) HEALTH STATUS; 656
(2) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 659
ILLNESSES;
(3) CLAIMS EXPERIENCE; 661
(4) RECEIPT OF HEALTH CARE; 663
(5) MEDICAL HISTORY; 665
(6) GENETIC INFORMATION; 667
(7) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 670
OUT OF ACTS OF DOMESTIC VIOLENCE;
(8) DISABILITY. 672
Sec. 1751.57. (A) THE FOLLOWING CONDITIONS APPLY TO ALL 674
INDIVIDUAL HEALTH INSURING CORPORATION CONTRACTS: 675
(1) EXCEPT AS PROVIDED IN SECTION 2742(b) TO (e) OF THE 679
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," 684
PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-42, AS 689
AMENDED, A HEALTH INSURING CORPORATION THAT PROVIDES INDIVIDUAL 690
COVERAGE TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN FORCE SUCH 691
COVERAGE AT THE OPTION OF THE INDIVIDUAL. 692
(2) SUCH INDIVIDUAL CONTRACTS ARE SUBJECT TO SECTIONS 2743 694
AND 2747 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 698
ACT OF 1996." 699
(3) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 703
SHALL APPLY TO HEALTH INSURING CORPORATION CONTRACTS OFFERED IN 704
THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO HEALTH 705
BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 706
16
(B) IN ACCORDANCE WITH 45 C.F.R. 148.102, THIS SECTION 711
ALSO APPLIES TO ALL GROUP HEALTH INSURING CORPORATION CONTRACTS 712
THAT ARE NOT SOLD IN CONNECTION WITH AN EMPLOYMENT-RELATED GROUP 713
HEALTH CARE PLAN AND THAT PROVIDE MORE THAN SHORT-TERM, LIMITED 714
DURATION COVERAGE.
Sec. 1751.58. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2721 717
OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 721
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-21, 727
AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP HEALTH 728
INSURING CORPORATION CONTRACTS THAT ARE SOLD IN CONNECTION WITH 729
AN EMPLOYMENT-RELATED GROUP HEALTH CARE PLAN AND THAT ARE NOT 730
SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 732
(A) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 736
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 740
A HEALTH INSURING CORPORATION OFFERS COVERAGE IN THE SMALL OR 741
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE 742
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT 743
THE OPTION OF THE CONTRACT HOLDER. 744
(B) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISION (E)(1) OF 747
SECTION 3924.03 AND SECTIONS 3924.033 AND 3924.27 OF THE REVISED 748
CODE. 749
(C) SUCH GROUP CONTRACTS SHALL PROVIDE FOR THE SPECIAL 752
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 755
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 758
Sec. 1751.59. (A) No individual or group health insuring 767
corporation policy, contract, or agreement providing THAT MAKES 768
family coverage AVAILABLE may be delivered, issued for delivery, 770
or renewed in this state, unless the policy, contract, or
agreement covers adopted children of the subscriber on the same 771
basis as other dependents. 772
(B) The coverage required by this section is subject to 774
the requirements and restrictions set forth in section 3924.51 of 775
the Revised Code. Coverage for dependent children living outside 777
the health insuring corporation's approved service area must be 778
17
provided if a court order requires the subscriber to provide 779
health care coverage.
Sec. 1751.61. (A) Each individual or group evidence of 789
coverage that is delivered, issued for delivery, or renewed by a 790
health insuring corporation in this state, and that provides 791
MAKES coverage AVAILABLE for family members of a subscriber, also 793
shall provide that coverage applicable to children is payable 794
from the moment of birth with respect to a newly born child of 795
the subscriber or subscriber's spouse. 796
(B) Coverage for a newly born child is effective for a 798
period of thirty-one days from the date of birth. 799
(C) To continue coverage for a newly born child beyond the 801
thirty-one day period described in division (B) of this section, 802
the subscriber shall notify the health insuring corporation 803
within that period.
(D) If payment of a specific premium rate is required to 805
provide coverage under this section for an additional child, the 806
evidence of coverage may require the subscriber to make this 807
payment to the health insuring corporation within the thirty-one 808
day period described in division (B) of this section in order to 809
continue the coverage beyond that period. 810
Sec. 1751.64. (A) As used in this section, "genetic 820
screening or testing" means a laboratory test of a person's genes 821
or chromosomes for abnormalities, defects, or deficiencies, 822
including carrier status, that are linked to physical or mental 823
disorders or impairments, or that indicate a susceptibility to 824
illness, disease, or other disorders, whether physical or mental, 825
which test is a direct test for abnormalities, defects, or 826
deficiencies, and not an indirect manifestation of genetic 827
disorders.
(B) No health insuring corporation, in processing an 830
application for coverage for health care services under an 831
individual or group health insuring corporation policy, contract, 832
or agreement or in determining insurability under such a policy, 833
18
contract, or agreement, shall do any of the following: 834
(1) Require an individual seeking coverage to submit to 836
genetic screening or testing; 837
(2) Take into consideration, other than in accordance with 840
division (F) of this section, the results of genetic screening or 841
testing;
(3) Make any inquiry to determine the results of genetic 843
screening or testing; 844
(4) Make a decision adverse to the applicant based on 846
entries in medical records or other reports of genetic screening 847
or testing. 848
(C) In developing and asking questions regarding medical 851
histories of applicants for coverage under an individual or group 852
health insuring corporation policy, contract, or agreement, no 853
health insuring corporation shall ask for the results of genetic 854
screening or testing or ask questions designed to ascertain the 855
results of genetic screening or testing. 856
(D) No health insuring corporation shall cancel or refuse 859
to issue or renew coverage for health care services based on the 860
results of genetic screening or testing. 861
(E) No health insuring corporation shall deliver, issue 864
for delivery, or renew an individual or group policy, contract, 865
or agreement in this state that limits benefits based on the 866
results of genetic screening or testing. 867
(F) A health insuring corporation may consider the results 870
of genetic screening or testing if the results are voluntarily 871
submitted by an applicant for coverage or renewal of coverage and 872
the results are favorable to the applicant. 873
(G) A violation of this section is an unfair and deceptive 876
act or practice in the business of insurance under sections 877
3901.19 to 3901.26 of the Revised Code. 879
Sec. 1751.65. (A) As used in this section, "genetic 889
screening or testing" means a laboratory test of a person's genes 890
or chromosomes for abnormalities, defects, or deficiencies, 891
19
including carrier status, that are linked to physical or mental 892
disorders or impairments, or that indicate a susceptibility to 893
illness, disease, or other disorders, whether physical or mental, 894
which test is a direct test for abnormalities, defects, or 895
deficiencies, and not an indirect manifestation of genetic 896
disorders. 897
(B) Upon the repeal of section 1751.64 of the Revised 900
Code, no health insuring corporation shall do either of the 902
following:
(1) Consider, in a manner adverse to an applicant or 904
insured, any information obtained from genetic screening or 905
testing conducted prior to the repeal of section 1751.64 of the 906
Revised Code in processing an application for coverage for health 909
care services under an individual or group policy, contract, or 910
agreement or in determining insurability under such a policy, 911
contract, or agreement; 912
(2) Inquire, directly or indirectly, into the results of 914
genetic screening or testing conducted prior to the repeal of 915
section 1751.64 of the Revised Code, or use such information, in 918
whole or in part, to cancel, refuse to issue or renew, or limit 919
benefits under, an individual or group policy, contract, or 920
agreement.
(C) Any health insuring corporation that has engaged in, 923
is engaged in, or is about to engage in a violation of division 924
(B) of this section is subject to the jurisdiction of the 926
superintendent of insurance under section 3901.04 of the Revised 927
Code.
Sec. 1751.67. (A) Each individual or group health 936
insuring corporation policy, contract, or agreement delivered, 937
issued for delivery, or renewed in this state that provides 938
maternity benefits shall provide coverage of inpatient care and 939
follow-up care for a mother and her newborn as follows: 940
(1) The policy, contract, or agreement shall cover a 942
minimum of forty-eight hours of inpatient care following a normal 944
20
vaginal delivery and a minimum of ninety-six hours of inpatient 945
care following a cesarean delivery. Services covered as 946
inpatient care shall include medical, educational, and any other 947
services that are consistent with the inpatient care recommended 948
in the protocols and guidelines developed by national 949
organizations that represent pediatric, obstetric, and nursing 950
professionals.
(2) The policy, contract, or agreement shall cover a 952
physician-directed source of follow-up care. Services covered as 954
follow-up care shall include physical assessment of the mother 955
and newborn, parent education, assistance and training in breast 956
or bottle feeding, assessment of the home support system,
performance of any medically necessary and appropriate clinical 957
tests, and any other services that are consistent with the 958
follow-up care recommended in the protocols and guidelines 959
developed by national organizations that represent pediatric, 960
obstetric, and nursing professionals. The coverage shall apply 961
to services provided in a medical setting or through home health 962
care visits. The coverage shall apply to a home health care 963
visit only if the provider who conducts the visit is 964
knowledgeable and experienced in maternity and newborn care. 965
When a decision is made in accordance with division (B) of 968
this section to discharge a mother or newborn prior to the
expiration of the applicable number of hours of inpatient care 969
required to be covered, the coverage of follow-up care shall 970
apply to all follow-up care that is provided within forty-eight 971
SEVENTY-TWO hours after discharge. When a mother or newborn 972
receives at least the number of hours of inpatient care required 974
to be covered, the coverage of follow-up care shall apply to 975
follow-up care that is determined to be medically necessary by 976
the provider responsible for discharging the mother or newborn. 977
(B) Any decision to shorten the length of inpatient stay 979
to less than that specified under division (A)(1) of this section 981
shall be made by the physician attending the mother or newborn, 982
21
except that if a nurse-midwife is attending the mother in 983
collaboration with a physician, the decision may be made by the 984
nurse-midwife. Decisions regarding early discharge shall be made 985
only after conferring with the mother or a person responsible for 986
the mother or newborn. For purposes of this division, a person 987
responsible for the mother or newborn may include a parent, 988
guardian, or any other person with authority to make medical 989
decisions for the mother or newborn.
(C)(1) No health insuring corporation may do either of the 991
following:
(a) Terminate the participation of a provider or health 993
care facility in an individual or group health care plan solely 994
for making recommendations for inpatient or follow-up care for a 995
particular mother or newborn that are consistent with the care 996
required to be covered by this section; 997
(b) Establish or offer monetary or other financial 999
incentives for the purpose of encouraging a person to decline the 1,001
inpatient or follow-up care required to be covered by this
section. 1,002
(2) Whoever violates division (C)(1)(a) or (b) of this 1,004
section has engaged in an unfair and deceptive act or practice in 1,005
the business of insurance under sections 3901.19 to 3901.26 of 1,006
the Revised Code.
(D) This section does not do any of the following: 1,008
(1) Require a policy, contract, or agreement to cover 1,010
inpatient or follow-up care that is not received in accordance 1,011
with the policy's, contract's, or agreement's terms pertaining to 1,012
the providers and facilities from which an individual is 1,013
authorized to receive health care services; 1,014
(2) Require a mother or newborn to stay in a hospital or 1,016
other inpatient setting for a fixed period of time following 1,017
delivery;
(3) Require a child to be delivered in a hospital or other 1,019
inpatient setting;
22
(4) Authorize a nurse-midwife to practice beyond the 1,021
authority to practice nurse-midwifery in accordance with Chapter 1,022
4723. of the Revised Code; 1,023
(5) Establish minimum standards of medical diagnosis, 1,025
care, or treatment for inpatient or follow-up care for a mother 1,026
or newborn. A deviation from the care required to be covered 1,027
under this section shall not, solely on the basis of this 1,028
section, give rise to a medical claim or to derivative claims for 1,029
relief, as those terms are defined in section 2305.11 of the 1,030
Revised Code.
Sec. 3901.044. THE SUPERINTENDENT OF INSURANCE MAY ADOPT 1,033
RULES IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE THAT 1,036
THE SUPERINTENDENT CONSIDERS NECESSARY AND ADVISABLE FOR THE 1,037
PURPOSE OF IMPLEMENTING THE "HEALTH INSURANCE PORTABILITY AND 1,041
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 1,046
42 U.S.C.A. 300gg, AS AMENDED, AND ANY REGULATION ADOPTED 1,048
THEREUNDER. 1,049
Sec. 3901.21. The following are hereby defined as unfair 1,058
and deceptive acts or practices in the business of insurance: 1,059
(A) Making, issuing, circulating, or causing or permitting 1,061
to be made, issued, or circulated, or preparing with intent to so 1,062
use, any estimate, illustration, circular, or statement 1,063
misrepresenting the terms of any policy issued or to be issued or 1,064
the benefits or advantages promised thereby or the dividends or 1,065
share of the surplus to be received thereon, or making any false 1,066
or misleading statements as to the dividends or share of surplus 1,067
previously paid on similar policies, or making any misleading 1,068
representation or any misrepresentation as to the financial 1,069
condition of any insurer as shown by the last preceding verified 1,070
statement made by it to the insurance department of this state, 1,071
or as to the legal reserve system upon which any life insurer 1,072
operates, or using any name or title of any policy or class of 1,073
policies misrepresenting the true nature thereof, or making any 1,074
misrepresentation or incomplete comparison to any person for the 1,075
23
purpose of inducing or tending to induce such person to purchase, 1,076
amend, lapse, forfeit, change, or surrender insurance. 1,077
Any written statement concerning the premiums for a policy 1,079
which refers to the net cost after credit for an assumed 1,080
dividend, without an accurate written statement of the gross 1,081
premiums, cash values, and dividends based on the insurer's 1,082
current dividend scale, which are used to compute the net cost 1,083
for such policy, and a prominent warning that the rate of 1,084
dividend is not guaranteed, is a misrepresentation for the 1,085
purposes of this division. 1,086
(B) Making, publishing, disseminating, circulating, or 1,088
placing before the public or causing, directly or indirectly, to 1,089
be made, published, disseminated, circulated, or placed before 1,090
the public, in a newspaper, magazine, or other publication, or in 1,091
the form of a notice, circular, pamphlet, letter, or poster, or 1,092
over any radio station, or in any other way, or preparing with 1,093
intent to so use, an advertisement, announcement, or statement 1,094
containing any assertion, representation, or statement, with 1,095
respect to the business of insurance or with respect to any 1,096
person in the conduct of his THE PERSON'S insurance business, 1,097
which is untrue, deceptive, or misleading. 1,098
(C) Making, publishing, disseminating, or circulating, 1,100
directly or indirectly, or aiding, abetting, or encouraging the 1,101
making, publishing, disseminating, or circulating, or preparing 1,102
with intent to so use, any statement, pamphlet, circular, 1,103
article, or literature, which is false as to the financial 1,104
condition of an insurer and which is calculated to injure any 1,105
person engaged in the business of insurance. 1,106
(D) Filing with any supervisory or other public official, 1,108
or making, publishing, disseminating, circulating, or delivering 1,109
to any person, or placing before the public, or causing directly 1,110
or indirectly to be made, published, disseminated, circulated, 1,111
delivered to any person, or placed before the public, any false 1,112
statement of financial condition of an insurer. 1,113
24
Making any false entry in any book, report, or statement of 1,115
any insurer with intent to deceive any agent or examiner lawfully 1,116
appointed to examine into its condition or into any of its 1,117
affairs, or any public official to whom such insurer is required 1,118
by law to report, or who has authority by law to examine into its 1,119
condition or into any of its affairs, or, with like intent, 1,120
willfully omitting to make a true entry of any material fact 1,121
pertaining to the business of such insurer in any book, report, 1,122
or statement of such insurer, or mutilating, destroying, 1,123
suppressing, withholding, or concealing any of its records. 1,124
(E) Issuing or delivering or permitting agents, officers, 1,126
or employees to issue or deliver agency company stock or other 1,127
capital stock or benefit certificates or shares in any common-law 1,128
corporation or securities or any special or advisory board 1,129
contracts or other contracts of any kind promising returns and 1,130
profits as an inducement to insurance. 1,131
(F) Making or permitting any unfair discrimination among 1,133
individuals of the same class and equal expectation of life in 1,134
the rates charged for any contract of life insurance or of life 1,135
annuity or in the dividends or other benefits payable thereon, or 1,136
in any other of the terms and conditions of such contract. 1,137
(G)(1) Except as otherwise expressly provided by law, 1,139
knowingly permitting or offering to make or making any contract 1,140
of life insurance, life annuity or accident and health insurance, 1,141
or agreement as to such contract other than as plainly expressed 1,142
in the contract issued thereon, or paying or allowing, or giving 1,143
or offering to pay, allow, or give, directly or indirectly, as 1,144
inducement to such insurance, or annuity, any rebate of premiums 1,145
payable on the contract, or any special favor or advantage in the 1,146
dividends or other benefits thereon, or any valuable 1,147
consideration or inducement whatever not specified in the 1,148
contract; or giving, or selling, or purchasing, or offering to 1,149
give, sell, or purchase, as inducement to such insurance or 1,150
annuity or in connection therewith, any stocks, bonds, or other 1,151
25
securities, or other obligations of any insurance company or 1,152
other corporation, association, or partnership, or any dividends 1,153
or profits accrued thereon, or anything of value whatsoever not 1,154
specified in the contract. 1,155
(2) Nothing in division (F) or division (G)(1) of this 1,157
section shall be construed as prohibiting any of the following 1,158
practices: (a) in the case of any contract of life insurance or 1,159
life annuity, paying bonuses to policyholders or otherwise 1,160
abating their premiums in whole or in part out of surplus 1,161
accumulated from nonparticipating insurance, provided that any 1,162
such bonuses or abatement of premiums shall be fair and equitable 1,163
to policyholders and for the best interests of the company and 1,164
its policyholders; (b) in the case of life insurance policies 1,165
issued on the industrial debit plan, making allowance to 1,166
policyholders who have continuously for a specified period made 1,167
premium payments directly to an office of the insurer in an 1,168
amount which fairly represents the saving in collection expenses; 1,169
(c) readjustment of the rate of premium for a group insurance 1,170
policy based on the loss or expense experience thereunder, at the 1,171
end of the first or any subsequent policy year of insurance 1,172
thereunder, which may be made retroactive only for such policy 1,173
year. 1,174
(H) Making, issuing, circulating, or causing or permitting 1,176
to be made, issued, or circulated, or preparing with intent to so 1,177
use, any statement to the effect that a policy of life insurance 1,178
is, is the equivalent of, or represents shares of capital stock 1,179
or any rights or options to subscribe for or otherwise acquire 1,180
any such shares in the life insurance company issuing that policy 1,181
or any other company. 1,182
(I) Making, issuing, circulating, or causing or permitting 1,184
to be made, issued or circulated, or preparing with intent to so 1,185
issue, any statement to the effect that payments to a 1,186
policyholder of the principal amounts of a pure endowment are 1,187
other than payments of a specific benefit for which specific 1,188
26
premiums have been paid. 1,189
(J) Making, issuing, circulating, or causing or permitting 1,191
to be made, issued, or circulated, or preparing with intent to so 1,192
use, any statement to the effect that any insurance company was 1,193
required to change a policy form or related material to comply 1,194
with Title XXXIX of the Revised Code or any regulation of the 1,195
superintendent of insurance, for the purpose of inducing or 1,196
intending to induce any policyholder or prospective policyholder 1,197
to purchase, amend, lapse, forfeit, change, or surrender 1,198
insurance. 1,199
(K) Aiding or abetting another to violate this section. 1,201
(L) Refusing to issue any policy of insurance, or 1,203
canceling or declining to renew such policy because of the sex or 1,204
marital status of the applicant, prospective insured, insured, or 1,205
policyholder. 1,206
(M) Making or permitting any unfair discrimination between 1,208
individuals of the same class and of essentially the same hazard 1,209
in the amount of premium, policy fees, or rates charged for any 1,210
policy or contract of insurance, other than life insurance, or in 1,211
the benefits payable thereunder, or in underwriting standards and 1,212
practices or eligibility requirements, or in any of the terms or 1,213
conditions of such contract, or in any other manner whatever. 1,214
(N) Refusing to make available disability income insurance 1,216
solely because the applicant's principal occupation is that of 1,217
managing a household. 1,218
(O) Refusing, when offering maternity benefits under any 1,220
individual or group sickness and accident insurance policy, to 1,221
make maternity benefits available to the policyholder for the 1,222
individual or individuals to be covered under any comparable 1,223
policy to be issued for delivery in this state, including family 1,224
members if the policy otherwise provides coverage for family 1,225
members. Nothing in this division shall be construed to prohibit 1,226
an insurer from imposing a reasonable waiting period for such 1,227
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE 1,228
27
POLICY, but in no event shall such waiting period exceed two 1,229
hundred seventy days. 1,230
(P) Using, or permitting to be used, a pattern settlement 1,232
as the basis of any offer of settlement. As used in this 1,233
division, "pattern settlement" means a method by which liability 1,234
is routinely imputed to a claimant without an investigation of 1,235
the particular occurrence upon which the claim is based and by 1,236
using a predetermined formula for the assignment of liability 1,237
arising out of occurrences of a similar nature. Nothing in this 1,238
division shall be construed to prohibit an insurer from 1,239
determining a claimant's liability by applying formulas or 1,240
guidelines to the facts and circumstances disclosed by the 1,241
insurer's investigation of the particular occurrence upon which a 1,242
claim is based. 1,243
(Q) Refusing to insure, or refusing to continue to insure, 1,245
or limiting the amount, extent, or kind of life or sickness and 1,246
accident insurance or annuity coverage available to an 1,247
individual, or charging an individual a different rate for the 1,248
same coverage solely because of blindness or partial blindness. 1,249
With respect to all other conditions, including the underlying 1,250
cause of blindness or partial blindness, persons who are blind or 1,251
partially blind shall be subject to the same standards of sound 1,252
actuarial principles or actual or reasonably anticipated 1,253
actuarial experience as are sighted persons. Refusal to insure 1,254
includes, but is not limited to, denial by an insurer of 1,255
disability insurance coverage on the grounds that the policy 1,256
defines "disability" as being presumed in the event that the 1,257
eyesight of the insured is lost. However, an insurer may exclude 1,258
from coverage disabilities consisting solely of blindness or 1,259
partial blindness when such conditions existed at the time the 1,260
policy was issued. To the extent that the provisions of this 1,261
division may appear to conflict with any provision of section 1,262
3999.16 of the Revised Code, this division applies. 1,263
(R)(1) Directly or indirectly offering to sell, selling, 1,265
28
or delivering, issuing for delivery, renewing, or using or 1,266
otherwise marketing any policy of insurance or insurance product 1,267
in connection with or in any way related to the grant of a 1,268
student loan guaranteed in whole or in part by an agency or 1,269
commission of this state or the United States, except insurance 1,270
that is required under federal or state law as a condition for 1,271
obtaining such a loan and the premium for which is included in 1,272
the fees and charges applicable to the loan; or, in the case of 1,273
an insurer or insurance agent, knowingly permitting any lender 1,274
making such loans to engage in such acts or practices in 1,275
connection with the insurer's or agent's insurance business. 1,276
(2) Except in the case of a violation of division (G) of 1,278
this section, division (R)(1) of this section does not apply to 1,279
either of the following: 1,280
(a) Acts or practices of an insurer, its agents, 1,282
representatives, or employees in connection with the grant of a 1,283
guaranteed student loan to its insured or the insured's spouse or 1,284
dependent children where such acts or practices take place more 1,285
than ninety days after the effective date of the insurance; 1,286
(b) Acts or practices of an insurer, its agents, 1,288
representatives, or employees in connection with the 1,289
solicitation, processing, or issuance of an insurance policy or 1,290
product covering the student loan borrower or his THE BORROWER'S 1,291
spouse or dependent children, where such acts or practices take 1,292
place more than one hundred eighty days after the date on which 1,293
the borrower is notified that the student loan was approved. 1,294
(S) Denying coverage, under any health insurance or health 1,296
care policy, contract, or plan providing family coverage, to any 1,297
natural or adopted child of the named insured or subscriber 1,298
solely on the basis that the child does not reside in the 1,299
household of the named insured or subscriber. 1,300
(T)(1) Using any underwriting standard or engaging in any 1,302
other act or practice that, directly or indirectly, due solely to 1,303
the actual or expected ANY health condition of STATUS-RELATED 1,305
29
FACTOR IN RELATION TO one or more individuals, does either of the 1,306
following:
(a) Terminates or fails to renew an existing individual 1,308
policy, contract, or plan of health benefits, or a health benefit 1,309
plan issued to a small AN employer as those terms are defined in 1,310
section 3924.01 of the Revised Code, for which an individual 1,311
would otherwise be eligible;
(b) With respect to a health benefit plan issued to a 1,313
small AN employer, as those terms are defined in section 3924.01 1,314
of the Revised Code, excludes or causes the exclusion of an 1,316
individual from coverage under an existing employer-provided 1,317
policy, contract, or plan of health benefits, except that an 1,318
insurer may exclude, on the basis of health status, a late 1,319
enrollee as defined in section 3924.01 of the Revised Code. 1,320
(2) The superintendent of insurance may adopt rules in 1,322
accordance with Chapter 119. of the Revised Code for purposes of 1,323
implementing division (T)(1) of this section. 1,324
(3) FOR PURPOSES OF DIVISION (T)(1) OF THIS SECTION, 1,328
"HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING: 1,329
(a) HEALTH STATUS; 1,331
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 1,334
ILLNESSES;
(c) CLAIMS EXPERIENCE; 1,336
(d) RECEIPT OF HEALTH CARE; 1,338
(e) MEDICAL HISTORY; 1,340
(f) GENETIC INFORMATION; 1,342
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 1,345
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 1,347
(U) With respect to a health benefit plan issued to a 1,349
small employer, as those terms are defined in section 3924.01 of 1,350
the Revised Code, negligently or willfully placing coverage for 1,351
adverse risks with a certain carrier, as defined in section 1,352
3924.01 of the Revised Code.
30
(V) Using any program, scheme, device, or other unfair act 1,354
or practice that, directly or indirectly, causes or results in 1,355
the placing of coverage for adverse risks with another carrier, 1,356
as defined in section 3924.01 of the Revised Code. 1,357
(W) Failing to comply with section 3923.23, 3923.231, 1,359
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 1,360
in any unfair, discriminatory reimbursement practice. 1,361
(X) Intentionally establishing an unfair premium for, or 1,363
misrepresenting the cost of, any insurance policy financed under 1,364
a premium finance agreement of an insurance premium finance 1,365
company. 1,366
With respect to private passenger automobile insurance, no 1,368
insurer shall charge different premium rates to persons residing 1,369
within the limits of any municipal corporation based solely on 1,370
the location of the residence of the insured within those limits. 1,371
The enumeration in sections 3901.19 to 3901.26 of the 1,373
Revised Code of specific unfair or deceptive acts or practices in 1,374
the business of insurance is not exclusive or restrictive or 1,375
intended to limit the powers of the superintendent of insurance 1,376
to adopt rules to implement this section, or to take action under 1,377
other sections of the Revised Code. 1,378
This section does not prohibit the sale of shares of any 1,380
investment company registered under the "Investment Company Act 1,381
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 1,382
policies, annuities, or other contracts described in section 1,383
3907.15 of the Revised Code. 1,384
As used in this section, "estimate," "statement," 1,386
"representation," "misrepresentation," "advertisement," or 1,387
"announcement" includes oral or written occurrences. 1,388
Sec. 3901.49. (A) As used in this section: 1,399
(1) "Genetic screening or testing" means a laboratory test 1,401
of a person's genes or chromosomes for abnormalities, defects, or 1,402
deficiencies, including carrier status, that are linked to 1,403
physical or mental disorders or impairments, or that indicate a 1,404
31
susceptibility to illness, disease, or other disorders, whether 1,405
physical or mental, which test is a direct test for 1,406
abnormalities, defects, or deficiencies, and not an indirect 1,407
manifestation of genetic disorders. 1,408
(2) "Insurer" means any person authorized under Title 1,410
XXXIX of the Revised Code to engage in the business of sickness 1,411
and accident insurance. 1,412
(3) "Sickness and accident insurance" means sickness and 1,414
accident insurance under Chapter 3923. of the Revised Code 1,415
excluding disability income insurance and excluding supplemental 1,416
policies of sickness and accident insurance. 1,417
(B) No insurer, in processing an application for an 1,419
individual or group policy of sickness and accident insurance or 1,420
in determining insurability under such a policy, shall do any of 1,421
the following: 1,422
(1) Require an individual seeking coverage to submit to 1,424
genetic screening or testing; 1,425
(2) Take into consideration, other than in accordance with 1,427
division (F) of this section, the results of genetic screening or 1,428
testing; 1,429
(3) Make any inquiry to determine the results of genetic 1,431
screening or testing; 1,432
(4) Make a decision adverse to the applicant based on 1,434
entries in medical records or other reports of genetic screening 1,435
or testing. 1,436
(C) In developing and asking questions regarding medical 1,438
histories of applicants for sickness and accident insurance, no 1,439
insurer shall ask for the results of genetic screening or testing 1,440
or ask questions designed to ascertain the results of genetic 1,441
screening or testing. 1,442
(D) No insurer shall cancel or refuse to issue or renew 1,444
coverage under a sickness and accident insurance policy based on 1,445
the results of genetic screening or testing. 1,446
(E) No insurer shall deliver, issue for delivery, or renew 1,448
32
an individual or group policy of sickness and accident insurance 1,449
in this state that limits benefits based on the results of 1,450
genetic screening or testing. 1,451
(F) An insurer may consider the results of genetic 1,453
screening or testing if the results are voluntarily submitted by 1,454
an applicant for coverage or renewal of coverage and the results 1,455
are favorable to the applicant. 1,456
(G) A violation of this section is an unfair and deceptive 1,458
act or practice in the business of insurance under sections 1,459
3901.19 to 3901.26 of the Revised Code. 1,460
Sec. 3901.491. (A) As used in this section: 1,469
(1) "Genetic screening or testing" means a laboratory test 1,471
of a person's genes or chromosomes for abnormalities, defects, or 1,472
deficiencies, including carrier status, that are linked to 1,473
physical or mental disorders or impairments, or that indicate a 1,474
susceptibility to illness, disease, or other disorders, whether 1,475
physical or mental, which test is a direct test for 1,476
abnormalities, defects, or deficiencies, and not an indirect 1,477
manifestation of genetic disorders. 1,478
(2) "Insurer" means any person authorized under Title 1,480
XXXIX of the Revised Code to engage in the business of sickness 1,481
and accident insurance. 1,482
(3) "Sickness and accident insurance" means sickness and 1,484
accident insurance under Chapter 3923. of the Revised Code 1,485
excluding disability income insurance and excluding supplemental 1,486
policies of sickness and accident insurance. 1,487
(B) Upon the repeal of section 3901.49 of the Revised Code 1,489
by Sub. H.B. No. 71 of the 120th general assembly, no insurer 1,490
shall do either of the following: 1,491
(1) Consider, in a manner adverse to an applicant or 1,493
insured, any information obtained from genetic screening or 1,494
testing conducted prior to the repeal of section 3901.49 of the 1,495
Revised Code in processing an application for an individual or 1,496
group policy of sickness and accident insurance, or in 1,497
33
determining insurability under such a policy; 1,498
(2) Inquire, directly or indirectly, into the results of 1,500
genetic screening or testing conducted prior to the repeal of 1,501
section 3901.49 of the Revised Code, or use such information, in 1,502
whole or in part, to cancel, refuse to issue or renew, or limit 1,503
benefits under, a sickness and accident insurance policy. 1,504
(C) Any insurer that has engaged in, is engaged in, or is 1,506
about to engage in a violation of division (B) of this section is 1,507
subject to the jurisdiction of the superintendent of insurance 1,508
under section 3901.04 of the Revised Code. 1,509
Sec. 3901.50. (A) As used in this section: 1,520
(1) "Genetic screening or testing" means a laboratory test 1,522
of a person's genes or chromosomes for abnormalities, defects, or 1,523
deficiencies, including carrier status, that are linked to 1,524
physical or mental disorders or impairments, or that indicate a 1,525
susceptibility to illness, disease, or other disorders, whether 1,526
physical or mental, which test is a direct test for 1,527
abnormalities, defects, or deficiencies, and not an indirect 1,528
manifestation of genetic disorders. 1,529
(2) "Self-insurer" means any government entity providing 1,531
coverage for health care services on a self-insurance basis. 1,532
(B) No self-insurer, in processing an application for 1,534
coverage under a plan of self-insurance or in determining 1,535
insurability under such a plan, shall do any of the following: 1,536
(1) Require an individual seeking coverage to submit to 1,538
genetic screening or testing; 1,539
(2) Take into consideration, other than in accordance with 1,541
division (F) of this section, the results of genetic screening or 1,542
testing; 1,543
(3) Make any inquiry to determine the results of genetic 1,545
screening or testing; 1,546
(4) Make a decision adverse to the applicant based on 1,548
entries in medical records or other reports of genetic screening 1,549
or testing. 1,550
34
(C) In developing and asking questions regarding medical 1,552
histories of applicants for coverage under a plan of 1,553
self-insurance, no self-insurer shall ask for the results of 1,554
genetic screening or testing or ask questions designed to 1,555
ascertain the results of genetic screening or testing. 1,556
(D) No self-insurer shall cancel or refuse to provide or 1,558
renew coverage for health care services based on the results of 1,559
genetic screening or testing. 1,560
(E) No self-insurer shall establish or modify a plan of 1,562
self-insurance in this state that limits benefits based on the 1,563
results of genetic screening or testing. 1,564
(F) A self-insurer may consider the results of genetic 1,566
screening or testing if the results are voluntarily submitted by 1,567
an applicant for coverage or renewal of coverage and the results 1,568
are favorable to the applicant. 1,569
(G) A violation of this section is an unfair and deceptive 1,571
act or practice in the business of insurance under sections 1,572
3901.19 to 3901.26 of the Revised Code. 1,573
Sec. 3901.501. (A) As used in this section: 1,582
(1) "Genetic screening or testing" means a laboratory test 1,584
of a person's genes or chromosomes for abnormalities, defects, or 1,585
deficiencies, including carrier status, that are linked to 1,586
physical or mental disorders or impairments, or that indicate a 1,587
susceptibility to illness, disease, or other disorders, whether 1,588
physical or mental, which test is a direct test for 1,589
abnormalities, defects, or deficiencies, and not an indirect 1,590
manifestation of genetic disorders. 1,591
(2) "Self-insurer" means any government entity providing 1,593
coverage for health care services on a self-insurance basis. 1,594
(B) Upon the repeal of section 3901.50 of the Revised Code 1,596
by Sub. H.B. No. 71 of the 120th general assembly, no 1,597
self-insurer shall do either of the following: 1,598
(1) Consider, in a manner adverse to an applicant or 1,600
insured, any information obtained from genetic screening or 1,601
35
testing conducted prior to the repeal of section 3901.50 of the 1,602
Revised Code in processing an application for coverage under a 1,603
plan of self-insurance or in determining insurability under such 1,604
a plan; 1,605
(2) Inquire, directly or indirectly, into the results of 1,607
genetic screening or testing conducted prior to the repeal of 1,608
section 3901.50 of the Revised Code, or use such information, in 1,609
whole or in part, to cancel, refuse to provide or renew, or limit 1,610
benefits under, a plan of self-insurance. 1,611
(C) Any self-insurer that has engaged in, is engaged in, 1,613
or is about to engage in a violation of division (B) of this 1,614
section is subject to the jurisdiction of the superintendent of 1,615
insurance under section 3901.04 of the Revised Code. 1,616
Sec. 3923.021. (A) As used in this section, "benefits 1,625
provided are not unreasonable in relation to the premium charged" 1,626
means the rates were calculated in accordance with sound 1,627
actuarial principles. 1,628
(B) With respect to any filing, made pursuant to section 1,630
3923.02 of the Revised Code, of any premium rates for any 1,631
individual policy of sickness and accident insurance or for any 1,632
indorsement or rider pertaining thereto, the superintendent of 1,633
insurance may, within thirty days after filing: 1,634
(1) Disapprove such filing if he finds AFTER FINDING that 1,636
the benefits provided are unreasonable in relation to the premium 1,638
charged. Such disapproval shall be effected by written order of 1,639
the superintendent, a copy of which shall be mailed to the 1,640
insurer that has made the filing. In the order, the 1,641
superintendent shall specify the reasons for his THE disapproval 1,642
and state that a hearing will be held within fifteen days after 1,644
requested in writing by the insurer. If a hearing is so 1,645
requested, the superintendent shall also give such public notice 1,646
as he THE SUPERINTENDENT considers appropriate. The 1,648
superintendent, within fifteen days after the commencement of any 1,649
hearing, shall issue a written order, a copy of which shall be 1,650
36
mailed to the insurer that has made the filing, either affirming 1,651
his THE prior disapproval or approving such filing if he finds 1,653
AFTER FINDING that the benefits provided are not unreasonable in 1,654
relation to the premium charged. 1,655
(2) Set a date for a public hearing to commence no later 1,657
than forty days after the filing. The superintendent shall give 1,658
the insurer making the filing twenty days' written notice of the 1,659
hearing and shall give such public notice as he THE 1,660
SUPERINTENDENT considers appropriate. The superintendent, within 1,662
twenty days after the commencement of a hearing, shall issue a 1,663
written order, a copy of which shall be mailed to the insurer 1,664
that has made the filing, either approving such filing if he THE 1,665
SUPERINTENDENT finds that the benefits provided are not 1,667
unreasonable in relation to the premium charged, or disapproving 1,668
such filing if he THE SUPERINTENDENT finds that the benefits 1,669
provided are unreasonable in relation to the premium charged. 1,670
This division does not apply to any insurer organized or 1,671
transacting the business of insurance under Chapter 3907. or 1,672
3909. of the Revised Code. 1,673
(3) Take no action, in which case such filing shall be 1,675
deemed to be approved and shall become effective upon the 1,676
thirty-first day after such filing, unless the superintendent has 1,677
previously given to the insurer his A written approval. 1,678
(C) At any time after any filing has been approved 1,680
pursuant to this section, the superintendent may, after a hearing 1,681
of which at least twenty days' written notice has been given to 1,682
the insurer that has made such filing and for which such public 1,683
notice as he THE SUPERINTENDENT considers appropriate has been 1,684
given, withdraw approval of such filing if he finds AFTER FINDING 1,686
that the benefits provided are unreasonable in relation to the 1,688
premium charged. Such withdrawal of approval shall be effected 1,689
by written order of the superintendent, a copy of which shall be 1,690
mailed to the insurer that has made the filing, which shall state 1,691
the ground for such withdrawal and the date, not less than forty 1,692
37
days after the date of such order, when the withdrawal or 1,693
approval shall become effective. 1,694
(D) The superintendent may retain at the insurer's expense 1,696
such attorneys, actuaries, accountants, and other experts not 1,697
otherwise a part of the superintendent's staff as shall be 1,698
reasonably necessary to assist in the preparation for and conduct 1,699
of any public hearing under this section. The expense for 1,700
retaining such experts and the expenses of the department of 1,701
insurance incurred in connection with such public hearing shall 1,702
be assessed against the insurer in an amount not to exceed one 1,703
one-hundredth of one per cent of the sum of premiums earned plus 1,704
net realized investment gain or loss of such insurer as reflected 1,705
in the most current annual statement on file with the 1,706
superintendent. Any person retained shall be under the direction 1,707
and control of the superintendent and shall act in a purely 1,708
advisory capacity. 1,709
(E) This section does not apply to any filing of any 1,711
premium rate or rating formula for individual sickness and 1,712
accident insurance policies offered in accordance with division 1,713
(M)(L) of section 3923.58 of the Revised Code, or for any 1,714
amendment thereto. 1,715
Sec. 3923.122. (A) Every policy of group sickness and 1,725
accident insurance providing hospital, surgical, or medical 1,726
expense coverage for other than specific diseases or accidents 1,727
only, and delivered, issued for delivery, or renewed in this 1,728
state on or after January 1, 1976, shall include a provision 1,729
giving each insured the option to convert to THE FOLLOWING: 1,730
(1) IN THE CASE OF AN INDIVIDUAL WHO IS NOT A FEDERALLY 1,733
ELIGIBLE INDIVIDUAL, any of the individual policies of hospital, 1,734
surgical, or medical expense insurance then being issued by the 1,735
insurer with benefit limits not to exceed those in effect under 1,736
the group policy;
(2) IN THE CASE OF A FEDERALLY ELIGIBLE INDIVIDUAL, A 1,738
BASIC OR STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF 1,739
38
THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY 1,740
SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND 1,741
SCOPE OF COVERED SERVICES. FOR PURPOSES OF DIVISION (A)(2) OF 1,742
THIS SECTION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE 1,743
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD 1,744
PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 1,745
(B) An option for conversion to an individual policy shall 1,747
be available without evidence of insurability to every insured, 1,748
including any person eligible under division (D) of this section, 1,749
who terminates his employment or membership in the group holding 1,750
the policy after having been continuously insured thereunder for 1,751
at least one year. 1,752
Upon receipt of the insured's written application and upon 1,754
payment of at least the first quarterly premium not later than 1,755
thirty-one days after the termination of coverage under the group 1,756
policy, the insurer shall issue a converted policy on a form then 1,757
available for conversion. The premium shall be in accordance 1,758
with the insurer's table of premium rates in effect on the later 1,759
of the following dates: 1,760
(1) The effective date of the converted policy; 1,762
(2) The date of application therefor; and shall be 1,764
applicable to the class of risk to which each person covered 1,766
belongs and to the form and amount of the policy at his THE
PERSON'S then attained age. HOWEVER, PREMIUMS CHARGED FEDERALLY 1,768
ELIGIBLE INDIVIDUALS MAY NOT EXCEED AN AMOUNT THAT IS TWO TIMES 1,770
THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER INDIVIDUAL OF 1,771
A GROUP TO WHICH THE INSURER IS CURRENTLY ACCEPTING NEW BUSINESS 1,772
AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED. 1,773
At the election of the insurer, a separate converted policy 1,775
may be issued to cover any dependent of an employee or member of 1,776
the group. 1,777
Except as provided in division (H) of this section, any 1,779
converted policy shall become effective as of the day following 1,780
the date of termination of insurance under the group policy. 1,781
39
Any probationary or waiting period set forth in the 1,783
converted policy is deemed to commence on the effective date of 1,784
the insured's coverage under the group policy. 1,785
(C) No insurer shall be required to issue a converted 1,787
policy to any person who is, or is eligible to be, covered for 1,788
benefits at least comparable to the group policy under: 1,789
(1) Title XVIII of the Social Security Act, as amended or 1,791
superseded; 1,792
(2) Any act of congress or law under this or any other 1,794
state of the United States that duplicates coverage offered under 1,795
division (C)(1) of this section; 1,796
(3) Any policy that duplicates coverage offered under 1,798
division (C)(1) of this section; 1,799
(4) Any other group sickness and accident insurance 1,801
providing hospital, surgical, or medical expense coverage for 1,802
other than specific diseases or accidents only. 1,803
(D) The option for conversion shall be available: 1,805
(1) Upon the death of the employee or member, to the 1,807
surviving spouse with respect to such of the spouse and 1,808
dependents as are then covered by the group policy; 1,809
(2) To a child solely with respect to himself THE CHILD 1,811
upon his attaining the limiting age of coverage under the group 1,813
policy while covered as a dependent thereunder; 1,814
(3) Upon the divorce, dissolution, or annulment of the 1,816
marriage of the employee or member, to the divorced spouse, or 1,817
former spouse in the event of annulment, of such employee or 1,818
member, or upon the legal separation of the spouse from such 1,819
employee or member, to the spouse. 1,820
Persons possessing the option for conversion pursuant to 1,822
this division shall be considered members for the purposes of 1,823
division (H) of this section. 1,824
(E) If coverage is continued under a group policy on an 1,826
employee following his retirement prior to the time he THE 1,827
EMPLOYEE is, or is eligible to be, covered by Title XVIII of the 1,829
40
Social Security Act, he THE EMPLOYEE may elect, in lieu of the 1,830
continuance of group insurance, to have the same conversion 1,832
rights as would apply had his THE EMPLOYEE'S insurance terminated 1,834
at retirement by reason of termination of employment. 1,835
(F) If the insurer and the group policyholder agree upon 1,837
one or more additional plans of benefits to be available for 1,838
converted policies, the applicant for the converted policy may 1,839
elect such a plan in lieu of a converted policy. 1,840
(G) The converted policy may contain provisions for 1,842
avoiding duplication of benefits provided pursuant to divisions 1,843
(C)(1), (2), (3), and (4) of this section or provided under any 1,844
other insured or noninsured plan or program. 1,845
(H) If an employee or member becomes entitled to obtain a 1,847
converted policy pursuant to this section, and if the employee or 1,848
member has not received notice of the conversion privilege at 1,849
least fifteen days prior to the expiration of the thirty-one-day 1,850
conversion period provided in division (B) of this section, then 1,851
the employee or member has an additional period within which to 1,852
exercise the privilege. This additional period shall expire 1,853
fifteen days after the employee or member receives notice, but in 1,854
no event shall the period extend beyond sixty days after the 1,855
expiration of the thirty-one-day conversion period. 1,856
Written notice presented to the employee or member, or 1,858
mailed by the policyholder to the last known address of the 1,859
employee or member as indicated on its records, constitutes 1,860
notice for the purpose of this division. In the case of a person 1,861
who is eligible for a converted policy under division (D) (2) or 1,862
(D)(3) of this section, a policyholder shall not be responsible 1,863
for presenting or mailing such notice, unless such policyholder 1,864
has actual knowledge of the person's eligibility for a converted 1,865
policy. 1,866
If an additional period is allowed by an employee or member 1,868
for the exercise of a conversion privilege, and if written 1,869
application for the converted policy, accompanied by at least the 1,870
41
first quarterly premium, is made after the expiration of the 1,871
thirty-one-day conversion period, but within the additional 1,872
period allowed an employee or member in accordance with this 1,873
division, the effective date of the converted policy shall be the 1,874
date of application. 1,875
(I) The converted policy may provide: 1,877
(1) That any hospital, surgical, or medical expense 1,879
benefits otherwise payable with respect to any person may be 1,880
reduced by the amount of any such benefits payable under the 1,881
group policy for the same loss after termination of coverage; 1,882
(2) For termination of coverage on any person who is, or 1,884
is eligible to be, covered pursuant to division (C) of this 1,885
section; 1,886
(3) That the insurer may request information in advance of 1,888
any premium due date of the policy as to whether the insured is, 1,889
or is eligible to be, covered pursuant to division (C) of this 1,890
section. If the insured is, or is eligible to be, covered, and 1,891
he THE INSURED fails to furnish the details of his THE INSURED'S 1,893
coverage or eligibility to the insurer within thirty-one days 1,894
after the date of the request, the benefits payable under the 1,895
converted policy may be based on the hospital, surgical, or 1,896
medical expenses actually incurred after excluding expenses to 1,897
the extent of the amount of benefits for which the insured is, or 1,898
is eligible to be, covered pursuant to division (C) of this 1,899
section.
(J) The converted policy may contain: 1,901
(1) Any exclusion, reduction, or limitation contained in 1,903
the group policy or customarily used in individual policies 1,904
issued by the insurer; 1,905
(2) Any provision permitted in this section; 1,907
(3) Any other provision not prohibited by law. 1,909
Any provision required or permitted in this section may be 1,911
made a part of any converted policy by means of an endorsement or 1,912
rider. 1,913
42
(K) The time limit specified in a converted policy for 1,915
certain defenses with respect to any person who was covered by a 1,916
group policy shall commence on the effective date of such 1,917
person's coverage under the group policy. 1,918
(L) No insurer shall use deterioration of health as the 1,920
basis for refusing to renew a converted policy. 1,921
(M) No insurer shall use age as the basis for refusing to 1,923
renew a converted policy. 1,924
(N) A converted policy made available pursuant to this 1,926
section shall, if delivery of the policy is to be made in this 1,927
state, comply with this section. If delivery of a converted 1,928
policy is to be made in another state, it may be on a form 1,929
offered by the insurer in the jurisdiction where the delivery is 1,930
to be made and which provides benefits substantially in 1,931
compliance with those required in a policy delivered in this 1,932
state. 1,933
(O) AS USED IN THIS SECTION, "FEDERALLY ELIGIBLE 1,936
INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 45 C.F.R. 1,938
148.103. 1,939
Sec. 3923.26. Every certificate furnished by an insurer in 1,948
connection with, or pursuant to any provision of, any group 1,949
POLICY OR CERTIFICATE OF sickness and accident insurance policy 1,950
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE 1,951
providing coverage on an expense-incurred basis, and every 1,953
individual POLICY OF sickness and accident insurance policy 1,955
DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE which 1,956
provides coverage on an expense-incurred basis, either of which 1,957
provides MAKES coverage AVAILABLE for family members of the 1,960
insured, shall, as to such family members' coverage, also provide 1,961
that any sickness and accident insurance benefits applicable for 1,962
children shall be payable with respect to a newly born child of 1,963
the insured from the moment of birth.
The coverage for newly born children shall consist of 1,965
coverage of injury or sickness, including the necessary care and 1,966
43
treatment of medically diagnosed congenital defects and birth 1,967
abnormalities. 1,968
If payment of a specific premium is required to provide 1,970
coverage for an additional child, the certificate or policy may 1,971
require that notification of birth of a newly born child and 1,972
payment of the required premium must be furnished to the insurer 1,973
within thirty-one days after the date of birth in order to have 1,974
the coverage continue beyond such period. 1,975
The requirements of this section apply to all such 1,977
individual or group sickness and accident insurance policies 1,978
delivered or issued for delivery in this state on or after 1,979
January 1, 1975, and all such individual or group sickness and 1,980
accident insurance policies renewed in this state on or after 1,981
January 1, 1978. 1,982
Sec. 3923.40. No individual or group policy of sickness 1,991
and accident insurance providing THAT MAKES family coverage 1,992
AVAILABLE may be delivered, issued for delivery, or renewed in 1,994
this state on or after January 1, 1989, unless the policy covers
adopted children of the insured on the same basis as other 1,995
dependents.
The coverage required by this section is subject to the 1,997
requirements and restrictions set forth in section 3924.51 of the 1,998
Revised Code. 1,999
Sec. 3923.57. Notwithstanding any provision of this 2,008
chapter, every individual policy of sickness and accident 2,009
insurance that is delivered, issued for delivery, or renewed in 2,010
this state is subject to the following conditions, as applicable: 2,011
(A) Pre-existing conditions provisions shall not exclude 2,013
or limit coverage for a period beyond twelve months following the 2,014
policyholder's effective date of coverage and may only relate to 2,015
conditions during the six months immediately preceding the 2,016
effective date of coverage. 2,017
(B) In determining whether a pre-existing conditions 2,019
provision applies to a policyholder or dependent, each policy 2,020
44
shall credit the time the policyholder or dependent was covered 2,021
under a previous policy, contract, or plan if the previous 2,023
coverage was continuous to a date not more than thirty days prior 2,025
to the effective date of the new coverage, exclusive of any 2,026
applicable service waiting period under the policy. 2,027
(C) Any such policy shall be renewable with respect to the 2,029
policyholder, or dependents of the policyholder, at the option of 2,030
the policyholder, except for any of the following reasons: 2,031
(1) Nonpayment of the required premiums by the 2,033
policyholder; 2,034
(2) Fraud or misrepresentation of the policyholder; 2,036
(3) When the insurer ceases to do the business of 2,038
individual sickness and accident insurance in this state, 2,039
provided that all of the following conditions are met: 2,040
(a) Notice of the decision to cease doing the business of 2,042
individual sickness and accident insurance is provided to the 2,043
department of insurance and the policyholder. 2,044
(b) An individual policy shall not be canceled by the 2,046
insurer for ninety days after the date of the notice required 2,048
under division (C)(3)(a) of this section unless the business has 2,049
been sold to another insurer. 2,050
(c) An insurer that ceases to do the business of 2,052
individual sickness and accident insurance in this state shall 2,053
not resume such business in this state for a period of five years 2,054
from the date of the notice required under division (C)(3)(a) of 2,055
this section (1) EXCEPT AS OTHERWISE PROVIDED IN DIVISION (C) OF 2,057
THIS SECTION, AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND 2,058
ACCIDENT INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR 2,059
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL. 2,060
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF AN 2,063
INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE OF 2,064
THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR CONTRIBUTIONS 2,067
IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE INSURER HAS NOT 2,068
45
RECEIVED TIMELY PREMIUM PAYMENTS.
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE THAT 2,071
CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION OF 2,072
MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN THE 2,075
INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION (D) OF THIS SECTION 2,076
AND THE APPLICABLE LAWS OF THIS STATE. 2,077
(d) IF THE INSURER OFFERS COVERAGE IN THE MARKET THROUGH A 2,080
NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES, LIVES, OR WORKS 2,081
IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE INSURER IS 2,082
AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT SUCH COVERAGE 2,083
IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY HEALTH 2,084
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e) IF THE COVERAGE IS MADE AVAILABLE IN THE INDIVIDUAL 2,087
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS, THE 2,088
MEMBERSHIP OF THE INDIVIDUAL IN THE ASSOCIATION, ON THE BASIS OF 2,089
WHICH THE COVERAGE IS PROVIDED, CEASES; PROVIDED, HOWEVER, THAT 2,090
SUCH COVERAGE IS TERMINATED UNDER DIVISION (C)(2)(e) OF THIS 2,093
SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH STATUS-RELATED 2,094
FACTOR OF COVERED INDIVIDUALS.
(3) AN INSURER MAY CANCEL OR DECIDE NOT TO RENEW THE 2,096
COVERAGE OF A DEPENDENT OF AN INDIVIDUAL IF THE DEPENDENT HAS 2,097
PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES FRAUD OR MADE AN 2,098
INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS OF 2,099
THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT BASED, 2,100
EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH STATUS-RELATED 2,101
FACTOR IN RELATION TO THE DEPENDENT.
(D)(1) IF AN INSURER DECIDES TO DISCONTINUE OFFERING A 2,104
PARTICULAR TYPE OF HEALTH INSURANCE COVERAGE OFFERED IN THE 2,105
INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE MAY BE DISCONTINUED BY 2,106
THE INSURER IF THE INSURER DOES ALL OF THE FOLLOWING: 2,107
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED COVERAGE 2,110
OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT LEAST 2,111
NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF THE 2,112
46
COVERAGE;
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE OF THIS 2,115
TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER INDIVIDUAL 2,116
HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY THE INSURER 2,117
FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF 2,120
THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE UNDER DIVISION 2,122
(D)(1)(b) OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY 2,123
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF 2,124
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE. 2,125
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL 2,127
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS STATE, 2,129
HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE INSURER ONLY 2,130
IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE DEPARTMENT OF 2,133
INSURANCE AND TO EACH INDIVIDUAL OF THE DISCONTINUATION AT LEAST 2,134
ONE HUNDRED EIGHTY DAYS PRIOR TO THE DATE OF THE EXPIRATION OF 2,135
THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED FOR DELIVERY 2,138
IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND COVERAGE UNDER 2,139
THAT HEALTH INSURANCE IN THAT MARKET IS NOT RENEWED. 2,140
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION 2,143
(D)(2) OF THIS SECTION IN THE INDIVIDUAL MARKET, THE INSURER 2,144
SHALL NOT PROVIDE FOR THE ISSUANCE OF ANY HEALTH INSURANCE 2,145
COVERAGE IN THE MARKET AND THIS STATE DURING THE FIVE-YEAR PERIOD 2,146
BEGINNING ON THE DATE OF THE DISCONTINUATION OF THE LAST HEALTH 2,147
INSURANCE COVERAGE NOT SO RENEWED. 2,148
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 2,151
section, both of the following apply:
(1) The benefit structure of any such policy may be 2,154
changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new 2,155
individual insureds. 2,156
(2) Any such policy may be rescinded for fraud, material 2,158
47
misrepresentation, or concealment by an applicant, policyholder, 2,159
or dependent AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, 2,161
MODIFY THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO 2,162
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS 2,163
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM 2,164
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM. 2,165
(F) SUCH POLICIES ARE SUBJECT TO SECTIONS 2743 AND 2747 OF 2,168
THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 2,172
1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg-43 2,178
AND 300gg-47, AS AMENDED. 2,179
(G) SECTIONS 3924.031 AND 3924.032 OF THE REVISED CODE 2,183
SHALL APPLY TO SICKNESS AND ACCIDENT INSURANCE POLICIES OFFERED 2,184
IN THE INDIVIDUAL MARKET IN THE SAME MANNER AS THEY APPLY TO 2,185
HEALTH BENEFIT PLANS OFFERED IN THE SMALL EMPLOYER MARKET. 2,186
IN ACCORDANCE WITH 45 C.F.R. 148.102, DIVISIONS (C) TO (G) 2,191
OF THIS SECTION ALSO APPLY TO ALL GROUP SICKNESS AND ACCIDENT 2,192
INSURANCE POLICIES THAT ARE NOT SOLD IN CONNECTION WITH AN 2,193
EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT PROVIDE MORE THAN 2,194
SHORT-TERM, LIMITED DURATION COVERAGE. 2,195
IN APPLYING DIVISIONS (C) TO (G) OF THIS SECTION WITH 2,199
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY AN 2,201
INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH ONE 2,202
OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER. 2,203
FOR PURPOSES OF THIS SECTION, ANY POLICY ISSUED PURSUANT TO 2,205
DIVISION (C) OF SECTION 3923.13 OF THE REVISED CODE IN CONNECTION 2,208
WITH A PUBLIC OR PRIVATE COLLEGE OR UNIVERSITY STUDENT HEALTH
INSURANCE PROGRAM IS CONSIDERED TO BE ISSUED TO A BONA FIDE 2,209
ASSOCIATION AND IS NOT SUBJECT TO DIVISIONS (C) TO (G) OF THIS 2,211
SECTION.
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS THE 2,214
SAME MEANING AS IN SECTION 3924.03 OF THE REVISED CODE, AND 2,216
"HEALTH STATUS-RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME 2,217
MEANINGS AS IN SECTION 3924.031 OF THE REVISED CODE. 2,219
48
This section does not apply to any policy that provides 2,221
coverage for specific diseases or accidents only, or to any 2,222
hospital indemnity, medicare supplement, long-term care, 2,223
disability income, one-time-limited-duration policy of no longer 2,224
than six months, or other policy that offers only supplemental 2,225
benefits. 2,226
Sec. 3923.571. EXCEPT AS OTHERWISE PROVIDED IN SECTION 2,228
2721 OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 2,233
OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 2,239
300gg-21, AS AMENDED, THE FOLLOWING CONDITIONS APPLY TO ALL GROUP 2,240
POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE SOLD IN
CONNECTION WITH AN EMPLOYMENT-RELATED GROUP HEALTH PLAN AND THAT 2,241
ARE NOT SUBJECT TO SECTION 3924.03 OF THE REVISED CODE: 2,242
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF 2,244
DIVISION (A) OF SECTION 3924.03 AND SECTION 3924.033 OF THE 2,246
REVISED CODE.
(B)(1) EXCEPT AS PROVIDED IN SECTION 2712(b) TO (e) OF THE 2,250
"HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF 2,254
AN INSURER OFFERS COVERAGE IN THE SMALL OR LARGE GROUP MARKET IN 2,255
CONNECTION WITH A GROUP POLICY, THE INSURER SHALL RENEW OR 2,256
CONTINUE IN FORCE SUCH COVERAGE AT THE OPTION OF THE 2,257
POLICYHOLDER.
(2) AN INSURER MAY CANCEL OR DECIDE NOT TO RENEW THE 2,259
COVERAGE OF AN EMPLOYEE OR OF A DEPENDENT OF AN EMPLOYEE IF THE 2,260
EMPLOYEE OR DEPENDENT, AS APPLICABLE, HAS PERFORMED AN ACT OR 2,261
PRACTICE THAT CONSTITUTES FRAUD OR MADE AN INTENTIONAL 2,262
MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS OF THE
COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT BASED, 2,263
EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH STATUS-RELATED 2,264
FACTOR IN RELATION TO THE EMPLOYEE OR DEPENDENT. 2,265
AS USED IN DIVISION (B)(2) OF THIS SECTION, "HEALTH 2,268
STATUS-RELATED FACTOR" HAS THE SAME MEANING AS IN SECTION
3924.031 OF THE REVISED CODE. 2,270
(C)(1) NO SUCH POLICY, OR INSURER OFFERING HEALTH 2,272
49
INSURANCE COVERAGE IN CONNECTION WITH SUCH A POLICY, SHALL 2,274
REQUIRE ANY INDIVIDUAL, AS A CONDITION OF COVERAGE OR CONTINUED 2,275
COVERAGE UNDER THE POLICY, TO PAY A PREMIUM OR CONTRIBUTION THAT 2,276
IS GREATER THAN THE PREMIUM OR CONTRIBUTION FOR A SIMILARLY 2,277
SITUATED INDIVIDUAL COVERED UNDER THE POLICY ON THE BASIS OF ANY 2,278
HEALTH STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO 2,279
AN INDIVIDUAL COVERED UNDER THE POLICY AS A DEPENDENT OF THE 2,280
INDIVIDUAL. 2,281
(2) NOTHING IN DIVISION (C)(1) OF THIS SECTION SHALL BE 2,284
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 2,285
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY, 2,286
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM 2,287
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE 2,288
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO 2,289
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION. 2,290
(D) SUCH POLICIES SHALL PROVIDE FOR THE SPECIAL ENROLLMENT 2,293
PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH INSURANCE 2,297
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 2,299
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 2,308
of the Revised Code: 2,309
(1) "Case characteristics," "eligible employee," "health 2,311
HEALTH benefit plan," "late enrollee," AND "MEWA," and 2,313
"pre-existing conditions provision" have the same meanings as in 2,314
section 3924.01 of the Revised Code. 2,315
(2) "Insurer" means any sickness and accident insurance 2,317
company authorized to issue health benefit plans DO BUSINESS in 2,318
this state, or MEWA authorized to issue insured health benefit 2,320
plans in this state. "Insurer" does not include any health 2,321
insuring corporation that is owned or operated by an insurer. 2,323
(3) "Small employer" means any person, firm, corporation, 2,325
or partnership actively engaged in business whose total employed 2,326
work force, on at least fifty per cent of its working days during 2,327
the preceding year, consisted of at least two unrelated eligible 2,328
employees but no more than twenty-five eligible employees, the 2,329
50
majority of whom were employed within this state. In determining 2,330
the number of eligible employees, companies that are affiliated 2,331
companies or that are eligible to file a combined tax return for 2,332
purposes of state taxation shall be considered one employer. In 2,333
determining whether the members of an association are small 2,334
employers, each member of the association shall be considered as 2,335
a separate person, firm, corporation, or partnership. 2,336
(4) "Small employer group" means any group consisting of 2,338
all of the eligible employees of a small employer, except those 2,339
employees who are covered, or are eligible for coverage, under 2,340
any other private or public health benefits arrangement, 2,341
including the medicare program established under Title XVIII of 2,342
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 2,343
as amended, or any other act of congress or law of this or any 2,344
other state of the United States that provides benefits 2,345
comparable to the benefits provided under this section 2,346
PRE-EXISTING CONDITIONS PROVISION" MEANS A POLICY PROVISION THAT 2,349
EXCLUDES OR LIMITS COVERAGE FOR CHARGES OR EXPENSES INCURRED 2,350
DURING A SPECIFIED PERIOD FOLLOWING THE INSURED'S EFFECTIVE DATE 2,351
OF COVERAGE AS TO A CONDITION WHICH, DURING A SPECIFIED PERIOD 2,352
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE, HAD 2,353
MANIFESTED ITSELF IN SUCH A MANNER AS WOULD CAUSE AN ORDINARILY 2,354
PRUDENT PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,355
TREATMENT OR FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR 2,356
TREATMENT WAS RECOMMENDED OR RECEIVED, OR A PREGNANCY EXISTING ON 2,357
THE EFFECTIVE DATE OF COVERAGE.
(B) Beginning in January of each year, insurers IN THE 2,360
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT 2,361
INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF THE REVISED 2,363
CODE, EXCEPT INDIVIDUAL POLICIES ISSUED PURSUANT TO SECTION 2,364
3923.122 OF THE REVISED CODE, shall accept applicants for open 2,368
enrollment coverage, as set forth in divisions (B)(1) and (2) of 2,369
this section DIVISION, in the order in which they apply for 2,371
coverage and subject to the limitation set forth in division (G) 2,372
51
of this section:. INSURERS
(1) Insurers in the business of issuing health benefit 2,374
plans to small employer groups shall accept small employer groups 2,375
for which coverage is not otherwise available and for whom 2,376
coverage had not been terminated by the employer or by an 2,377
insurer, health maintenance organization, or health insuring 2,379
corporation during the preceding twelve-month period;
(2) Insurers in the business of issuing individual 2,381
policies of sickness and accident insurance as contemplated by 2,382
section 3923.021 of the Revised Code, except individual policies 2,383
issued pursuant to section 3923.122 of the Revised Code, shall 2,384
either accept individuals pursuant to the open enrollment 2,385
requirements of section 3941.53 of the Revised Code, if subject 2,386
to that section, or accept for coverage pursuant to this section 2,388
individuals to whom both of the following conditions apply: 2,389
(a)(1) The individual is not applying for coverage as an 2,391
employee of an employer, as a member of an association, or as a 2,392
member of any other group. 2,393
(b)(2) The individual is not covered, and is not eligible 2,395
for coverage, under any other private or public health benefits 2,396
arrangement, including the medicare program established under 2,397
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,398
U.S.C.A. 301, as amended, or any other act of congress or law of 2,399
this or any other state of the United States that provides 2,400
benefits comparable to the benefits provided under this section, 2,401
any medicare supplement policy, or any conversion or continuation 2,402
of coverage policy under state or federal law. 2,403
(C) An insurer shall offer to any individual or small 2,405
employer group accepted under this section the small employer 2,407
health care plan established by the board of directors of the 2,408
Ohio small employer health reinsurance program under division (A) 2,410
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 2,411
plan in benefit plan design and scope of covered services. 2,412
52
An insurer may offer other health benefit plans in addition 2,414
to, but not in lieu of, the plan required to be offered under 2,415
this division. These additional health benefit plans shall 2,416
provide, at a minimum, the coverage provided by the small 2,417
employer health care plan or any health benefit plan that is 2,418
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 2,419
For purposes of this division, the superintendent of 2,421
insurance shall determine whether a health benefit plan is 2,422
substantially similar to the small employer health care plan in 2,423
benefit plan design and scope of covered services. 2,424
(D) Health benefit plans issued under this section may 2,426
establish pre-existing conditions provisions that exclude or 2,427
limit coverage for a period of up to twelve months following the 2,428
individual's effective date of coverage and that may relate only 2,429
to conditions during the six months immediately preceding the 2,430
effective date of coverage. However, an insurer may exclude a 2,431
late enrollee for a period of up to eighteen months following the 2,432
individual's date of application for coverage. 2,433
(E) Premiums charged to groups or individuals under this 2,435
section may not exceed an amount that is two and one-half times 2,436
the highest rate charged any other group with similar case 2,437
characteristics or any other individual to which the insurer is 2,438
currently accepting new business, and for which similar 2,439
copayments and deductibles are applied. 2,440
(F) In offering health benefit plans under this section, 2,442
an insurer may require the purchase of health benefit plans that 2,443
condition the reimbursement of health services upon the use of a 2,444
specific network of providers. 2,445
(G)(1) In no event shall an insurer be required to accept 2,447
annually under this section either individuals or small employer 2,448
groups that WHO, in the aggregate, would cause the insurer to 2,449
have a total number of new insureds that is more than one-half 2,451
per cent of its total number of insured individuals in this state 2,452
53
per year, as contemplated by section 3923.021 of the Revised 2,453
Code, and small group certificate holders of health benefit plans 2,454
in this state per year, calculated as of the immediately 2,456
preceding thirty-first day of December and excluding the 2,457
insurer's medicare supplement policies and conversion or 2,458
continuation of coverage policies under state or federal law and 2,459
any policies described in division (N)(M) of this section. If an 2,460
insurer is subject to, and elects to operate under, the 2,462
individual open enrollment requirements of section 3941.53 of the 2,463
Revised Code, in no event shall the insurer be required to accept 2,464
annually under this section small employer groups that would 2,465
cause the insurer to have a total number of new insureds that is 2,466
more than one-half per cent of its total number of small group 2,467
certificate holders calculated as set forth in division (G)(1) of 2,468
this section.
(2) An officer of the insurer shall certify to the 2,470
department of insurance when it has met the enrollment limit set 2,471
forth in division (G)(1) of this section. Upon providing such 2,472
certification, the insurer shall be relieved of its open 2,473
enrollment requirement under this section for the remainder of 2,474
the calendar year. 2,475
(H) An insurer shall not be required to accept under this 2,477
section applicants who, at the time of enrollment, are confined 2,478
to a health care facility because of chronic illness, permanent 2,479
injury, or other infirmity that would cause economic impairment 2,480
to the insurer if the applicants were accepted, or to make the 2,481
effective date of benefits for individuals or groups accepted 2,482
under this section earlier than ninety days after the date of 2,483
acceptance. 2,484
(I) The requirements of this section do not apply to any 2,486
insurer that is currently in a state of supervision, insolvency, 2,487
or liquidation. If an insurer demonstrates to the satisfaction 2,488
of the superintendent that the requirements of this section would 2,490
place the insurer in a state of supervision, insolvency, or 2,491
54
liquidation, the superintendent may waive or modify the 2,492
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 2,494
a period of not more than one year. At the expiration of such 2,495
time, a new showing of need for a waiver or modification by the 2,496
insurer shall be made before a new waiver or modification is 2,497
issued or imposed.
(J) No hospital, health care facility, or health care 2,499
practitioner, and no person who employs any health care 2,500
practitioner, shall balance bill any individual or dependent of 2,501
an individual or any eligible employee or dependent of an 2,503
employee for any health care supplies or services provided to the
individual or dependent or the eligible employee or dependent, 2,504
who is insured under a policy or enrolled under a health benefit 2,506
plan issued under this section. The hospital, health care 2,507
facility, or health care practitioner, or any person that employs 2,508
the health care practitioner, shall accept payments made to it by 2,509
the insurer under the terms of the policy or contract insuring or 2,511
covering such individual as payment in full for such health care 2,512
supplies or services. 2,513
As used in this division, "hospital" has the same meaning 2,515
as in section 3727.01 of the Revised Code; "health care 2,516
practitioner" has the same meaning as in section 4769.01 of the 2,517
Revised Code; and "balance bill" means charging or collecting an 2,518
amount in excess of the amount reimbursable or payable under the 2,519
policy or health care service contract issued to an individual or 2,520
group under this section for such health care supply or service. 2,521
"Balance bill" does not include charging for or collecting 2,522
copayments or deductibles required by the policy or contract. 2,523
(K) An insurer shall pay an agent a commission in the 2,525
amount of five per cent of the premium charged for initial 2,526
placement or for otherwise securing the issuance of a policy or 2,527
contract issued to an individual or small employer group under 2,528
this section, and four per cent of the premium charged for the
55
renewal of such a policy or contract. The superintendent may 2,529
adopt, in accordance with Chapter 119. of the Revised Code, such 2,530
rules as are necessary to enforce this division. 2,531
(L) Except as otherwise provided in this section, sections 2,533
3924.01 to 3924.06 of the Revised Code apply to all health 2,534
benefit plans issued under this section. 2,535
(M) Individuals accepted for coverage under this section 2,537
may be issued contracts and certificates subject to the 2,538
requirements of section 3923.12 of the Revised Code. The 2,539
coverage issued to such individuals is not subject to the 2,540
requirements of section 3923.021 of the Revised Code. 2,541
(N)(M) This section does not apply to any policy that 2,543
provides coverage for specific diseases or accidents only, or to 2,545
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 2,547
than six months, or other policy that offers only supplemental 2,548
benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION: 2,550
(1) "CARRIER," "HEALTH BENEFIT PLAN," "MEWA," AND 2,552
"PRE-EXISTING CONDITIONS PROVISION" HAVE THE SAME MEANINGS AS IN 2,554
SECTION 3924.01 OF THE REVISED CODE.
(2) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE 2,556
INDIVIDUAL AS DEFINED IN 45 C.F.R. 148.103. 2,557
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 2,558
FOLLOWING:
(a) HEALTH STATUS; 2,560
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 2,562
ILLNESSES; 2,563
(c) CLAIMS EXPERIENCE; 2,565
(d) RECEIPT OF HEALTH CARE; 2,567
(e) MEDICAL HISTORY; 2,569
(f) GENETIC INFORMATION; 2,571
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 2,573
OUT OF ACTS OF DOMESTIC VIOLENCE; 2,574
56
(h) DISABILITY. 2,576
(4) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR 2,578
CASE CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE 2,579
APPLICABLE CARRIER FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF 2,580
THE APPLICABLE BASE PREMIUM RATE AND THE CORRESPONDING HIGHEST 2,581
PREMIUM RATE.
(5) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 2,583
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 2,584
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 2,585
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 2,586
UNDER CONTRACT WITH THE CARRIER.
(B) BEGINNING IN JANUARY OF EACH YEAR, CARRIERS IN THE 2,588
BUSINESS OF ISSUING HEALTH BENEFIT PLANS TO INDIVIDUALS OR 2,589
NONEMPLOYER GROUPS SHALL ACCEPT FEDERALLY ELIGIBLE INDIVIDUALS 2,590
FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS SECTION, IN THE 2,591
ORDER IN WHICH THEY APPLY FOR COVERAGE AND SUBJECT TO THE 2,592
LIMITATION SET FORTH IN DIVISION (J) OF THIS SECTION. 2,593
(C) NO CARRIER SHALL DO EITHER OF THE FOLLOWING: 2,595
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT 2,597
OF, SUCH INDIVIDUALS; 2,598
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH 2,600
COVERAGE.
(D) A CARRIER SHALL OFFER TO FEDERALLY ELIGIBLE 2,602
INDIVIDUALS THE BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD 2,603
OF DIRECTORS OF THE OHIO HEALTH REINSURANCE PROGRAM OR PLANS 2,604
SUBSTANTIALLY SIMILAR TO THE BASIC AND STANDARD PLAN IN BENEFIT 2,606
DESIGN AND SCOPE OF COVERED SERVICES. FOR PURPOSES OF THIS 2,607
DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER 2,608
A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. 2,609
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY 2,611
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED 2,612
ANY OTHER INDIVIDUAL TO WHICH THE CARRIER IS CURRENTLY ACCEPTING 2,613
NEW BUSINESS, AND FOR WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES 2,614
57
ARE APPLIED.
(F) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE 2,616
INDIVIDUAL MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 2,617
OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY 2,619
APPLY FOR SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE 2,620
SERVICE AREA OF THE NETWORK PLAN; 2,622
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 2,624
COVERAGE TO FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS 2,625
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,626
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 2,628
SERVICES ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE 2,629
CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT HOLDERS AND 2,630
INDIVIDUALS.
(b) THE CARRIER IS APPLYING DIVISION (F)(2) OF THIS 2,632
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT 2,633
REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS. 2,634
(G) A CARRIER THAT, PURSUANT TO DIVISION (F)(2) OF THIS 2,637
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF 2,638
A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET 2,639
WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS 2,640
AFTER THE DATE THE COVERAGE IS DENIED. 2,641
(H) A CARRIER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO 2,643
FEDERALLY ELIGIBLE INDIVIDUALS IF THE CARRIER HAS DEMONSTRATED 2,644
BOTH OF THE FOLLOWING TO THE SUPERINTENDENT: 2,645
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 2,647
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 2,648
(2) THE CARRIER IS APPLYING DIVISION (H) OF THIS SECTION 2,650
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE 2,651
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND 2,652
WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 2,653
THOSE INDIVIDUALS.
(I) A CARRIER THAT, PURSUANT TO DIVISION (H) OF THIS 2,655
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY 2,656
58
ELIGIBLE INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 2,657
INDIVIDUAL MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY 2,658
DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE CARRIER 2,660
HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER HAS 2,661
SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER. 2,662
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 2,665
SECTION, A CARRIER SHALL NOT BE REQUIRED TO ACCEPT ANNUALLY UNDER 2,667
THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS WHO, IN THE 2,668
AGGREGATE, WOULD CAUSE THE CARRIER TO HAVE A TOTAL NUMBER OF NEW 2,669
INSUREDS THAT IS MORE THAN ONE-HALF PER CENT OF ITS TOTAL NUMBER 2,670
OF INSURED INDIVIDUALS AND NONEMPLOYER GROUPS IN THIS STATE PER 2,671
YEAR, CALCULATED AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY
OF DECEMBER AND EXCLUDING THE CARRIER'S MEDICARE SUPPLEMENT 2,673
POLICIES AND CONVERSION OR CONTINUATION OF COVERAGE POLICIES 2,675
UNDER STATE OR FEDERAL LAW AND ANY POLICIES DESCRIBED IN DIVISION 2,676
(M) OF SECTION 3923.58 OF THE REVISED CODE. 2,677
(2) AN OFFICER OF THE CARRIER SHALL CERTIFY TO THE 2,679
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET 2,680
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH 2,681
CERTIFICATION, THE CARRIER SHALL BE RELIEVED OF ITS OPEN 2,682
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF 2,683
THE CALENDAR YEAR UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, 2,685
ALL THE CARRIERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET 2,686
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,688
SECTION. IN THAT EVENT, CARRIERS SHALL AGAIN ACCEPT APPLICANTS 2,689
FOR OPEN ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO 2,690
THE ENROLLMENT LIMIT SET FORTH IN DIVISION (J)(1) OF THIS 2,692
SECTION.
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 2,694
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 2,695
(L) THE REQUIREMENTS OF THIS SECTION DO NOT APPLY TO ANY 2,697
HEALTH BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 2,698
OF THE REVISED CODE.
59
Sec. 3923.59. Any insurer may reinsure coverage of any 2,707
individual, small employer group, or member of that NONEMPLOYER 2,708
group acquired under section 3923.58 OR 3923.581 of the Revised 2,711
Code with the Ohio small employer health OPEN ENROLLMENT 2,712
reinsurance program in accordance with division (G) of section 2,714
3924.11 of the Revised Code. Premium rates charged for coverage 2,715
reinsured by the program shall be established in accordance with 2,716
section 3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the 2,725
Revised Code, each individual or group policy of sickness and 2,727
accident insurance delivered, issued for delivery, or renewed in 2,728
this state that provides maternity benefits shall provide
coverage of inpatient care and follow-up care for a mother and 2,729
her newborn as follows:
(1) The policy shall cover a minimum of forty-eight hours 2,732
of inpatient care following a normal vaginal delivery and a 2,733
minimum of ninety-six hours of inpatient care following a 2,734
cesarean delivery. Services covered as inpatient care shall 2,735
include medical, educational, and any other services that are 2,736
consistent with the inpatient care recommended in the protocols 2,737
and guidelines developed by national organizations that represent 2,738
pediatric, obstetric, and nursing professionals. 2,739
(2) The policy shall cover a physician-directed source of 2,741
follow-up care. Services covered as follow-up care shall include 2,742
physical assessment of the mother and newborn, parent education, 2,743
assistance and training in breast or bottle feeding, assessment 2,744
of the home support system, performance of any medically 2,745
necessary and appropriate clinical tests, and any other services 2,746
that are consistent with the follow-up care recommended in the 2,747
protocols and guidelines developed by national organizations that 2,749
represent pediatric, obstetric, and nursing professionals. The 2,750
coverage shall apply to services provided in a medical setting or 2,751
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,752
60
conducts the visit is knowledgeable and experienced in maternity 2,753
and newborn care.
When a decision is made in accordance with division (B) of 2,755
this section to discharge a mother or newborn prior to the 2,756
expiration of the applicable number of hours of inpatient care 2,757
required to be covered, the coverage of follow-up care shall 2,758
apply to all follow-up care that is provided within forty-eight 2,759
SEVENTY-TWO hours after discharge. When a mother or newborn 2,760
receives at least the number of hours of inpatient care required 2,761
to be covered, the coverage of follow-up care shall apply to 2,762
follow-up care that is determined to be medically necessary by 2,763
the health care professionals responsible for discharging the 2,764
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,767
to less than that specified under division (A)(1) of this section 2,769
shall be made by the physician attending the mother or newborn, 2,770
except that if a nurse-midwife is attending the mother in 2,771
collaboration with a physician, the decision may be made by the 2,772
nurse-midwife. Decisions regarding early discharge shall be made 2,773
only after conferring with the mother or a person responsible for 2,774
the mother or newborn. For purposes of this division, a person 2,775
responsible for the mother or newborn may include a parent, 2,776
guardian, or any other person with authority to make medical 2,777
decisions for the mother or newborn.
(C)(1) No sickness and accident insurer may do either of 2,780
the following:
(a) Terminate the participation of a health care 2,783
professional or health care facility as a provider under a
sickness and accident insurance policy solely for making 2,784
recommendations for inpatient or follow-up care for a particular 2,785
mother or newborn that are consistent with the care required to 2,786
be covered by this section; 2,787
(b) Establish or offer monetary or other financial 2,790
incentives for the purpose of encouraging a person to decline the 2,791
61
inpatient or follow-up care required to be covered by this 2,792
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,796
section has engaged in an unfair and deceptive act or practice in 2,797
the business of insurance under sections 3901.19 to 3901.26 of 2,798
the Revised Code. 2,800
(D) This section does not do any of the following: 2,803
(1) Require a policy to cover inpatient or follow-up care 2,806
that is not received in accordance with the policy's terms 2,807
pertaining to the health care professionals and facilities from 2,808
which an individual is authorized to receive health care 2,809
services.;
(2) Require a mother or newborn to stay in a hospital or 2,812
other inpatient setting for a fixed period of time following
delivery; 2,813
(3) Require a child to be delivered in a hospital or other 2,816
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,818
authority to practice nurse-midwifery in accordance with Chapter 2,820
4723. of the Revised Code; 2,822
(5) Establish minimum standards of medical diagnosis, care 2,825
or treatment for inpatient or follow-up care for a mother or 2,826
newborn. A deviation from the care required to be covered under 2,827
this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those 2,828
terms are defined in section 2305.11 of the Revised Code. 2,831
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the 2,840
Revised Code, each public employee benefit plan established or 2,842
modified in this state that provides maternity benefits shall 2,843
provide coverage of inpatient care and follow-up care for a 2,844
mother and her newborn as follows: 2,845
(1) The plan shall cover a minimum of forty-eight hours of 2,847
inpatient care following a normal vaginal delivery and a minimum 2,849
of ninety-six hours of inpatient care following a cesarean 2,850
62
delivery. Services covered as inpatient care shall include 2,851
medical, educational, and any other services that are consistent 2,852
with the inpatient care recommended in the protocols and 2,853
guidelines developed by national organizations that represent 2,854
pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of 2,856
follow-up care. Services covered as follow-up care shall include 2,857
physical assessment of the mother and newborn, parent education, 2,858
assistance and training in breast or bottle feeding, assessment 2,859
of the home support system, performance of any medically 2,860
necessary and appropriate clinical tests, and any other services 2,861
that are consistent with the follow-up care recommended in the 2,862
protocols and guidelines developed by national organizations that 2,864
represent pediatric, obstetric, and nursing professionals. The 2,865
coverage shall apply to services provided in a medical setting or 2,866
through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who 2,867
conducts the visit is knowledgeable and experienced in maternity 2,868
and newborn care.
When a decision is made in accordance with division (B) of 2,870
this section to discharge a mother or newborn prior to the 2,871
expiration of the applicable number of hours of inpatient care 2,872
required to be covered, the coverage of follow-up care shall 2,873
apply to all follow-up care that is provided within forty-eight 2,874
SEVENTY-TWO hours after discharge. When a mother or newborn 2,875
receives at least the number of hours of inpatient care required 2,876
to be covered, the coverage of follow-up care shall apply to 2,877
follow-up care that is determined to be medically necessary by 2,878
the health care professionals responsible for discharging the 2,879
mother or newborn.
(B) Any decision to shorten the length of inpatient stay 2,882
to less than that specified under division (A)(1) of this section 2,884
shall be made by the physician attending the mother or newborn, 2,885
except that if a nurse-midwife is attending the mother in 2,886
63
collaboration with a physician, the decision may be made by the 2,887
nurse-midwife. Decisions regarding early discharge shall be made 2,888
only after conferring with the mother or a person responsible for 2,889
the mother or newborn. For purposes of this division, a person 2,890
responsible for the mother or newborn may include a parent, 2,891
guardian, or any other person with authority to make medical 2,892
decisions for the mother or newborn.
(C)(1) No public employer who offers an employee benefit 2,895
plan may do either of the following: 2,896
(a) Terminate the participation of a health care 2,899
professional or health care facility as a provider under the plan 2,900
solely for making recommendations for inpatient or follow-up care 2,901
for a particular mother or newborn that are consistent with the 2,902
care required to be covered by this section; 2,903
(b) Establish or offer monetary or other financial 2,906
incentives for the purpose of encouraging a person to decline the 2,907
inpatient or follow-up care required to be covered by this 2,908
section.
(2) Whoever violates division (C)(1)(a) or (b) of this 2,912
section has engaged in an unfair and deceptive act or practice in 2,913
the business of insurance under sections 3901.19 to 3901.26 of 2,914
the Revised Code. 2,916
(D) This section does not do any of the following: 2,919
(1) Require a plan to cover inpatient or follow-up care 2,922
that is not received in accordance with the plan's terms 2,923
pertaining to the health care professionals and facilities from 2,924
which an individual is authorized to receive health care 2,925
services.;
(2) Require a mother or newborn to stay in a hospital or 2,928
other inpatient setting for a fixed period of time following
delivery; 2,929
(3) Require a child to be delivered in a hospital or other 2,932
inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the 2,934
64
authority to practice nurse-midwifery in accordance with Chapter 2,936
4723. of the Revised Code; 2,938
(5) Establish minimum standards of medical diagnosis, 2,940
care, or treatment for inpatient or follow-up care for a mother 2,941
or newborn. A deviation from the care required to be covered 2,942
under this section shall not, solely on the basis of this 2,943
section, give rise to a medical claim or derivative medical 2,944
claim, as those terms are defined in section 2305.11 of the 2,945
Revised Code. 2,947
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 2,956
the Revised Code: 2,957
(A) "Actuarial certification" means a written statement 2,959
prepared by a member of the American academy of actuaries, or by 2,960
any other person acceptable to the superintendent of insurance, 2,961
that states that, based upon the person's examination, a carrier 2,962
offering health benefit plans to small employers is in compliance 2,963
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 2,964
certification" shall include a review of the appropriate records 2,965
of, and the actuarial assumptions and methods used by, the 2,966
carrier relative to establishing premium rates for the health 2,967
benefit plans. 2,968
(B) "Adjusted average market premium price" means the 2,970
average market premium price as determined by the board of 2,972
directors of the Ohio small employer health reinsurance program 2,973
either on the basis of the arithmetic mean of all carriers' 2,974
premium rates for an SEHC plan sold to groups with similar case 2,975
characteristics by all carriers selling SEHC plans in the state, 2,977
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 2,979
plan that is issued by a carrier and that covers at least two but 2,980
no more than fifty employees of a small employer, the lowest 2,982
premium rate for a new or existing business prescribed by the 2,983
carrier for the same or similar coverage under a plan or 2,984
arrangement covering any small employer with similar case 2,985
65
characteristics.
(D) "Carrier" means any sickness and accident insurance 2,987
company or health insuring corporation authorized to issue health 2,990
benefit plans in this state or a MEWA. A sickness and accident 2,992
insurance company that owns or operates a health insuring 2,993
corporation, either as a separate corporation or as a line of 2,995
business, shall be considered as a separate carrier from that 2,996
health insuring corporation for purposes of sections 3924.01 to 2,998
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 3,000
employer, the geographic area in which the employees work; the 3,001
age and sex of the individual employees and their dependents; the 3,002
appropriate industry classification as determined by the carrier; 3,003
the number of employees and dependents; and such other objective 3,004
criteria as may be established by the carrier. "Case 3,005
characteristics" does not include claims experience, health 3,006
status, or duration of coverage from the date of issue. 3,007
(F) "Dependent" means the spouse or child of an eligible 3,009
employee, subject to applicable terms of the health benefits plan 3,010
covering the employee. 3,011
(G) "Eligible employee" means an employee who works a 3,013
normal work week of twenty-five or more hours. "Eligible 3,014
employee" does not include a temporary or substitute employee, or 3,016
a seasonal employee who works only part of the calendar year on 3,017
the basis of natural or suitable times or circumstances. 3,018
(H) "Financially impaired" means a program member that, 3,020
after April 14, 1993, is not insolvent but is determined by the 3,023
superintendent to be potentially unable to fulfill its 3,024
contractual obligations, or is placed under an order of 3,025
rehabilitation or conservation by a court of competent 3,026
jurisdiction or under an order of supervision by the 3,027
superintendent.
(I) "Health benefit plan" means any hospital or medical 3,029
expense policy or certificate or any health plan provided by a 3,031
66
carrier, that is delivered, issued for delivery, renewed, or used 3,033
in this state on or after the date occurring six months after 3,034
November 24, 1995. "Health benefit plan" does not include 3,036
policies covering only accident, credit, dental, disability 3,037
income, long-term care, hospital indemnity, medicare supplement, 3,038
specified disease, or vision care; coverage under a 3,039
one-time-limited-duration policy of no longer than six months; 3,041
coverage issued as a supplement to liability insurance; insurance 3,042
arising out of a workers' compensation or similar law; automobile 3,043
medical-payment insurance; or insurance under which benefits are 3,044
payable with or without regard to fault and which is statutorily 3,045
required to be contained in any liability insurance policy or 3,046
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 3,048
period immediately following any service waiting period 3,049
established by an employer. 3,050
(K)(I) "Late enrollee" means an eligible employee or 3,052
dependent who requests enrollment ENROLLS in a small employer's 3,053
health benefit plan following OTHER THAN DURING the initial 3,055
enrollment FIRST period provided under the terms of the first 3,057
plan for IN which the employee or dependent was IS eligible 3,058
through the small employer, unless any of the following apply: 3,060
(1) The individual: 3,062
(a) Was covered under another health benefit plan at the 3,065
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 3,067
coverage under another health benefit plan was the reason for 3,070
declining enrollment;
(c) Has lost coverage under another health benefit plan as 3,073
a result of the termination of employment, a reduction of hours 3,074
worked per week, the termination of the other plan's coverage, 3,075
death of a spouse, or divorce; and 3,076
(d) Requests enrollment within thirty days after the 3,078
termination of coverage under another health benefit plan. 3,079
67
(2) The individual is employed by an employer who offers 3,081
multiple health benefit plans and the individual elects a 3,082
different health benefit plan during an open enrollment period. 3,083
(3) A court has ordered coverage to be provided for a 3,085
spouse or minor child under a covered employee's plan and a 3,086
request for enrollment is made within thirty days after issuance 3,087
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 3,089
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,092
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996," PUB. L. 3,098
NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 300gg, AS AMENDED. 3,101
(L)(J) "MEWA" means any "multiple employer welfare 3,103
arrangement" as defined in section 3 of the "Federal Employee 3,104
Retirement Income Security Act of 1974," 88 Stat. 832, 29 3,105
U.S.C.A. 1001, as amended, except for any arrangement which is 3,106
fully insured as defined in division (b)(6)(D) of section 514 of 3,107
that act. 3,108
(M)(K) "Midpoint rate" means, for small employers with 3,110
similar case characteristics and plan designs and as determined 3,111
by the applicable carrier for a rating period, the arithmetic 3,112
average of the applicable base premium rate and the corresponding 3,113
highest premium rate. 3,114
(N)(L) "Pre-existing conditions provision" means a policy 3,116
provision that excludes or limits coverage for charges or 3,118
expenses incurred during a specified period following the 3,119
insured's effective ENROLLMENT date of coverage as to a condition 3,121
which, during a specified period immediately preceding the 3,122
effective date of coverage, had manifested itself in such a 3,123
manner as would cause an ordinarily prudent person to seek 3,124
medical advice, diagnosis, care, or treatment or for which 3,125
medical advice, diagnosis, care, or treatment was recommended or 3,126
received, or DURING a pregnancy existing on SPECIFIED PERIOD 3,128
IMMEDIATELY PRECEDING the effective ENROLLMENT date of coverage. 3,129
GENETIC INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN 3,131
THE ABSENCE OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH 3,132
68
INFORMATION.
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, 3,134
WITH RESPECT TO AN INDIVIDUAL COVERED UNDER A GROUP HEALTH 3,135
BENEFIT PLAN, THE DATE OF ENROLLMENT OF THE INDIVIDUAL IN THE 3,136
PLAN OR, IF EARLIER, THE FIRST DAY OF THE WAITING PERIOD FOR SUCH 3,138
ENROLLMENT.
(O)(M) "Service waiting period" means the period of time 3,140
after employment begins before an eligible employee may enroll in 3,142
IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any 3,143
applicable health benefit plan offered by the small employer.
(P)(N)(1) "Small employer" means any person, firm, 3,146
corporation, partnership, or association actively engaged in 3,147
business whose total, IN CONNECTION WITH A GROUP HEALTH BENEFIT 3,148
PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN YEAR, AN 3,149
EMPLOYER WHO employed work force consisted of, on at least fifty 3,150
per cent of its working days during the preceding year, AN 3,151
AVERAGE OF at least two but no more than fifty eligible 3,153
employees, the majority of whom were employed within the state ON 3,154
BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND WHO EMPLOYS 3,155
AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN YEAR.
(2) In determining the number of eligible employees for 3,157
FOR purposes of division (P)(N)(1) of this section, companies 3,158
which are affiliated companies or which are eligible to file a 3,160
combined tax return for purposes of state taxation ALL PERSONS 3,162
TREATED AS A SINGLE EMPLOYER UNDER SUBSECTION (b), (c), (m), OR 3,164
(o) OF SECTION 414 OF THE "INTERNAL REVENUE CODE OF 1986," 100 3,168
STAT. 2085, 26 U.S.C.A. 1, AS AMENDED, shall be considered one 3,171
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE 3,172
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF 3,173
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED 3,174
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS REASONABLY 3,176
EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN THE CURRENT 3,177
CALENDAR YEAR. ANY REFERENCE IN DIVISION (N) OF THIS SECTION TO 3,178
AN "EMPLOYER" INCLUDES ANY PREDECESSOR OF THE EMPLOYER. Except 3,180
69
as otherwise specifically provided, provisions of sections 3,181
3924.01 to 3924.14 of the Revised Code that apply to a small 3,182
employer that has a health benefit plan shall continue to apply 3,183
until the plan anniversary following the date the employer no 3,184
longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small employer health 3,187
care plan, which is a health benefit plan for small INDIVIDUALS 3,188
AND employers established by the board in accordance with section 3,190
3924.10 of the Revised Code. 3,191
Sec. 3924.02. (A) An individual or group health benefit 3,200
plan is subject to sections 3924.01 to 3924.14 of the Revised 3,201
Code if it provides health care benefits covering at least two 3,203
but no more than fifty employees of a small employer, and if it 3,204
meets either of the following conditions: 3,205
(1) Any portion of the premium or benefits is paid by a 3,207
small employer, or any covered individual is reimbursed, whether 3,208
through wage adjustments or otherwise, by a small employer for 3,209
any portion of the premium. 3,210
(2) The health benefit plan is treated by the employer or 3,212
any of the covered individuals as part of a plan or program for 3,213
purposes of section 106 or 162 of the "Internal Revenue Code of 3,214
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,215
(B) Notwithstanding division (A) of this section, 3,217
divisions (D), (E)(2), (F), AND (G) to (J) of section 3924.03 of 3,219
the Revised Code and section 3924.04 of the Revised Code do not 3,221
apply to health benefit policies that are not sold to owners of 3,222
small businesses as an employment benefit plan. Such policies 3,223
shall clearly state that they are not being sold as an employment 3,224
benefit plan and that the owner of the business is not 3,225
responsible, either directly or indirectly, for paying the 3,226
premium or benefits.
(C) Every health benefit plan offered or delivered by a 3,228
carrier, other than a health insuring corporation, to a small 3,230
employer is subject to sections 3923.23, 3923.231, 3923.232, 3,231
70
3923.233, and 3923.234 of the Revised Code and any other 3,232
provision of the Revised Code that requires the reimbursement, 3,233
utilization, or consideration of a specific category of a 3,234
licensed or certified health care practitioner. 3,235
(D) Except as expressly provided in sections 3924.01 to 3,237
3924.14 of the Revised Code, no health benefit plan offered to a 3,238
small employer is subject to any of the following: 3,239
(1) Any law that would inhibit any carrier from 3,241
contracting with providers or groups of providers with respect to 3,242
health care services or benefits; 3,243
(2) Any law that would impose any restriction on the 3,245
ability to negotiate with providers regarding the level or method 3,246
of reimbursing care or services provided under the health benefit 3,247
plan; 3,248
(3) Any law that would require any carrier to either 3,250
include a specific provider or class of provider when contracting 3,251
for health care services or benefits, or to exclude any class of 3,252
provider that is generally authorized by statute to provide such 3,253
care. 3,254
Sec. 3924.03. Health EXCEPT AS OTHERWISE PROVIDED IN 3,263
SECTION 2721 OF THE "HEALTH INSURANCE PORTABILITY AND 3,268
ACCOUNTABILITY ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 3,273
42 U.S.C.A. 300gg-21, AS AMENDED, HEALTH benefit plans covering 3,275
small employers are subject to the following conditions, as 3,276
applicable:
(A)(1) Pre-existing conditions provisions shall not 3,278
exclude or limit coverage for a period beyond twelve months, OR 3,279
EIGHTEEN MONTHS IN THE CASE OF A LATE ENROLLEE, following the 3,280
individual's effective ENROLLMENT date of coverage and may only 3,281
relate to conditions during A PHYSICAL OR MENTAL CONDITION, 3,283
REGARDLESS OF THE CAUSE OF THE CONDITION, FOR WHICH MEDICAL 3,285
ADVICE, DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED 3,286
WITHIN the six months immediately preceding the effective 3,288
ENROLLMENT date of coverage.
71
DIVISION (A)(1) OF THIS SECTION IS SUBJECT TO THE 3,291
EXCEPTIONS SET FORTH IN SECTION 2701(d) OF THE "HEALTH INSURANCE 3,294
PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,297
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION 3,299
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF 3,300
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR 3,301
DEPENDENT AS OF THE ENROLLMENT DATE. 3,302
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE COUNTED, 3,305
WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A GROUP HEALTH 3,306
BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE ENROLLMENT 3,307
DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL OF WHICH THE 3,308
INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE COVERAGE. 3,309
SUBSECTIONS (c)(2) TO (4) AND (e) OF SECTION 2701 OF THE "HEALTH 3,311
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996" APPLY WITH 3,315
RESPECT TO CREDITING PREVIOUS COVERAGE. 3,316
(4) AS USED IN DIVISION (A) OF THIS SECTION: 3,319
(a) "CREDITABLE COVERAGE" HAS THE SAME MEANING AS IN 3,322
SECTION 2701(c)(1) OF THE "HEALTH INSURANCE PORTABILITY AND 3,326
ACCOUNTABILITY ACT OF 1996." 3,327
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN INDIVIDUAL 3,330
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF ENROLLMENT 3,331
OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE FIRST DAY OF 3,332
THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions 3,334
provision applies to an eligible employee or dependent, all 3,335
health benefit plans shall credit the time the person was covered 3,336
under a previous employer-based health benefit plan provided by a 3,337
carrier if the previous coverage was continuous to a date not 3,339
more than thirty days prior to the effective date of the new 3,341
coverage, exclusive of any applicable service waiting period 3,342
under the plan. 3,343
(C) Any such health benefit plan shall be renewable with 3,345
respect to all eligible employees or dependents at the option of 3,346
the policyholder, contract holder, or small employer, except for 3,347
72
any of the following reasons: 3,348
(1) Nonpayment of the required premiums by the 3,350
policyholder, contract holder, or employer; 3,351
(2) Fraud or misrepresentation of the policyholder, 3,353
contract holder, or employer or, with respect to coverage of 3,354
individual insureds, the insureds or their representatives ; 3,356
(3) When the total number of insured individuals covered 3,358
under all of the health benefit plans of any one employer is less 3,359
than the total number of individuals or percentage of individuals 3,360
required by participation requirements under any specific health 3,361
benefit plan of that employer; 3,362
(4) Noncompliance with any plan provision that has been 3,364
approved by the superintendent of insurance; 3,365
(5) When the carrier ceases doing business in the small 3,367
employer market, provided that all of the following conditions 3,368
are met: 3,369
(a) Notice of the decision to cease to do business in the 3,371
small employer market is provided to the department of insurance, 3,372
the board of directors of the Ohio small employer health 3,373
reinsurance program, the policyholder or contract holder, and the 3,374
employer. 3,375
(b) Health benefit plans subject to sections 3924.01 to 3,377
3924.14 of the Revised Code shall not be canceled by the carrier 3,378
for ninety days after the date of the notice required under 3,380
division (C)(5)(a) of this section unless the business has been 3,381
sold to another carrier or the cancellations are approved by the 3,382
superintendent. 3,383
(c) A carrier that ceases to do business in the small 3,385
employer marketplace is prohibited from re-entering the small 3,386
employer marketplace for a period of five years from the date of 3,387
the notice required under division (C)(5)(a) of this section. 3,388
(D) Notwithstanding division (C) of this section, any such 3,390
health benefit plan or any coverage provided to an individual 3,391
under such a plan may be rescinded for fraud, material 3,392
73
misrepresentation, or concealment by an applicant, employee, 3,393
dependent, or small employer. 3,394
(E) Every carrier doing business in the small employer 3,396
market may underwrite and rate small employer groups, as 3,397
permitted by sections 3924.01 to 3924.14 of the Revised Code, 3,398
using accepted underwriting and actuarial practices (1) EXCEPT 3,400
AS PROVIDED IN SECTION 2712(b) TO (e) OF THE "HEALTH INSURANCE 3,402
PORTABILITY AND ACCOUNTABILITY ACT OF 1996," IF A CARRIER OFFERS 3,404
COVERAGE IN THE SMALL EMPLOYER MARKET IN CONNECTION WITH A GROUP 3,405
HEALTH BENEFIT PLAN, THE CARRIER SHALL RENEW OR CONTINUE IN FORCE 3,406
SUCH COVERAGE AT THE OPTION OF THE PLAN SPONSOR OF THE PLAN. 3,407
(2) A CARRIER MAY CANCEL OR DECIDE NOT TO RENEW THE 3,409
COVERAGE OF ANY ELIGIBLE EMPLOYEE OR OF A DEPENDENT OF AN 3,410
ELIGIBLE EMPLOYEE IF THE EMPLOYEE OR DEPENDENT, AS APPLICABLE, 3,412
HAS PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES FRAUD OR MADE 3,413
AN INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS 3,414
OF THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT
BASED, EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH 3,415
STATUS-RELATED FACTOR IN RELATION TO THE EMPLOYEE OR DEPENDENT. 3,416
AS USED IN DIVISION (B)(2) OF THIS SECTION, "HEALTH 3,419
STATUS-RELATED FACTOR" HAS THE SAME MEANING AS IN SECTION
3924.031 OF THE REVISED CODE. 3,420
(F)(C) A carrier shall not exclude any eligible employee 3,422
or dependent, who would otherwise be covered under a health 3,423
benefit plan, on the basis of any actual or expected health 3,424
condition of the employee or dependent. However, a carrier may 3,425
exclude a late enrollee for a period of up to twenty-four months 3,426
or may, in the discretion of the carrier, extend coverage to the 3,427
late enrollee at any time during that period. A carrier also may 3,428
medically underwrite a late enrollee. 3,429
If, prior to the effective date of this amendment NOVEMBER 3,432
24, 1995, a carrier excluded an eligible employee or dependent, 3,433
other than a late enrollee, on the basis of an actual or expected 3,434
health condition, the carrier shall, upon the initial renewal of 3,435
74
the coverage on or after that date, extend coverage to the 3,436
employee or dependent if all other eligibility requirements are 3,437
met.
(G)(D) No health benefit plan issued by a carrier shall 3,440
limit or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 3,442
medical condition, or accident, except for pre-existing 3,443
conditions as permitted under division (A) of this section. If a 3,444
health benefit plan that is delivered or issued for delivery 3,446
prior to April 14, 1993, contains such limitations or exclusions, 3,448
by use of a rider or amendment applicable to a specific 3,449
individual, the plan shall eliminate the use of such riders or 3,450
amendments within eighteen months after April 14, 1993. 3,451
(H)(E)(1) EXCEPT AS PROVIDED IN SECTIONS 3924.031 AND 3,454
3924.032 OF THE REVISED CODE, AND SUBJECT TO SUCH RULES AS MAY BE 3,457
ADOPTED BY THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH 3,458
CHAPTER 119. OF THE REVISED CODE, A CARRIER SHALL OFFER AND MAKE 3,459
AVAILABLE EVERY HEALTH BENEFIT PLAN THAT IT IS ACTIVELY MARKETING 3,460
TO EVERY SMALL EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH 3,461
COVERAGE.
DIVISION (E)(1) OF THIS SECTION DOES NOT APPLY TO A HEALTH 3,464
BENEFIT PLAN THAT A CARRIER MAKES AVAILABLE IN THE SMALL EMPLOYER 3,465
MARKET ONLY THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS. 3,466
DIVISION (E)(1) OF THIS SECTION SHALL NOT BE CONSTRUED TO 3,469
PRECLUDE A CARRIER FROM ESTABLISHING EMPLOYER CONTRIBUTION RULES 3,470
OR GROUP PARTICIPATION RULES FOR THE OFFERING OF COVERAGE IN 3,471
CONNECTION WITH A GROUP HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER 3,472
MARKET, AS ALLOWED UNDER THE LAW OF THIS STATE. AS USED IN 3,473
DIVISION (E)(1) OF THIS SECTION, "EMPLOYER CONTRIBUTION RULE" 3,475
MEANS A REQUIREMENT RELATING TO THE MINIMUM LEVEL OR AMOUNT OF 3,476
EMPLOYER CONTRIBUTION TOWARD THE PREMIUM FOR ENROLLMENT OF 3,477
EMPLOYEES AND DEPENDENTS AND "GROUP PARTICIPATION RULE" MEANS A 3,478
REQUIREMENT RELATING TO THE MINIMUM NUMBER OF EMPLOYEES OR 3,479
DEPENDENTS THAT MUST BE ENROLLED IN RELATION TO A SPECIFIED 3,480
75
PERCENTAGE OR NUMBER OF ELIGIBLE INDIVIDUALS OR EMPLOYEES OF AN 3,481
EMPLOYER.
(2) Each health benefit plan, at the time of initial group 3,483
enrollment, shall make coverage available to all the eligible 3,484
employees of a small employer without a service waiting period. 3,485
The decision of whether to impose a service waiting period shall 3,487
be made by the small employer. Such waiting periods shall not be 3,488
greater than ninety days. 3,489
(3) EACH HEALTH BENEFIT PLAN SHALL PROVIDE FOR THE SPECIAL 3,492
ENROLLMENT PERIODS DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,495
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,498
(I)(F) The benefit structure of any health benefit plan 3,501
may, AT THE TIME OF COVERAGE RENEWAL, be changed by the carrier 3,503
to make it consistent with the benefit structure contained in 3,504
health benefit plans being marketed to new small employer groups. 3,505
IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE SMALL EMPLOYER 3,507
MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW OF 3,509
THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL EMPLOYER 3,510
GROUP PLANS.
(J)(G) A carrier may obtain any facts and information 3,512
necessary to apply this section, or supply those facts and 3,513
information to any other third-party payer, without the consent 3,514
of the beneficiary. Each person claiming benefits under a health 3,515
benefit plan shall provide any facts and information necessary to 3,516
apply this section. 3,517
FOR PURPOSES OF THIS SECTION, "BONA FIDE ASSOCIATION" MEANS 3,520
AN ASSOCIATION THAT HAS BEEN ACTIVELY IN EXISTENCE FOR AT LEAST 3,521
FIVE YEARS; HAS BEEN FORMED AND MAINTAINED IN GOOD FAITH FOR 3,522
PURPOSES OTHER THAN OBTAINING INSURANCE; DOES NOT CONDITION 3,523
MEMBERSHIP IN THE ASSOCIATION ON ANY HEALTH STATUS-RELATED 3,524
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,526
RELATING TO AN INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; 3,527
MAKES HEALTH INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION 3,528
76
AVAILABLE TO ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED 3,529
FACTOR, AS DEFINED IN SECTION 3924.031 OF THE REVISED CODE, 3,532
RELATING TO SUCH MEMBERS OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE 3,533
THROUGH A MEMBER; DOES NOT MAKE HEALTH INSURANCE COVERAGE OFFERED 3,534
THROUGH THE ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A 3,535
MEMBER OF THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT 3,536
IMPOSED BY THE SUPERINTENDENT. TO MAINTAIN ITS STATUS AS A "BONA 3,537
FIDE ASSOCIATION," EACH ASSOCIATION SHALL ANNUALLY CERTIFY TO THE 3,538
SUPERINTENDENT THAT IT MEETS THE REQUIREMENTS OF THIS PARAGRAPH. 3,539
Sec. 3924.031. (A) AS USED IN THIS SECTION AND SECTION 3,542
3924.032 OF THE REVISED CODE: 3,544
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 3,546
FOLLOWING: 3,547
(a) HEALTH STATUS; 3,549
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 3,552
ILLNESSES;
(c) CLAIMS EXPERIENCE; 3,554
(d) RECEIPT OF HEALTH CARE; 3,556
(e) MEDICAL HISTORY; 3,558
(f) GENETIC INFORMATION; 3,560
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 3,563
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 3,565
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A 3,567
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE, 3,568
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE 3,569
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF PROVIDERS 3,571
UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS A HEALTH BENEFIT PLAN IN THE SMALL 3,574
EMPLOYER MARKET THROUGH A NETWORK PLAN, THE CARRIER MAY DO BOTH 3,575
OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH 3,577
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR 3,578
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN; 3,579
77
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE 3,581
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH 3,582
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE: 3,583
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO DELIVER 3,586
SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL GROUPS 3,587
BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP CONTRACT 3,588
HOLDERS AND MEMBERS.
(b) THE CARRIER IS APPLYING DIVISION (B)(2) OF THIS 3,591
SECTION UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE 3,592
CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES 3,593
AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO 3,594
SUCH EMPLOYEES AND DEPENDENTS. 3,595
(C) A CARRIER THAT, PURSUANT TO DIVISION (B)(2) OF THIS 3,599
SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE AREA 3,600
OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL EMPLOYER 3,601
MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE HUNDRED EIGHTY 3,602
DAYS AFTER THE DATE THE COVERAGE IS DENIED. 3,603
Sec. 3924.032. (A) A CARRIER MAY REFUSE TO ISSUE HEALTH 3,606
BENEFIT PLANS IN THE SMALL EMPLOYER MARKET IF THE CARRIER HAS 3,607
DEMONSTRATED BOTH OF THE FOLLOWING TO THE SUPERINTENDENT OF 3,608
INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES 3,610
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE. 3,611
(2) THE CARRIER IS APPLYING DIVISION (A) OF THIS SECTION 3,614
UNIFORMLY TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS 3,615
STATE CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE 3,616
AND WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS 3,617
AND THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH 3,618
STATUS-RELATED FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS. 3,619
(B) A CARRIER THAT, PURSUANT TO DIVISION (A) OF THIS 3,623
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE 3,624
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED 3,625
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE 3,626
78
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER 3,627
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL 3,628
COVERAGE, WHICHEVER IS LATER. 3,629
(C) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF 3,632
THIS SECTION ON A SERVICE-AREA-SPECIFIC BASIS. 3,633
Sec. 3924.033. (A) EACH CARRIER, IN CONNECTION WITH THE 3,636
OFFERING OF A HEALTH BENEFIT PLAN TO A SMALL EMPLOYER, SHALL 3,637
DISCLOSE TO THE EMPLOYER, AS PART OF ITS SOLICITATION AND SALES 3,638
MATERIALS, THAT THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,639
SECTION IS AVAILABLE UPON REQUEST. 3,640
(B) A CARRIER SHALL PROVIDE THE FOLLOWING INFORMATION TO A 3,643
SMALL EMPLOYER UPON REQUEST: 3,644
(1) THE PROVISIONS OF THE PLAN CONCERNING THE CARRIER'S 3,647
RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY AFFECT 3,648
CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO RENEWABILITY OF 3,651
COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY 3,653
PRE-EXISTING CONDITION EXCLUSION; 3,654
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL HEALTH 3,657
BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION DESCRIBED IN DIVISION (B) OF THIS 3,661
SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER 3,662
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE 3,663
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT PLAN. 3,665
(D) NOTHING IN THIS SECTION REQUIRES A CARRIER TO DISCLOSE 3,668
ANY INFORMATION THAT IS BY LAW PROPRIETARY AND TRADE SECRET 3,669
INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit 3,678
entity to be known as the "Ohio small employer health reinsurance 3,680
program." Any carrier issuing health benefit plans in this state 3,681
on or after April 14, 1993, may be a member of the program. 3,682
(B) A carrier may elect to be a member of the program by 3,684
79
filing a written intention to participate with the superintendent 3,686
of insurance at least thirty days prior to the implementation of 3,687
the program. Any carrier that does not file a written intention 3,688
to participate within that time period may not participate for 3,689
three years after April 14, 1993, and may file an intention to 3,691
participate only at that time or on any subsequent three-year 3,692
anniversary date. However, the superintendent may permit a 3,693
carrier to participate in the program at other intervals for 3,694
reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A 3,696
CARRIER TO PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE 3,697
SHOWN. THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 3,698
CARRIERS SEEKING TO CHANGE THEIR STATUS UNDER THIS DIVISION. 3,699
Sec. 3924.08. (A) The board of directors of the Ohio 3,708
small employer health reinsurance program shall consist of nine 3,709
appointed members who shall serve staggered terms as determined 3,710
by the initial board for its members and by the plan of operation 3,711
of the program for members of subsequent boards. Within thirty 3,712
days after April 14, 1993, the members of the board shall be 3,713
appointed, as follows: 3,714
(1) The chairperson of the senate committee having 3,716
jurisdiction over insurance shall appoint the following members: 3,717
(a) Two member carriers that are small employer carriers; 3,719
(b) One member carrier that is a health maintenance 3,721
organization predominantly in the small employer market; 3,722
(c) One representative of providers of health care. 3,724
(2) The chairperson of the committee in the house of 3,726
representatives having jurisdiction over insurance shall appoint 3,727
the following members: 3,728
(a) One member carrier that is a small employer carrier; 3,730
(b) One member carrier whose principal health insurance 3,732
business is in the large employer market; 3,733
(c) One representative of an employer with fifty or fewer 3,735
employees; 3,736
80
(d) One representative of consumers in this state. 3,738
(3) The superintendent OF INSURANCE shall appoint a 3,740
representative of a member carrier operating in the small 3,742
employer market who is a fellow of the society of actuaries. 3,743
The superintendent, a member of the house of 3,745
representatives appointed by the speaker of the house of 3,746
representatives, and a member of the senate appointed by the 3,747
president of the senate, shall be ex-officio members of the 3,748
board. The membership of all boards subsequent to the initial 3,749
board shall reflect the distribution described in division (A) of 3,751
this section.
The chairperson of the initial board and each subsequent 3,753
board shall represent a small employer member carrier and shall 3,754
be elected by a majority of the voting members of the board. 3,755
Each chairperson shall serve for the maximum duration established 3,756
in the plan of operation. 3,757
(B) Within one hundred eighty days after the appointment 3,759
of the initial board, the board shall establish a plan of 3,760
operation and, thereafter, any amendments to the plan that are 3,761
necessary or suitable, to assure the fair, reasonable, and 3,762
equitable administration of the program. The board shall, 3,763
immediately upon adoption, provide to the superintendent copies 3,764
of the plan of operation and all subsequent amendments to it. 3,765
(C) The plan of operation shall establish rules, 3,767
conditions, and procedures for all of the following: 3,768
(1) The handling and accounting of assets and moneys of 3,770
the program and for an annual fiscal reporting to the 3,771
superintendent; 3,772
(2) Filling vacancies on the board; 3,774
(3) Selecting an administering insurer, which shall be a 3,776
carrier as defined in section 3924.01 of the Revised Code, and 3,777
setting forth the powers and duties of the administering insurer; 3,778
(4) Reinsuring risks in accordance with sections 3924.07 3,780
to 3924.14 of the Revised Code; 3,781
81
(5) Collecting assessments subject to section 3924.13 of 3,783
the Revised Code from all members to provide for claims reinsured 3,784
by the program and for administrative expenses incurred or 3,785
estimated to be incurred during the period for which the 3,786
assessment is made; 3,787
(6) Providing protection for carriers from the financial 3,789
risk associated with small employers that present poor credit 3,790
risks; 3,791
(7) Establishing standards for the coverage of small 3,793
employers that have a high turnover of employees; 3,794
(8) Establishing an appeals process for carriers to seek 3,796
relief when a carrier has experienced an unfair share of 3,797
administrative and credit risks; 3,798
(9) Establishing the adjusted average market premium 3,800
prices for use by the SEHC plan for INDIVIDUALS, FOR groups of 3,802
two to twenty-five employees, and for groups of twenty-six to 3,803
fifty employees that are offered in the state; 3,804
(10) Establishing participation standards at issue and 3,806
renewal for reinsured cases; 3,807
(11) Reinsuring risks and collecting assessments in 3,809
accordance with division (G) of section 3924.11 of the Revised 3,810
Code; 3,811
(12) Any additional matters as determined by the board. 3,813
Sec. 3924.09. The Ohio small employer health reinsurance 3,822
program shall have the general powers and authority granted under 3,823
the laws of the state to insurance companies licensed to transact 3,824
sickness and accident insurance, except the power to issue 3,825
insurance. The board of directors of the program also shall have 3,826
the specific authority to do all of the following: 3,827
(A) Enter into contracts as are necessary or proper to 3,829
carry out the provisions and purposes of sections 3924.07 to 3,830
3924.14 of the Revised Code, including the authority to enter 3,831
into contracts with similar programs of other states for the 3,832
joint performance of common functions, or with persons or other 3,833
82
organizations for the performance of administrative functions; 3,834
(B) Sue or be sued, including taking any legal actions 3,836
necessary or proper for recovery of any assessments for, on 3,837
behalf of, or against any program or board member; 3,838
(C) Take such legal action as is necessary to avoid the 3,840
payment of improper claims against the program; 3,841
(D) Design the SEHC plan which, when offered by a carrier, 3,843
is eligible for reinsurance and issue reinsurance policies in 3,844
accordance with the requirements of sections 3924.07 to 3924.14 3,845
of the Revised Code; 3,846
(E) Establish rules, conditions, and procedures pertaining 3,848
to the reinsurance of members' risks by the program; 3,849
(F) Establish appropriate rates, rate schedules, rate 3,851
adjustments, rate classifications, and any other actuarial 3,852
functions appropriate to the operation of the program; 3,853
(G) Assess members in accordance with division (G) of 3,856
section 3924.11 and the provisions of section 3924.13 of the 3,857
Revised Code, and make such advance interim assessments as may be 3,858
reasonable and necessary for organizational and interim operating 3,859
expenses. Any interim assessments shall be credited as offsets 3,860
against any regular assessments due following the close of the 3,861
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 3,863
other committees if necessary to provide technical assistance 3,864
with respect to the operation of the program, policy and other 3,865
contract design, and any other function within the authority of 3,866
the program; 3,867
(I) Borrow money to effect the purposes of the program. 3,869
Any notes or other evidence of indebtedness of the program not in 3,870
default shall be legal investments for carriers and may be 3,871
carried as admitted assets. 3,872
(J) Reinsure risks, collect assessments, and otherwise 3,874
carry out its duties under division (G) of section 3924.11 of the 3,875
Revised Code.; 3,876
83
(K) Study the operation of the Ohio small employer health 3,879
reinsurance program and the open enrollment reinsurance program 3,880
and, based on its findings, make legislative recommendations to 3,881
the general assembly for improvements in the effectiveness, 3,882
operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF 3,884
SECTIONS 1751.16, 3923.122, AND 3923.581 OF THE REVISED CODE. 3,885
Sec. 3924.10. (A) The board of directors of the Ohio 3,894
small employer health reinsurance program shall design the SEHC 3,895
plan which, when offered by a carrier, is eligible for 3,896
reinsurance under the program. The board shall establish the 3,897
form and level of coverage to be made available by carriers in 3,898
their SEHC plan. In designing the plan the board shall also 3,900
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 3,901
of coverage established by the board shall specify which 3,902
components of a health benefit plan offered by a small employer 3,903
carrier may be reinsured. The SEHC plan is subject to division 3,905
(C) of section 3924.02 of the Revised Code and to the provisions 3,906
in Chapters 1751., 3923., and any other chapter of the Revised 3,908
Code that require coverage or the offer of coverage of a health 3,909
care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 3,912
eighty days after its appointment. The plan may include cost 3,913
containment features including any of the following:
(1) Utilization review of health care services, including 3,915
review of the medical necessity of hospital and physician 3,916
services; 3,917
(2) Case management benefit alternatives; 3,919
(3) Selective contracting with hospitals, physicians, and 3,921
other health care providers; 3,922
(4) Reasonable benefit differentials applicable to 3,924
participating and nonparticipating providers; 3,925
(5) Employee assistance program options that provide 3,927
84
preventive and early intervention mental health and substance 3,928
abuse services; 3,929
(6) Other provisions for the cost-effective management of 3,931
the plan. 3,932
(C) An SEHC plan established for use by health insuring 3,935
corporations shall be consistent with the basic method of 3,937
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 3,939
insurance, in the form and manner prescribed by the 3,940
superintendent, that the SEHC plan filed by the carrier is in 3,942
substantial compliance with the provisions of the board SEHC 3,943
plan. Upon receipt by the superintendent of the certification, 3,944
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 3,946
date that the program becomes operational and as a condition of 3,947
transacting business in this state, renew coverage provided to 3,948
any individual or group under its SEHC plan. 3,949
(F) A carrier shall not be required to renew coverage 3,951
where the superintendent finds that renewal of coverage would 3,952
place the carrier in a financially impaired condition. The 3,953
superintendent shall determine when the carrier is no longer 3,954
financially impaired and is, therefore, subject to the guaranteed 3,955
renewability requirements. 3,956
Sec. 3924.11. Any member of the Ohio small employer health 3,965
reinsurance program may reinsure small employer groups or 3,966
individuals in accordance with the following conditions and 3,967
limitations: 3,968
(A) With respect to eligible employees and their 3,970
dependents who are hired subsequent to the commencement of the 3,971
employer's coverage by a carrier and who are not late enrollees, 3,972
and with respect to employees of an employer who are otherwise 3,973
eligible for insurance but were excluded by the carrier's 3,974
underwriting and who are not late enrollees, coverage may be 3,975
reinsured in either ANY of the following ways: 3,976
85
(1) Except in the case of late enrollees, within sixty 3,978
days after the commencement of their coverage under the plan; 3,979
(2) In the case of late enrollees WHO WERE NOT ELIGIBLE TO 3,982
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,983
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,986
ACT OF 1996," PUB. L. NO. 104-191, 110 STAT. 1955, 42 U.S.C.A. 3,988
300gg-42, AS AMENDED, eighteen months after the date the late 3,990
enrollee becomes a member of the small employer's plan; 3,991
(3) IN THE CASE OF LATE ENROLLEES WHO WERE ELIGIBLE TO 3,993
ENROLL DURING A SPECIAL ENROLLMENT PERIOD DESCRIBED IN SECTION 3,995
2701(f) OF THE "HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 3,998
ACT OF 1996," AS AMENDED, WITHIN SIXTY DAYS AFTER THE 3,999
COMMENCEMENT OF THEIR COVERAGE UNDER THE PLAN. 4,000
(B)(1) The carrier may reinsure either the entire eligible 4,003
group or any eligible individual, in accordance with the premium 4,005
rates established in section 3924.12 of the Revised Code, upon 4,007
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,010
dependents of an eligible employee, who were previously excluded 4,011
from group coverage for medical reasons, and shall reinsure such 4,012
employees or dependents within sixty days after the carrier is 4,013
required to include them in the group coverage.
(C) With respect to an SEHC plan, the program shall 4,016
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,018
the program shall reinsure the level of coverage provided up to, 4,019
but not exceeding, the level of coverage provided in an SEHC 4,020
plan. In the coverage provided to small employers, carriers 4,021
shall be required to use high-cost care management, hospital 4,022
precertification techniques, and other cost containment 4,023
mechanisms established by the program. 4,024
(E) A carrier may not reinsure existing business, except 4,026
pursuant to division (A) of this section. 4,027
(F) If an employer group is covered under a plan other 4,029
86
than an SEHC plan and the carrier chooses to reinsure the group 4,030
subsequent to the initial coverage period, or if a new individual 4,031
joins the group and the carrier wants to reinsure that 4,032
individual, the carrier shall not force the employer to change to 4,034
an SEHC plan. The carrier shall allow the employer to maintain 4,035
the same benefit plan and reinsure only that portion of the plan 4,036
that is consistent with an SEHC plan.
(G) With respect to coverage provided to a small employer 4,038
group or AN individual acquired under section 3923.58 OR A 4,039
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 3923.581 of 4,040
the Revised Code, the following conditions and limitations apply: 4,042
(1) Within sixty days after the commencement of the 4,045
initial coverage, any carrier may reinsure coverage of an entire 4,046
small employer group, or of eligible employees or dependents of 4,047
such group, or any SUCH AN individual acquired under section 4,048
3923.58 of the Revised Code with the OPEN ENROLLMENT REINSURANCE 4,050
program IN ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A 4,052
carrier may reinsure, within sixty days after the effective date 4,054
of coverage, an employee eligible for coverage under section 4,056
3923.58 of the Revised Code. Premium rates charged for coverage 4,057
reinsured by the program shall be established in accordance with 4,058
section 3924.12 of the Revised Code. 4,059
(2) The board of directors of the OHIO HEALTH REINSURANCE 4,062
program shall establish the open enrollment reinsurance fund for 4,063
coverage provided under section 3923.58 of the Revised Code AND, 4,064
WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, COVERAGE PROVIDED 4,066
UNDER SECTION 3923.581 OF THE REVISED CODE. The fund shall be 4,067
maintained separately from any reinsurance fund established for 4,068
small employer health care plans issued pursuant to sections
3924.07 to 3924.14 of the Revised Code. The board shall 4,069
calculate, on a retrospective basis, the amount needed for 4,070
maintenance of the open enrollment reinsurance fund and, on the 4,071
basis of that calculation, shall determine the amount to be 4,072
assessed each carrier that is required to provide open enrollment 4,073
87
coverage. 4,074
Assessments shall be apportioned by the board among all 4,076
carriers participating in the open enrollment reinsurance program 4,077
in proportion to their respective shares of the total premiums, 4,078
net of reinsurance premiums paid by a carrier for open enrollment 4,079
coverage and net of reinsurance premiums paid by the carrier for 4,080
all other small group and individual health benefit plans, earned 4,081
in this state from all health benefit plans covering small 4,082
employers and individuals that are issued by all such carriers 4,083
during the calendar year coinciding with or ending during the 4,084
fiscal year of the open enrollment program, or on any other 4,085
equitable basis reflecting coverage of small employers and 4,086
individuals in this state as may be provided in the plan of 4,087
operation adopted by the board. In no event shall the assessment 4,088
of any carrier under this section exceed, on an annual basis, 4,090
three per cent of its Ohio premiums for health benefit plans 4,091
covering small employers and individuals as reported on its most 4,092
recent annual statement filed with the superintendent of 4,093
insurance.
The board shall submit its determination of the amount of 4,095
the assessment to the superintendent for review of the accuracy 4,097
of the calculation of the assessment. Upon approval by the 4,098
superintendent, each carrier shall, within thirty days after 4,099
receipt of the notice of assessment, submit the assessment to the 4,100
board for purposes of the open enrollment reinsurance fund. 4,101
(3) If the assessments made and collected pursuant to 4,103
division (G)(2) of this section are not sufficient to pay the 4,104
claims reinsured under division (G) of this section and the 4,105
allocated administrative expenses, incurred or estimated to be 4,106
incurred during the period for which the assessment was made, the 4,107
secretary of the board shall immediately notify the 4,108
superintendent, and the superintendent shall suspend the 4,109
operation of open enrollment under section 3923.58 of the Revised 4,110
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER 4,111
88
SECTION 3923.581 OF THE REVISED CODE until the board has 4,112
collected in subsequent years through assessments made pursuant 4,113
to division (G)(2) of this section an amount sufficient to pay 4,114
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,116
under section 3923.58 of the Revised Code may elect not to 4,118
participate in the open enrollment reinsurance program under 4,119
division (G) of this section by filing an application with the 4,120
superintendent and obtaining the superintendent's approval. In 4,121
determining whether to approve an application, the superintendent 4,122
shall consider whether the carrier meets all of the following 4,123
standards: 4,124
(i) Demonstration by the carrier of a substantial and 4,126
established market presence; 4,127
(ii) Demonstrated experience in the small employer group 4,129
INDIVIDUAL market and history of rating and underwriting small 4,130
employer groups INDIVIDUAL PLANS; 4,132
(iii) Commitment to comply with the requirements of 4,134
section 3923.58 of the Revised Code; 4,135
(iv) Financial ability to assume and manage the risk of 4,137
enrolling open enrollment groups and individuals without the need 4,138
for, or protection of, reinsurance. 4,139
(b) A carrier whose application for nonparticipation has 4,141
been rejected by the superintendent may appeal the decision in 4,142
accordance with Chapter 119. of the Revised Code. A carrier that 4,143
has received approval of the superintendent not to participate in 4,144
the open enrollment reinsurance program shall, on or before the 4,145
first day of December, annually certify to the superintendent 4,146
that it continues to meet the standards described in division 4,147
(G)(4)(a) of this section. 4,148
(c) In any year subsequent to the year in which its 4,150
application not to participate has been approved, a carrier may 4,151
elect to participate in the open enrollment reinsurance program 4,152
by giving notice to the superintendent and board on or before the 4,153
89
thirty-first day of December. If, after a period of 4,154
nonparticipation, a carrier elects to participate in the open 4,155
enrollment reinsurance program, the carrier retains the risks it 4,156
assumed during the period when it was not participating. 4,157
(d) The superintendent may, at any time, authorize a 4,159
carrier to modify an election not to participate if the risk from 4,160
the carrier's open enrollment business jeopardizes the financial 4,161
condition of the carrier. If the superintendent authorizes the 4,162
carrier to again participate in the open enrollment reinsurance 4,163
program, the carrier shall retain the risks it assumed during the 4,164
period of nonparticipation. 4,165
(5) At the time of acquiring a small employer group, a 4,167
carrier shall determine whether to reinsure the entire group or 4,168
any individual pursuant to section 3924.12 of the Revised Code. 4,169
(6)(a) The open enrollment reinsurance program shall be 4,172
operated separately from the Ohio small employer health 4,173
reinsurance program.
(b) A carrier's election to participate in the open 4,175
enrollment reinsurance program under division (G) of this section 4,177
shall not be construed as an election to participate in the Ohio 4,178
small employer health reinsurance program under section 3924.07 4,179
of the Revised Code.
Sec. 3924.111. (A) The Ohio small employer health 4,190
reinsurance program shall not provide reinsurance for any 4,191
individual reinsured under the program until five thousand 4,192
dollars in benefit payments have been made by a member of the 4,193
program for services provided to that individual during a
calendar year, which payments would have been reimbursed through 4,194
the program but for the five-thousand-dollar deductible. The 4,195
member shall retain ten per cent of the next fifty thousand 4,196
dollars of benefit payments made during that calendar year, and 4,197
the program shall reinsure the remainder. However, a member's 4,198
maximum liability under this section with respect to any one 4,199
individual reinsured under the program shall not exceed ten 4,200
90
thousand dollars in any one calendar year. 4,201
(B) The board of directors of the Ohio small employer 4,204
health reinsurance program shall periodically review the 4,205
deductible amount and the maximum liability amount set forth in 4,206
division (A) of this section and, considering the rate of 4,207
inflation, adjust each amount as the board considers necessary. 4,208
Sec. 3924.12. (A) Except as provided in division (B) of 4,217
this section, premium rates charged for coverage reinsured by the 4,218
Ohio small employer health reinsurance program shall be 4,219
established as follows: 4,220
(1) For whole group reinsurance coverage, one and one-half 4,222
times the adjusted average market premium price established by 4,223
the program for that classification or group with similar 4,224
characteristics and coverage, with respect to the eligible 4,225
employees of a small employer and their dependents, all of whose 4,226
coverage is reinsured with the program, minus a ceding expense 4,227
factor determined by the board of directors of the program; 4,228
(2) For individual reinsurance coverage, five times the 4,230
adjusted average market premium price established by the program 4,231
for an individual in that classification or group with similar 4,232
characteristics and coverage, with respect to an eligible 4,233
employee or the employee's dependents, minus a ceding expense 4,235
factor determined by the board. 4,236
(B) Premium rates charged for reinsurance by the program 4,238
to a health insuring corporation that is approved by the 4,240
secretary of health and human services as a federally qualified 4,241
health maintenance organization pursuant to the "Social Security 4,242
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as 4,243
such is subject to requirements that limit the amount of risk 4,244
that may be ceded to the program, may be modified to reflect the 4,245
portion of risk that may be ceded to the program. 4,246
Sec. 3924.13. (A) Following the close of each calendar 4,255
year, the administering insurer of the Ohio small employer health 4,256
reinsurance program shall determine the net premiums, the program 4,257
91
expenses for administration, and the incurred losses, if any, for 4,258
the year, taking into account investment income and other 4,259
appropriate gains and losses. For purposes of this section, 4,260
health benefit plan premiums earned by MEWAs shall be established 4,261
by adding paid claim losses and administrative expenses of the 4,262
MEWA. Health benefit plan premiums and benefits paid by a 4,264
carrier that are less than an amount determined by the board of 4,265
directors of the program to justify the cost of collection shall 4,266
not be considered for purposes of determining assessments. For 4,267
purposes of this division, "net premiums" means health benefit 4,268
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 4,270
assessments of carriers in accordance with this division. 4,271
Assessments shall be apportioned by the board among all carriers 4,272
participating in the program in proportion to their respective 4,273
shares of the total premiums, net of reinsurance premiums paid 4,274
for coverage under this program earned in the state from health 4,275
benefit plans covering small employers that are issued by 4,276
participating members during the calendar year coinciding with or 4,277
ending during the fiscal year of the program, or on any other 4,278
equitable basis reflecting coverage of small employers as may be 4,279
provided in the plan of operation. An assessment shall be made 4,280
pursuant to this division against a health insuring corporation 4,281
that is approved by the secretary of health and human services as 4,284
a federally qualified health maintenance organization pursuant to 4,285
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 4,286
as amended, subject to an assessment adjustment formula adopted 4,287
by the board for such health insuring corporations that 4,288
recognizes the restrictions imposed on the entities by federal 4,290
law. The adjustment formula shall be adopted by the board prior 4,292
to the first anniversary of the program's operation. In no event 4,293
shall the assessment made pursuant to this division exceed, on an 4,294
annual basis, one per cent of the carrier's Ohio small employer 4,296
group premium as reported on its most recent annual statement 4,297
92
filed with the superintendent of insurance. If an excess is 4,298
actuarially projected, the superintendent may take any action 4,299
necessary to lower the assessment to the maximum level of one per 4,300
cent.
(C) If assessments exceed actual losses and administrative 4,302
expenses of the program, the excess shall be held at interest and 4,303
used by the board to offset future losses or to reduce program 4,304
premiums. As used in this division, "future losses" includes 4,305
reserves for incurred but not reported claims. 4,306
(D) Each carrier's proportion of participation in the 4,308
program shall be determined annually by the board based on annual 4,310
statements and other reports deemed necessary by the board and 4,311
filed by the carrier with the board. MEWAs shall report to the 4,312
board claims payments made and administrative expenses incurred 4,313
in this state on an annual basis on a form prescribed by the 4,314
superintendent.
(E) Provision shall be made in the plan of operation for 4,316
the imposition of an interest penalty for late payment of 4,317
assessments. 4,318
(F) A carrier may seek from the superintendent a 4,320
deferment, in whole or in part, from any assessment issued by the 4,321
board. The superintendent may defer, in whole or in part, the 4,322
assessment of a carrier if, in the opinion of the superintendent, 4,323
payment of the assessment would endanger the carrier's ability to 4,324
fulfill its contractual obligations. 4,325
(G) In the event an assessment against a carrier is 4,327
deferred in whole or in part, the amount by which the assessment 4,328
is deferred may be assessed against the other carriers in a 4,329
manner consistent with the basis for assessments set forth in 4,330
this section. In such event, the other carriers assessed shall 4,331
have a claim in the amount of the assessment against the carrier 4,332
receiving the deferment. The carrier receiving the deferment 4,333
shall remain liable to the program for the amount deferred. The 4,334
superintendent may attach appropriate conditions to any 4,335
93
deferment. 4,336
Sec. 3924.14. Neither the participation as members of the 4,345
Ohio small employer health reinsurance program or as members of 4,346
the board of directors of the program, the establishment of 4,348
rates, forms, or procedures for coverage issued by the program, 4,349
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 4,350
legal action or any criminal or civil liability or penalty 4,351
against the program, the board, or any of its members either 4,352
jointly or separately.
Sec. 3924.27. (A) AS USED IN THIS SECTION: 4,355
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE 4,357
THE SAME MEANINGS AS IN SECTION 3924.01 OF THE REVISED CODE. 4,358
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE 4,360
FOLLOWING: 4,361
(a) HEALTH STATUS; 4,363
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL 4,366
ILLNESSES;
(c) CLAIMS EXPERIENCE; 4,368
(d) RECEIPT OF HEALTH CARE; 4,370
(e) MEDICAL HISTORY; 4,372
(f) GENETIC INFORMATION; 4,374
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING 4,377
OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY. 4,379
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING 4,381
HEALTH INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH 4,382
BENEFIT PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF 4,383
ENROLLMENT OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A 4,384
PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR 4,385
CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE 4,386
PLAN ON THE BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION 4,387
TO THE INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS 4,388
A DEPENDENT OF THE INDIVIDUAL. 4,389
94
(C) NOTHING IN DIVISION (B) OF THIS SECTION SHALL BE 4,393
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED 4,394
FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO PREVENT A 4,395
GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING GROUP HEALTH 4,396
INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM DISCOUNTS OR 4,397
REBATES OR MODIFYING OTHERWISE APPLICABLE COPAYMENTS OR 4,398
DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF HEALTH 4,399
PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section: 4,408
(1) "Child" means, in connection with any adoption or 4,410
placement for adoption of the child, an individual who has not 4,411
attained age eighteen as of the date of the adoption or placement 4,412
for adoption. 4,413
(2) "Health insurer" has the same meaning as in section 4,415
3924.41 of the Revised Code. 4,416
(3) "Placement for adoption" means the assumption and 4,418
retention by a person of a legal obligation for total or partial 4,419
support of a child in anticipation of the adoption of the child. 4,420
The child's placement with a person terminates upon the 4,421
termination of that legal obligation. 4,422
(B) If an individual or group health plan of a health 4,424
insurer provides MAKES coverage AVAILABLE for dependent children 4,426
of participants or beneficiaries, the plan shall provide benefits 4,427
to dependent children placed with participants or beneficiaries 4,428
for adoption under the same terms and conditions as apply to the 4,429
natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become 4,430
final. 4,431
(C) A health plan described in division (B) of this 4,433
section shall not restrict coverage under the plan of any 4,435
dependent child adopted by a participant or beneficiary, or 4,436
placed with a participant or beneficiary for adoption, solely on 4,437
the basis of a pre-existing condition of the child at the time 4,438
that the child would otherwise become eligible for coverage under 4,439
95
the plan, if the adoption or placement for adoption occurs while 4,440
the participant or beneficiary is eligible for coverage under the 4,441
plan.
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 4,450
the Revised Code: 4,451
(A) "Account holder" means the natural person who opens a 4,454
medical savings account or on whose behalf a medical savings 4,455
account is opened.
(B) "Eligible medical expense" means any expense for a 4,458
service rendered by a licensed health care provider or a 4,459
Christian Science practitioner, or for an article, device, or 4,460
drug prescribed by a licensed health care provider or provided by 4,461
a Christian Science practitioner, when intended for use in the 4,463
mitigation, treatment, or prevention of disease; ANY AMOUNT PAID 4,464
FOR TRANSPORTATION TO THE LOCATION AT WHICH SUCH A SERVICE IS 4,465
RENDERED; ANY AMOUNT PAID FOR LODGING NECESSITATED BY THE RECEIPT 4,466
OF CARE AT A NONLOCAL HOSPITAL; or premiums paid for 4,467
comprehensive sickness and accident insurance, coverage under a 4,469
health care plan of a health insuring corporation organized under 4,470
Chapter 1751. of the Revised Code, long-term care insurance as 4,472
defined in section 3923.41 of the Revised Code, Medicare MEDICARE 4,473
supplemental coverage as defined in section 3923.33 of the 4,475
Revised Code, or payments made pursuant to cost sharing 4,476
agreements under comprehensive sickness and accident plans. An 4,477
"eligible medical expense" does not include expenses otherwise 4,478
paid or reimbursed, including medical expenses paid or reimbursed 4,479
under an automobile or motor vehicle insurance policy, a workers' 4,480
compensation insurance policy or plan, or an employer-sponsored 4,481
health coverage policy, plan, or contract.
(C) "Qualified dependent" means a child of an account 4,484
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 4,487
twenty-three years of age and a full-time student at an
accredited college or university; 4,488
96
(2) The child is not self-sufficient due to physical or 4,490
mental disorders or impairments; 4,491
(3) The child is legally entitled to the provision of 4,493
proper or necessary subsistence, education, medical care, or 4,494
other care necessary for the child's health, guidance, or 4,495
well-being and is not otherwise emancipated, self-supporting, 4,496
married, or a member of the armed forces of the United States 4,498
DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE 4,499
"INTERNAL REVENUE CODE OF 1986," 100 STAT. 2085, 26 U.S.C.A. 1, 4,500
AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened 4,509
by or on behalf of any natural person, to pay the person's 4,510
eligible medical expenses and the eligible medical expenses of 4,511
that person's spouse or qualified dependent. A medical savings 4,512
account may be opened by or on behalf of a person only if that 4,515
person participates in a sickness or accident insurance plan, a 4,516
plan offered by a health insuring corporation organized under 4,517
Chapter 1751. of the Revised Code, or a self-funded, 4,518
employer-sponsored health benefit plan established pursuant to 4,519
the "Employee Retirement Income Security Act of 1974," 88 Stat. 4,520
832, 29 U.S.C.A. 1001, as amended. While the medical savings
account is open, the account holder shall continue to participate 4,521
in such a plan.
(B) A person who refuses to participate in a policy, plan, 4,524
or contract of health coverage that is funded by the person's 4,525
employer, and who receives additional monetary compensation by 4,526
virtue of refusing that coverage, may not open a medical savings 4,527
account unless the medical savings account also is sponsored by 4,528
the person's employer. 4,529
Sec. 3924.63. The owners of interest in a medical savings 4,539
account are the account holder, AND the account holder's spouse, 4,540
and qualified dependents. No medical savings account shall be 4,541
subject to garnishment or attachment. 4,543
Sec. 3924.64. (A) At the time a medical savings account 4,553
97
is opened, an administrator for the account shall be designated. 4,554
If an employer opens an account for an employee, the employer may 4,555
designate the administrator. If an account is opened by any 4,556
person other than an employer, or if an employer chooses not to 4,557
designate an administrator for an account opened for an employee, 4,558
the account holder shall designate the administrator. The 4,559
administrator shall manage the account in a fiduciary capacity 4,560
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 4,563
of the following:
(1) A federally or state-chartered bank, savings and loan 4,566
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 4,568
(3) An insurer authorized under Title XXXIX of the Revised 4,571
Code to engage in the business of sickness and accident 4,572
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 4,575
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 4,578
Revised Code;
(6) A certified public accountant; 4,580
(7) An employer that administers an employee benefit plan 4,583
subject to regulation under the "Employee Retirement Income 4,584
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 4,586
amended, or that maintains medical savings accounts for its 4,587
employees;
(8) Health insuring corporations organized under Chapter 4,590
1751. of the Revised Code.
(C) Each administrator shall send to the account holder, 4,593
at least annually, a statement setting forth the balance 4,594
remaining in the account holder's account and detailing the 4,595
activity in the account since the last statement was issued. 4,596
Upon an administrator's receipt of a written request from an 4,597
account holder for a current statement, the administrator shall 4,598
98
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 4,601
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 4,602
account holder, OR the account holder's spouse, or qualified 4,604
dependents, the administrator shall reimburse the account holder 4,605
for, or shall pay for, the eligible medical expense with funds 4,606
from the account holder's account, if sufficient funds are 4,607
available in the account holder's account. If there are not 4,608
sufficient funds in the account to fully reimburse the account 4,609
holder or pay the expenses, the administrator shall reimburse the 4,611
account holder or pay the expenses using whatever funds are in 4,612
the account. The reimbursement or payment shall be made within 4,613
thirty days of the administrator's receipt of the documentation. 4,614
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 4,615
expense does not count toward meeting the deductible or other 4,616
obligation for the receipt of benefits that is required by the 4,617
insurer or other third-party payer providing health coverage to 4,618
the account holder. The administrator shall keep a record of the 4,619
amounts disbursed from the account for documented eligible 4,620
medical expenses and of the dates on which the expenses were 4,621
incurred. This record shall be made available to any sickness 4,622
and accident insurer or other third-party payer providing health 4,623
coverage to the account holder, for use by the insurer or 4,624
third-party payer in determining whether the account holder has 4,625
met the deductible or other obligation required for the receipt 4,626
of benefits from the insurer or third-party payer. 4,627
(E) When an account is opened, the administrator shall 4,630
give written notice to the account holder of the date of the last 4,631
business day of the administrator's business year. 4,632
Sec. 3924.66. (A) In determining Ohio adjusted gross 4,641
income under Chapter 5747. of the Revised Code, an account holder 4,642
may deduct an amount equaling the total of the deposits that the 4,644
99
account holder, the account holder's spouse, or the account 4,645
holder's employer made to the account during the taxable year, to 4,646
the extent that the funds for the deposits have not otherwise 4,647
been deducted or excluded in determining the account holder's
federal adjusted gross income. The amount deducted by an account 4,649
holder for a taxable year shall not exceed three thousand 4,650
dollars. If two married persons each have an account, each 4,651
spouse may claim the deduction described in this section, and the 4,653
amount deducted by each spouse shall not exceed three thousand 4,654
dollars, whether the spouses file returns jointly or separately. 4,655
(B) The maximum deduction allowed under division (A) of 4,657
this section shall be adjusted annually by the department of 4,658
taxation to reflect increases in the consumer price index for all 4,659
items for all urban consumers for the north central region, as 4,660
published by the United States bureau of labor statistics. 4,661
(C) In determining Ohio adjusted gross income under 4,663
Chapter 5747. of the Revised Code, an account holder may deduct 4,664
the investment earnings of a medical savings account from the 4,665
account holder's federal adjusted gross income, to the extent 4,666
that these earnings have been included in the account holder's 4,667
federal adjusted gross income.
(D) In determining Ohio adjusted gross income under 4,669
Chapter 5747. of the Revised Code, an account holder shall add to 4,670
the account holder's federal adjusted gross income an amount 4,671
equal to the sum of the amounts described in divisions (D)(1) and 4,673
(2) of this section to the extent that those amounts were 4,674
included in the account holder's federal adjusted gross income 4,675
and previously deducted in determining the account holder's Ohio 4,677
adjusted gross income. In determining the extent to which 4,678
amounts withdrawn from the account shall be included in the 4,679
account holder's Ohio adjusted gross income, the tax commissioner 4,681
shall be guided by the provisions of sections 72 and 408 of the 4,682
Internal Revenue Code governing the determination of the amount 4,683
of withdrawals from an individual retirement account to be 4,684
100
included in federal gross income.
(1) Amounts withdrawn from the account during the taxable 4,687
year used for any purpose other than to reimburse the account 4,688
holder for, or to pay, the eligible medical expenses of the 4,689
account holder, OR the account holder's spouse, or qualified 4,691
dependents; 4,692
(2) Investment earnings during the taxable year on amounts 4,694
withdrawn from the account that are described in division (D)(1) 4,695
of this section. 4,696
(E) Amounts withdrawn from a medical savings account to 4,698
reimburse the account holder for, or to pay, the account holder's 4,699
eligible medical expenses, or the eligible medical expenses of 4,700
the account holder's spouse or qualified dependents, shall not be 4,702
included in the account holder's Ohio adjusted gross income in 4,703
determining taxes due under Chapter 5747. of the Revised Code. 4,704
(F) If a qualified dependent of an account holder becomes 4,707
ineligible to continue to participate in the account holder's 4,709
policy, plan, or contract of health coverage, the account holder 4,710
may withdraw funds from the account holder's account and use
those funds to pay the premium for the first year of a policy, 4,711
plan, or contract of health coverage for the qualified dependent 4,712
and to pay any deductible for the first year of that policy, 4,714
plan, or contract. Funds withdrawn and used for that purpose 4,715
shall not be included in the account holder's Ohio adjusted gross 4,716
income in determining taxes due under Chapter 5747. of the 4,717
Revised Code. 4,718
Sec. 3924.67. An account holder may withdraw funds from 4,728
the account holder's account at any time, for any purpose.
However, the administrator of a medical savings account shall not 4,729
disburse funds to an account holder during the year in which the 4,731
funds were deposited, except to reimburse the account holder for, 4,732
or pay for, a documented eligible medical expense of the account 4,733
holder, OR the account holder's spouse, or a qualified dependent. 4,734
Sec. 3924.68. (A) If an account holder, whose medical 4,744
101
savings account has been opened by the account holder's employer, 4,745
later ceases to be employed by that employer, the account holder 4,746
may, within sixty days of the account holder's final date of 4,747
employment, request in writing to the administrator of the 4,749
account that the administrator continue to administer the 4,750
account.
(1) If the administrator agrees to continue to administer 4,753
the account, funds in the account may continue to be used to pay 4,754
the eligible medical expenses of the account holder, AND the 4,755
account holder's spouse, and qualified dependents, pursuant to 4,756
sections 3924.61 to 3924.74 of the Revised Code. 4,758
If the account holder later becomes employed by a new 4,760
employer that opens a new medical savings account on the account 4,761
holder's behalf, the account holder may transfer any funds 4,763
remaining in the account opened by the account holder's former 4,764
employer to the account opened by the account holder's new 4,765
employer. For purposes of determining taxes due under Chapter 4,767
5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, 4,768
nor shall it be considered a deposit to a medical savings 4,769
account.
(2) If the administrator does not agree to continue to 4,772
administer the account, or if the account holder requests that 4,773
the account be closed, the administrator shall close the account 4,774
and mail a check or other negotiable instrument in the amount of 4,775
the account balance as of that date to the account holder. The 4,776
amount distributed shall be included in the account holder's Ohio 4,777
adjusted gross income in determining taxes due under Chapter 4,778
5747. of the Revised Code. 4,779
(B) Within sixty days of the account holder's final date 4,781
of employment, the account holder may transfer any funds 4,783
remaining in the account opened by the account holder's former 4,784
employer to another medical savings account owned by the account 4,785
holder. For purposes of determining taxes due under Chapter 4,786
102
5747,. of the Revised Code, this transfer of funds shall not be 4,787
considered a withdrawal of funds from a medical savings account, 4,788
nor shall it be considered a deposit to a medical savings
account. 4,789
(C) An administrator of an account opened by an employer 4,791
shall not close an account without the permission of the account 4,792
holder until at least sixty-one days after the account holder's 4,793
final date of employment. The employer shall notify the 4,794
administrator of the employee's final date of employment. 4,795
Sec. 3924.73. (A) As used in this section: 4,804
(1) "Health care insurer" means any person legally engaged 4,806
in the business of providing sickness and accident insurance 4,807
contracts in this state, a health insuring corporation organized 4,809
under Chapter 1751. of the Revised Code, or any legal entity that 4,810
is self-insured and provides health care benefits to its
employees or members. 4,811
(2) "Small employer" has the same meaning as in division 4,813
(P) of section 3924.01 of the Revised Code. 4,814
(B)(1) Subject to division (B)(2) of this section, nothing 4,817
in sections 3924.61 to 3924.74 of the Revised Code shall be 4,818
construed to limit the rights, privileges, or protections of 4,819
employees or small employers under sections 3924.01 to 3924.14 of 4,820
the Revised Code. 4,821
(2) If any account holder enrolls or applies to enroll in 4,823
a policy or contract offered by a health care insurer providing 4,824
sickness and accident coverage that is more comprehensive than, 4,825
and has a deductible amount that is less than, the coverage and 4,826
deductible amount of the policy under which the account holder 4,827
currently is enrolled, the health care insurer to which the 4,828
account holder applies may subject the account holder to the same 4,830
medical review, waiting periods, and underwriting requirements to 4,831
which the health care insurer generally subjects other enrollees 4,832
or applicants, unless the account holder enrolls or applies to 4,833
enroll during a designated period of open enrollment. 4,834
103
Section 2. That existing sections 1739.05, 1751.06, 4,836
1751.15, 1751.16, 1751.18, 1751.59, 1751.61, 1751.64, 1751.65, 4,837
1751.67, 3901.21, 3901.49, 3901.491, 3901.50, 3901.501, 3923.021, 4,838
3923.122, 3923.26, 3923.40, 3923.57, 3923.58, 3923.59, 3923.63, 4,840
3923.64, 3924.01, 3924.02, 3924.03, 3924.07, 3924.08, 3924.09, 4,841
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51, 4,842
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, 4,843
and 3924.73 and section 3941.53 of the Revised Code are hereby 4,844
repealed.
Section 3. The amendments to sections 1751.59, 1751.61, 4,846
3923.122, 3923.26, 3923.40, and 3924.51 of the Revised Code by 4,847
this act shall apply to contracts, evidences of coverage, 4,848
policies, and plans that are delivered, issued for delivery, 4,849
renewed, or established in this state on or after the effective 4,850
date of this section. 4,851
Section 4. The amendment of sections 1751.64, 3901.49, and 4,853
3901.50 of the Revised Code is not intended to supersede the 4,854
earlier repeal, with delayed effective dates, of those sections. 4,855
Section 5. This act is hereby declared to be an emergency 4,857
measure necessary for the immediate preservation of the public 4,858
peace, health, and safety. The reason for such necessity is that 4,859
Ohio must meet the federal deadline relative to the 4,860
implementation of the federal Health Insurance Portability and
Accountability Act of 1996. Ohio's failure to meet this deadline 4,861
could result in the federal government assuming regulation over 4,862
certain areas of health insurance, thereby disrupting the stable 4,863
health insurance market in Ohio that currently exists under Ohio 4,864
law. Meeting the federal deadline will protect the public health 4,866
and safety of the citizens of this state by ensuring the
stability of the health insurance market through the continued 4,867
regulation of this market by the state. Therefore, this act 4,868
shall go into immediate effect.