As Introduced 1
122nd General Assembly 4
Regular Session H. B. No. 698 5
1997-1998 6
REPRESENTATIVE VAN VYVEN 8
10
A B I L L
To amend sections 1739.01, 1751.01, 1751.02, 12
1751.03, 1751.05, 1751.06, 1751.11, 1751.12, 13
1751.13, 1751.15, 1751.16, 1751.20, 1751.31, 14
1751.46, 1751.55, 1751.58, 1751.59, 1751.60, 15
1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 16
3923.122, 3923.571, 3923.58, 3924.01, 3924.03, 18
3924.08, 3924.09, 3924.10, 3924.11, 3999.22, 19
5112.01, and 5112.08, to enact sections 1751.141 20
and 1751.151 of the Revised Code, and to amend 22
Section 3 of Am. Sub. S.B. 67 of the 122nd 23
General Assembly, to conform provisions in the 24
Health Insuring Corporation Law and the Sickness 25
and Accident Insurance Law with the Health 26
Insurance Portability and Accountability Act of 27
1996, to clarify other provisions in these laws, 28
to specify how health insuring corporations are 29
to bring their net worth into compliance with the 30
Health Insuring Corporation Law, and to maintain 31
the provisions of this act on and after October 32
1, 1998, by amending the versions of sections 33
1751.02, 1751.03, 1751.13, and 3924.10 of the 34
Revised Code that take effect on that date. 35
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 37
Section 1. That sections 1739.01, 1751.01, 1751.02, 39
1751.03, 1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 1751.15, 40
1751.16, 1751.20, 1751.31, 1751.46, 1751.55, 1751.58, 1751.59, 41
2
1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 42
3923.122, 3923.571, 3923.58, 3924.01, 3924.03, 3924.08, 3924.09, 44
3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 be amended and
sections 1751.141 and 1751.151 of the Revised Code be enacted to 46
read as follows:
Sec. 1739.01. As used in sections 1739.01 to 1739.22 of 55
the Revised Code: 56
(A) "Agreement" means a written agreement executed by 58
members of a multiple employer welfare arrangement that 59
establishes an arrangement, provides for its operation, and 60
through which each member agrees to assume and discharge all 61
liability under sections 1739.01 to 1739.22 of the Revised Code 62
relating to or arising out of the operation of the arrangement in 63
proportion to the ratio of the total number of covered employees 64
employed by the member at the time the liability arose to the 65
total number of covered employees employed by all members of the 66
arrangement at the time the liability arose. 67
(B) "Excess insurance" or "stop-loss insurance" means an 69
insurance policy purchased by a multiple employer welfare 70
arrangement under which it receives reimbursement for benefits it 71
pays in excess of a preset deductible or limit. 72
(C) "Fully-insured FULLY INSURED program" means a program 74
by which benefits are provided to members, employees of members, 76
or the dependents of such members or employees, through the 77
purchase of sickness and accident insurance from an insurance 78
company licensed to do business in this state or health services 79
purchased from a health maintenance organization INSURING 80
CORPORATION authorized to do business in this state. 82
(D) "Group self-insurance program" means a program by 84
which benefits are provided to members, employees of members, or 85
the dependents of such members or employees, other than through 86
sickness and accident insurance purchased from an insurance 87
company licensed to do business in this state or health care 88
services purchased from a health maintenance organization 89
3
INSURING CORPORATION authorized to do business in this state. 90
(E) "Member" means an individual or an employer that is a 92
member of an organization sponsoring a multiple employer welfare 93
arrangement. 94
(F) "Multiple employer welfare arrangement" means an 96
employee welfare benefit plan, trust, or any other arrangement, 97
whether such plan, trust, or arrangement is subject to the 98
"Employee Retirement Income Security Act of 1974," 88 Stat. 829, 99
29 U.S.C.A. 1001, as amended, that is established or maintained 100
for the purpose of offering or providing, through group insurance 101
or group self-insurance programs, medical, surgical, or hospital 102
care or benefits, or benefits in the event of sickness, accident, 103
disability, or death, to the employees, and their dependents, of 104
two or more employers, or to two or more self-employed 105
individuals and their dependents. 106
(G) "Premium" means any type of consideration paid to a 108
multiple employer welfare arrangement by a member for coverage 109
under the arrangement. 110
(H) "Surplus" means the total assets of the multiple 112
employer welfare arrangement less its liabilities and reserves as 113
determined in accordance with the requirements of sections 114
1739.01 to 1739.21 of the Revised Code. 115
(I) "Third-party administrator" has the same meaning as 117
"administrator" in section 3959.01 of the Revised Code. 118
Sec. 1751.01. As used in this chapter: 127
(A) "Basic health care services" means the following 130
services when medically necessary: 131
(1) Physician's services, except when such services are 133
supplemental under division (B) of this section; 135
(2) Inpatient hospital services; 137
(3) Outpatient medical services; 139
(4) Emergency health services; 141
(5) Urgent care services; 143
(6) Diagnostic laboratory services and diagnostic and 145
4
therapeutic radiologic services; 146
(7) Preventive health care services, including, but not 148
limited to, voluntary family planning services, infertility 149
services, periodic physical examinations, prenatal obstetrical 150
care, and well-child care. 151
"Basic health care services" does not include experimental 153
procedures. 154
A health insuring corporation shall not offer coverage for 156
a health care service, defined as a basic health care service by 157
this division, unless it offers coverage for all listed basic 158
health care services. However, this requirement does not apply 160
to the coverage of beneficiaries enrolled in Title XVIII of the 161
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 163
amended, pursuant to a medicare risk contract or medicare cost 164
contract, or to the coverage of beneficiaries enrolled in the 165
federal employee health benefits program pursuant to 5 U.S.C.A. 167
8905, or to the coverage of beneficiaries enrolled in Title XIX 168
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 170
301, as amended, known as the medical assistance program or 171
medicaid, provided by the Ohio department of human services under 172
Chapter 5111. of the Revised Code, or to the coverage of 174
beneficiaries under any federal health care program regulated by 175
a federal regulatory body, OR TO THE COVERAGE OF BENEFICIARIES 176
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE 177
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE 179
SERVICES.
(B) "Supplemental health care services" means any health 182
care services other than basic health care services that a health 183
insuring corporation may offer, alone or in combination with 184
either basic health care services or other supplemental health 185
care services, and includes:
(1) Services of facilities for intermediate or long-term 187
care, or both; 188
(2) Dental care services; 190
5
(3) Vision care and optometric services including lenses 192
and frames; 193
(4) Podiatric care or foot care services; 195
(5) Mental health services including psychological 197
services; 198
(6) Short-term outpatient evaluative and 200
crisis-intervention mental health services; 201
(7) Medical or psychological treatment and referral 203
services for alcohol and drug abuse or addiction; 204
(8) Home health services; 206
(9) Prescription drug services; 208
(10) Nursing services; 210
(11) Services of a dietitian licensed under Chapter 4759. 213
of the Revised Code;
(12) Physical therapy services; 215
(13) Chiropractic services; 217
(14) Any other category of services approved by the 219
superintendent of insurance. 220
(C) "Specialty health care services" means one of the 222
supplemental health care services listed in division (B)(1) to 224
(13) of this section, when provided by a health insuring 225
corporation on an outpatient-only basis and not in combination 226
with other supplemental health care services.
(D) "Closed panel plan" means a health care plan that 228
requires enrollees to use participating providers. 229
(E) "Compensation" means remuneration for the provision of 232
health care services, determined on other than a fee-for-service 233
or discounted-fee-for-service basis.
(F) "Contractual periodic prepayment" means the formula 236
for determining the premium rate for all subscribers of a health 237
insuring corporation. 238
(G) "Corporation" means a corporation formed under Chapter 241
1701. or 1702. of the Revised Code or the similar laws of another 243
state.
6
(H) "Emergency health services" means those health care 246
services that must be available on a seven-days-per-week, 247
twenty-four-hours-per-day basis in order to prevent jeopardy to 248
an enrollee's health status that would occur if such services 249
were not received as soon as possible, and includes, where 250
appropriate, provisions for transportation and indemnity payments 251
or service agreements for out-of-area coverage. 252
(I) "Enrollee" means any natural person who is entitled to 255
receive health care benefits provided by a health insuring 256
corporation.
(J) "Evidence of coverage" means any certificate, 259
agreement, policy, or contract issued to a subscriber that sets 260
out the coverage and other rights to which such person is 261
entitled under a health care plan. 262
(K) "Health care facility" means any facility, except a 265
health care practitioner's office, that provides preventive, 266
diagnostic, therapeutic, acute convalescent, rehabilitation, 267
mental health, mental retardation, intermediate care, or skilled 268
nursing services. 269
(L) "Health care services" means any BASIC, SUPPLEMENTAL, 272
AND SPECIALTY HEALTH CARE services involved in or incident to the 273
furnishing of preventive, diagnostic, therapeutic, or 274
rehabilitative care. 275
(M) "Health delivery network" means any group of providers 278
or health care facilities, or both, or any representative 279
thereof, that have entered into an agreement to offer health care 281
services in a panel rather than on an individual basis. 282
(N) "Health insuring corporation" means a corporation, as 285
defined in division (G) of this section, that, pursuant to a 286
policy, contract, certificate, or agreement, pays for, 287
reimburses, or provides, delivers, arranges for, or otherwise 288
makes available, basic health care services, supplemental health 289
care services, or specialty health care services, or a 290
combination of basic health care services and either supplemental 291
7
health care services or specialty health care services, through 293
either an open panel plan or a closed panel plan. 294
"Health insuring corporation" does not include a limited 297
liability company formed pursuant to Chapter 1705. of the Revised 299
Code, AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED CODE 305
IF THAT INSURER OFFERS ONLY OPEN PANEL PLANS UNDER WHICH ALL 306
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING RECEIVE THEIR 307
COMPENSATION DIRECTLY FROM THE INSURER, a corporation formed by 308
or on behalf of a political subdivision or a department, office, 309
or institution of the state, or a public entity formed by or on 310
behalf of a board of county commissioners, a county board of 312
mental retardation and developmental disabilities, an alcohol and 314
drug addiction services board, a board of alcohol, drug 315
addiction, and mental health services, or a community mental 316
health board, as those terms are used in Chapters 340. and 5126. 317
of the Revised Code. Except as provided by division (D) of 320
section 1751.02 of the Revised Code, or as otherwise provided by 323
law, no board, commission, agency, or other entity under the 325
control of a political subdivision may accept insurance risk in 326
providing for health care services. However, nothing in this 327
division shall be construed as prohibiting such entities from 328
purchasing the services of a health insuring corporation or a 329
third-party administrator licensed under Chapter 3959. of the 330
Revised Code. 331
(O) "Intermediary organization" means a health delivery 334
network or other entity that contracts with licensed health 335
insuring corporations or self-insured employers, or both, to 336
provide health care services, and that enters into contractual 338
arrangements with other entities for the provision of health care 339
services for the purpose of fulfilling the terms of its contracts 340
with the health insuring corporations and self-insured employers. 341
(P) "Intermediate care" means residential care above the 344
level of room and board for patients who require personal 345
assistance and health-related services, but who do not require 346
8
skilled nursing care.
(Q) "Medical record" means the personal information that 349
relates to an individual's physical or mental condition, medical 350
history, or medical treatment. 351
(R)(1) "Open panel plan" means a health care plan that 353
provides incentives for enrollees to use participating providers 354
and that also allows enrollees to use providers that are not 355
participating providers.
(2) No health insuring corporation may offer an open panel 358
plan, unless the health insuring corporation is also licensed as 359
an insurer under Title XXXIX of the Revised Code, the health 360
insuring corporation, on the effective date of this section JUNE 361
4, 1997, holds a certificate of authority or license to operate 363
under Chapter 1736. or 1740. of the Revised Code, or an insurer 364
licensed under Title XXXIX of the Revised Code is responsible for 366
the out-of-network risk as evidenced by both an evidence of
coverage filing under section 1751.11 of the Revised Code and a 368
policy and certificate filing under section 3923.02 of the 369
Revised Code. 370
(S) "PANEL" MEANS A GROUP OF PROVIDERS OR HEALTH CARE 372
FACILITIES THAT HAVE JOINED TOGETHER TO DELIVER HEALTH CARE 373
SERVICES THROUGH A CONTRACTUAL ARRANGEMENT WITH A HEALTH INSURING 375
CORPORATION, EMPLOYER GROUP, OR OTHER PAYOR.
(T) "Person" has the same meaning as in section 1.59 of 377
the Revised Code, and, unless the context otherwise requires, 378
includes any insurance company holding a certificate of authority 379
under Title XXXIX of the Revised Code, any subsidiary and 381
affiliate of an insurance company, and any government agency. 382
(T)(U) "Premium rate" means any set fee regularly paid by 385
a subscriber to a health insuring corporation. A "premium rate" 386
does not include a one-time membership fee, an annual
administrative fee, or a nominal access fee, paid to a managed 387
health care system under which the recipient of health care 388
services remains solely responsible for any charges accessed for 389
9
those services by the provider or health care facility. 390
(U)(V) "Primary care provider" means a provider that is 393
designated by a health insuring corporation to supervise, 394
coordinate, or provide initial care or continuing care to an 395
enrollee, and that may be required by the health insuring 396
corporation to initiate a referral for specialty care and to 397
maintain supervision of the health care services rendered to the 398
enrollee.
(V)(W) "Provider" means any natural person or partnership 401
of natural persons who are licensed, certified, accredited, or 402
otherwise authorized in this state to furnish health care 403
services, or any professional association organized under Chapter 404
1785. of the Revised Code, provided that nothing in this chapter 406
or other provisions of law shall be construed to preclude a 407
health insuring corporation, health care practitioner, or 408
organized health care group associated with a health insuring 409
corporation from employing nurse practitioners, dietitians, 410
physicians' assistants, dental assistants, dental hygienists, 411
optometric technicians, or other allied health personnel who are 412
licensed, certified, accredited, or otherwise authorized in this 413
state to furnish health care services.
(W)(X) "Provider sponsored organization" means a 416
corporation, as defined in division (G) of this section, that is 417
at least eighty per cent owned or controlled by one or more 419
hospitals, as defined in section 3727.01 of the Revised Code, or 420
one or more physicians licensed to practice medicine or surgery 421
or osteopathic medicine and surgery under Chapter 4731. of the 422
Revised Code, or any combination of such physicians and 423
hospitals. Such control is presumed to exist if at least eighty 424
per cent of the voting rights or governance rights of a provider 425
sponsored organization are directly or indirectly owned, 426
controlled, or otherwise held by any combination of the 427
physicians and hospitals described in this division. 428
(X)(Y) "Solicitation document" means the written materials 430
10
provided to prospective subscribers or enrollees, or both, and 432
used for advertising and marketing to induce enrollment in the 433
health care plans of a health insuring corporation. 434
(Y)(Z) "Subscriber" means a person who is responsible for 437
making payments to a health insuring corporation for 438
participation in a health care plan, or an enrollee whose 439
employment or other status is the basis of eligibility for 440
enrollment in a health insuring corporation.
(Z)(AA) "Urgent care services" means those health care 443
services that are appropriately provided for an unforeseen 444
condition of a kind that usually requires medical attention 445
without delay but that does not pose a threat to the life, limb, 446
or permanent health of the injured or ill person, and may include 448
such health care services provided out of the health insuring 449
corporation's approved service area pursuant to indemnity 450
payments or service agreements.
Sec. 1751.02. (A) Notwithstanding any law in this state 459
to the contrary, any corporation, as defined in section 1751.01 461
of the Revised Code, may apply to the superintendent of insurance 463
for a certificate of authority to establish and operate a health 464
insuring corporation. If the corporation applying for a 465
certificate of authority is a foreign corporation domiciled in a 466
state without laws similar to those of this chapter, the 468
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 469
chapter.
(B) No person shall establish, operate, or perform the 472
services of a health insuring corporation in this state without 474
obtaining a certificate of authority under this chapter. 475
(C) Except as provided by division (D) of this section, no 478
political subdivision or department, office, or institution of 479
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 480
this state, shall establish, operate, or perform the services of 481
11
a health insuring corporation. Nothing in this section shall be 484
construed to preclude a board of county commissioners, a county 485
board of mental retardation and developmental disabilities, an 486
alcohol and drug addiction services board, a board of alcohol, 487
drug addiction, and mental health services, or a community mental 488
health board, or a public entity formed by or on behalf of any of 489
these boards, from using managed care techniques in carrying out 490
the board's or public entity's duties pursuant to the 491
requirements of Chapters 307., 329., 340., and 5126. of the 493
Revised Code. However, no such board or public entity may 495
operate so as to compete in the private sector with health 496
insuring corporations holding certificates of authority under 497
this chapter.
(D) A corporation formed by or on behalf of a publicly 499
owned, operated, or funded hospital or health care facility may 500
apply to the superintendent for a certificate of authority under 502
division (A) of this section to establish and operate a health 503
insuring corporation.
(E) A health insuring corporation shall operate in this 506
state in compliance with this chapter and with sections 3702.51 507
to 3702.62 of the Revised Code, and shall operate in conformity 510
with its filings with the superintendent under this chapter, 511
including filings made pursuant to sections 1751.03, 1751.11, 512
1751.12, and 1751.31 of the Revised Code. 514
(F) An insurer licensed under Title XXXIX of the Revised 518
Code need not obtain a certificate of authority as a health 519
insuring corporation to offer an open panel plan as long as the 520
providers and health care facilities participating in the open 521
panel plan receive their compensation directly from the insurer. 522
If the providers and health care facilities participating in the 523
open panel plan receive their compensation from any person other 524
than the insurer, or if the insurer offers a closed panel plan, 525
the insurer must obtain a certificate of authority as a health 526
insuring corporation.
12
(G) An intermediary organization need not obtain a 529
certificate of authority as a health insuring corporation, 530
regardless of the method of reimbursement to the intermediary 531
organization, as long as a health insuring corporation or a 533
self-insured employer maintains the ultimate responsibility to 534
assure delivery of all health care services required by the
contract between the health insuring corporation and the 535
subscriber and the laws of this state or between the self-insured 536
employer and its employees. 537
Nothing in this section shall be construed to require any 539
health care facility, provider, health delivery network, or 540
intermediary organization that contracts with a health insuring 541
corporation or self-insured employer, regardless of the method of 543
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 544
certificate of authority as a health insuring corporation under 545
this chapter, unless otherwise provided, in the case of contracts 547
with a self-insured employer, by operation of the "Employee 548
Retirement Income Security Act of 1974," 88 Stat. 829, 29 553
U.S.C.A. 1001, as amended. 555
(H) Any health delivery network doing business in this 558
state, INCLUDING ANY HEALTH DELIVERY NETWORK THAT IS FUNCTIONING 559
AS AN INTERMEDIARY ORGANIZATION DOING BUSINESS IN THIS STATE, 561
that is not required to obtain a certificate of authority under 562
this chapter shall certify to the superintendent annually, not 563
later than the first day of July, and shall provide a statement 565
signed by the highest ranking official which includes the 566
following information:
(1) The health delivery network's full name and the 568
address of its principal place of business; 569
(2) A statement that the health delivery network is not 571
required to obtain a certificate of authority under this chapter 572
to conduct its business. 573
(I) The superintendent shall not issue a certificate of 576
13
authority to a health insuring corporation that is a provider 577
sponsored organization unless all health care plans to be offered 578
by the health insuring corporation provide basic health care 579
services. Substantially all of the physicians and hospitals with 580
ownership or control of the provider sponsored organization, as 581
defined in division (W)(X) of section 1751.01 of the Revised 583
Code, shall also be participating providers for the provision of 585
basic health care services for health care plans offered by the 586
provider sponsored organization. If a health insuring 587
corporation that is a provider sponsored organization offers 588
health care plans that do not provide basic health care services, 589
the health insuring corporation shall be deemed, for purposes of 590
section 1751.35 of the Revised Code, to have failed to 591
substantially comply with this chapter. 592
Except as specifically provided in this division and in 594
division (C) of section 1751.28 of the Revised Code, the 596
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 597
same manner that these provisions apply to all health insuring 598
corporations that are not provider sponsored organizations. 599
(J) Nothing in this section shall be construed to apply to 601
any multiple employer welfare arrangement operating pursuant to 602
Chapter 1739. of the Revised Code. 603
(K) Any person who violates division (B) of this section, 607
and any health delivery network that fails to comply with 608
division (H) of this section, is subject to the penalties set 609
forth in section 1751.45 of the Revised Code. 611
(L) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 614
1998.
Sec. 1751.03. (A) Each application for a certificate of 624
authority under this chapter shall be verified by an officer or 625
authorized representative of the applicant, shall be in a format 626
prescribed by the superintendent of insurance, and shall set 627
forth or be accompanied by the following: 628
14
(1) A certified copy of the applicant's articles of 630
incorporation and all amendments to the articles of 631
incorporation; 632
(2) A copy of any regulations adopted for the government 634
of the corporation, any bylaws, and any similar documents, and a 635
copy of all amendments to these regulations, bylaws, and 636
documents. The corporate secretary shall certify that these 637
regulations, bylaws, documents, and amendments have been properly 639
adopted or approved.
(3) A list of the names, addresses, and official positions 642
of the persons responsible for the conduct of the applicant, 643
including all members of the board, the principal officers, and 644
the person responsible for completing or filing financial 645
statements with the department of insurance, accompanied by a 646
completed original biographical affidavit and release of 647
information for each of these persons on forms acceptable to the 648
department;
(4) A full and complete disclosure of the extent and 650
nature of any contractual or other financial arrangement between 651
the applicant and any provider or a person listed in division 652
(A)(3) of this section, including, but not limited to, a full and 654
complete disclosure of the financial interest held by any such 655
provider or person in any health care facility, provider, or 656
insurer that has entered into a financial relationship with the 657
health insuring corporation; 658
(5) A description of the applicant, its facilities, and 660
its personnel, including, but not limited to, the location, hours 662
of operation, and telephone numbers of all contracted facilities; 663
(6) The applicant's projected annual enrollee population 665
over a three-year period; 666
(7) A clear and specific description of the health care 668
plan or plans to be used by the applicant, including a 669
description of the proposed providers, procedures for accessing 670
care, and the form of all proposed and existing contracts 671
15
relating to the administration, delivery, or financing of health 672
care services; 673
(8) A copy of each type of evidence of coverage and 675
identification card or similar document to be issued to 676
subscribers; 677
(9) A copy of each type of individual or group policy, 679
contract, or agreement to be used; 680
(10) The schedule of the proposed contractual periodic 682
prepayments or premium rates, or both, accompanied by appropriate 683
supporting data; 684
(11) A financial plan which provides a three-year 686
projection of operating results, including the projected 687
expenses, income, and sources of working capital; 688
(12) The enrollee complaint procedure to be utilized as 690
required under section 1751.19 of the Revised Code; 693
(13) A description of the procedures and programs to be 695
implemented on an ongoing basis to assure the quality of health 696
care services delivered to enrollees; 697
(14) A statement describing the geographic area or areas 699
to be served, by county; 700
(15) A copy of all solicitation documents; 702
(16) A balance sheet and other financial statements 704
showing the applicant's assets, liabilities, income, and other 705
sources of financial support; 706
(17) A description of the nature and extent of any 708
reinsurance program to be implemented, and a demonstration that 709
errors and omission insurance and, if appropriate, fidelity 710
insurance, will be in place upon the applicant's receipt of a 711
certificate of authority; 712
(18) Copies of all proposed or in force related-party or 714
intercompany agreements with an explanation of the financial 715
impact of these agreements on the applicant. If the applicant 716
intends to enter into a contract for managerial or administrative 718
services, with either an affiliated or an unaffiliated person,
16
the applicant shall provide a copy of the contract and a detailed 719
description of the person to provide these services. The 721
description shall include that person's experience in managing or 722
administering health care plans, a copy of that person's most 723
recent audited financial statement, and a completed biographical 724
affidavit on a form acceptable to the superintendent for each of 725
that person's principal officers and board members and for any 726
additional employee to be directly involved in providing 727
managerial or administrative services to the health insuring 728
corporation. If the person to provide managerial or 729
administrative services is affiliated with the health insuring 730
corporation, the contract must provide for payment for services 731
based on actual costs.
(19) A statement from the applicant's board that the 733
admitted assets of the applicant have not been and will not be 734
pledged or hypothecated; 735
(20) A statement from the applicant's board that the 737
applicant will submit monthly financial statements during the 738
first year of operations; 739
(21) The name and address of the applicant's Ohio 742
statutory agent for service of process, notice, or demand; 743
(22) Copies of all documents the applicant filed with the 745
secretary of state; 746
(23) The location of those books and records of the 748
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL 749
BE MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, 750
AND WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF 751
DOMICILE OR IN OHIO IF THE APPLICANT IS A FOREIGN CORPORATION; 752
(24) The applicant's federal identification number, 754
corporate address, and mailing address; 755
(25) An internal and external organizational chart; 758
(26) A list of the assets representing the initial net 760
worth of the applicant; 761
(27) If the applicant has a parent company, the parent 763
17
company's guaranty, on a form acceptable to the superintendent, 764
that the applicant will maintain Ohio's minimum net worth. If no 767
parent company exists, a statement regarding the availability of 768
future funds if needed.
(28) The names and addresses of the applicant's actuary 770
and external auditors; 771
(29) If the applicant is a foreign corporation, a copy of 773
the most recent financial statements filed with the insurance 774
regulatory agency in the applicant's state of domicile; 775
(30) If the applicant is a foreign corporation, a 777
statement from the insurance regulatory agency of the applicant's 778
state of domicile stating that the regulatory agency has no 779
objection to the applicant applying for an Ohio license and that 780
the applicant is in good standing in the applicant's state of 781
domicile; 782
(31) Any other information that the superintendent may 784
require. 785
(B)(1) A health insuring corporation, unless otherwise 788
provided for in this chapter OR IN SECTION 3901.321 OF THE 789
REVISED CODE, shall file a timely notice with the superintendent 790
describing any change to the corporation's articles of 791
incorporation or regulations, or any major modification to its 792
operations as set out in the information required by division (A) 794
of this section that affects any of the following: 795
(a) The solvency of the health insuring corporation; 798
(b) The health insuring corporation's continued provision 801
of services that it has contracted to provide; 802
(c) The manner in which the health insuring corporation 805
conducts its business.
(2) If the change or modification is to be the result of 807
an action to be taken by the health insuring corporation, the 808
notice shall be filed with the superintendent prior to the health 809
insuring corporation taking the action. The action shall be 811
deemed approved if the superintendent does not disapprove it 812
18
within sixty days of filing. 813
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION (B)(1) OR 816
(2) OF THIS SECTION SHALL ALSO SERVE AS THE SUBMISSION OF A 817
NOTICE WHEN REQUIRED FOR THE SUPERINTENDENT'S REVIEW FOR PURPOSES 818
OF SECTION 3901.341 OF THE REVISED CODE, IF THE NOTICE CONTAINS 820
ALL OF THE INFORMATION THAT SECTION 3901.341 OF THE REVISED CODE 824
REQUIRES FOR SUCH SUBMISSIONS AND A COPY OF ANY WRITTEN 825
AGREEMENT. THE FILING OF SUCH A NOTICE, FOR THE PURPOSE OF 826
SATISFYING THIS DIVISION AND SECTION 3901.341 OF THE REVISED 829
CODE, SHALL BE SUBJECT TO THE SIXTY-DAY REVIEW PERIOD OF DIVISION 830
(B)(2) OF THIS SECTION. 831
(C)(1) No health insuring corporation shall expand its 834
approved service area until a copy of the request for expansion, 835
accompanied by documentation of the network of providers, FORMS 837
OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS RELATING TO THE 838
DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF PROPOSED 839
CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR GROUP 840
CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING DATA, enrollment 841
projections, plan of operation, and any other changes have been 842
filed with the superintendent. 843
(2) Within ten calendar days after receipt of a complete 845
filing under division (C)(1) of this section, the superintendent 847
shall refer the appropriate jurisdictional issues to the director 848
of health pursuant to section 1751.04 of the Revised Code. 850
(3) Within seventy-five days after the superintendent's 852
receipt of a complete filing under division (C)(1) of this 854
section, the superintendent shall determine whether the plan for 855
expansion is lawful, fair, and reasonable. The superintendent 856
may not make a determination until the superintendent has 857
received the director's certification of compliance, which the 858
director shall furnish within forty-five days after referral 859
under division (C)(2) of this section. The director shall not 861
certify that the requirements of section 1751.04 of the Revised 862
Code are not met, unless the applicant has been given an 864
19
opportunity for a hearing as provided in division (D) of section 866
1751.04 of the Revised Code. The forty-five-day and 867
seventy-five-day review periods provided for in division (C)(3) 869
of this section shall cease to run as of the date on which the 870
notice of the applicant's right to request a hearing is mailed 871
and shall remain suspended until the director issues a final 872
certification. 873
(4) If the superintendent has not approved or disapproved 875
all or a portion of a service area expansion within the 876
seventy-five-day period provided for in division (C)(3) of this 878
section, the filing shall be deemed approved. 879
(5) Disapproval of all or a portion of the filing shall be 882
effected by written notice, which shall state the grounds for the 883
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 884
(D) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 887
1998.
Sec. 1751.05. (A) The superintendent of insurance shall 897
issue or deny a certificate of authority to establish or operate 898
a health insuring corporation to any corporation filing an 899
application pursuant to section 1751.03 of the Revised Code 901
within forty-five days of the superintendent's receipt of the 902
certification from the director of health under division (C) of 903
section 1751.04 of the Revised Code. A certificate of authority 904
shall be issued upon payment of the application fee prescribed in 905
section 1751.44 of the Revised Code if the superintendent is 906
satisfied that the following conditions are met: 907
(1) The persons responsible for the conduct of the affairs 910
of the applicant are competent, trustworthy, and possess good 911
reputations.
(2) The director certifies, in accordance with division 913
(C) of section 1751.04 of the Revised Code, that the 914
organization's proposed plan of operation meets the requirements 915
of division (B) of that section and sections 3702.51 to 3702.62 917
20
of the Revised Code. If, after the director has certified 918
compliance, the application is amended in a manner that affects 919
its approval under section 1751.04 of the Revised Code, the 920
superintendent shall request the director to review and recertify 921
the amended plan of operation. Within forty-five days of receipt 922
of the amended plan from the superintendent, the director shall 923
certify to the superintendent, pursuant to section 1751.04 of the 924
Revised Code, whether or not the amended plan meets the 926
requirements of section 1751.04 of the Revised Code. The 927
superintendent's forty-five-day review period shall cease to run 928
as of the date on which the amended plan is transmitted to the 929
director and shall remain suspended until the superintendent 930
receives a new certification from the director.
(3) The applicant constitutes an appropriate mechanism to 932
effectively provide or arrange for the provision of the basic 933
health care services, supplemental health care services, or 934
specialty health care services to be provided to enrollees. 935
(4) The applicant is financially responsible, complies 937
with section 1751.28 of the Revised Code, and may reasonably be 939
expected to meet its obligations to enrollees and prospective 940
enrollees. In making this determination, the superintendent may 941
consider: 942
(a) The financial soundness of the applicant's 944
arrangements for health care services, including the applicant's 945
proposed contractual periodic prepayments or premiums and the use 946
of copayments or deductibles; 947
(b) The adequacy of working capital; 949
(c) Any agreement with an insurer, a government, or any 952
other person for insuring the payment of the cost of health care 953
services or providing for automatic applicability of an 954
alternative coverage in the event of discontinuance of the health 955
insuring corporation's operations; 956
(d) Any agreement with providers or health care facilities 958
for the provision of health care services; 959
21
(e) Any deposit of securities submitted in accordance with 962
section 1751.27 of the Revised Code as a guarantee that the 963
obligations will be performed. 964
(5) The applicant has submitted documentation of an 966
arrangement to provide health care services to its enrollees 967
until the expiration of the enrollees' contracts with the 968
applicant if a health care plan or the operations of the health 969
insuring corporation are discontinued prior to the expiration of 970
the enrollees' contracts. An arrangement to provide health care 971
services may be made by using any one, or any combination, of the 973
following methods:
(a) The maintenance of insolvency insurance; 975
(b) A provision in contracts with providers and health 978
care facilities, but no health insuring corporation shall rely 979
solely on such a provision for more than thirty days; 980
(c) An agreement with other health insuring corporations 983
or insurers, providing enrollees with automatic conversion rights 984
upon the discontinuation of a health care plan or the health 985
insuring corporation's operations; 986
(d) Such other methods as approved by the superintendent. 988
(6) Nothing in the applicant's proposed method of 990
operation, as shown by the information submitted pursuant to 991
section 1751.03 of the Revised Code or by independent 993
investigation, will cause harm to an enrollee or to the public at 995
large, as determined by the superintendent.
(7) Any deficiencies certified by the director have been 997
corrected. 998
(8) The applicant has deposited securities as set forth in 1,001
section 1751.27 of the Revised Code.
(B) If an applicant elects to fulfill the requirements of 1,004
division (A)(5) of this section through an agreement with other 1,006
health insuring corporations or insurers, the agreement shall 1,007
require those health insuring corporations or insurers to give 1,008
thirty days' notice to the superintendent prior to cancellation 1,009
22
or discontinuation of the agreement for any reason. 1,010
(C) A certificate of authority shall be denied only after 1,013
compliance with the requirements of section 1751.36 of the 1,014
Revised Code.
Sec. 1751.06. Upon obtaining a certificate of authority as 1,023
required under this chapter, a health insuring corporation may do 1,025
all of the following:
(A) Enroll individuals and their dependents in either of 1,027
the following circumstances: 1,028
(1) The individual resides or lives in the approved 1,030
service area.
(2) The individual's place of employment is located in the 1,033
approved service area.
(B) Contract with providers and health care facilities for 1,035
the health care services to which enrollees are entitled under 1,036
the terms of the health insuring corporation's health care 1,037
contracts;
(C) Contract with insurance companies authorized to do 1,040
business in this state for insurance, indemnity, or reimbursement 1,041
against the cost of providing emergency and nonemergency health 1,042
care services for enrollees, subject to the provisions set forth 1,043
in this chapter and the limitations set forth in the Revised 1,045
Code;
(D) Contract with any person pursuant to the requirements 1,047
of division (A)(18) of section 1751.03 of the Revised Code for 1,048
managerial or administrative services, or for data processing, 1,049
actuarial analysis, billing services, or any other services 1,050
authorized by the superintendent of insurance. However, a health 1,052
insuring corporation shall not enter into a contract for any of 1,053
the services listed in this division with an insurance company 1,054
that is not authorized to engage in the business of insurance in 1,055
this state.
(E) Accept from governmental agencies, private agencies, 1,057
corporations, associations, groups, individuals, or other 1,058
23
persons, payments covering all or part of the costs of planning, 1,059
development, construction, and the provision of health care 1,060
services;
(F) Purchase, lease, construct, renovate, operate, or 1,062
maintain health care facilities, and their ancillary equipment, 1,063
and any property necessary in the transaction of the business of 1,064
the health insuring corporation;
(G) In the employer group market, impose an affiliation 1,067
period of not more than sixty days, OR FOR LATE ENROLLEES AN
AFFILIATION PERIOD OF NOT MORE THAN NINETY DAYS, which period 1,068
begins on the individual's date of enrollment and runs 1,069
concurrently with any waiting period imposed under the coverage. 1,070
For purposes of this division, "affiliation period" means a 1,071
period of time which, under the terms of the coverage offered, 1,072
must expire before the coverage becomes effective. No health 1,073
care services or benefits need to be provided during an 1,074
affiliation period, and no periodic prepayments can be charged 1,075
for any coverage during that period. 1,076
(H) If a health insuring corporation offers coverage in 1,079
the small employer group market through a network plan, limit or 1,080
deny the coverage in accordance with section 3924.031 of the 1,081
Revised Code; 1,083
(I) Refuse to issue coverage in the small employer group 1,086
market pursuant to section 3924.032 of the Revised Code; 1,088
(J) Establish employer contribution rules or group 1,091
participation rules for the offering of coverage in connection 1,092
with a group contract in the small employer group market, as 1,093
provided in division (E)(1) of section 3924.03 of the Revised 1,095
Code. 1,096
Nothing in this section shall be construed as prohibiting a 1,098
health insuring corporation without other commercial enrollment 1,099
from contracting solely with federal health care programs 1,100
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 1,102
24
authority of a health insuring corporation to perform those 1,103
functions not otherwise prohibited by law. 1,104
Sec. 1751.11. (A) Every subscriber of a health insuring 1,114
corporation is entitled to an evidence of coverage for the health 1,115
care plan under which health care benefits are provided. 1,117
(B) Every subscriber of a health insuring corporation that 1,119
offers basic health care services is entitled to an 1,120
identification card or similar document that specifies the health 1,121
insuring corporation's name as stated in its articles of 1,122
incorporation, and any trade or fictitious names used by the 1,123
health insuring corporation. The identification card or document 1,124
shall list at least one telephone number that provides the 1,125
subscriber with access to health care on a 1,126
twenty-four-hour-per-day TWENTY-FOUR-HOURS-PER-DAY,
seven-day-per-week SEVEN-DAYS-PER-WEEK basis. 1,127
(C) No evidence of coverage, or amendment to the evidence 1,129
of coverage, shall be delivered, issued for delivery, renewed, or 1,130
used, until the form of the evidence of coverage or amendment has 1,131
been filed by the health insuring corporation with the 1,132
superintendent of insurance. If the superintendent does not 1,133
disapprove the evidence of coverage or amendment within sixty 1,134
days after it is filed it shall be deemed approved, unless the 1,135
superintendent sooner gives approval for the evidence of coverage 1,136
or amendment. With respect to an amendment to an approved 1,137
evidence of coverage, the superintendent only may disapprove 1,138
provisions amended or added to the evidence of coverage. If the 1,139
superintendent determines within the sixty-day period that any 1,140
evidence of coverage or amendment fails to meet the requirements 1,141
of this section, the superintendent shall so notify the health 1,142
insuring corporation and it shall be unlawful for the health 1,143
insuring corporation to use such evidence of coverage or 1,144
amendment. At any time, the superintendent, upon at least thirty 1,146
days' written notice to a health insuring corporation, may 1,147
withdraw an approval, deemed or actual, of any evidence of
25
coverage or amendment on any of the grounds stated in this 1,148
section. Such disapproval shall be effected by a written order, 1,149
which shall state the grounds for disapproval and shall be issued 1,151
in accordance with Chapter 119. of the Revised Code. 1,153
(D) No evidence of coverage or amendment shall be 1,155
delivered, issued for delivery, renewed, or used: 1,156
(1) If it contains provisions or statements that are 1,158
inequitable, untrue, misleading, or deceptive; 1,159
(2) Unless it contains a clear, concise, and complete 1,161
statement of the following: 1,162
(a) The health care services and insurance or other 1,165
benefits, if any, to which the enrollee is entitled under the 1,166
health care plan;
(b) Any exclusions or limitations on the health care 1,169
services, type of health care services, benefits, or type of 1,170
benefits to be provided, including copayments or deductibles; 1,171
(c) The enrollee's personal financial obligation for 1,173
noncovered services; 1,174
(d) Where and in what manner general information and 1,177
information as to how services may be obtained is available, 1,178
including the telephone number; 1,179
(e) The premium rate with respect to individual and 1,181
conversion contracts, and relevant copayment provisions with 1,182
respect to all contracts. The statement of the premium rate, 1,183
however, may be contained in a separate insert. 1,184
(f) The method utilized by the health insuring corporation 1,187
for resolving enrollee complaints. 1,188
(3) Unless it provides for the continuation of an 1,190
enrollee's coverage, in the event that the enrollee's coverage 1,191
under the policy, contract, certificate, or agreement terminates 1,192
while the enrollee is receiving inpatient care in a hospital. 1,193
This continuation of coverage shall terminate at the earliest 1,194
occurrence of any of the following: 1,195
(a) The enrollee's discharge from the hospital; 1,197
26
(b) The determination by the enrollee's attending 1,199
physician that inpatient care is no longer medically indicated 1,200
for the enrollee;
(c) The enrollee's reaching the limit for contractual 1,202
benefits; 1,203
(d) THE EFFECTIVE DATE OF ANY NEW COVERAGE. 1,206
(4) Unless it contains a provision that states, in 1,208
substance, that the health insuring corporation is not a member 1,209
of any guaranty fund, and that in the event of the health 1,210
insuring corporation's insolvency, the enrollee is protected only 1,212
to the extent that the hold harmless provision required by
section 1751.13 of the Revised Code applies to the health care 1,214
services rendered; 1,215
(5) Unless it contains a provision that states, in 1,217
substance, that in the event of the insolvency of the health 1,218
insuring corporation, the enrollee may be financially responsible 1,220
for health care services rendered by a provider or health care 1,221
facility that is not under contract to the health insuring 1,222
corporation, whether or not the health insuring corporation 1,223
authorized the use of the provider or health care facility. 1,224
(E) Notwithstanding division (D) of this section, a health 1,228
insuring corporation may use an evidence of coverage that
provides for the coverage of beneficiaries enrolled in Title 1,230
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 1,231
U.S.C.A. 301, as amended, pursuant to a medicare risk contract or 1,233
medicare cost contract, or an evidence of coverage that provides 1,234
for the coverage of beneficiaries enrolled in the federal 1,235
employees health benefits program pursuant to 5 U.S.C.A. 8905, or 1,238
an evidence of coverage that provides for the coverage of 1,239
beneficiaries enrolled in Title XIX of the "Social Security Act," 1,241
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the 1,242
medical assistance program or medicaid, provided by the Ohio 1,244
department of human services under Chapter 5111. of the Revised 1,245
Code, or an evidence of coverage that provides for the coverage 1,246
27
of beneficiaries under any other federal health care program 1,247
regulated by a federal regulatory body, OR AN EVIDENCE OF 1,248
COVERAGE THAT PROVIDES FOR THE COVERAGE OF BENEFICIARIES UNDER 1,249
ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS 1,250
BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, 1,252
if both of the following apply: 1,254
(1) The evidence of coverage has been approved by the 1,256
United States department of health and human services, the United 1,258
States office of personnel management, or the Ohio department of 1,259
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,260
(2) The evidence of coverage is filed with the 1,262
superintendent of insurance prior to use and is accompanied by 1,263
documentation of approval from the United States department of 1,265
health and human services, the United States office of personnel 1,266
management, or the Ohio department of human services, OR THE 1,267
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,268
Sec. 1751.12. (A)(1) No contractual periodic prepayment 1,278
and no premium rate for nongroup and conversion policies for 1,279
health care services, or any amendment to them, may be used by 1,280
any health insuring corporation at any time until the contractual 1,281
periodic prepayment and premium rate, or amendment, have been 1,282
filed with the superintendent of insurance, and shall not be 1,283
effective until the expiration of sixty days after their filing 1,284
unless the superintendent sooner gives approval. THE FILING 1,285
SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE FORM 1,286
PRESCRIBED BY THE SUPERINTENDENT. The superintendent shall 1,288
disapprove the filing, if the superintendent determines within 1,289
the sixty-day period that the contractual periodic prepayment or 1,290
premium rate, or amendment, is not in accordance with sound 1,291
actuarial principles or is not reasonably related to the 1,292
applicable coverage and characteristics of the applicable class 1,293
of enrollees. The superintendent shall notify the health 1,294
insuring corporation of the disapproval, and it shall thereafter 1,295
be unlawful for the health insuring corporation to use the 1,296
28
contractual periodic prepayment or premium rate, or amendment. 1,297
(2) No contractual periodic prepayment for group policies 1,300
for health care services shall be used until the contractual 1,301
periodic prepayment has been filed with the superintendent. THE 1,302
FILING SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE 1,303
FORM PRESCRIBED BY THE SUPERINTENDENT. The superintendent may 1,305
reject a filing made under division (A)(2) of this section at any 1,306
time, with at least thirty days' written notice to a health 1,307
insuring corporation, if the contractual periodic prepayment is 1,308
not in accordance with sound actuarial principles or is not 1,310
reasonably related to the applicable coverage and characteristics 1,311
of the applicable class of enrollees. 1,312
(3) At any time, the superintendent, upon at least thirty 1,314
days' written notice to a health insuring corporation, may 1,315
withdraw the approval given under division (A)(1) of this 1,316
section, deemed or actual, of any contractual periodic prepayment 1,318
or premium rate, or amendment, based on information that either 1,319
of the following applies:
(a) The contractual periodic prepayment or premium rate, 1,322
or amendment, is not in accordance with sound actuarial 1,323
principles.
(b) The contractual periodic prepayment or premium rate, 1,326
or amendment, is not reasonably related to the applicable 1,327
coverage and characteristics of the applicable class of 1,328
enrollees.
(4) Any disapproval under division (A)(1) of this section, 1,330
any rejection of a filing made under division (A)(2) of this 1,332
section, or any withdrawal of approval under division (A)(3) of 1,333
this section, shall be effected by a written notice, which shall 1,334
state the specific basis for the disapproval, rejection, or 1,335
withdrawal and shall be issued in accordance with Chapter 119. of 1,336
the Revised Code. 1,337
(B) Notwithstanding division (A) of this section, a health 1,340
insuring corporation may use a contractual periodic prepayment or 1,341
29
premium rate for policies used for the coverage of beneficiaries 1,342
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 1,344
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 1,346
risk contract or medicare cost contract, or for policies used for 1,347
the coverage of beneficiaries enrolled in the federal employees 1,348
health benefits program pursuant to 5 U.S.C.A. 8905, or for 1,351
policies used for the coverage of beneficiaries enrolled in Title 1,352
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 1,354
U.S.C.A. 301, as amended, known as the medical assistance program 1,357
or medicaid, provided by the Ohio department of human services 1,358
under Chapter 5111. of the Revised Code, or for policies used for 1,359
the coverage of beneficiaries under any other federal health care 1,360
program regulated by a federal regulatory body, OR FOR POLICIES 1,362
USED FOR THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT 1,363
COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED 1,364
INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the 1,366
following apply: 1,367
(1) The contractual periodic prepayment or premium rate 1,369
has been approved by the United States department of health and 1,370
human services, the United States office of personnel management, 1,372
or the Ohio department of human services, OR THE DEPARTMENT OF 1,373
ADMINISTRATIVE SERVICES.
(2) The contractual periodic prepayment or premium rate is 1,375
filed with the superintendent prior to use and is accompanied by 1,376
documentation of approval from the United States department of 1,378
health and human services, the United States office of personnel 1,380
management, or the Ohio department of human services, OR THE 1,382
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,383
(C) The administrative expense portion of all contractual 1,386
periodic prepayment or premium rate filings submitted to the 1,387
superintendent for review must reflect the actual cost of 1,388
administering the product. The superintendent may require that 1,389
the administrative expense portion of the filings be itemized and 1,390
supported.
30
(D)(1) Copayments and deductibles must be reasonable and 1,393
must not be a barrier to the necessary utilization of services by 1,394
enrollees.
(2) A health insuring corporation may not impose copayment 1,397
charges on basic health care services that exceed thirty per cent 1,398
of the total cost of providing any single covered health care 1,399
service, except for physician office visits, emergency health 1,400
services, and urgent care services. The total cost of providing 1,401
a health care service is the cost to the health insuring 1,402
corporation of providing the health care service to its enrollees 1,404
as reduced by any applicable provider discount. An open panel 1,406
plan may not impose copayments on out-of-network benefits that 1,407
exceed fifty per cent of the total cost of providing any single 1,408
covered health care service.
(3) To ensure that copayments are not a barrier to the 1,410
utilization of basic health care services, a health insuring 1,411
corporation may not impose, in any contract year, on any 1,412
subscriber or enrollee, copayments that exceed two hundred per 1,413
cent of the total annual premium rate to the subscriber or 1,414
enrollees. This limitation of two hundred per cent does not 1,416
include any reasonable copayments that are not a barrier to the 1,417
necessary utilization of health care services by enrollees and 1,418
that are imposed on physician office visits, emergency health 1,419
services, urgent care services, supplemental health care 1,420
services, or specialty health care services.
(E) A health insuring corporation shall not impose 1,423
lifetime maximums on basic health care services. However, a 1,424
health insuring corporation may establish a benefit limit for 1,425
inpatient hospital services that are provided pursuant to a 1,426
policy, contract, certificate, or agreement for supplemental 1,427
health care services.
Sec. 1751.13. (A)(1) A health insuring corporation shall, 1,437
either directly or indirectly, enter into contracts for the 1,438
provision of health care services with a sufficient number and 1,439
31
types of providers and health care facilities to ensure that all 1,440
covered health care services will be accessible to enrollees from 1,441
a contracted provider or health care facility. 1,442
(2) When a health insuring corporation is unable to 1,444
provide a covered health care service from a contracted provider 1,445
or health care facility, the health insuring corporation must 1,446
provide that health care service from a noncontracted provider or 1,448
health care facility consistent with the terms of the enrollee's 1,449
policy, contract, certificate, or agreement. The health insuring 1,450
corporation shall either ensure that the health care service be 1,451
provided at no greater cost to the enrollee than if the enrollee 1,452
had obtained the health care service from a contracted provider 1,453
or health care facility, or make other arrangements acceptable to 1,454
the superintendent of insurance. 1,455
(3) Nothing in this section shall prohibit a health 1,457
insuring corporation from entering into contracts with 1,458
out-of-state providers or health care facilities that are 1,459
licensed, certified, accredited, or otherwise authorized in that 1,460
state. 1,461
(B)(1) A health insuring corporation shall, either 1,464
directly or indirectly, enter into contracts with all providers 1,465
and health care facilities through which health care services are 1,466
provided to its enrollees.
(2) A health insuring corporation, upon written request, 1,468
shall assist its contracted providers in finding stop-loss or 1,469
reinsurance carriers.
(C) A health insuring corporation shall file an annual 1,471
certificate with the superintendent certifying that all provider 1,472
contracts and contracts with health care facilities through which 1,473
health care services are being provided contain the following: 1,474
(1) A description of the method by which the provider or 1,476
health care facility will be notified of the specific health care 1,478
services for which the provider or health care facility will be 1,479
responsible, including any limitations or conditions on such 1,480
32
services;
(2) The specific hold harmless provision specifying 1,482
protection of enrollees set forth as follows: 1,483
"[Provider/Health Care Facility< agrees that in no event, 1,486
including but not limited to nonpayment by the health insuring 1,487
corporation, insolvency of the health insuring corporation, or 1,488
breach of this agreement, shall [Provider/Health Care Facility< 1,490
bill, charge, collect a deposit from, seek remuneration or 1,491
reimbursement from, or have any recourse against, a subscriber, 1,492
enrollee, person to whom health care services have been provided, 1,494
or person acting on behalf of the covered enrollee, for health 1,495
care services provided pursuant to this agreement. This does not 1,496
prohibit [Provider/Health Care Facility< from collecting 1,497
co-insurance, deductibles, or copayments as specifically provided 1,499
in the evidence of coverage, or fees for uncovered health care 1,500
services delivered on a fee-for-service basis to persons 1,501
referenced above, nor from any recourse against the health 1,502
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 1,504
facility to continue to provide covered health care services to 1,505
enrollees in the event of the health insuring corporation's 1,506
insolvency or discontinuance of operations. The provisions shall 1,508
require the provider or health care facility to continue to 1,509
provide covered health care services to enrollees as needed to 1,510
complete any medically necessary procedures commenced but 1,511
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A 1,512
MEDICALLY NECESSARY PROCEDURE SHALL INCLUDE THE RENDERING OF ALL 1,514
MEDICALLY NECESSARY FOLLOW-UP CARE FOR THAT PROCEDURE. If an 1,515
enrollee is receiving necessary inpatient care at a hospital, the 1,516
provisions may limit the required provision of covered health 1,517
care services relating to that inpatient care in accordance with 1,518
division (D)(3) of section 1751.11 of the Revised Code, and may 1,520
also limit such required provision of covered health care 1,521
33
services to the period ending thirty days after the health 1,522
insuring corporation's insolvency or discontinuance of 1,523
operations.
The provisions required by division (C)(3) of this section 1,526
shall not require any provider or health care facility to 1,527
continue to provide any covered health care service after the
occurrence of any of the following: 1,528
(a) The end of the thirty-day period following the entry 1,530
of a liquidation order under Chapter 3903. of the Revised Code; 1,532
(b) The end of the enrollee's period of coverage for a 1,534
contractual prepayment or premium; 1,535
(c) The enrollee obtains equivalent coverage with another 1,537
health insuring corporation or insurer, or the enrollee's 1,538
employer obtains such coverage for the enrollee; 1,539
(d) The enrollee or the enrollee's employer terminates 1,541
coverage under the contract; 1,542
(e) A liquidator effects a transfer of the health insuring 1,545
corporation's obligations under the contract under division 1,546
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 1,548
responsibilities of the health insuring corporation, and of the 1,549
contracted providers and health care facilities, with respect to 1,550
administrative policies and programs, including, but not limited 1,551
to, payments systems, utilization review, quality assessment and 1,552
improvement programs, credentialing, confidentiality 1,553
requirements, and any applicable federal or state programs; 1,555
(5) A provision regarding the availability and 1,557
confidentiality of those health records maintained by providers 1,558
and health care facilities to monitor and evaluate the quality of 1,560
care, to conduct evaluations and audits, and to determine on a 1,561
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 1,562
The provision shall include terms requiring the provider or 1,563
health care facility to make these health records available to 1,564
34
appropriate state and federal authorities involved in assessing 1,565
the quality of care or in investigating the grievances or 1,566
complaints of enrollees, and requiring the provider or health 1,567
care facility to comply with applicable state and federal laws 1,568
related to the confidentiality of medical or health records. 1,570
(6) A provision that states that contractual rights and 1,572
responsibilities may not be assigned or delegated by the provider 1,574
or health care facility without the prior written consent of the 1,575
health insuring corporation;
(7) A provision requiring the provider or health care 1,577
facility to maintain adequate professional liability and 1,578
malpractice insurance. The provision shall also require the 1,579
provider or health care facility to notify the health insuring 1,580
corporation not more than ten days after the provider's or health 1,582
care facility's receipt of notice of any reduction or
cancellation of such coverage. 1,583
(8) A provision requiring the provider or health care 1,585
facility to observe, protect, and promote the rights of enrollees 1,587
as patients;
(9) A provision requiring the provider or health care 1,589
facility to provide health care services without discrimination 1,590
on the basis of a patient's participation in the health care 1,591
plan, age, sex, ethnicity, religion, sexual preference, health 1,592
status, or disability, and without regard to the source of 1,593
payments made for health care services rendered to a patient. 1,594
This requirement shall not apply to circumstances when the 1,595
provider or health care facility appropriately does not render 1,596
services due to limitations arising from the provider's or health 1,598
care facility's lack of training, experience, or skill, or due to 1,599
licensing restrictions.
(10) A provision containing the specifics of any 1,601
obligation on the PRIMARY CARE provider or health care facility 1,602
to provide, or to arrange for the provision of, covered health 1,604
care services twenty-four hours per day, seven days per week; 1,605
35
(11) A provision setting forth procedures for the 1,607
resolution of disputes arising out of the contract; 1,608
(12) A provision stating that the hold harmless provision 1,610
required by division (C)(2) of this section shall survive the 1,612
termination of the contract with respect to services covered and 1,613
provided under the contract during the time the contract was in 1,614
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 1,615
(13) A provision requiring those terms that are used in 1,617
the contract and that are defined by this chapter, be used in the 1,619
contract in a manner consistent with those definitions. 1,620
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF 1,622
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 1,627
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 1,630
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 1,631
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 1,632
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 1,635
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 1,640
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 1,643
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 1,644
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 1,648
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 1,649
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, OR TO 1,650
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 1,651
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 1,652
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,653
(D) No health insuring corporation contract with a 1,656
provider or health care facility shall do either of the 1,657
following:
(1) Offer an inducement to the provider or health care 1,659
facility, directly or indirectly, to reduce or limit medically 1,660
necessary health care services to a covered enrollee; 1,661
(2) Penalize a provider or health care facility that 1,663
assists an enrollee to seek a reconsideration of the health 1,664
36
insuring corporation's decision to deny or limit benefits to the 1,665
enrollee. 1,666
(E) Any contract between a health insuring corporation and 1,669
an intermediary organization shall clearly specify that the 1,670
health insuring corporation must approve or disapprove the 1,671
participation of any provider or health care facility with which 1,672
the intermediary organization contracts. 1,673
(F) If an intermediary organization that is not a health 1,675
delivery network contracting solely with self-insured employers 1,676
subcontracts with a provider or health care facility, the 1,677
subcontract with the provider or health care facility shall do 1,678
all of the following:
(1) Contain the provisions required by divisions (C) and 1,681
(G) of this section, as made applicable to an intermediary 1,682
organization, without the inclusion of inducements or penalties 1,683
described in division (D) of this section; 1,684
(2) Acknowledge that the health insuring corporation is a 1,686
third-party beneficiary to the agreement; 1,687
(3) Acknowledge the health insuring corporation's role in 1,689
approving the participation of the provider or health care 1,690
facility, pursuant to division (E) of this section. 1,692
(G) Any provider contract or contract with a health care 1,695
facility shall clearly specify the health insuring corporation's 1,696
statutory responsibility to monitor and oversee the offering of 1,697
covered health care services to its enrollees. 1,698
(H)(1) A health insuring corporation shall maintain its 1,701
provider contracts and its contracts with health care facilities 1,702
at one or more of its places of business in this state, and shall 1,703
provide copies of these contracts to facilitate regulatory review 1,704
upon written notice by the superintendent of insurance. 1,705
(2) Any contract with an intermediary organization shall 1,707
include provisions requiring the intermediary organization to 1,708
provide the superintendent with regulatory access to all books, 1,709
records, financial information, and documents related to the 1,710
37
provision of health care services to subscribers and enrollees 1,711
under the contract. The contract shall require the intermediary 1,712
organization to maintain such books, records, financial 1,713
information, and documents at its principal place of business in 1,714
this state and to preserve them for at least three years in a 1,715
manner that facilitates regulatory review. 1,716
(I)(1) A health insuring corporation shall provide notice 1,718
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A 1,720
contract with FOR THE PROVISION OF HEALTH CARE SERVICES BETWEEN 1,721
THE HEALTH INSURING CORPORATION AND a primary care physician or 1,723
hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF
THE CONTRACT. 1,724
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 1,726
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE 1,727
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH 1,728
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE PRIMARY 1,730
CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF THE 1,731
SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE 1,732
PREVIOUS TWELVE MONTHS. 1,733
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 1,735
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR A 1,737
DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE 1,738
PREVIOUS TWELVE MONTHS. 1,739
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL 1,741
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A PRIMARY 1,743
CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE TERMINATION OF 1,744
THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION OF THE CONTRACT 1,745
TERMINATION IS MAILED TO A SUBSCRIBER AT THE SUBSCRIBER'S LAST 1,746
KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do not apply to 1,749
any health insuring corporation that, on the effective date of 1,750
this section JUNE 4, 1997, holds a certificate of authority or 1,751
38
license to operate under Chapter 1740. of the Revised Code. 1,753
(K) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 1,756
1998.
Sec. 1751.141. A HEALTH INSURING CORPORATION SHALL PROVIDE 1,759
COVERAGE FOR A SUBSCRIBER'S DEPENDENT CHILDREN LIVING OUTSIDE THE 1,760
HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA IF A COURT 1,761
ORDER REQUIRES THE SUBSCRIBER TO PROVIDE HEALTH CARE COVERAGE TO 1,762
THE DEPENDENT CHILDREN.
Sec. 1751.15. (A) After a health insuring corporation has 1,771
furnished, directly or indirectly, basic health care services for 1,772
a period of twenty-four months, and if it currently meets the 1,773
financial requirements set forth in section 1751.28 of the 1,774
Revised Code and had net income as reported to the superintendent 1,775
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 1,776
less than thirty days during its month of licensure for 1,778
individuals who are not federally eligible individuals. 1,779
(B) During the open enrollment period described in 1,781
division (A) of this section, the health insuring corporation 1,782
shall accept applicants and their dependents in the order in 1,783
which they apply for enrollment and in accordance with any of the 1,784
following:
(1) Up to its capacity, as determined by the health 1,786
insuring corporation subject to review by the superintendent; 1,787
(2) If less than its capacity, one per cent of the health 1,789
insuring corporation's total number of subscribers residing in 1,790
this state as of the immediately preceding thirty-first day of 1,791
December. 1,792
(C) Where a health insuring corporation demonstrates to 1,794
the satisfaction of the superintendent that such open enrollment 1,795
would jeopardize its economic viability, the superintendent may 1,796
do any of the following:
(1) Waive the requirement for open enrollment; 1,798
(2) Impose a limit on the number of applicants and their 1,800
39
dependents that must be enrolled; 1,801
(3) Authorize such underwriting restrictions upon open 1,803
enrollment as are necessary to do any of the following: 1,804
(a) Preserve its financial stability; 1,806
(b) Prevent excessive adverse selection; 1,808
(c) Avoid unreasonably high or unmarketable charges for 1,810
coverage of health care services. 1,811
(D)(1) A request to the superintendent under division (C) 1,814
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 1,815
documentation, including financial data. In reviewing the 1,816
request, the superintendent may consider various factors, 1,817
including the size of the health insuring corporation, the health 1,818
insuring corporation's net worth and profitability, the health 1,819
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 1,820
(2) Any action taken by the superintendent under division 1,822
(C) of this section shall be effective for a period of not more 1,824
than one year. At the expiration of such time, a new 1,825
demonstration of the health insuring corporation's need for the 1,826
restriction, limit, or waiver shall be made before a new 1,827
restriction, limit, or waiver is granted by the superintendent. 1,828
(3) Irrespective of the granting of any restriction, 1,830
limit, or waiver by the superintendent, a health insuring 1,831
corporation may reject an applicant or a dependent of the 1,832
applicant during its open enrollment period if the applicant or 1,833
dependent: 1,834
(a) Was eligible for and was covered under any 1,836
employer-sponsored health care coverage, or if employer-sponsored 1,837
health care coverage was available at the time of open 1,838
enrollment;
(b) Is eligible for continuation coverage under state or 1,840
federal law; 1,841
(c) Is eligible for medicare, and the health insuring 1,843
40
corporation does not have an agreement on appropriate payment 1,844
mechanisms with the governmental agency administering the 1,845
medicare program.
(E) A health insuring corporation shall not be required 1,847
either to enroll applicants or their dependents who are confined 1,848
to a health care facility because of chronic illness, permanent 1,849
injury, or other infirmity that would cause economic impairment 1,850
to the health insuring corporation if such applicants or their 1,851
dependents were enrolled or to make the effective date of 1,852
benefits for applicants or their dependents enrolled under this 1,853
section earlier than ninety days after the date of enrollment. 1,854
(F) A health insuring corporation shall not be required to 1,856
cover the fees or costs, or both, for any basic health care 1,857
service related to a transplant of a body organ if the transplant 1,858
occurs within one year after the effective date of an enrollee's 1,859
coverage under this section. This limitation on coverage does 1,860
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 1,861
(G) Each health insuring corporation required to hold an 1,863
open enrollment pursuant to division (A) of this section shall 1,864
file with the superintendent, not later than sixty days prior to 1,865
the commencement of the proposed open enrollment period, the 1,866
following documents:
(1) The proposed public notice of open enrollment; 1,868
(2) The evidence of coverage approved pursuant to section 1,870
1751.11 of the Revised Code that will be used during open 1,872
enrollment;
(3) The contractual periodic prepayment and premium rate 1,874
approved pursuant to section 1751.12 of the Revised Code that 1,875
will be applicable during open enrollment; 1,876
(4) Any solicitation document approved pursuant to section 1,879
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 1,880
(5) A list of the proposed dates of publication of the 1,882
41
public notice, and the names of the newspapers in which the 1,883
notice will appear; 1,884
(6) Any request for a restriction, limit, or waiver with 1,886
respect to the open enrollment period, along with any supporting 1,887
documentation. 1,888
(H)(1) An open enrollment period shall not satisfy the 1,890
requirements of this section unless the health insuring 1,891
corporation provides adequate public notice in accordance with 1,892
divisions (H)(2) and (3) of this section. No public notice shall 1,893
be used until the form of the public notice has been filed by the 1,894
health insuring corporation with the superintendent. If the 1,895
superintendent does not disapprove the public notice within sixty 1,896
days after it is filed, it shall be deemed approved, unless the 1,897
superintendent sooner gives approval for the public notice. If 1,898
the superintendent determines within this sixty-day period that 1,899
the public notice fails to meet the requirements of this section, 1,900
the superintendent shall so notify the health insuring 1,901
corporation and it shall be unlawful for the health insuring 1,902
corporation to use the public notice. Such disapproval shall be 1,903
effected by a written order, which shall state the grounds for 1,904
disapproval and shall be issued in accordance with Chapter 119. 1,905
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 1,907
section shall be published in at least one newspaper of general 1,908
circulation in each county in the health insuring corporation's 1,909
service area, at least once in each of the two weeks immediately 1,910
preceding the month in which the open enrollment is to occur and 1,911
in each week of that month, or until the enrollment limitation is 1,912
reached, whichever occurs first. The notice published during the 1,913
last week of open enrollment shall appear not less than five days 1,914
before the end of the open enrollment period. It shall be at 1,915
least two newspaper columns wide or two and one-half inches wide, 1,917
whichever is larger. The first two lines of the text shall be 1,918
published in not less than twelve-point, boldface type. The 1,919
42
remainder of the text of the notice shall be published in not 1,920
less than eight-point type. The entire public notice shall be 1,921
surrounded by a continuous black line not less than one-eighth of 1,922
an inch wide.
(3) The following information shall be included in the 1,924
public notice provided under division (H)(2) of this section: 1,925
(a) The dates that open enrollment will be held and the 1,927
date coverage obtained under the open enrollment will become 1,928
effective;
(b) Notice that an applicant or the applicant's dependents 1,930
will not be denied coverage during open enrollment because of a 1,931
preexisting health condition, but that some limitations and 1,932
restrictions may apply;
(c) The address where a person may obtain an application; 1,934
(d) The telephone number that a person may call to request 1,936
an application or to ask questions; 1,938
(e) The date the first payment will be due; 1,940
(f) The actual rates or range of rates that will be 1,942
applicable for applicants; 1,943
(g) Any limitation granted by the superintendent on the 1,946
number of applications that will be accepted by the health 1,947
insuring corporation.
(4) Within thirty days after the end of an open enrollment 1,950
period, the health insuring corporation shall submit to the 1,951
superintendent proof of publication for the public notices, and 1,952
shall report the total number of applicants and their dependents 1,953
enrolled during the open enrollment period. 1,954
(I)(1) No health insuring corporation may employ any 1,956
scheme, plan, or device that restricts the ability of any person 1,957
to enroll during open enrollment. 1,958
(2) No health insuring corporation may require enrollment 1,960
to be made in person. Every health insuring corporation shall 1,961
permit application for coverage by mail. A representative of the 1,963
health insuring corporation may visit an applicant who has
43
submitted an application by mail, in order to explain the 1,964
operations of the health insuring corporation and to answer any 1,965
questions the applicant may have. Every health insuring 1,966
corporation shall make open enrollment applications and 1,967
solicitation documents readily available to any potential 1,968
applicant who requests such material. 1,969
(J) An application postmarked on the last day of an open 1,971
enrollment period shall qualify as a valid application, 1,972
regardless of the date on which it is received by the health 1,973
insuring corporation.
(K) This section does not apply to any health insuring 1,975
corporation that offers only supplemental health care services or 1,977
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 1,978
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 1,979
U.S.C.A. 301, as amended, and that has no other commercial 1,980
enrollment, or to any health insuring corporation that offers 1,981
plans only through other federal health care programs regulated 1,982
by federal regulatory bodies and that has no other commercial 1,983
enrollment, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 1,984
PLANS ONLY THROUGH CONTRACTS COVERING OFFICERS OR EMPLOYEES OF 1,985
THE STATE THAT HAVE BEEN ENTERED INTO BY THE DEPARTMENT OF 1,987
ADMINISTRATIVE SERVICES AND THAT HAS NO OTHER COMMERCIAL 1,988
ENROLLMENT.
(L) Each health insuring corporation shall accept 1,991
federally eligible individuals for open enrollment coverage as 1,992
provided in section 3923.581 of the Revised Code. A health 1,994
insuring corporation may reinsure coverage of any federally 1,995
eligible individual acquired under that section with the open 1,996
enrollment reinsurance program in accordance with division (G) of 1,998
section 3924.11 of the Revised Code. Fixed periodic prepayment 2,001
rates charged for coverage reinsured by the program shall be 2,002
established in accordance with section 3924.12 of the Revised 2,003
Code. 2,004
44
(M) As used in this section, "federally eligible 2,007
individual" means an eligible individual as defined in 45 C.F.R. 2,009
148.103. 2,010
Sec. 1751.151. AT LEAST ONCE IN EVERY TWELVE-MONTH 2,012
PERIOD, A HEALTH INSURING CORPORATION SHALL PROVIDE TO ALL 2,014
ELIGIBLE EMPLOYEES OF A GROUP COVERED BY A GROUP HEALTH CARE PLAN 2,015
OF THE HEALTH INSURING CORPORATION, INCLUDING LATE ENROLLEES AS 2,016
DEFINED IN SECTION 3924.01 OF THE REVISED CODE, THE OPTION TO 2,018
ENROLL IN THE GROUP HEALTH CARE PLAN. THE ENROLLMENT OPTION 2,019
SHALL BE PROVIDED FOR A MINIMUM PERIOD OF THIRTY CONSECUTIVE 2,020
DAYS.
Sec. 1751.16. (A) Except as provided in division (F) of 2,029
this section, every group contract issued by a health insuring 2,030
corporation shall provide an option for conversion to an 2,031
individual contract issued on a direct-payment basis to any 2,032
subscriber covered by the group contract who terminates 2,033
employment or membership in the group, unless: 2,034
(1) Termination of the conversion option or contract is 2,036
based upon nonpayment of premium after reasonable notice in 2,037
writing has been given by the health insuring corporation to the 2,038
subscriber. 2,039
(2) The subscriber is, or is eligible to be, covered for 2,041
benefits at least comparable to the group contract under any of 2,042
the following: 2,043
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 2,045
(1935), 42 U.S.C.A. 301, as amended; 2,046
(b) Any act of congress or law under this or any other 2,048
state of the United States providing coverage at least comparable 2,049
to the benefits under division (A)(2)(a) of this section; 2,050
(c) Any policy of insurance or health care plan providing 2,052
coverage at least comparable to the benefits under division 2,053
(A)(2)(a) of this section. 2,054
(B)(1) The direct-payment contract offered by the health 2,056
insuring corporation pursuant to division (A) of this section 2,058
45
shall provide the following: 2,060
(a) In the case of an individual who is not a federally 2,063
eligible individual, benefits comparable to benefits in any of 2,064
the individual contracts then being issued to individual 2,065
subscribers by the health insuring corporation; 2,066
(b) In the case of a federally eligible individual, a 2,069
basic and standard plan established by the board of directors of 2,070
the Ohio health reinsurance program or plans substantially 2,071
similar to the basic and standard plan in benefit design and 2,072
scope of covered services. For purposes of division (B)(1)(b) of 2,074
this section, the superintendent of insurance shall determine 2,075
whether a plan is substantially similar to the basic or standard 2,076
plan in benefit design and scope of covered services. The 2,077
contractual periodic prepayments charged for such plans may not 2,078
exceed an amount that is two times the midpoint of the standard 2,079
rate charged any other individual of a group to which the 2,080
organization is currently accepting new business and for which 2,081
similar copayments and deductibles are applied. 2,082
(2) The direct payment contract offered pursuant to 2,084
division (A) of this section may include a coordination of 2,086
benefits provision as approved by the superintendent. 2,087
(3) For purposes of division (B) of this section 2,090
"federally eligible individual" means an eligible individual as 2,091
defined in 45 C.F.R. 148.103. 2,094
(C) The option for conversion shall be available: 2,096
(1) Upon the death of the subscriber, to the surviving 2,098
spouse with respect to such of the spouse and dependents as are 2,100
then covered by the group contract; 2,101
(2) To a child solely with respect to the child upon the 2,103
child's attaining the limiting age of coverage under the group 2,104
contract while covered as a dependent under the contract; 2,105
(3) Upon the divorce, dissolution, or annulment of the 2,107
marriage of the subscriber, to the divorced spouse, or, in the 2,108
event of annulment, to the former spouse of the subscriber. 2,110
46
(D) No health insuring corporation shall use age as the 2,112
basis for refusing to renew a converted contract. 2,113
(E) Written notice of the conversion option provided by 2,116
this section shall be given to the subscriber by the health 2,117
insuring corporation by mail. The notice shall be sent to the 2,118
subscriber's address in the records of the employer upon receipt 2,119
of notice from the employer of the event giving rise to the 2,120
conversion option. If the subscriber has not received notice of 2,121
the conversion privilege at least fifteen days prior to the 2,122
expiration of the thirty-day conversion period, then the 2,123
subscriber shall have an additional period within which to 2,124
exercise the privilege. This additional period shall expire 2,125
fifteen days after the subscriber receives notice, but in no 2,126
event shall the period extend beyond sixty days after the 2,127
expiration of the thirty-day conversion period. 2,128
(F) This section does not apply to any group contract 2,130
offering only supplemental health care services or specialty 2,131
health care services.
Sec. 1751.20. (A) No health insuring corporation, or 2,141
agent, employee, or representative of a health insuring 2,142
corporation, shall use any advertisement or solicitation 2,143
document, or shall engage in any activity, that is unfair, 2,144
untrue, misleading, or deceptive.
(B) No health insuring corporation shall use a name that 2,147
is deceptively similar to the name or description of any 2,148
insurance or surety corporation doing business in this state. 2,149
(C) All solicitation documents, advertisements, evidences 2,152
of coverage, and enrollee identification cards used by a health 2,153
insuring corporation shall contain the health insuring 2,154
corporation's name. The use of a trade name, an insurance group 2,155
designation, the name of a parent company, the name of a division 2,156
of an affiliated insurance company, a service mark, a slogan, a 2,157
symbol, or other device, without the name of the health insuring 2,158
corporation as stated in its articles of incorporation, shall not 2,159
47
satisfy this requirement if the usage would have the capacity and 2,160
tendency to mislead or deceive persons as to the true identity of 2,161
the health insuring corporation. 2,162
(D) No solicitation document or advertisement used by a 2,165
health insuring corporation shall contain any words, symbols, or 2,166
physical materials that are so similar in content, phraseology, 2,167
shape, color, or other characteristic to those used by an agency 2,168
of the federal government or this state, that prospective 2,169
enrollees may be led to believe that the solicitation document or 2,170
advertisement is connected with an agency of the federal 2,171
government or this state. 2,172
(E) A HEALTH INSURING CORPORATION THAT PROVIDES BASIC 2,174
HEALTH CARE SERVICES MAY USE THE PHRASE "HEALTH MAINTENANCE 2,176
ORGANIZATION" OR THE ABBREVIATION "HMO" IN ITS MARKETING NAME, 2,177
ADVERTISING, SOLICITATION DOCUMENTS, OR MARKETING LITERATURE, OR 2,179
IN REFERENCE TO THE PHRASE "DOING BUSINESS AS" OR THE
ABBREVIATION "DBA." 2,180
(F) This section does not apply to the coverage of 2,182
beneficiaries enrolled in Title XVIII of the "Social Security 2,184
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, pursuant 2,187
to a medicare risk contract or medicare cost contract, or to the 2,188
coverage of beneficiaries enrolled in the federal employee health 2,189
benefits program pursuant to 5 U.S.C.A. 8905, or to the coverage 2,191
of beneficiaries enrolled in Title XIX of the "Social Security 2,192
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as 2,194
the medical assistance program or medicaid, provided by the Ohio 2,195
department of human services under Chapter 5111. of the Revised 2,196
Code, or to the coverage of beneficiaries under any federal 2,198
health care program regulated by a federal regulatory body, OR TO 2,199
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 2,200
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 2,201
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,202
Sec. 1751.31. (A) Any changes in a health insuring 2,212
corporation's solicitation document shall be filed with the 2,213
48
superintendent of insurance. The superintendent, within sixty 2,214
days of filing, may disapprove any solicitation document or 2,215
amendment to it on any of the grounds stated in this section. 2,216
Such disapproval shall be effected by written notice to the 2,217
health insuring corporation. The notice shall state the grounds 2,218
for disapproval and shall be issued in accordance with Chapter 2,219
119. of the Revised Code. 2,220
(B) The solicitation document shall contain all 2,223
information necessary to enable a consumer to make an informed 2,224
choice as to whether or not to enroll in the health insuring 2,225
corporation. The information shall include a specific 2,226
description of the health care services to be available and the 2,227
approximate number and type of full-time equivalent medical 2,228
practitioners. The information shall be presented in the 2,229
solicitation document in a manner that is clear, concise, and 2,230
intelligible to prospective applicants in the proposed service 2,231
area.
(C) Every potential applicant whose subscription to a 2,234
health care plan is solicited shall receive, at or before the 2,235
time of solicitation, a solicitation document approved by the 2,236
superintendent.
(D) Notwithstanding division (A) of this section, a health 2,239
insuring corporation may use a solicitation document that the 2,240
corporation uses in connection with policies for beneficiaries of 2,241
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,243
U.S.C.A. 301, as amended, pursuant to a medicare risk contract or 2,245
medicare cost contract, or for policies for beneficiaries of the 2,246
federal employees health benefits program pursuant to 5 U.S.C.A. 2,248
8905, or for policies for beneficiaries of Title XIX of the 2,250
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 2,253
amended, known as the medical assistance program or medicaid, 2,254
provided by the Ohio department of human services under Chapter 2,255
5111. of the Revised Code, or for policies for beneficiaries of 2,256
any other federal health care program regulated by a federal 2,257
49
regulatory body, OR FOR POLICIES FOR BENEFICIARIES OF CONTRACTS 2,258
COVERING OFFICERS OR EMPLOYEES OF THE STATE ENTERED INTO BY THE 2,260
DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the following 2,261
apply: 2,262
(1) The solicitation document has been approved by the 2,264
United States department of health and human services, the United 2,265
States office of personnel management, or the Ohio department of 2,267
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,268
(2) The solicitation document is filed with the 2,270
superintendent of insurance prior to use and is accompanied by 2,271
documentation of approval from the United States department of 2,274
health and human services, the United States office of personnel 2,276
management, or the Ohio department of human services, OR THE 2,278
DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,279
(E) No health insuring corporation, or its agents or 2,282
representatives, shall use monetary or other valuable 2,283
consideration, engage in misleading or deceptive practices, or 2,284
make untrue, misleading, or deceptive representations to induce 2,285
enrollment. Nothing in this division shall prohibit incentive 2,286
forms of remuneration such as commission sales programs for the 2,287
health insuring corporation's employees and agents. 2,288
(F) Any person obligated for any part of a premium rate in 2,291
connection with an enrollment agreement, in addition to any right 2,292
otherwise available to revoke an offer, may cancel such agreement 2,293
within seventy-two hours after having signed the agreement or 2,294
offer to enroll. Cancellation occurs when written notice of the 2,295
cancellation is given to the health insuring corporation or its 2,296
agents or other representatives. A notice of cancellation mailed 2,297
to the health insuring corporation shall be considered to have 2,298
been filed on its postmark date. 2,299
(G) Nothing in this section shall prohibit healthy 2,301
lifestyle programs. 2,302
Sec. 1751.46. (A) The superintendent of insurance and the 2,312
director of health may contract with qualified persons to make 2,313
50
recommendations concerning the determinations required to be made 2,314
by the superintendent or the director relative to an expansion of 2,315
a service area pursuant to division (C) of section 1751.03 of the 2,317
Revised Code, an application for a certificate of authority 2,319
pursuant to sections 1751.04 and 1751.05 of the Revised Code, a 2,321
contractual periodic prepayment or premium rate pursuant to 2,322
section 1751.12 of the Revised Code, and an examination pursuant 2,324
to division (B) of section 1751.34 of the Revised Code. The 2,326
recommendations may be accepted in full or in part, or may be 2,327
rejected, by the superintendent or director. 2,328
THE TOTAL COST OF A CONTRACT WITH A QUALIFIED PERSON 2,330
PURSUANT TO THIS DIVISION SHALL BE BORNE BY THE HEALTH INSURING 2,331
CORPORATION THAT IS THE SUBJECT OF THE DETERMINATION REQUIRED TO 2,332
BE MADE BY THE SUPERINTENDENT OR THE DIRECTOR. 2,333
(B) No qualified person placed on contract by the 2,336
superintendent or the director pursuant to division (A) of this 2,338
section shall have a conflict of interest with the department of 2,339
insurance, the department of health, or the health insuring 2,340
corporation.
Sec. 1751.55. A health insuring corporation policy, 2,349
contract, or agreement shall not be construed to exclude illness 2,350
or injury upon the ground that the subscriber might have elected 2,351
to have such illness or injury covered by workers' compensation 2,352
under division (A)(3) of section 4123.01 CHAPTER 4123. of the 2,354
Revised Code unless the policy, contract, or agreement clearly 2,356
excludes work or occupational related illness or injury, or the 2,357
policy, contract, or agreement, or a separate writing signed by 2,358
the subscriber, informs the subscriber that such coverage is 2,359
excluded and may be available to the subscriber under workers' 2,360
compensation as the sole proprietor of a business, a member of a 2,361
partnership, or an officer of a family farm corporation. 2,362
Sec. 1751.58. Except as otherwise provided in section 2721 2,372
of the "Health Insurance Portability and Accountability Act of 2,376
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 2,382
51
as amended, the following conditions apply to all group health 2,383
insuring corporation contracts that are sold in connection with 2,384
an employment-related group health care plan and that are not 2,385
subject to section 3924.03 of the Revised Code: 2,387
(A)(1) Except as provided in section 2712(b) to (e) of the 2,391
"Health Insurance Portability and Accountability Act of 1996," if 2,395
a health insuring corporation offers coverage in the small or 2,396
large group market in connection with a group contract, the 2,397
organization shall renew or continue in force such coverage at 2,398
the option of the contract holder. 2,399
(2) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 2,402
TO RENEW THE COVERAGE OF ANY ELIGIBLE EMPLOYEE OR OF A DEPENDENT 2,403
OF AN ELIGIBLE EMPLOYEE UNDER THE GROUP CONTRACT IF THE EMPLOYEE 2,404
OR DEPENDENT, AS APPLICABLE, HAS PERFORMED AN ACT OR PRACTICE 2,405
THAT CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION 2,406
OF MATERIAL FACT UNDER THE TERMS OF THE COVERAGE AND IF THE 2,407
CANCELLATION OR NONRENEWAL IS NOT BASED, EITHER DIRECTLY OR 2,408
INDIRECTLY, ON ANY HEALTH STATUS-RELATED FACTOR IN RELATION TO 2,409
THE EMPLOYEE OR DEPENDENT.
(B) Such group contracts are subject to division 2,411
(E)(1)(A)(3) of section 3924.03 and sections 3924.033 and 3924.27 2,413
of the Revised Code. 2,414
(C) Such group contracts shall provide for the special 2,417
enrollment periods described in section 2701(f) of the "Health 2,419
Insurance Portability and Accountability Act of 1996." 2,423
Sec. 1751.59. (A) No individual or group health insuring 2,432
corporation policy, contract, or agreement that makes family 2,434
coverage available may be delivered, issued for delivery, or 2,436
renewed in this state, unless the policy, contract, or agreement
covers adopted children of the subscriber on the same basis as 2,437
other dependents. 2,438
(B) The coverage required by this section is subject to 2,440
the requirements and restrictions set forth in section 3924.51 of 2,442
the Revised Code. Coverage for dependent children living outside 2,444
52
the health insuring corporation's approved service area must be 2,445
provided if a court order requires the subscriber to provide 2,446
health care coverage.
Sec. 1751.60. (A) Except as provided for in divisions (E) 2,456
and (F) of this section, every provider or health care facility 2,458
that contracts with a health insuring corporation to provide 2,459
health care services to the health insuring corporation's 2,460
enrollees or subscribers shall seek compensation for covered 2,461
services solely from the health insuring corporation and not, 2,462
under any circumstances, from the enrollees or subscribers, 2,463
except for approved deductibles and copayments. 2,464
(B) No subscriber or enrollee of a health insuring 2,467
corporation is liable to any contracting provider or health care 2,468
facility for the cost of any covered health care services, if the 2,469
subscriber or enrollee has acted in accordance with the evidence 2,470
of coverage.
(C) Except as provided for in divisions (E) and (F) of 2,474
this section, every contract between a health insuring 2,475
corporation and provider or health care facility shall contain a 2,476
provision approved by the superintendent of insurance requiring 2,477
the provider or health care facility to seek compensation solely 2,478
from the health insuring corporation and not, under any 2,479
circumstances, from the subscriber or enrollee, except for 2,480
approved deductibles and copayments. 2,481
(D) Nothing in this section shall be construed as 2,484
preventing a provider or health care facility from billing the 2,485
enrollee or subscriber of a health insuring corporation for 2,486
noncovered services.
(E) Upon application by a health insuring corporation and 2,489
a provider or health care facility, the superintendent may waive 2,490
the requirements of divisions (A) and (C) of this section when, 2,492
in addition to the reserve requirements contained in section 2,493
1751.28 of the Revised Code, the health insuring corporation 2,496
provides sufficient assurances to the superintendent that the 2,497
53
provider or health care facility has been provided with financial 2,498
guarantees. No waiver of the requirements of divisions (A) and 2,499
(C) of this section is effective as to enrollees or subscribers 2,501
for whom the health insuring corporation is compensated under a 2,502
provider agreement or risk contract entered into pursuant to 2,503
Chapter 5111. or 5115. of the Revised Code. 2,506
(F) The requirements of divisions (A) to (C) of this 2,510
section apply only to health care services provided to an 2,511
enrollee or subscriber prior to the effective date of a 2,512
termination of a contract between the health insuring corporation 2,513
and the provider or health care facility. 2,514
Sec. 1751.62. (A) As used in this section, "screening 2,524
mammography" means a radiologic examination utilized to detect 2,525
unsuspected breast cancer at an early stage in an asymptomatic 2,526
woman and includes the x-ray examination of the breast using 2,527
equipment that is dedicated specifically for mammography, 2,528
including the x-ray tube, filter, compression device, screens, 2,529
film, and cassettes, and that has an average radiation exposure 2,530
delivery of less than one rad mid-breast. "Screening 2,531
mammography" includes two views for each breast. The term also 2,532
includes the professional interpretation of the film. 2,533
"Screening mammography" does not include diagnostic 2,535
mammography. 2,536
(B) Every individual or group health insuring corporation 2,539
policy, contract, or agreement providing basic health care 2,540
services that is delivered, issued for delivery, or renewed in 2,541
this state shall provide benefits for the expenses of both of the 2,542
following: 2,543
(1) Screening mammography to detect the presence of breast 2,546
cancer in adult women;
(2) Cytologic screening for the presence of cervical 2,548
cancer. 2,549
(C) The benefits provided under division (B)(1) of this 2,553
section shall cover expenses in accordance with all of the 2,554
54
following:
(1) If a woman is at least thirty-five years of age but 2,556
under forty years of age, one screening mammography; 2,557
(2) If a woman is at least forty years of age but under 2,559
fifty years of age, either of the following: 2,560
(a) One screening mammography every two years; 2,563
(b) If a licensed physician has determined that the woman 2,566
has risk factors to breast cancer, one screening mammography 2,567
every year.
(3) If a woman is at least fifty years of age but under 2,569
sixty-five years of age, one screening mammography every year. 2,571
(D)(1) The benefits provided under division (B)(1) of this 2,575
section shall not exceed eighty-five dollars per year unless a 2,576
lower amount is established pursuant to a provider contract. 2,577
(2) The benefit paid in accordance with division (D)(1) of 2,580
this section shall constitute full payment. No institutional or 2,581
professional health care provider shall seek or receive 2,582
remuneration in excess of the payment made in accordance with 2,583
division (D)(1) of this section, except for approved deductibles 2,585
and copayments.
(E) The benefits provided under division (B)(1) of this 2,589
section shall be provided only for screening mammographies that 2,590
are performed in a health care facility or mobile mammography 2,591
screening unit that is accredited under the American college of 2,592
radiology mammography accreditation program or in a hospital as 2,593
defined in section 3727.01 of the Revised Code. 2,595
(F) The benefits provided under divisions (B)(1) and (2) 2,599
of this section shall be provided according to the terms of the 2,600
subscriber contract.
(G) The benefits provided under division (B)(2) of this 2,604
section shall be provided only for cytologic screenings that are 2,605
processed and interpreted in a laboratory certified by the 2,606
college of American pathologists or in a hospital as defined in 2,607
section 3727.01 of the Revised Code. 2,609
55
Sec. 1907.161. (A) As used in this section, "health care 2,619
coverage" means sickness and accident insurance or other coverage 2,620
of hospitalization, surgical care, major medical care,
disability, dental care, eye care, medical care, hearing aids, 2,621
and prescription drugs or any combination of those benefits or 2,622
services.
(B) The board of county commissioners, after consultation 2,625
with the judges of the county court, shall negotiate and contract 2,626
for, purchase, or otherwise procure group health care coverage
for the judges and their spouses and dependents from insurance 2,627
companies authorized to engage in the business of insurance in 2,628
this state under Title XXXIA XXXIX of the Revised Code, medical 2,630
care corporations organized under Chapter 1737. of the Revised
Code, health care corporations organized under Chapter 1738. of 2,632
the Revised Code, or health maintenance organizations INSURING 2,633
CORPORATIONS organized under Chapter 1742. 1751. of the Revised 2,635
Code, except that, if the county provides group health care 2,637
coverage for its employees, the group health care coverage 2,638
required by this section shall be provided, if possible, through 2,639
the policy or plan under which the group health care coverage is 2,640
provided for the county employees.
(C) The portion of the costs, premiums, or charges for the 2,643
group health care coverage procured pursuant to division (B) of 2,644
this section that is not paid by the judges of the county court, 2,645
or all of the costs, premiums, or charges for the group health 2,646
care coverage if the judges will not be paying any portion of 2,647
those costs, premiums, or charges, shall be paid out of the
county treasury. 2,648
Sec. 2305.252. (A) As used in this section: 2,657
(1) "Review board, committee, risk management personnel, 2,659
or corporation" means any of the following: 2,660
(a) A peer review committee of a hospital, a nonprofit 2,662
health care corporation that is a member of the hospital or of 2,663
which the hospital is a member, or a community mental health 2,664
56
center;
(b) A board or committee of a hospital or of a nonprofit 2,666
health care corporation that is a member of the hospital or of 2,667
which the hospital is a member reviewing professional 2,668
qualifications or activities of the hospital medical staff or 2,669
applicants for admission to the medical staff;
(c) A utilization committee of a state or local society 2,671
composed of doctors of medicine or doctors of osteopathic 2,672
medicine and surgery or doctors of podiatric medicine; 2,673
(d) A peer review committee of nursing home providers or 2,675
administrators, including a corporation engaged in performing the 2,676
functions of a peer review committee of nursing home providers or 2,677
administrators, or a corporation engaged in performing the 2,678
functions of another type of peer review or professional 2,680
standards review committee;
(e) A peer review committee, professional standards review 2,682
committee, or arbitration committee of a state or local society 2,683
composed of doctors of medicine, doctors of osteopathic medicine 2,684
and surgery, doctors of dentistry, doctors of optometry, doctors 2,685
of podiatric medicine, psychologists, or registered pharmacists; 2,686
(f) A peer review committee of a health maintenance 2,688
organization INSURING CORPORATION that has at least a two-thirds 2,690
majority of member physicians in active practice and that 2,691
conducts professional credentialing and quality review activities 2,692
involving the competence or professional conduct of health care
providers, which conduct adversely affects, or could adversely 2,693
affect, the health or welfare of any patient. For purposes of 2,694
this division, "health maintenance organization INSURING 2,695
CORPORATION" includes wholly-owned WHOLLY OWNED subsidiaries of a 2,696
health maintenance organization INSURING CORPORATION. 2,697
(g) A peer review committee of any insurer authorized 2,699
under Title XXXIX of the Revised Code to do the business of 2,700
sickness and accident insurance in this state that has at least a 2,701
two-thirds majority of physicians in active practice and that 2,702
57
conducts professional credentialing and quality review activities 2,703
involving the competence or professional conduct of health care 2,704
providers, which conduct adversely affects, or could adversely
affect, the health or welfare of any patient; 2,705
(h) A peer review committee of any insurer authorized 2,707
under Title XXXIX of the Revised Code to do the business of 2,708
sickness and accident insurance in this state that has at least a 2,709
two-thirds majority of physicians in active practice and that 2,710
conducts professional credentialing and quality review activities 2,711
involving the competence or professional conduct of a health care 2,712
facility that has contracted with the insurer to provide health
care services to insureds, which conduct adversely affects, or 2,713
could adversely affect, the health or welfare of any patient; 2,714
(i) A peer review committee of an insurer authorized under 2,716
Title XXXIX of the Revised Code to do the business of medical 2,717
professional liability insurance in this state and that conducts 2,718
professional quality review activities involving the competence 2,719
or professional conduct of health care providers, which conduct 2,720
adversely affects, or could affect, the health or welfare of any 2,721
patient;
(j) A peer review committee of a health care entity. 2,723
(2) "Peer review committee" means a utilization review 2,725
committee, quality assurance committee, quality improvement 2,726
committee, tissue committee, credentialing committee, and any 2,727
other committee that conducts professional credentialing and 2,728
quality review activities involving the competence or
professional conduct of health care practitioners. 2,729
(3) "Health care entity" means a government entity, a 2,731
for-profit or nonprofit corporation, a limited liability company, 2,732
a partnership, a professional corporation, a state or local 2,733
society as described in division (A)(1)(c) of this section, or 2,734
other health care organization, including, but not limited to, 2,735
health care entities described in division (A)(1) of this 2,736
section, whether acting on its own behalf or on behalf of or in 2,737
58
affiliation with other health care entities, that conducts, as 2,738
part of its purpose, professional credentialing and quality
review activities involving the competence or professional 2,739
conduct of health care practitioners. 2,740
(4) "Incident report or risk management report" means a 2,743
report of an incident involving injury or potential injury to a
patient as a result of patient care by a health care entity that 2,744
is prepared by or for the use of a review board, committee, risk 2,745
management personnel, or corporation and is within the scope of 2,746
the functions of that review board, committee, risk management 2,747
personnel, or corporation.
(5) "Tort action" means a civil action for damages for 2,750
injury, death, or loss to a patient of a health care entity. 2,751
"Tort action" includes a product liability claim but does not 2,752
include a civil action for a breach of contract or another 2,753
agreement between persons.
(B) Notwithstanding any contrary provision of section 2,756
149.43, 1742.141 1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 2,757
of the Revised Code, an incident report or risk management report 2,759
and the contents of an incident report or risk management report 2,760
are not subject to discovery in, and are not admissible in 2,761
evidence in the trial of, a tort action. An individual who
prepares or has knowledge of the contents of an incident report 2,762
or risk management report shall not testify and shall not be 2,763
required to testify in a tort action as to the contents of the 2,764
report. This division does not prohibit or limit the discovery 2,765
or admissibility of testimony or evidence relating to patient 2,766
care that is within a person's personal knowledge. 2,767
(C) Except as specified in division (B) of this section, 2,770
this section does not affect any provision of section 1742.141 2,771
1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 of the Revised 2,773
Code that describes, imposes, or confers an immunity from tort or 2,774
other civil liability, a forfeiture of an immunity from tort or 2,775
other civil liability, a requirement of confidentiality, a 2,776
59
limitation upon the use of information, data, reports, or 2,777
records, tort or other civil liability, or a limitation upon 2,778
discovery of matter, introduction into evidence of matter, or 2,779
testimony pertaining to matter in a tort or other civil action. 2,780
This section does not affect a privileged communication between 2,781
an attorney and the attorney's client under section 2317.02 of 2,782
the Revised Code.
(D) This section shall be considered to be purely remedial 2,784
in operation and shall be applied in a remedial manner in any 2,785
civil action in which this section is relevant, whether the civil 2,786
action is pending in court or commenced on or after the effective 2,787
date of this section JANUARY 27, 1997, regardless of when the 2,788
cause of action accrued and notwithstanding any other section of 2,789
the Revised Code or prior rule of law of this state. 2,790
Sec. 3901.21. The following are hereby defined as unfair 2,799
and deceptive acts or practices in the business of insurance: 2,800
(A) Making, issuing, circulating, or causing or permitting 2,802
to be made, issued, or circulated, or preparing with intent to so 2,803
use, any estimate, illustration, circular, or statement 2,804
misrepresenting the terms of any policy issued or to be issued or 2,805
the benefits or advantages promised thereby or the dividends or 2,806
share of the surplus to be received thereon, or making any false 2,807
or misleading statements as to the dividends or share of surplus 2,808
previously paid on similar policies, or making any misleading 2,809
representation or any misrepresentation as to the financial 2,810
condition of any insurer as shown by the last preceding verified 2,811
statement made by it to the insurance department of this state, 2,812
or as to the legal reserve system upon which any life insurer 2,813
operates, or using any name or title of any policy or class of 2,814
policies misrepresenting the true nature thereof, or making any 2,815
misrepresentation or incomplete comparison to any person for the 2,816
purpose of inducing or tending to induce such person to purchase, 2,817
amend, lapse, forfeit, change, or surrender insurance. 2,818
Any written statement concerning the premiums for a policy 2,820
60
which refers to the net cost after credit for an assumed 2,821
dividend, without an accurate written statement of the gross 2,822
premiums, cash values, and dividends based on the insurer's 2,823
current dividend scale, which are used to compute the net cost 2,824
for such policy, and a prominent warning that the rate of 2,825
dividend is not guaranteed, is a misrepresentation for the 2,826
purposes of this division. 2,827
(B) Making, publishing, disseminating, circulating, or 2,829
placing before the public or causing, directly or indirectly, to 2,830
be made, published, disseminated, circulated, or placed before 2,831
the public, in a newspaper, magazine, or other publication, or in 2,832
the form of a notice, circular, pamphlet, letter, or poster, or 2,833
over any radio station, or in any other way, or preparing with 2,834
intent to so use, an advertisement, announcement, or statement 2,835
containing any assertion, representation, or statement, with 2,836
respect to the business of insurance or with respect to any 2,837
person in the conduct of the person's insurance business, which 2,839
is untrue, deceptive, or misleading. 2,840
(C) Making, publishing, disseminating, or circulating, 2,842
directly or indirectly, or aiding, abetting, or encouraging the 2,843
making, publishing, disseminating, or circulating, or preparing 2,844
with intent to so use, any statement, pamphlet, circular, 2,845
article, or literature, which is false as to the financial 2,846
condition of an insurer and which is calculated to injure any 2,847
person engaged in the business of insurance. 2,848
(D) Filing with any supervisory or other public official, 2,850
or making, publishing, disseminating, circulating, or delivering 2,851
to any person, or placing before the public, or causing directly 2,852
or indirectly to be made, published, disseminated, circulated, 2,853
delivered to any person, or placed before the public, any false 2,854
statement of financial condition of an insurer. 2,855
Making any false entry in any book, report, or statement of 2,857
any insurer with intent to deceive any agent or examiner lawfully 2,858
appointed to examine into its condition or into any of its 2,859
61
affairs, or any public official to whom such insurer is required 2,860
by law to report, or who has authority by law to examine into its 2,861
condition or into any of its affairs, or, with like intent, 2,862
willfully omitting to make a true entry of any material fact 2,863
pertaining to the business of such insurer in any book, report, 2,864
or statement of such insurer, or mutilating, destroying, 2,865
suppressing, withholding, or concealing any of its records. 2,866
(E) Issuing or delivering or permitting agents, officers, 2,868
or employees to issue or deliver agency company stock or other 2,869
capital stock or benefit certificates or shares in any common-law 2,870
corporation or securities or any special or advisory board 2,871
contracts or other contracts of any kind promising returns and 2,872
profits as an inducement to insurance. 2,873
(F) Making or permitting any unfair discrimination among 2,875
individuals of the same class and equal expectation of life in 2,876
the rates charged for any contract of life insurance or of life 2,877
annuity or in the dividends or other benefits payable thereon, or 2,878
in any other of the terms and conditions of such contract. 2,879
(G)(1) Except as otherwise expressly provided by law, 2,881
knowingly permitting or offering to make or making any contract 2,882
of life insurance, life annuity or accident and health insurance, 2,883
or agreement as to such contract other than as plainly expressed 2,884
in the contract issued thereon, or paying or allowing, or giving 2,885
or offering to pay, allow, or give, directly or indirectly, as 2,886
inducement to such insurance, or annuity, any rebate of premiums 2,887
payable on the contract, or any special favor or advantage in the 2,888
dividends or other benefits thereon, or any valuable 2,889
consideration or inducement whatever not specified in the 2,890
contract; or giving, or selling, or purchasing, or offering to 2,891
give, sell, or purchase, as inducement to such insurance or 2,892
annuity or in connection therewith, any stocks, bonds, or other 2,893
securities, or other obligations of any insurance company or 2,894
other corporation, association, or partnership, or any dividends 2,895
or profits accrued thereon, or anything of value whatsoever not 2,896
62
specified in the contract. 2,897
(2) Nothing in division (F) or division (G)(1) of this 2,899
section shall be construed as prohibiting any of the following 2,900
practices: (a) in the case of any contract of life insurance or 2,901
life annuity, paying bonuses to policyholders or otherwise 2,902
abating their premiums in whole or in part out of surplus 2,903
accumulated from nonparticipating insurance, provided that any 2,904
such bonuses or abatement of premiums shall be fair and equitable 2,905
to policyholders and for the best interests of the company and 2,906
its policyholders; (b) in the case of life insurance policies 2,907
issued on the industrial debit plan, making allowance to 2,908
policyholders who have continuously for a specified period made 2,909
premium payments directly to an office of the insurer in an 2,910
amount which fairly represents the saving in collection expenses; 2,911
(c) readjustment of the rate of premium for a group insurance 2,912
policy based on the loss or expense experience thereunder, at the 2,913
end of the first or any subsequent policy year of insurance 2,914
thereunder, which may be made retroactive only for such policy 2,915
year. 2,916
(H) Making, issuing, circulating, or causing or permitting 2,918
to be made, issued, or circulated, or preparing with intent to so 2,919
use, any statement to the effect that a policy of life insurance 2,920
is, is the equivalent of, or represents shares of capital stock 2,921
or any rights or options to subscribe for or otherwise acquire 2,922
any such shares in the life insurance company issuing that policy 2,923
or any other company. 2,924
(I) Making, issuing, circulating, or causing or permitting 2,926
to be made, issued or circulated, or preparing with intent to so 2,927
issue, any statement to the effect that payments to a 2,928
policyholder of the principal amounts of a pure endowment are 2,929
other than payments of a specific benefit for which specific 2,930
premiums have been paid. 2,931
(J) Making, issuing, circulating, or causing or permitting 2,933
to be made, issued, or circulated, or preparing with intent to so 2,934
63
use, any statement to the effect that any insurance company was 2,935
required to change a policy form or related material to comply 2,936
with Title XXXIX of the Revised Code or any regulation of the 2,937
superintendent of insurance, for the purpose of inducing or 2,938
intending to induce any policyholder or prospective policyholder 2,939
to purchase, amend, lapse, forfeit, change, or surrender 2,940
insurance. 2,941
(K) Aiding or abetting another to violate this section. 2,943
(L) Refusing to issue any policy of insurance, or 2,945
canceling or declining to renew such policy because of the sex or 2,946
marital status of the applicant, prospective insured, insured, or 2,947
policyholder. 2,948
(M) Making or permitting any unfair discrimination between 2,950
individuals of the same class and of essentially the same hazard 2,951
in the amount of premium, policy fees, or rates charged for any 2,952
policy or contract of insurance, other than life insurance, or in 2,953
the benefits payable thereunder, or in underwriting standards and 2,954
practices or eligibility requirements, or in any of the terms or 2,955
conditions of such contract, or in any other manner whatever. 2,956
(N) Refusing to make available disability income insurance 2,958
solely because the applicant's principal occupation is that of 2,959
managing a household. 2,960
(O) Refusing, when offering maternity benefits under any 2,962
individual or group sickness and accident insurance policy, to 2,963
make maternity benefits available to the policyholder for the 2,964
individual or individuals to be covered under any comparable 2,965
policy to be issued for delivery in this state, including family 2,966
members if the policy otherwise provides coverage for family 2,967
members. Nothing in this division shall be construed to prohibit 2,968
an insurer from imposing a reasonable waiting period for such 2,969
benefits under an A NONFEDERALLY ELIGIBLE individual sickness and 2,971
accident insurance policy OR A NONEMPLOYER-RELATED GROUP SICKNESS 2,972
AND ACCIDENT INSURANCE POLICY, but in no event shall such waiting 2,974
period exceed two hundred seventy days.
64
(P) Using, or permitting to be used, a pattern settlement 2,976
as the basis of any offer of settlement. As used in this 2,977
division, "pattern settlement" means a method by which liability 2,978
is routinely imputed to a claimant without an investigation of 2,979
the particular occurrence upon which the claim is based and by 2,980
using a predetermined formula for the assignment of liability 2,981
arising out of occurrences of a similar nature. Nothing in this 2,982
division shall be construed to prohibit an insurer from 2,983
determining a claimant's liability by applying formulas or 2,984
guidelines to the facts and circumstances disclosed by the 2,985
insurer's investigation of the particular occurrence upon which a 2,986
claim is based. 2,987
(Q) Refusing to insure, or refusing to continue to insure, 2,989
or limiting the amount, extent, or kind of life or sickness and 2,990
accident insurance or annuity coverage available to an 2,991
individual, or charging an individual a different rate for the 2,992
same coverage solely because of blindness or partial blindness. 2,993
With respect to all other conditions, including the underlying 2,994
cause of blindness or partial blindness, persons who are blind or 2,995
partially blind shall be subject to the same standards of sound 2,996
actuarial principles or actual or reasonably anticipated 2,997
actuarial experience as are sighted persons. Refusal to insure 2,998
includes, but is not limited to, denial by an insurer of 2,999
disability insurance coverage on the grounds that the policy 3,000
defines "disability" as being presumed in the event that the 3,001
eyesight of the insured is lost. However, an insurer may exclude 3,002
from coverage disabilities consisting solely of blindness or 3,003
partial blindness when such conditions existed at the time the 3,004
policy was issued. To the extent that the provisions of this 3,005
division may appear to conflict with any provision of section 3,006
3999.16 of the Revised Code, this division applies. 3,007
(R)(1) Directly or indirectly offering to sell, selling, 3,009
or delivering, issuing for delivery, renewing, or using or 3,010
otherwise marketing any policy of insurance or insurance product 3,011
65
in connection with or in any way related to the grant of a 3,012
student loan guaranteed in whole or in part by an agency or 3,013
commission of this state or the United States, except insurance 3,014
that is required under federal or state law as a condition for 3,015
obtaining such a loan and the premium for which is included in 3,016
the fees and charges applicable to the loan; or, in the case of 3,017
an insurer or insurance agent, knowingly permitting any lender 3,018
making such loans to engage in such acts or practices in 3,019
connection with the insurer's or agent's insurance business. 3,020
(2) Except in the case of a violation of division (G) of 3,022
this section, division (R)(1) of this section does not apply to 3,023
either of the following: 3,024
(a) Acts or practices of an insurer, its agents, 3,026
representatives, or employees in connection with the grant of a 3,027
guaranteed student loan to its insured or the insured's spouse or 3,028
dependent children where such acts or practices take place more 3,029
than ninety days after the effective date of the insurance; 3,030
(b) Acts or practices of an insurer, its agents, 3,032
representatives, or employees in connection with the 3,033
solicitation, processing, or issuance of an insurance policy or 3,034
product covering the student loan borrower or the borrower's 3,035
spouse or dependent children, where such acts or practices take 3,037
place more than one hundred eighty days after the date on which 3,038
the borrower is notified that the student loan was approved. 3,039
(S) Denying coverage, under any health insurance or health 3,041
care policy, contract, or plan providing family coverage, to any 3,042
natural or adopted child of the named insured or subscriber 3,043
solely on the basis that the child does not reside in the 3,044
household of the named insured or subscriber. 3,045
(T)(1) Using any underwriting standard or engaging in any 3,047
other act or practice that, directly or indirectly, due solely to 3,048
any health status-related factor in relation to one or more 3,049
individuals, does either of the following:
(a) Terminates or fails to renew an existing individual 3,051
66
policy, contract, or plan of health benefits, or a health benefit 3,052
plan issued to an employer, for which an individual would 3,053
otherwise be eligible;
(b) With respect to a health benefit plan issued to an 3,055
employer, excludes or causes the exclusion of an individual from 3,056
coverage under an existing employer-provided policy, contract, or 3,057
plan of health benefits.
(2) The superintendent of insurance may adopt rules in 3,059
accordance with Chapter 119. of the Revised Code for purposes of 3,060
implementing division (T)(1) of this section. 3,061
(3) For purposes of division (T)(1) of this section, 3,064
"health status-related factor" means any of the following: 3,065
(a) Health status; 3,067
(b) Medical condition, including both physical and mental 3,070
illnesses;
(c) Claims experience; 3,072
(d) Receipt of health care; 3,074
(e) Medical history; 3,076
(f) Genetic information; 3,078
(g) Evidence of insurability, including conditions arising 3,081
out of acts of domestic violence;
(h) Disability. 3,083
(U) With respect to a health benefit plan issued to a 3,085
small employer, as those terms are defined in section 3924.01 of 3,086
the Revised Code, negligently or willfully placing coverage for 3,087
adverse risks with a certain carrier, as defined in section 3,088
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 3,090
or practice that, directly or indirectly, causes or results in 3,091
the placing of coverage for adverse risks with another carrier, 3,092
as defined in section 3924.01 of the Revised Code. 3,093
(W) Failing to comply with section 3923.23, 3923.231, 3,095
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 3,096
in any unfair, discriminatory reimbursement practice. 3,097
67
(X) Intentionally establishing an unfair premium for, or 3,099
misrepresenting the cost of, any insurance policy financed under 3,100
a premium finance agreement of an insurance premium finance 3,101
company. 3,102
(Y)(1)(a) Limiting coverage under, refusing to issue, 3,104
canceling, or refusing to renew, any individual policy or 3,105
contract of life insurance, or limiting coverage under or 3,106
refusing to issue any individual policy or contract of health 3,107
insurance, for the reason that the insured or applicant for 3,108
insurance is or has been a victim of domestic violence; 3,109
(b) Adding a surcharge or rating factor to a premium of 3,111
any individual policy or contract of life or health insurance for 3,112
the reason that the insured or applicant for insurance is or has 3,113
been a victim of domestic violence; 3,114
(c) Denying coverage under, or limiting coverage under, 3,116
any policy or contract of life or health insurance, for the 3,117
reason that a claim under the policy or contract arises from an 3,118
incident of domestic violence;
(d) Inquiring, directly or indirectly, of an insured 3,120
under, or of an applicant for, a policy or contract of life or 3,121
health insurance, as to whether the insured or applicant is or 3,122
has been a victim of domestic violence, or inquiring as to 3,123
whether the insured or applicant has sought shelter or protection 3,124
from domestic violence or has sought medical or psychological
treatment as a victim of domestic violence. 3,125
(2) Nothing in division (Y)(1) of this section shall be 3,127
construed to prohibit an insurer from inquiring as to, or from 3,128
underwriting or rating a risk on the basis of, a person's 3,129
physical or mental condition, even if the condition has been 3,130
caused by domestic violence, provided that all of the following 3,131
apply:
(a) The insurer routinely considers the condition in 3,133
underwriting or in rating risks, and does so in the same manner 3,134
for a victim of domestic violence as for an insured or applicant 3,135
68
who is not a victim of domestic violence; 3,136
(b) The insurer does not refuse to issue any policy or 3,138
contract of life or health insurance or cancel or refuse to renew 3,140
any policy or contract of life insurance, solely on the basis of
the condition, except where such refusal to issue, cancellation, 3,141
or refusal to renew is based on sound actuarial principles or is 3,142
related to actual or reasonably anticipated experience; 3,143
(c) The insurer does not consider a person's status as 3,145
being or as having been a victim of domestic violence, in itself, 3,146
to be a physical or mental condition; 3,147
(d) The underwriting or rating of a risk on the basis of 3,149
the condition is not used to evade the intent of division (Y)(1) 3,151
of this section, or of any other provision of the Revised Code. 3,153
(3)(a) Nothing in division (Y)(1) of this section shall be 3,156
construed to prohibit an insurer from refusing to issue a policy 3,157
or contract of life insurance insuring the life of a person who 3,158
is or has been a victim of domestic violence if the person who 3,159
committed the act of domestic violence is the applicant for the 3,160
insurance or would be the owner of the insurance policy or 3,161
contract.
(b) Nothing in division (Y)(2) of this section shall be 3,164
construed to permit an insurer to cancel or refuse to renew any 3,165
policy or contract of health insurance in violation of the 3,166
"Health Insurance Portability and Accountability Act of 1996," 3,167
110 Stat. 1955, 42 U.S.C.A. 300gg-41(b), as amended, or in a 3,169
manner that violates or is inconsistent with any provision of the 3,170
Revised Code that implements the "Health Insurance Portability 3,172
and Accountability Act of 1996." 3,173
(4) An insurer is immune from any civil or criminal 3,176
liability that otherwise might be incurred or imposed as a result
of any action taken by the insurer to comply with division (Y) of 3,178
this section.
(5) As used in division (Y) of this section, "domestic 3,181
violence" means any of the following acts: 3,182
69
(a) Knowingly causing or attempting to cause physical harm 3,184
to a family or household member; 3,186
(b) Recklessly causing serious physical harm to a family 3,188
or household member; 3,190
(c) Knowingly causing, by threat of force, a family or 3,192
household member to believe that the person will cause imminent 3,193
physical harm to the family or household member. 3,194
For the purpose of division (Y)(5) of this section, "family 3,198
or household member" has the same meaning as in section 2919.25
of the Revised Code. 3,199
Nothing in division (Y)(5) of this section shall be 3,202
construed to require, as a condition to the application of 3,203
division (Y) of this section, that the act described in division 3,205
(Y)(5) of this section be the basis of a criminal prosecution. 3,207
With respect to private passenger automobile insurance, no 3,209
insurer shall charge different premium rates to persons residing 3,210
within the limits of any municipal corporation based solely on 3,211
the location of the residence of the insured within those limits. 3,212
The enumeration in sections 3901.19 to 3901.26 of the 3,214
Revised Code of specific unfair or deceptive acts or practices in 3,215
the business of insurance is not exclusive or restrictive or 3,216
intended to limit the powers of the superintendent of insurance 3,217
to adopt rules to implement this section, or to take action under 3,218
other sections of the Revised Code. 3,219
This section does not prohibit the sale of shares of any 3,221
investment company registered under the "Investment Company Act 3,222
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 3,223
policies, annuities, or other contracts described in section 3,224
3907.15 of the Revised Code. 3,225
As used in this section, "estimate," "statement," 3,227
"representation," "misrepresentation," "advertisement," or 3,228
"announcement" includes oral or written occurrences. 3,229
Sec. 3923.021. (A) As used in this section, "benefits 3,238
provided are not unreasonable in relation to the premium charged" 3,239
70
means the rates were calculated in accordance with sound 3,240
actuarial principles. 3,241
(B) With respect to any filing, made pursuant to section 3,243
3923.02 of the Revised Code, of any premium rates for any 3,244
individual policy of sickness and accident insurance or for any 3,245
indorsement or rider pertaining thereto, the superintendent of 3,246
insurance may, within thirty days after filing: 3,247
(1) Disapprove such filing after finding that the benefits 3,250
provided are unreasonable in relation to the premium charged. 3,251
Such disapproval shall be effected by written order of the 3,252
superintendent, a copy of which shall be mailed to the insurer 3,253
that has made the filing. In the order, the superintendent shall 3,254
specify the reasons for the disapproval and state that a hearing 3,256
will be held within fifteen days after requested in writing by 3,257
the insurer. If a hearing is so requested, the superintendent 3,258
shall also give such public notice as the superintendent 3,259
considers appropriate. The superintendent, within fifteen days 3,261
after the commencement of any hearing, shall issue a written 3,262
order, a copy of which shall be mailed to the insurer that has 3,263
made the filing, either affirming the prior disapproval or 3,264
approving such filing after finding that the benefits provided 3,265
are not unreasonable in relation to the premium charged. 3,267
(2) Set a date for a public hearing to commence no later 3,269
than forty days after the filing. The superintendent shall give 3,270
the insurer making the filing twenty days' written notice of the 3,271
hearing and shall give such public notice as the superintendent 3,273
considers appropriate. The superintendent, within twenty days 3,274
after the commencement of a hearing, shall issue a written order, 3,275
a copy of which shall be mailed to the insurer that has made the 3,276
filing, either approving such filing if the superintendent finds 3,277
that the benefits provided are not unreasonable in relation to 3,279
the premium charged, or disapproving such filing if the 3,280
superintendent finds that the benefits provided are unreasonable 3,282
in relation to the premium charged. This division does not apply 3,283
71
to any insurer organized or transacting the business of insurance 3,284
under Chapter 3907. or 3909. of the Revised Code. 3,285
(3) Take no action, in which case such filing shall be 3,287
deemed to be approved and shall become effective upon the 3,288
thirty-first day after such filing, unless the superintendent has 3,289
previously given to the insurer a written approval. 3,290
(C) At any time after any filing has been approved 3,292
pursuant to this section, the superintendent may, after a hearing 3,293
of which at least twenty days' written notice has been given to 3,294
the insurer that has made such filing and for which such public 3,295
notice as the superintendent considers appropriate has been 3,296
given, withdraw approval of such filing after finding that the 3,298
benefits provided are unreasonable in relation to the premium 3,300
charged. Such withdrawal of approval shall be effected by 3,301
written order of the superintendent, a copy of which shall be 3,302
mailed to the insurer that has made the filing, which shall state 3,303
the ground for such withdrawal and the date, not less than forty 3,304
days after the date of such order, when the withdrawal or 3,305
approval shall become effective. 3,306
(D) The superintendent may retain at the insurer's expense 3,308
such attorneys, actuaries, accountants, and other experts not 3,309
otherwise a part of the superintendent's staff as shall be 3,310
reasonably necessary to assist in the preparation for and conduct 3,311
of any public hearing under this section. The expense for 3,312
retaining such experts and the expenses of the department of 3,313
insurance incurred in connection with such public hearing shall 3,314
be assessed against the insurer in an amount not to exceed one 3,315
one-hundredth of one per cent of the sum of premiums earned plus 3,316
net realized investment gain or loss of such insurer as reflected 3,317
in the most current annual statement on file with the 3,318
superintendent. Any person retained shall be under the direction 3,319
and control of the superintendent and shall act in a purely 3,320
advisory capacity. 3,321
(E) This section does not apply to any filing of any 3,323
72
premium rate or rating formula for individual sickness and 3,324
accident insurance policies offered in accordance with division 3,325
(L) of section 3923.58 of the Revised Code, or for any amendment 3,327
thereto.
Sec. 3923.122. (A) Every policy of group sickness and 3,336
accident insurance providing hospital, surgical, or medical 3,337
expense coverage for other than specific diseases or accidents 3,338
only, and delivered, issued for delivery, or renewed in this 3,339
state on or after January 1, 1976, shall include a provision 3,340
giving each insured the option to convert to the following: 3,341
(1) In the case of an individual who is not a federally 3,344
eligible individual, any of the individual policies of hospital, 3,345
surgical, or medical expense insurance then being issued by the 3,346
insurer with benefit limits not to exceed those in effect under 3,347
the group policy;
(2) In the case of a federally eligible individual, a 3,349
basic or standard plan established by the board of directors of 3,350
the Ohio health reinsurance program or plans substantially 3,351
similar to the basic and standard plan in benefit design and 3,352
scope of covered services. For purposes of division (A)(2) of 3,353
this section, the superintendent of insurance shall determine 3,354
whether a plan is substantially similar to the basic or standard 3,355
plan in benefit design and scope of covered services. 3,356
(B) An option for conversion to an individual policy shall 3,358
be available without evidence of insurability to every insured, 3,359
including any person eligible under division (D) of this section, 3,360
who terminates employment or membership in the group holding the 3,362
policy after having been continuously insured thereunder for at 3,363
least one year.
Upon receipt of the insured's written application and upon 3,365
payment of at least the first quarterly premium not later than 3,366
thirty-one days after the termination of coverage under the group 3,367
policy, the insurer shall issue a converted policy on a form then 3,368
available for conversion. The premium shall be in accordance 3,369
73
with the insurer's table of premium rates in effect on the later 3,370
of the following dates: 3,371
(1) The effective date of the converted policy; 3,373
(2) The date of application therefor; and shall be 3,375
applicable to the class of risk to which each person covered 3,377
belongs and to the form and amount of the policy at the person's 3,378
then attained age. However, premiums charged federally eligible 3,379
individuals may not exceed an amount that is two times the 3,381
midpoint of the standard rate charged any other individual of a 3,382
group to which the insurer is currently accepting new business 3,383
and for which similar copayments and deductibles are applied. 3,384
At the election of the insurer, a separate converted policy 3,386
may be issued to cover any dependent of an employee or member of 3,387
the group. 3,388
Except as provided in division (H) of this section, any 3,390
converted policy shall become effective as of the day following 3,391
the date of termination of insurance under the group policy. 3,392
Any probationary or waiting period set forth in the 3,394
converted policy is deemed to commence on the effective date of 3,395
the insured's coverage under the group policy. 3,396
(C) No insurer shall be required to issue a converted 3,398
policy to any person who is, or is eligible to be, covered for 3,399
benefits at least comparable to the group policy under: 3,400
(1) Title XVIII of the Social Security Act, as amended or 3,402
superseded; 3,403
(2) Any act of congress or law under this or any other 3,405
state of the United States that duplicates coverage offered under 3,406
division (C)(1) of this section; 3,407
(3) Any policy that duplicates coverage offered under 3,409
division (C)(1) of this section; 3,410
(4) Any other group sickness and accident insurance 3,412
providing hospital, surgical, or medical expense coverage for 3,413
other than specific diseases or accidents only. 3,414
(D) The option for conversion shall be available: 3,416
74
(1) Upon the death of the employee or member, to the 3,418
surviving spouse with respect to such of the spouse and 3,419
dependents as are then covered by the group policy; 3,420
(2) To a child solely with respect to the child upon 3,422
attaining the limiting age of coverage under the group policy 3,423
while covered as a dependent thereunder; 3,424
(3) Upon the divorce, dissolution, or annulment of the 3,426
marriage of the employee or member, to the divorced spouse, or 3,427
former spouse in the event of annulment, of such employee or 3,428
member, or upon the legal separation of the spouse from such 3,429
employee or member, to the spouse. 3,430
Persons possessing the option for conversion pursuant to 3,432
this division shall be considered members for the purposes of 3,433
division (H) of this section. 3,434
(E) If coverage is continued under a group policy on an 3,436
employee following retirement prior to the time the employee is, 3,438
or is eligible to be, covered by Title XVIII of the Social 3,439
Security Act, the employee may elect, in lieu of the continuance 3,440
of group insurance, to have the same conversion rights as would 3,442
apply had the employee's insurance terminated at retirement by 3,444
reason of termination of employment. 3,445
(F) If the insurer and the group policyholder agree upon 3,447
one or more additional plans of benefits to be available for 3,448
converted policies, the applicant for the converted policy may 3,449
elect such a plan in lieu of a converted policy. 3,450
(G) The converted policy may contain provisions for 3,452
avoiding duplication of benefits provided pursuant to divisions 3,453
(C)(1), (2), (3), and (4) of this section or provided under any 3,454
other insured or noninsured plan or program. 3,455
(H) If an employee or member becomes entitled to obtain a 3,457
converted policy pursuant to this section, and if the employee or 3,458
member has not received notice of the conversion privilege at 3,459
least fifteen days prior to the expiration of the thirty-one-day 3,460
conversion period provided in division (B) of this section, then 3,461
75
the employee or member has an additional period within which to 3,462
exercise the privilege. This additional period shall expire 3,463
fifteen days after the employee or member receives notice, but in 3,464
no event shall the period extend beyond sixty days after the 3,465
expiration of the thirty-one-day conversion period. 3,466
Written notice presented to the employee or member, or 3,468
mailed by the policyholder to the last known address of the 3,469
employee or member as indicated on its records, constitutes 3,470
notice for the purpose of this division. In the case of a person 3,471
who is eligible for a converted policy under division (D)(2) or 3,472
(D)(3) of this section, a policyholder shall not be responsible 3,473
for presenting or mailing such notice, unless such policyholder 3,474
has actual knowledge of the person's eligibility for a converted 3,475
policy. 3,476
If an additional period is allowed by an employee or member 3,478
for the exercise of a conversion privilege, and if written 3,479
application for the converted policy, accompanied by at least the 3,480
first quarterly premium, is made after the expiration of the 3,481
thirty-one-day conversion period, but within the additional 3,482
period allowed an employee or member in accordance with this 3,483
division, the effective date of the converted policy shall be the 3,484
date of application. 3,485
(I) The converted policy may provide: 3,487
(1) That THAT any hospital, surgical, or medical expense 3,489
benefits otherwise payable with respect to any person may be 3,490
reduced by the amount of any such benefits payable under the 3,491
group policy for the same loss after termination of coverage; 3,492
(2) For termination of coverage on any person who is, or 3,494
is eligible to be, covered pursuant to division (C) of this 3,495
section; 3,496
(3) That the insurer may request information in advance of 3,498
any premium due date of the policy as to whether the insured is, 3,499
or is eligible to be, covered pursuant to division (C) of this 3,500
section. If the insured is, or is eligible to be, covered, and 3,501
76
the insured fails to furnish the details of the insured's 3,503
coverage or eligibility to the insurer within thirty-one days 3,504
after the date of the request, the benefits payable under the 3,505
converted policy may be based on the hospital, surgical, or 3,506
medical expenses actually incurred after excluding expenses to 3,507
the extent of the amount of benefits for which the insured is, or 3,508
is eligible to be, covered pursuant to division (C) of this 3,509
section.
(J) The converted policy may contain: 3,511
(1) Any exclusion, reduction, or limitation contained in 3,513
the group policy or customarily used in individual policies 3,514
issued by the insurer; 3,515
(2) Any provision permitted in this section; 3,517
(3) Any other provision not prohibited by law. 3,519
Any provision required or permitted in this section may be 3,521
made a part of any converted policy by means of an endorsement or 3,522
rider. 3,523
(K) The time limit specified in a converted policy for 3,525
certain defenses with respect to any person who was covered by a 3,526
group policy shall commence on the effective date of such 3,527
person's coverage under the group policy. 3,528
(L) No insurer shall use deterioration of health as the 3,530
basis for refusing to renew a converted policy. 3,531
(M) No insurer shall use age as the basis for refusing to 3,533
renew a converted policy. 3,534
(N) A converted policy made available pursuant to this 3,536
section shall, if delivery of the policy is to be made in this 3,537
state, comply with this section. If delivery of a converted 3,538
policy is to be made in another state, it may be on a form 3,539
offered by the insurer in the jurisdiction where the delivery is 3,540
to be made and which provides benefits substantially in 3,541
compliance with those required in a policy delivered in this 3,542
state. 3,543
(O) As used in this section, "federally eligible 3,546
77
individual" means an eligible individual as defined in 45 C.F.R. 3,548
148.103. 3,549
Sec. 3923.571. Except as otherwise provided in section 3,558
2721 of the "Health Insurance Portability and Accountability Act 3,563
of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 3,568
300gg-21, as amended, the following conditions apply to all group 3,570
policies of sickness and accident insurance that are sold in
connection with an employment-related group health plan and that 3,571
are not subject to section 3924.03 of the Revised Code: 3,572
(A) Any such policy shall comply with the requirements of 3,574
division (A) of section 3924.03 and section 3924.033 of the 3,575
Revised Code. 3,576
(B)(1) Except as provided in section 2712(b) to (e) of the 3,580
"Health Insurance Portability and Accountability Act of 1996," if 3,584
an insurer offers coverage in the small or large group market in 3,585
connection with a group policy, the insurer shall renew or 3,586
continue in force such coverage at the option of the 3,587
policyholder.
(2) An insurer may cancel or decide not to renew the 3,589
coverage of an employee or of a dependent of an employee if the 3,590
employee or dependent, as applicable, has performed an act or 3,591
practice that constitutes fraud or made an intentional 3,592
misrepresentation of material fact under the terms of the
coverage and if the cancellation or nonrenewal is not based, 3,593
either directly or indirectly, on any health status-related 3,594
factor in relation to the employee or dependent. 3,595
As used in division (B)(2) of this section, "health 3,598
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 3,600
(C)(1) No such policy, or insurer offering health 3,602
insurance coverage in connection with such a policy, shall 3,604
require any individual, as a condition of coverage or continued 3,605
coverage under the policy, to pay a premium or contribution that 3,606
is greater than the premium or contribution for a similarly 3,607
78
situated individual covered under the policy on the basis of any 3,608
health status-related factor in relation to the individual or to 3,609
an individual covered under the policy as a dependent of the 3,610
individual. 3,611
(2) Nothing in division (C)(1) of this section shall be 3,614
construed to restrict the amount that an employer may be charged 3,615
for coverage under a group policy, or to prevent a group policy, 3,616
and an insurer offering group health insurance coverage, from 3,617
establishing premium discounts or rebates or modifying otherwise 3,618
applicable copayments or deductibles in return for adherence to 3,619
programs of health promotion and disease prevention. 3,620
(D) Such policies shall provide for the special enrollment 3,623
periods described in section 2701(f) of the "Health Insurance 3,626
Portability and Accountability Act of 1996." 3,629
(E) AN INSURER MAY DELAY COVERAGE OF A LATE ENROLLEE FOR 3,632
UP TO TWELVE MONTHS. HOWEVER, ANY PRE-EXISTING CONDITION 3,633
PROVISION THAT IMPOSES AN EXCLUSIONARY PERIOD ON SUCH A LATE 3,634
ENROLLEE SHALL RUN CONCURRENTLY WITH THE DELAY IN COVERAGE. AS 3,635
USED IN THIS DIVISION, A "LATE ENROLLEE" MEANS AN ELIGIBLE 3,636
EMPLOYEE OR DEPENDENT WHO ENROLLS IN A HEALTH BENEFIT PLAN OTHER 3,637
THAN DURING THE FIRST PERIOD IN WHICH THE EMPLOYEE OR DEPENDENT 3,638
IS ELIGIBLE TO ENROLL UNDER THE PLAN OR DURING A SPECIAL 3,639
ENROLLMENT PERIOD DESCRIBED IN SECTION 2701(f) OF THE "HEALTH 3,642
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996." 3,645
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 3,654
of the Revised Code: 3,655
(1) "Health benefit plan" and "MEWA" have the same 3,658
meanings as in section 3924.01 of the Revised Code. 3,659
(2) "Insurer" means any sickness and accident insurance 3,661
company authorized to do business in this state, or MEWA 3,664
authorized to issue insured health benefit plans in this state. 3,665
"Insurer" does not include any health insuring corporation that
is owned or operated by an insurer. 3,667
(3) "Pre-existing conditions provision" means a policy 3,670
79
provision that excludes or limits coverage for charges or 3,671
expenses incurred during a specified period following the 3,672
insured's effective date of coverage as to a condition which, 3,673
during a specified period immediately preceding the effective 3,674
date of coverage, had manifested itself in such a manner as would 3,676
cause an ordinarily prudent person to seek medical advice,
diagnosis, care, or treatment or for which medical advice, 3,677
diagnosis, care, or treatment was recommended or received, or a 3,678
pregnancy existing on the effective date of coverage. 3,679
(B) Beginning in January of each year, insurers in the 3,682
business of issuing individual policies of sickness and accident 3,683
insurance as contemplated by section 3923.021 of the Revised 3,684
Code, except individual policies issued pursuant to section 3,686
3923.122 of the Revised Code, shall accept applicants for open 3,690
enrollment coverage, as set forth in this division, in the order 3,692
in which they apply for coverage and subject to the limitation 3,693
set forth in division (G) of this section. Insurers shall accept 3,694
for coverage pursuant to this section individuals to whom both of 3,697
the following conditions apply:
(1) The individual is not applying for coverage as an 3,699
employee of an employer, as a member of an association, or as a 3,700
member of any other group. 3,701
(2) The individual is not covered, and is not eligible for 3,703
coverage, under any other private or public health benefits 3,704
arrangement, including the medicare program established under 3,705
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 3,706
U.S.C.A. 301, as amended, or any other act of congress or law of 3,707
this or any other state of the United States that provides 3,708
benefits comparable to the benefits provided under this section, 3,709
any medicare supplement policy, or any continuation of coverage 3,711
policy under state or federal law.
(C) An insurer shall offer to any individual accepted 3,714
under this section the small employer health care plan BASIC AND 3,715
STANDARD PLANS established by the board of directors of the Ohio 3,717
80
health reinsurance program under division (A) of section 3924.10 3,719
of the Revised Code or a health benefit plan PLANS that is ARE 3,721
substantially similar to the small employer health care plan 3,722
BASIC AND STANDARD PLANS in benefit plan design and scope of 3,723
covered services.
An insurer may offer other health benefit plans in addition 3,725
to, but not in lieu of, the plan PLANS required to be offered 3,726
under this division. These additional A BASIC health benefit 3,728
plans PLAN shall provide, at a minimum, the coverage provided by 3,730
the small employer OHIO health care BASIC plan or any health 3,731
benefit plan that is substantially similar to the small employer 3,732
OHIO health care BASIC plan in benefit plan design and scope of 3,734
covered services. A STANDARD HEALTH BENEFIT PLAN SHALL PROVIDE, 3,735
AT A MINIMUM, THE COVERAGE PROVIDED BY THE OHIO HEALTH CARE 3,736
STANDARD PLAN OR ANY HEALTH BENEFIT PLAN THAT IS SUBSTANTIALLY 3,737
SIMILAR TO THE OHIO HEALTH CARE STANDARD PLAN IN BENEFIT PLAN 3,738
DESIGN AND SCOPE OF COVERED SERVICES.
For purposes of this division, the superintendent of 3,740
insurance shall determine whether a health benefit plan is 3,741
substantially similar to the small employer OHIO health care 3,743
BASIC plan in benefit plan design and scope of covered services. 3,745
(D) Health benefit plans issued under this section may 3,747
establish pre-existing conditions provisions that exclude or 3,748
limit coverage for a period of up to twelve months following the 3,749
individual's effective date of coverage and that may relate only 3,750
to conditions during the six months immediately preceding the 3,751
effective date of coverage. 3,752
(E) Premiums charged to individuals under this section may 3,755
not exceed an amount that is two and one-half times the highest 3,756
rate charged any other individual to which the insurer is
currently accepting new business, and for which similar 3,757
copayments and deductibles are applied. 3,758
(F) In offering health benefit plans under this section, 3,760
an insurer may require the purchase of health benefit plans that 3,761
81
condition the reimbursement of health services upon the use of a 3,762
specific network of providers. 3,763
(G)(1) In no event shall an insurer be required to accept 3,765
annually under this section individuals who, in the aggregate, 3,766
would cause the insurer to have a total number of new insureds 3,769
that is more than one-half per cent of its total number of 3,770
insured individuals in this state per year, as contemplated by 3,771
section 3923.021 of the Revised Code, calculated as of the 3,772
immediately preceding thirty-first day of December and excluding 3,773
the insurer's medicare supplement policies and conversion or 3,774
continuation of coverage policies under state or federal law and 3,775
any policies described in division (M)(L) of this section. 3,776
(2) An officer of the insurer shall certify to the 3,778
department of insurance when it has met the enrollment limit set 3,779
forth in division (G)(1) of this section. Upon providing such 3,780
certification, the insurer shall be relieved of its open 3,781
enrollment requirement under this section for the remainder of 3,782
the calendar year. 3,783
(H) An insurer shall not be required to accept under this 3,785
section applicants who, at the time of enrollment, are confined 3,786
to a health care facility because of chronic illness, permanent 3,787
injury, or other infirmity that would cause economic impairment 3,788
to the insurer if the applicants were accepted, or to make the 3,789
effective date of benefits for individuals accepted under this 3,791
section earlier than ninety days after the date of acceptance. 3,792
(I) The requirements of this section do not apply to any 3,794
insurer that is currently in a state of supervision, insolvency, 3,795
or liquidation. If an insurer demonstrates to the satisfaction 3,796
of the superintendent that the requirements of this section would 3,798
place the insurer in a state of supervision, insolvency, or 3,799
liquidation, the superintendent may waive or modify the 3,800
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 3,802
a period of not more than one year. At the expiration of such 3,803
82
time, a new showing of need for a waiver or modification by the 3,804
insurer shall be made before a new waiver or modification is 3,805
issued or imposed.
(J) No hospital, health care facility, or health care 3,807
practitioner, and no person who employs any health care 3,808
practitioner, shall balance bill any individual or dependent of 3,809
an individual for any health care supplies or services provided 3,810
to the individual or dependent who is insured under a policy 3,812
issued under this section. The hospital, health care facility, 3,814
or health care practitioner, or any person that employs the 3,815
health care practitioner, shall accept payments made to it by the 3,816
insurer under the terms of the policy or contract insuring or 3,817
covering such individual as payment in full for such health care 3,818
supplies or services. 3,819
As used in this division, "hospital" has the same meaning 3,821
as in section 3727.01 of the Revised Code; "health care 3,822
practitioner" has the same meaning as in section 4769.01 of the 3,823
Revised Code; and "balance bill" means charging or collecting an 3,824
amount in excess of the amount reimbursable or payable under the 3,825
policy or health care service contract issued to an individual 3,826
under this section for such health care supply or service. 3,827
"Balance bill" does not include charging for or collecting 3,828
copayments or deductibles required by the policy or contract. 3,829
(K) An insurer shall pay an agent a commission in the 3,831
amount of five per cent of the premium charged for initial 3,832
placement or for otherwise securing the issuance of a policy or 3,833
contract issued to an individual under this section, and four per 3,835
cent of the premium charged for the renewal of such a policy or 3,836
contract. The superintendent may adopt, in accordance with 3,837
Chapter 119. of the Revised Code, such rules as are necessary to 3,838
enforce this division.
(L) Individuals accepted for coverage under this section 3,840
may be issued contracts and certificates subject to the 3,841
requirements of section 3923.12 of the Revised Code. The 3,842
83
coverage issued to such individuals is not subject to the 3,843
requirements of section 3923.021 of the Revised Code. 3,844
(M) This section does not apply to any policy that 3,846
provides coverage for specific diseases or accidents only, or to 3,848
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 3,850
than six months, or other policy that offers only supplemental 3,851
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 3,860
the Revised Code: 3,861
(A) "Actuarial certification" means a written statement 3,863
prepared by a member of the American academy of actuaries, or by 3,864
any other person acceptable to the superintendent of insurance, 3,865
that states that, based upon the person's examination, a carrier 3,866
offering health benefit plans to small employers is in compliance 3,867
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 3,868
certification" shall include a review of the appropriate records 3,869
of, and the actuarial assumptions and methods used by, the 3,870
carrier relative to establishing premium rates for the health 3,871
benefit plans. 3,872
(B) "Adjusted average market premium price" means the 3,874
average market premium price as determined by the board of 3,876
directors of the Ohio health reinsurance program either on the 3,877
basis of the arithmetic mean of all carriers' premium rates for 3,879
an SEHC OHC plan sold to groups with similar case characteristics 3,881
by all carriers selling SEHC OHC plans in the state, or on any 3,883
other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 3,885
plan that is issued by a carrier and that covers at least two but 3,886
no more than fifty employees of a small employer, the lowest 3,888
premium rate for a new or existing business prescribed by the 3,889
carrier for the same or similar coverage under a plan or 3,890
arrangement covering any small employer with similar case 3,891
characteristics.
84
(D) "Carrier" means any sickness and accident insurance 3,893
company or health insuring corporation authorized to issue health 3,896
benefit plans in this state or a MEWA. A sickness and accident 3,898
insurance company that owns or operates a health insuring 3,899
corporation, either as a separate corporation or as a line of 3,901
business, shall be considered as a separate carrier from that 3,902
health insuring corporation for purposes of sections 3924.01 to 3,904
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 3,906
employer, the geographic area in which the employees work; the 3,907
age and sex of the individual employees and their dependents; the 3,908
appropriate industry classification as determined by the carrier; 3,909
the number of employees and dependents; and such other objective 3,910
criteria as may be established by the carrier. "Case 3,911
characteristics" does not include claims experience, health 3,912
status, or duration of coverage from the date of issue. 3,913
(F) "Dependent" means the spouse or child of an eligible 3,915
employee, subject to applicable terms of the health benefits plan 3,916
covering the employee. 3,917
(G) "Eligible employee" means an employee who works a 3,919
normal work week of twenty-five or more hours. "Eligible 3,920
employee" does not include a temporary or substitute employee, or 3,922
a seasonal employee who works only part of the calendar year on 3,923
the basis of natural or suitable times or circumstances. 3,924
(H) "Health benefit plan" means any hospital or medical 3,926
expense policy or certificate or any health plan provided by a 3,928
carrier, that is delivered, issued for delivery, renewed, or used 3,930
in this state on or after the date occurring six months after 3,931
November 24, 1995. "Health benefit plan" does not include 3,933
policies covering only accident, credit, dental, disability 3,934
income, long-term care, hospital indemnity, medicare supplement, 3,935
specified disease, or vision care; coverage under a 3,936
one-time-limited-duration policy of no longer than six months; 3,938
coverage issued as a supplement to liability insurance; insurance 3,939
85
arising out of a workers' compensation or similar law; automobile 3,940
medical-payment insurance; or insurance under which benefits are 3,941
payable with or without regard to fault and which is statutorily 3,942
required to be contained in any liability insurance policy or 3,943
equivalent self-insurance.
(I) "Late enrollee" means an eligible employee or 3,945
dependent who enrolls in a small employer's health benefit plan 3,948
other than during the first period in which the employee or 3,949
dependent is eligible to enroll under the plan or during a 3,951
special enrollment period described in section 2701(f) of the 3,952
"Health Insurance Portability and Accountability Act of 1996," 3,957
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg, as 3,963
amended.
(J) "MEWA" means any "multiple employer welfare 3,965
arrangement" as defined in section 3 of the "Federal Employee 3,966
Retirement Income Security Act of 1974," 88 Stat. 832, 29 3,967
U.S.C.A. 1001, as amended, except for any arrangement which is 3,968
fully insured as defined in division (b)(6)(D) of section 514 of 3,969
that act. 3,970
(K) "Midpoint rate" means, for small employers with 3,972
similar case characteristics and plan designs and as determined 3,973
by the applicable carrier for a rating period, the arithmetic 3,974
average of the applicable base premium rate and the corresponding 3,975
highest premium rate. 3,976
(L) "Pre-existing conditions provision" means a policy 3,978
provision that excludes or limits coverage for charges or 3,980
expenses incurred during a specified period following the 3,981
insured's enrollment date as to a condition for which medical 3,983
advice, diagnosis, care, or treatment was recommended or received 3,984
during a specified period immediately preceding the enrollment 3,987
date. Genetic information shall not be treated as such a 3,988
condition in the absence of a diagnosis of the condition related 3,989
to such information. 3,990
For purposes of this division, "enrollment date" means, 3,992
86
with respect to an individual covered under a group health 3,993
benefit plan, the date of enrollment of the individual in the 3,994
plan or, if earlier, the first day of the waiting period for such 3,996
enrollment.
(M) "Service waiting period" means the period of time 3,998
after employment begins before an employee is eligible to be 3,999
covered for benefits under the terms of any applicable health 4,001
benefit plan offered by the small employer.
(N)(1) "Small employer" means, in connection with a group 4,005
health benefit plan and with respect to a calendar year and a
plan year, an employer who employed an average of at least two 4,006
but no more than fifty eligible employees on business days during 4,008
the preceding calendar year and who employs at least two 4,010
employees on the first day of the plan year.
(2) For purposes of division (N)(1) of this section, all 4,013
persons treated as a single employer under subsection (b), (c), 4,014
(m), or (o) of section 414 of the "Internal Revenue Code of 4,018
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be 4,022
considered one employer. In the case of an employer that was not 4,023
in existence throughout the preceding calendar year, the 4,024
determination of whether the employer is a small or large 4,025
employer shall be based on the average number of eligible 4,026
employees that it is reasonably expected the employer will employ 4,027
on business days in the current calendar year. Any reference in 4,028
division (N) of this section to an "employer" includes any 4,030
predecessor of the employer. Except as otherwise specifically 4,031
provided, provisions of sections 3924.01 to 3924.14 of the 4,032
Revised Code that apply to a small employer that has a health 4,033
benefit plan shall continue to apply until the plan anniversary 4,034
following the date the employer no longer meets the requirements 4,035
of this division.
(O) "SEHC OHC plan" means an Ohio small employer health 4,039
care plan, which is a health benefit THE BASIC, STANDARD, OR 4,040
CARRIER REIMBURSEMENT plan for small individuals and employers 4,042
87
AND INDIVIDUALS established by the board in accordance with 4,043
section 3924.10 of the Revised Code. 4,044
Sec. 3924.03. Except as otherwise provided in section 2721 4,053
of the "Health Insurance Portability and Accountability Act of 4,059
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 4,065
as amended, health benefit plans covering small employers are 4,066
subject to the following conditions, as applicable:
(A)(1) Pre-existing conditions provisions shall not 4,068
exclude or limit coverage for a period beyond twelve months, or 4,069
eighteen months in the case of a late enrollee, following the 4,070
individual's enrollment date and may only relate to a physical or 4,073
mental condition, regardless of the cause of the condition, for 4,075
which medical advice, diagnosis, care, or treatment was 4,076
recommended or received within the six months immediately
preceding the enrollment date. 4,078
Division (A)(1) of this section is subject to the 4,081
exceptions set forth in section 2701(d) of the "Health Insurance 4,084
Portability and Accountability Act of 1996." 4,087
(2) The period of any such pre-existing condition 4,089
exclusion shall be reduced by the aggregate of the periods of 4,090
creditable coverage, if any, applicable to the employee or 4,091
dependent as of the enrollment date. 4,092
(3) A period of creditable coverage shall not be counted, 4,095
with respect to enrollment of an individual under a group health 4,096
benefit plan, if, after that period and before the enrollment 4,097
date, there was a sixty-three-day period during all of which the 4,098
individual was not covered under any creditable coverage. 4,099
Subsections (c)(2) to (4) and (e) of section 2701 of the "Health 4,101
Insurance Portability and Accountability Act of 1996" apply with 4,105
respect to crediting previous coverage. 4,106
(4) As used in division (A) of this section: 4,109
(a) "Creditable coverage" has the same meaning as in 4,112
section 2701(c)(1) of the "Health Insurance Portability and 4,115
Accountability Act of 1996." 4,117
88
(b) "Enrollment date" means, with respect to an individual 4,120
covered under a group health benefit plan, the date of enrollment 4,121
of the individual in the plan or, if earlier, the first day of 4,122
the waiting period for such enrollment.
(B)(1) Except as provided in section 2712(b) to (e) of the 4,125
"Health Insurance Portability and Accountability Act of 1996," if 4,126
a carrier offers coverage in the small employer market in 4,127
connection with a group health benefit plan, the carrier shall 4,128
renew or continue in force such coverage at the option of the 4,129
plan sponsor of the plan. 4,130
(2) A carrier may cancel or decide not to renew the 4,132
coverage of any eligible employee or of a dependent of an 4,133
eligible employee if the employee or dependent, as applicable, 4,135
has performed an act or practice that constitutes fraud or made 4,136
an intentional misrepresentation of material fact under the terms 4,137
of the coverage and if the cancellation or nonrenewal is not
based, either directly or indirectly, on any health 4,138
status-related factor in relation to the employee or dependent. 4,139
As used in division (B)(2) of this section, "health 4,142
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 4,143
(C) A carrier shall not exclude any eligible employee or 4,145
dependent, who would otherwise be covered under a health benefit 4,146
plan, on the basis of any actual or expected health condition of 4,148
the employee or dependent.
If, prior to November 24, 1995, a carrier excluded an 4,152
eligible employee or dependent, other than a late enrollee, on 4,153
the basis of an actual or expected health condition, the carrier 4,154
shall, upon the initial renewal of the coverage on or after that 4,155
date, extend coverage to the employee or dependent if all other 4,156
eligibility requirements are met.
(D) No health benefit plan issued by a carrier shall limit 4,159
or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 4,161
89
medical condition, or accident, except for pre-existing 4,162
conditions as permitted under division (A) of this section. If a 4,163
health benefit plan that is delivered or issued for delivery 4,165
prior to April 14, 1993, contains such limitations or exclusions, 4,167
by use of a rider or amendment applicable to a specific 4,168
individual, the plan shall eliminate the use of such riders or 4,169
amendments within eighteen months after April 14, 1993. 4,170
(E)(1) Except as provided in sections 3924.031 and 4,173
3924.032 of the Revised Code, and subject to such rules as may be 4,176
adopted by the superintendent of insurance in accordance with
Chapter 119. of the Revised Code, a carrier shall offer and make 4,178
available every health benefit plan that it is actively marketing 4,179
to every small employer that applies to the carrier for such 4,180
coverage.
Division (E)(1) of this section does not apply to a health 4,183
benefit plan that a carrier makes available in the small employer 4,184
market only through one or more bona fide associations. 4,185
Division (E)(1) of this section shall not be construed to 4,188
preclude a carrier from establishing employer contribution rules 4,189
or group participation rules for the offering of coverage in 4,190
connection with a group health benefit plan in the small employer 4,191
market, as allowed under the law of this state. As used in 4,192
division (E)(1) of this section, "employer contribution rule" 4,194
means a requirement relating to the minimum level or amount of 4,195
employer contribution toward the premium for enrollment of 4,196
employees and dependents and "group participation rule" means a 4,197
requirement relating to the minimum number of employees or 4,198
dependents that must be enrolled in relation to a specified 4,199
percentage or number of eligible individuals or employees of an 4,200
employer.
(2) Each health benefit plan, at the time of initial group 4,202
enrollment, shall make coverage available to all the eligible 4,203
employees of a small employer without a service waiting period. 4,204
The decision of whether to impose a service waiting period shall 4,206
90
be made by the small employer. Such waiting periods shall not be 4,207
greater than ninety days. 4,208
(3) Each health benefit plan shall provide for the special 4,211
enrollment periods described in section 2701(f) of the "Health 4,213
Insurance Portability and Accountability Act of 1996." 4,217
(4) A CARRIER MAY DELAY COVERAGE OF A LATE ENROLLEE FOR UP 4,220
TO TWELVE MONTHS AFTER THE DATE THE APPLICATION IS RECEIVED.
HOWEVER, ANY PRE-EXISTING CONDITION PROVISION THAT IMPOSES AN 4,222
EXCLUSIONARY PERIOD ON SUCH A LATE ENROLLEE SHALL RUN 4,223
CONCURRENTLY WITH THE DELAY IN COVERAGE. 4,224
(F) The benefit structure of any health benefit plan may, 4,227
at the time of coverage renewal, be changed by the carrier to 4,229
make it consistent with the benefit structure contained in health 4,230
benefit plans being marketed to new small employer groups. If 4,231
the health benefit plan is available in the small employer market 4,233
other than only through one or more bona fide associations, the 4,234
modification must be consistent with the law of this state and 4,235
effective on a uniform basis among small employer group plans. 4,236
(G) A carrier may obtain any facts and information 4,238
necessary to apply this section, or supply those facts and 4,239
information to any other third-party payer, without the consent 4,240
of the beneficiary. Each person claiming benefits under a health 4,241
benefit plan shall provide any facts and information necessary to 4,242
apply this section. 4,243
For purposes of this section, "bona fide association" means 4,246
an association that has been actively in existence for at least 4,247
five years; has been formed and maintained in good faith for 4,248
purposes other than obtaining insurance; does not condition 4,249
membership in the association on any health status-related 4,250
factor, as defined in section 3924.031 of the Revised Code, 4,252
relating to an individual, including an employee or dependent; 4,253
makes health insurance coverage offered through the association 4,254
available to all members regardless of any health status-related 4,255
factor, as defined in section 3924.031 of the Revised Code, 4,258
91
relating to such members or to individuals eligible for coverage 4,259
through a member; does not make health insurance coverage offered 4,260
through the association available other than in connection with a 4,261
member of the association; and meets any other requirement 4,262
imposed by the superintendent. To maintain its status as a "bona 4,263
fide association," each association shall annually certify to the 4,264
superintendent that it meets the requirements of this paragraph. 4,265
Sec. 3924.08. (A) The board of directors of the Ohio 4,274
health reinsurance program shall consist of nine appointed 4,276
members who shall serve staggered terms as determined by the 4,277
initial board for its members and by the plan of operation of the 4,278
program for members of subsequent boards. Within thirty days 4,279
after April 14, 1993, the members of the board shall be
appointed, as follows: 4,280
(1) The chairperson of the senate committee having 4,282
jurisdiction over insurance shall appoint the following members: 4,283
(a) Two member carriers that are small employer carriers; 4,285
(b) One member carrier that is a health insuring 4,287
corporation predominantly in the small employer market; 4,288
(c) One representative of providers of health care. 4,290
(2) The chairperson of the committee in the house of 4,292
representatives having jurisdiction over insurance shall appoint 4,293
the following members: 4,294
(a) One member carrier that is a small employer carrier; 4,296
(b) One member carrier whose principal health insurance 4,298
business is in the large employer market; 4,299
(c) One representative of an employer with fifty or fewer 4,301
employees; 4,302
(d) One representative of consumers in this state. 4,304
(3) The superintendent of insurance shall appoint a 4,306
representative of a member carrier operating in the small 4,308
employer market who is a fellow of the society of actuaries. 4,309
The superintendent, a member of the house of 4,311
representatives appointed by the speaker of the house of 4,312
92
representatives, and a member of the senate appointed by the 4,313
president of the senate, shall be ex-officio members of the 4,314
board. The membership of all boards subsequent to the initial 4,315
board shall reflect the distribution described in division (A) of 4,317
this section.
The chairperson of the initial board and each subsequent 4,319
board shall represent a small employer member carrier and shall 4,320
be elected by a majority of the voting members of the board. 4,321
Each chairperson shall serve for the maximum duration established 4,322
in the plan of operation. 4,323
(B) Within one hundred eighty days after the appointment 4,325
of the initial board, the board shall establish a plan of 4,326
operation and, thereafter, any amendments to the plan that are 4,327
necessary or suitable, to assure the fair, reasonable, and 4,328
equitable administration of the program. The board shall, 4,329
immediately upon adoption, provide to the superintendent copies 4,330
of the plan of operation and all subsequent amendments to it. 4,331
(C) The plan of operation shall establish rules, 4,333
conditions, and procedures for all of the following: 4,334
(1) The handling and accounting of assets and moneys of 4,336
the program and for an annual fiscal reporting to the 4,337
superintendent; 4,338
(2) Filling vacancies on the board; 4,340
(3) Selecting an administering insurer, which shall be a 4,342
carrier as defined in section 3924.01 of the Revised Code, and 4,343
setting forth the powers and duties of the administering insurer; 4,344
(4) Reinsuring risks in accordance with sections 3924.07 4,346
to 3924.14 of the Revised Code; 4,347
(5) Collecting assessments subject to section 3924.13 of 4,349
the Revised Code from all members to provide for claims reinsured 4,350
by the program and for administrative expenses incurred or 4,351
estimated to be incurred during the period for which the 4,352
assessment is made; 4,353
(6) Providing protection for carriers from the financial 4,355
93
risk associated with small employers that present poor credit 4,356
risks; 4,357
(7) Establishing standards for the coverage of small 4,359
employers that have a high turnover of employees; 4,360
(8) Establishing an appeals process for carriers to seek 4,362
relief when a carrier has experienced an unfair share of 4,363
administrative and credit risks; 4,364
(9) Establishing the adjusted average market premium 4,366
prices for use by the SEHC OHC plan for individuals, for groups 4,368
of two to twenty-five employees, and for groups of twenty-six to 4,370
fifty employees that are offered in the state; 4,371
(10) Establishing participation standards at issue and 4,373
renewal for reinsured cases; 4,374
(11) Reinsuring risks and collecting assessments in 4,376
accordance with division (G) of section 3924.11 of the Revised 4,377
Code; 4,378
(12) Any additional matters as determined by the board. 4,380
Sec. 3924.09. The Ohio health reinsurance program shall 4,390
have the general powers and authority granted under the laws of 4,391
the state to insurance companies licensed to transact sickness 4,392
and accident insurance, except the power to issue insurance. The 4,393
board of directors of the program also shall have the specific 4,394
authority to do all of the following:
(A) Enter into contracts as are necessary or proper to 4,396
carry out the provisions and purposes of sections 3924.07 to 4,397
3924.14 of the Revised Code, including the authority to enter 4,398
into contracts with similar programs of other states for the 4,399
joint performance of common functions, or with persons or other 4,400
organizations for the performance of administrative functions; 4,401
(B) Sue or be sued, including taking any legal actions 4,403
necessary or proper for recovery of any assessments for, on 4,404
behalf of, or against any program or board member; 4,405
(C) Take such legal action as is necessary to avoid the 4,407
payment of improper claims against the program; 4,408
94
(D) Design the SEHC OHC plan which, when offered by a 4,411
carrier, is eligible for reinsurance and issue reinsurance 4,412
policies in accordance with the requirements of sections 3924.07 4,413
to 3924.14 of the Revised Code; 4,414
(E) Establish rules, conditions, and procedures pertaining 4,416
to the reinsurance of members' risks by the program; 4,417
(F) Establish appropriate rates, rate schedules, rate 4,419
adjustments, rate classifications, and any other actuarial 4,420
functions appropriate to the operation of the program; 4,421
(G) Assess members in accordance with division (G) of 4,424
section 3924.11 and the provisions of section 3924.13 of the 4,425
Revised Code, and make such advance interim assessments as may be 4,426
reasonable and necessary for organizational and interim operating 4,427
expenses. Any interim assessments shall be credited as offsets 4,428
against any regular assessments due following the close of the 4,429
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 4,431
other committees if necessary to provide technical assistance 4,432
with respect to the operation of the program, policy and other 4,433
contract design, and any other function within the authority of 4,434
the program; 4,435
(I) Borrow money to effect the purposes of the program. 4,437
Any notes or other evidence of indebtedness of the program not in 4,438
default shall be legal investments for carriers and may be 4,439
carried as admitted assets. 4,440
(J) Reinsure risks, collect assessments, and otherwise 4,442
carry out its duties under division (G) of section 3924.11 of the 4,443
Revised Code; 4,444
(K) Study the operation of the Ohio health reinsurance 4,446
program and the open enrollment reinsurance program and, based on 4,448
its findings, make legislative recommendations to the general 4,449
assembly for improvements in the effectiveness, operation, and 4,450
integrity of the programs;
(L) Design a basic and standard plan for purposes of 4,452
95
sections 1751.16, 3923.122, and 3923.581 of the Revised Code. 4,453
Sec. 3924.10. (A) The board of directors of the Ohio 4,462
health reinsurance program shall design the SEHC plan OHC BASIC, 4,464
STANDARD, AND CARRIER REIMBURSEMENT PLANS which, when offered by 4,465
a carrier, is ARE eligible for reinsurance under the program. 4,466
The board shall establish the form and level of coverage to be 4,467
made available by carriers in their SEHC plan OHC PLANS. In 4,468
designing the plan PLANS the board shall also establish benefit 4,471
levels, deductibles, coinsurance factors, exclusions, and 4,472
limitations for the plan PLANS. The forms and levels of coverage 4,474
established by the board shall specify which components of a 4,475
health benefit plan PLANS offered by a carrier may be reinsured. 4,476
The SEHC plan is OHC PLANS ARE subject to division (C) of section 4,478
3924.02 of the Revised Code and to the provisions in Chapters 4,479
1751., 3923., and any other chapter of the Revised Code that 4,481
require coverage or the offer of coverage of a health care 4,482
service or benefit.
(B) The board shall adopt the SEHC plan OHC PLANS within 4,485
one hundred eighty days after its appointment THE EFFECTIVE DATE 4,486
OF THIS AMENDMENT. The plan PLANS may include cost containment 4,488
features including any of the following:
(1) Utilization review of health care services, including 4,490
review of the medical necessity of hospital and physician 4,491
services; 4,492
(2) Case management benefit alternatives; 4,494
(3) Selective contracting with hospitals, physicians, and 4,496
other health care providers; 4,497
(4) Reasonable benefit differentials applicable to 4,499
participating and nonparticipating providers; 4,500
(5) Employee assistance program options that provide 4,502
preventive and early intervention mental health and substance 4,503
abuse services; 4,504
(6) Other provisions for the cost-effective management of 4,506
the plan PLANS. 4,507
96
(C) An SEHC plan OHC PLANS established for use by health 4,511
insuring corporations shall be consistent with the basic method 4,514
of operation of such corporations.
(D) Each carrier shall certify to the superintendent of 4,516
insurance, in the form and manner prescribed by the 4,517
superintendent, that the SEHC plan OHC PLANS filed by the carrier 4,520
is ARE in substantial compliance with the provisions of the board 4,522
SEHC plan OHC PLANS. Upon receipt by the superintendent of the 4,524
certification, the carrier may use the certified plan PLANS. 4,525
(E) Each carrier shall, on and after sixty days after the 4,527
date that the program becomes operational and as a condition of 4,528
transacting business in this state, renew coverage provided to 4,529
any individual or group under its SEHC plan OHC PLANS. 4,531
(F) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 4,534
1998.
Sec. 3924.11. Any member of the Ohio health reinsurance 4,544
program may reinsure small employer groups or individuals in 4,545
accordance with the following conditions and limitations: 4,546
(A) With respect to eligible employees and their 4,548
dependents who are hired subsequent to the commencement of the 4,549
employer's coverage by a carrier and who are not late enrollees, 4,550
and with respect to employees of an employer who are otherwise 4,551
eligible for insurance but were excluded by the carrier's 4,552
underwriting and who are not late enrollees, coverage may be 4,553
reinsured in any of the following ways: 4,554
(1) Except in the case of late enrollees, within sixty 4,556
days after the commencement of their coverage under the plan; 4,557
(2) In the case of late enrollees who were not eligible to 4,560
enroll during a special enrollment period described in section 4,561
2701(f) of the "Health Insurance Portability and Accountability 4,563
Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 4,566
300gg-42, as amended, eighteen months after the date the late 4,568
enrollee becomes a member of the small employer's plan; 4,569
(3) In the case of late enrollees who were eligible to 4,571
97
enroll during a special enrollment period described in section 4,572
2701(f) of the "Health Insurance Portability and Accountability 4,574
Act of 1996," as amended, within sixty days after the 4,576
commencement of their coverage under the plan A SMALL EMPLOYER 4,578
GROUP OR INDIVIDUAL MAY BE REINSURED WITHIN SIXTY DAYS AFTER THE 4,579
COMMENCEMENT OF THE GROUP'S OR INDIVIDUAL'S COVERAGE UNDER THE 4,580
PLAN.
(B)(1) The carrier may reinsure either the entire eligible 4,583
group or any eligible individual, in accordance with the premium 4,585
rates established in section 3924.12 of the Revised Code, upon 4,587
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,590
dependents of an eligible employee, who were previously excluded 4,591
from group coverage for medical reasons, and shall reinsure such 4,592
employees or dependents within sixty days after the carrier is 4,593
required to include them in the group coverage.
(C) With respect to an SEHC OHC plan, the program shall 4,596
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,598
the program shall reinsure the level of coverage provided up to, 4,599
but not exceeding, the level of coverage provided in an SEHC OHC 4,601
CARRIER REIMBURSEMENT plan. In the coverage provided to small 4,602
employers, carriers shall be required to use high-cost care 4,603
management, hospital precertification techniques, and other cost 4,604
containment mechanisms established by the program. 4,605
(E) A carrier may not reinsure existing business, except 4,607
pursuant to division (A) of this section. 4,608
(F) If an employer group is covered under a plan other 4,610
than an SEHC OHC CARRIER REIMBURSEMENT plan and the carrier 4,612
chooses to reinsure the group subsequent to the initial coverage 4,613
period, or if a new individual joins the group and the carrier 4,614
wants to reinsure that individual, the carrier shall not force 4,615
the employer to change to an SEHC OHC CARRIER REIMBURSEMENT plan. 4,616
The carrier shall allow the employer to maintain the same benefit 4,618
98
plan and reinsure only that portion of the plan that is 4,619
consistent with an SEHC OHC CARRIER REIMBURSEMENT plan. 4,620
(G) With respect to coverage provided to an individual 4,622
acquired under section 3923.58 or a federally eligible individual 4,624
acquired under section 3923.581 of the Revised Code, the 4,625
following conditions and limitations apply: 4,626
(1) Within sixty days after the commencement of the 4,629
initial coverage, any carrier may reinsure coverage of such an 4,630
individual with the open enrollment reinsurance program in 4,632
accordance with division (G) of this section. Premium rates 4,633
charged for coverage reinsured by the program shall be 4,635
established in accordance with section 3924.12 of the Revised 4,636
Code.
(2) The board of directors of the Ohio health reinsurance 4,639
program shall establish the open enrollment reinsurance fund for 4,640
coverage provided under section 3923.58 of the Revised Code and, 4,641
with respect to federally eligible individuals, coverage provided 4,643
under section 3923.581 of the Revised Code. The fund shall be 4,644
maintained separately from any reinsurance fund established for 4,645
small employer OHIO health care plans issued pursuant to sections 4,646
3924.07 to 3924.14 of the Revised Code. The board shall 4,647
calculate, on a retrospective basis, the amount needed for 4,648
maintenance of the open enrollment reinsurance fund and, on the 4,649
basis of that calculation, shall determine the amount to be 4,650
assessed each carrier that is required to provide open enrollment 4,651
coverage. 4,652
Assessments shall be apportioned by the board among all 4,654
carriers participating in the open enrollment reinsurance program 4,655
in proportion to their respective shares of the total premiums, 4,656
net of reinsurance premiums paid by a carrier for open enrollment 4,657
coverage and net of reinsurance premiums paid by the carrier for 4,658
all other individual health benefit plans, earned in this state 4,660
from all health benefit plans covering individuals that are
issued by all such carriers during the calendar year coinciding 4,663
99
with or ending during the fiscal year of the open enrollment 4,664
program, or on any other equitable basis reflecting coverage of 4,665
individuals in this state as may be provided in the plan of 4,666
operation adopted by the board. In no event shall the assessment 4,667
of any carrier under this section exceed, on an annual basis, 4,669
three per cent of its Ohio premiums for health benefit plans 4,670
covering individuals as reported on its most recent annual 4,671
statement filed with the superintendent of insurance. 4,672
The board shall submit its determination of the amount of 4,674
the assessment to the superintendent for review of the accuracy 4,676
of the calculation of the assessment. Upon approval by the 4,677
superintendent, each carrier shall, within thirty days after 4,678
receipt of the notice of assessment, submit the assessment to the 4,679
board for purposes of the open enrollment reinsurance fund. 4,680
(3) If the assessments made and collected pursuant to 4,682
division (G)(2) of this section are not sufficient to pay the 4,683
claims reinsured under division (G) of this section and the 4,684
allocated administrative expenses, incurred or estimated to be 4,685
incurred during the period for which the assessment was made, the 4,686
secretary of the board shall immediately notify the 4,687
superintendent, and the superintendent shall suspend the 4,688
operation of open enrollment under section 3923.58 of the Revised 4,689
Code and, with respect to federally eligible individuals, under 4,690
section 3923.581 of the Revised Code until the board has 4,691
collected in subsequent years through assessments made pursuant 4,692
to division (G)(2) of this section an amount sufficient to pay 4,693
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,695
under section 3923.58 of the Revised Code may elect not to 4,697
participate in the open enrollment reinsurance program under 4,698
division (G) of this section by filing an application with the 4,699
superintendent and obtaining the superintendent's approval. In 4,700
determining whether to approve an application, the superintendent 4,701
shall consider whether the carrier meets all of the following 4,702
100
standards: 4,703
(i) Demonstration by the carrier of a substantial and 4,705
established market presence; 4,706
(ii) Demonstrated experience in the individual market and 4,709
history of rating and underwriting individual plans; 4,710
(iii) Commitment to comply with the requirements of 4,712
section 3923.58 of the Revised Code; 4,713
(iv) Financial ability to assume and manage the risk of 4,715
enrolling open enrollment individuals without the need for, or 4,717
protection of, reinsurance.
(b) A carrier whose application for nonparticipation has 4,719
been rejected by the superintendent may appeal the decision in 4,720
accordance with Chapter 119. of the Revised Code. A carrier that 4,721
has received approval of the superintendent not to participate in 4,722
the open enrollment reinsurance program shall, on or before the 4,723
first day of December, annually certify to the superintendent 4,724
that it continues to meet the standards described in division 4,725
(G)(4)(a) of this section. 4,726
(c) In any year subsequent to the year in which its 4,728
application not to participate has been approved, a carrier may 4,729
elect to participate in the open enrollment reinsurance program 4,730
by giving notice to the superintendent and board on or before the 4,731
thirty-first day of December. If, after a period of 4,732
nonparticipation, a carrier elects to participate in the open 4,733
enrollment reinsurance program, the carrier retains the risks it 4,734
assumed during the period when it was not participating. 4,735
(d) The superintendent may, at any time, authorize a 4,737
carrier to modify an election not to participate if the risk from 4,738
the carrier's open enrollment business jeopardizes the financial 4,739
condition of the carrier. If the superintendent authorizes the 4,740
carrier to again participate in the open enrollment reinsurance 4,741
program, the carrier shall retain the risks it assumed during the 4,742
period of nonparticipation. 4,743
(5)(a) The open enrollment reinsurance program shall be 4,746
101
operated separately from the Ohio health reinsurance program. 4,747
(b) A carrier's election to participate in the open 4,749
enrollment reinsurance program under division (G) of this section 4,751
shall not be construed as an election to participate in the Ohio 4,752
health reinsurance program under section 3924.07 of the Revised 4,753
Code.
Sec. 3999.22. (A) As used in this section: 4,762
(1) "Claim" means any attempt to cause a health care 4,764
insurer to make payment of a health care benefit. 4,765
(2) "Health care benefit" means the right under a contract 4,767
or a certificate or policy of insurance to have a payment made by 4,768
a health care insurer for a specified health care service. 4,769
(3) "Health care insurer" means any person that is 4,771
authorized to do the business of sickness and accident insurance; 4,772
any prepaid dental plan, medical care corporation, health care 4,773
corporation, dental care corporation, or health maintenance 4,774
organization; INSURING CORPORATION, and any legal entity that is 4,776
self-insured and provides health care benefits to its employees 4,777
or members.
(B) No person shall knowingly solicit, offer, pay, or 4,779
receive any kickback, bribe, or rebate, directly or indirectly, 4,780
overtly or covertly, in cash or in kind, in return for referring 4,781
an individual for the furnishing of health care services or goods 4,782
for which whole or partial reimbursement is or may be made by a 4,783
health care insurer, except as authorized by the health care or 4,784
health insurance contract, policy, or plan. This division does 4,785
not apply to any of the following: 4,786
(1) Deductibles, copayments, or similar amounts owed by 4,788
the person covered by the health care or health insurance 4,789
contract, policy, or plan; 4,790
(2) Discounts or similar reductions in prices; 4,792
(3) Any amount paid within a bona fide legal entity, or 4,794
within legal entities under common ownership or control, 4,795
including any amount paid to an employee in a bona fide 4,796
102
employment relationship; 4,797
(4) Any amount paid as part of a bona fide lease, 4,799
management, or other business contract. 4,800
(C) Nothing in this section shall be construed to apply to 4,802
any of the following: 4,803
(1) A provider who provides goods or services requested by 4,805
an individual that are not covered by the individual's health 4,806
care or health insurance contract, policy, or plan; 4,807
(2) A provider who, in good faith, provides goods or 4,809
services ordered by another health care provider; 4,810
(3) A provider who, in good faith, resubmits a claim 4,812
previously submitted that has not been paid or denied within 4,813
thirty days of the original submission, if the provider notifies 4,814
the payor or returns any duplicate payment within sixty days 4,815
after receipt of the duplicate payment; 4,816
(4) A provider who, in good faith, makes a diagnosis that 4,818
differs from the interpretation of a diagnosis reached by a 4,819
health care insurer in the payment of claims. 4,820
(D) Whoever violates this section is guilty of a felony of 4,822
the fifth degree on a first offense and a felony of the fourth 4,823
degree on each subsequent offense. 4,824
Sec. 5112.01. As used in sections 5112.02 to 5112.21 of 4,833
the Revised Code:
(A)(1) "Hospital" means a nonfederal hospital to which 4,835
either of the following applies: 4,836
(a) The hospital is registered under section 3701.07 of 4,838
the Revised Code as a general medical and surgical hospital or a 4,839
pediatric general hospital, and provides inpatient hospital 4,840
services, as defined in 42 C.F.R. 440.10; 4,841
(b) The hospital is recognized under the medicare program 4,843
established by Title XVIII of the "Social Security Act," 49 Stat. 4,845
620 (1935), 42 U.S.C.A. 301, as amended, as a cancer hospital and 4,847
is exempt from the medicare prospective payment system. 4,848
"Hospital" does not include a hospital operated by a health 4,850
103
maintenance organization INSURING CORPORATION that has been 4,851
issued a certificate of authority under section 1742.05 1751.05 4,853
of the Revised Code or a hospital that does not charge patients 4,855
for services.
(2) "Disproportionate share hospital" means a hospital 4,857
that meets the definition of a disproportionate share hospital in 4,858
rules adopted under section 5112.03 of the Revised Code. 4,859
(B) "Bad debt," "charity care," "courtesy care," and 4,861
"contractual allowances" have the same meanings given these terms 4,862
in regulations adopted under Title XVIII of the "Social Security 4,864
Act." 4,865
(C) "Cost reporting period" means the twelve-month period 4,867
used by a hospital in reporting costs for purposes of Title XVIII 4,869
of the "Social Security Act." 4,870
(D) "Governmental hospital" means a county hospital with 4,872
more than five hundred registered beds or a state-owned and 4,874
-operated hospital with more than five hundred registered beds. 4,875
(E) "Indigent care pool" means the sum of the following: 4,877
(1) The total of assessments to be paid in a program year 4,879
by all hospitals under section 5112.06 of the Revised Code, less 4,880
the assessments deposited into the legislative budget services 4,881
fund under section 5112.19 of the Revised Code; 4,883
(2) The total amount of intergovernmental transfers 4,885
required to be made in the same program year by governmental 4,886
hospitals under section 5112.07 of the Revised Code, less the 4,887
amount of transfers deposited into the legislative budget 4,889
services fund under section 5112.19 of the Revised Code; 4,890
(3) The total amount of federal matching funds that will 4,892
be made available in the same program year as a result of 4,893
payments the department of human services makes to hospitals 4,894
under section 5112.08 of the Revised Code. 4,895
(F) "Intergovernmental transfer" means any transfer of 4,897
money by a governmental hospital under section 5112.07 of the 4,898
Revised Code.
104
(G) "Medical assistance program" means the program of 4,900
medical assistance established under section 5111.01 of the 4,901
Revised Code and Title XIX of the "Social Security Act." 4,902
(H) "Program year" means a period beginning the first day 4,904
of October, or a later date designated in rules adopted under 4,905
section 5112.03 of the Revised Code, and ending the thirtieth day 4,906
of September, or an earlier date designated in rules adopted 4,907
under that section. 4,908
(I) "Registered beds" means the total number of hospital 4,910
beds registered with the department of health, as reported in the 4,911
most recent "directory of registered hospitals" published by the 4,912
department of health. 4,913
(J) "Total facility costs" means the total costs for all 4,915
services rendered to all patients, including the direct, 4,916
indirect, and overhead cost to the hospital of all services, 4,917
supplies, equipment, and capital related to the care of patients, 4,918
regardless of whether patients are enrolled in a health 4,919
maintenance organization INSURING CORPORATION, excluding costs 4,920
associated with providing skilled nursing services in 4,922
distinct-part nursing facility units, as shown on the hospital's 4,923
cost report filed under section 5112.04 of the Revised Code. 4,924
Effective October 1, 1993, if rules adopted under section 5112.03 4,925
of the Revised Code so provide, "total facility costs" may 4,926
exclude costs associated with providing care to recipients of any 4,927
of the governmental programs listed in division (B) of that 4,928
section.
(K) "Uncompensated care" means bad debt and charity care. 4,930
Sec. 5112.08. The director of human services shall adopt 4,939
rules under section 5112.03 of the Revised Code establishing a 4,940
methodology to pay hospitals that is sufficient to expend all 4,941
money in the indigent care pool. Under the rules: 4,942
(A) The department of human services shall classify 4,944
similar hospitals into groups and allocate funds for distribution 4,945
within each group. 4,946
105
(B) The department shall establish a method of allocating 4,948
funds to each group of hospitals, taking into consideration the 4,949
relative amount of indigent care provided by each group. The 4,950
amount to be allocated to each group shall be based on any 4,951
combination of the following indicators of indigent care that the 4,952
director considers appropriate: 4,953
(1) Total costs, volume, or proportion of services to 4,955
recipients of the medical assistance program, including 4,956
recipients enrolled in health maintenance organizations INSURING 4,957
CORPORATIONS; 4,958
(2) Total costs, volume, or proportion of services to 4,960
low-income patients in addition to recipients of the medical 4,961
assistance program, which may include recipients of Title V of 4,963
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 4,965
as amended, general assistance established under Chapter 5113. of 4,966
the Revised Code, and disability assistance established under 4,967
Chapter 5115. of the Revised Code; 4,968
(3) The amount of uncompensated care provided by the 4,970
hospitals; 4,971
(4) Other factors that the director considers to be 4,973
appropriate indicators of indigent care. 4,974
(C) The department shall distribute funds to hospitals in 4,976
each group in a manner that first may provide for an additional 4,977
payment to individual hospitals that provide a high proportion of 4,978
indigent care in relation to the total care provided by the 4,979
hospital or in relation to other hospitals. The department shall 4,980
establish a formula to distribute the remainder of the funds 4,981
allocated to the group to all hospitals in the group. The 4,982
formula shall be consistent with section 1923 of the "Social 4,983
Security Act," 42 U.S.C.A. 1396r-4, as amended, and shall be 4,986
based on any combination of the indicators of indigent care 4,987
listed in division (B) of this section that the director 4,989
considers appropriate.
(D) The department shall make payments to each hospital in 4,991
106
installments not later than ten working days after the deadline 4,992
established in rules for each hospital to pay an installment on 4,993
its assessment under section 5112.06 of the Revised Code. In the 4,994
case of a governmental hospital that makes intergovernmental 4,995
transfers, the department shall pay an installment under this 4,996
section not later than ten working days after the earlier of that 4,997
deadline or the deadline established in rules for the 4,998
governmental hospital to pay an installment on its 4,999
intergovernmental transfer. If the amount in the hospital care 5,000
assurance program fund and the hospital care assurance match fund 5,001
created under section 5112.18 of the Revised Code is insufficient 5,002
to make the total payments for which hospitals are eligible to 5,003
receive in any period, the department shall reduce the amount of 5,004
each payment by the percentage by which the amount is 5,005
insufficient. The department shall pay hospitals any amounts not 5,006
paid in the period in which they are due as soon as moneys are 5,007
available in the funds. 5,008
Section 2. That existing sections 1739.01, 1751.01, 5,010
1751.02, 1751.03, 1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 5,011
1751.15, 1751.16, 1751.20, 1751.31, 1751.46, 1751.55, 1751.58, 5,012
1751.59, 1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 5,013
3923.122, 3923.571, 3923.58, 3924.01, 3924.03, 3924.08, 3924.09, 5,015
3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 of the Revised 5,016
Code are hereby repealed. 5,017
Section 3. That sections 1751.02, 1751.03, 1751.13, and 5,019
3924.10 of the Revised Code, as amended by Am. Sub. H.B. 361 of 5,020
the 122nd General Assembly, be amended to read as follows: 5,021
Sec. 1751.02. (A) Notwithstanding any law in this state 5,030
to the contrary, any corporation, as defined in section 1751.01 5,032
of the Revised Code, may apply to the superintendent of insurance 5,034
for a certificate of authority to establish and operate a health 5,035
insuring corporation. If the corporation applying for a 5,036
certificate of authority is a foreign corporation domiciled in a 5,037
state without laws similar to those of this chapter, the 5,039
107
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 5,040
chapter.
(B) No person shall establish, operate, or perform the 5,043
services of a health insuring corporation in this state without 5,045
obtaining a certificate of authority under this chapter. 5,046
(C) Except as provided by division (D) of this section, no 5,049
political subdivision or department, office, or institution of 5,050
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 5,051
this state, shall establish, operate, or perform the services of 5,052
a health insuring corporation. Nothing in this section shall be 5,055
construed to preclude a board of county commissioners, a county 5,056
board of mental retardation and developmental disabilities, an 5,057
alcohol and drug addiction services board, a board of alcohol, 5,058
drug addiction, and mental health services, or a community mental 5,059
health board, or a public entity formed by or on behalf of any of 5,060
these boards, from using managed care techniques in carrying out 5,061
the board's or public entity's duties pursuant to the 5,062
requirements of Chapters 307., 329., 340., and 5126. of the 5,064
Revised Code. However, no such board or public entity may 5,066
operate so as to compete in the private sector with health 5,067
insuring corporations holding certificates of authority under 5,068
this chapter.
(D) A corporation formed by or on behalf of a publicly 5,070
owned, operated, or funded hospital or health care facility may 5,071
apply to the superintendent for a certificate of authority under 5,073
division (A) of this section to establish and operate a health 5,074
insuring corporation.
(E) A health insuring corporation shall operate in this 5,077
state in compliance with this chapter and Chapter 1753. of the 5,078
Revised Code, and with sections 3702.51 to 3702.62 of the Revised 5,080
Code, and shall operate in conformity with its filings with the 5,082
superintendent under this chapter, including filings made 5,083
108
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 5,084
the Revised Code. 5,086
(F) An insurer licensed under Title XXXIX of the Revised 5,090
Code need not obtain a certificate of authority as a health 5,091
insuring corporation to offer an open panel plan as long as the 5,092
providers and health care facilities participating in the open 5,093
panel plan receive their compensation directly from the insurer. 5,094
If the providers and health care facilities participating in the 5,095
open panel plan receive their compensation from any person other 5,096
than the insurer, or if the insurer offers a closed panel plan, 5,097
the insurer must obtain a certificate of authority as a health 5,098
insuring corporation.
(G) An intermediary organization need not obtain a 5,101
certificate of authority as a health insuring corporation, 5,102
regardless of the method of reimbursement to the intermediary 5,103
organization, as long as a health insuring corporation or a 5,105
self-insured employer maintains the ultimate responsibility to 5,106
assure delivery of all health care services required by the
contract between the health insuring corporation and the 5,107
subscriber and the laws of this state or between the self-insured 5,108
employer and its employees. 5,109
Nothing in this section shall be construed to require any 5,111
health care facility, provider, health delivery network, or 5,112
intermediary organization that contracts with a health insuring 5,113
corporation or self-insured employer, regardless of the method of 5,115
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 5,116
certificate of authority as a health insuring corporation under 5,117
this chapter, unless otherwise provided, in the case of contracts 5,119
with a self-insured employer, by operation of the "Employee 5,120
Retirement Income Security Act of 1974," 88 Stat. 829, 29 5,125
U.S.C.A. 1001, as amended. 5,127
(H) Any health delivery network doing business in this 5,130
state, INCLUDING ANY HEALTH DELIVERY NETWORK THAT IS FUNCTIONING 5,131
109
AS AN INTERMEDIARY ORGANIZATION DOING BUSINESS IN THIS STATE, 5,133
that is not required to obtain a certificate of authority under 5,134
this chapter shall certify to the superintendent annually, not 5,135
later than the first day of July, and shall provide a statement 5,137
signed by the highest ranking official which includes the 5,138
following information:
(1) The health delivery network's full name and the 5,140
address of its principal place of business; 5,141
(2) A statement that the health delivery network is not 5,143
required to obtain a certificate of authority under this chapter 5,144
to conduct its business. 5,145
(I) The superintendent shall not issue a certificate of 5,148
authority to a health insuring corporation that is a provider 5,149
sponsored organization unless all health care plans to be offered 5,150
by the health insuring corporation provide basic health care 5,151
services. Substantially all of the physicians and hospitals with 5,152
ownership or control of the provider sponsored organization, as 5,153
defined in division (W)(X) of section 1751.01 of the Revised 5,155
Code, shall also be participating providers for the provision of 5,157
basic health care services for health care plans offered by the 5,158
provider sponsored organization. If a health insuring 5,159
corporation that is a provider sponsored organization offers 5,160
health care plans that do not provide basic health care services, 5,161
the health insuring corporation shall be deemed, for purposes of 5,162
section 1751.35 of the Revised Code, to have failed to 5,163
substantially comply with this chapter. 5,164
Except as specifically provided in this division and in 5,166
division (C) of section 1751.28 of the Revised Code, the 5,168
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 5,169
same manner that these provisions apply to all health insuring 5,170
corporations that are not provider sponsored organizations. 5,171
(J) Nothing in this section shall be construed to apply to 5,173
any multiple employer welfare arrangement operating pursuant to 5,174
110
Chapter 1739. of the Revised Code. 5,175
(K) Any person who violates division (B) of this section, 5,179
and any health delivery network that fails to comply with 5,180
division (H) of this section, is subject to the penalties set 5,181
forth in section 1751.45 of the Revised Code. 5,183
Sec. 1751.03. (A) Each application for a certificate of 5,193
authority under this chapter shall be verified by an officer or 5,194
authorized representative of the applicant, shall be in a format 5,195
prescribed by the superintendent of insurance, and shall set 5,196
forth or be accompanied by the following: 5,197
(1) A certified copy of the applicant's articles of 5,199
incorporation and all amendments to the articles of 5,200
incorporation; 5,201
(2) A copy of any regulations adopted for the government 5,203
of the corporation, any bylaws, and any similar documents, and a 5,204
copy of all amendments to these regulations, bylaws, and 5,205
documents. The corporate secretary shall certify that these 5,206
regulations, bylaws, documents, and amendments have been properly 5,208
adopted or approved.
(3) A list of the names, addresses, and official positions 5,211
of the persons responsible for the conduct of the applicant, 5,212
including all members of the board, the principal officers, and 5,213
the person responsible for completing or filing financial 5,214
statements with the department of insurance, accompanied by a 5,215
completed original biographical affidavit and release of 5,216
information for each of these persons on forms acceptable to the 5,217
department;
(4) A full and complete disclosure of the extent and 5,219
nature of any contractual or other financial arrangement between 5,220
the applicant and any provider or a person listed in division 5,221
(A)(3) of this section, including, but not limited to, a full and 5,223
complete disclosure of the financial interest held by any such 5,224
provider or person in any health care facility, provider, or 5,225
insurer that has entered into a financial relationship with the 5,226
111
health insuring corporation; 5,227
(5) A description of the applicant, its facilities, and 5,229
its personnel, including, but not limited to, the location, hours 5,231
of operation, and telephone numbers of all contracted facilities; 5,232
(6) The applicant's projected annual enrollee population 5,234
over a three-year period; 5,235
(7) A clear and specific description of the health care 5,237
plan or plans to be used by the applicant, including a 5,238
description of the proposed providers, procedures for accessing 5,239
care, and the form of all proposed and existing contracts 5,240
relating to the administration, delivery, or financing of health 5,241
care services; 5,242
(8) A copy of each type of evidence of coverage and 5,244
identification card or similar document to be issued to 5,245
subscribers; 5,246
(9) A copy of each type of individual or group policy, 5,248
contract, or agreement to be used; 5,249
(10) The schedule of the proposed contractual periodic 5,251
prepayments or premium rates, or both, accompanied by appropriate 5,252
supporting data; 5,253
(11) A financial plan which provides a three-year 5,255
projection of operating results, including the projected 5,256
expenses, income, and sources of working capital; 5,257
(12) The enrollee complaint procedure to be utilized as 5,259
required under section 1751.19 of the Revised Code; 5,262
(13) A description of the procedures and programs to be 5,264
implemented on an ongoing basis to assure the quality of health 5,265
care services delivered to enrollees, including, if applicable, a 5,266
description of a quality assurance program complying with the 5,268
requirements of sections 1751.73 to 1751.75 of the Revised Code;
(14) A statement describing the geographic area or areas 5,270
to be served, by county; 5,271
(15) A copy of all solicitation documents; 5,273
(16) A balance sheet and other financial statements 5,275
112
showing the applicant's assets, liabilities, income, and other 5,276
sources of financial support; 5,277
(17) A description of the nature and extent of any 5,279
reinsurance program to be implemented, and a demonstration that 5,280
errors and omission insurance and, if appropriate, fidelity 5,281
insurance, will be in place upon the applicant's receipt of a 5,282
certificate of authority; 5,283
(18) Copies of all proposed or in force related-party or 5,285
intercompany agreements with an explanation of the financial 5,286
impact of these agreements on the applicant. If the applicant 5,287
intends to enter into a contract for managerial or administrative 5,289
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 5,290
description of the person to provide these services. The 5,292
description shall include that person's experience in managing or 5,293
administering health care plans, a copy of that person's most 5,294
recent audited financial statement, and a completed biographical 5,295
affidavit on a form acceptable to the superintendent for each of 5,296
that person's principal officers and board members and for any 5,297
additional employee to be directly involved in providing 5,298
managerial or administrative services to the health insuring 5,299
corporation. If the person to provide managerial or 5,300
administrative services is affiliated with the health insuring 5,301
corporation, the contract must provide for payment for services 5,302
based on actual costs.
(19) A statement from the applicant's board that the 5,304
admitted assets of the applicant have not been and will not be 5,305
pledged or hypothecated; 5,306
(20) A statement from the applicant's board that the 5,308
applicant will submit monthly financial statements during the 5,309
first year of operations; 5,310
(21) The name and address of the applicant's Ohio 5,313
statutory agent for service of process, notice, or demand; 5,314
(22) Copies of all documents the applicant filed with the 5,316
113
secretary of state; 5,317
(23) The location of those books and records of the 5,319
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL 5,320
BE MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, 5,321
AND WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF 5,323
DOMICILE OR IN OHIO IF THE APPLICANT IS A FOREIGN CORPORATION; 5,325
(24) The applicant's federal identification number, 5,327
corporate address, and mailing address; 5,328
(25) An internal and external organizational chart; 5,331
(26) A list of the assets representing the initial net 5,333
worth of the applicant; 5,334
(27) If the applicant has a parent company, the parent 5,336
company's guaranty, on a form acceptable to the superintendent, 5,337
that the applicant will maintain Ohio's minimum net worth. If no 5,340
parent company exists, a statement regarding the availability of 5,341
future funds if needed.
(28) The names and addresses of the applicant's actuary 5,343
and external auditors; 5,344
(29) If the applicant is a foreign corporation, a copy of 5,346
the most recent financial statements filed with the insurance 5,347
regulatory agency in the applicant's state of domicile; 5,348
(30) If the applicant is a foreign corporation, a 5,350
statement from the insurance regulatory agency of the applicant's 5,351
state of domicile stating that the regulatory agency has no 5,352
objection to the applicant applying for an Ohio license and that 5,353
the applicant is in good standing in the applicant's state of 5,354
domicile; 5,355
(31) Any other information that the superintendent may 5,357
require. 5,358
(B)(1) A health insuring corporation, unless otherwise 5,361
provided for in this chapter OR IN SECTION 3901.321 OF THE 5,363
REVISED CODE, shall file a timely notice with the superintendent 5,365
describing any change to the corporation's articles of 5,366
incorporation or regulations, or any major modification to its 5,367
114
operations as set out in the information required by division (A) 5,369
of this section that affects any of the following: 5,370
(a) The solvency of the health insuring corporation; 5,373
(b) The health insuring corporation's continued provision 5,376
of services that it has contracted to provide; 5,377
(c) The manner in which the health insuring corporation 5,380
conducts its business.
(2) If the change or modification is to be the result of 5,382
an action to be taken by the health insuring corporation, the 5,383
notice shall be filed with the superintendent prior to the health 5,384
insuring corporation taking the action. The action shall be 5,386
deemed approved if the superintendent does not disapprove it 5,387
within sixty days of filing. 5,388
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION (B)(1) OR 5,391
(2) OF THIS SECTION SHALL ALSO SERVE AS THE SUBMISSION OF A 5,392
NOTICE WHEN REQUIRED FOR THE SUPERINTENDENT'S REVIEW FOR PURPOSES 5,393
OF SECTION 3901.341 OF THE REVISED CODE, IF THE NOTICE CONTAINS 5,395
ALL OF THE INFORMATION THAT SECTION 3901.341 OF THE REVISED CODE 5,399
REQUIRES FOR SUCH SUBMISSIONS AND A COPY OF ANY WRITTEN 5,400
AGREEMENT. THE FILING OF SUCH A NOTICE, FOR THE PURPOSE OF 5,401
SATISFYING THIS DIVISION AND SECTION 3901.341 OF THE REVISED 5,404
CODE, SHALL BE SUBJECT TO THE SIXTY-DAY REVIEW PERIOD OF DIVISION 5,405
(B)(2) OF THIS SECTION. 5,406
(C)(1) No health insuring corporation shall expand its 5,409
approved service area until a copy of the request for expansion, 5,410
accompanied by documentation of the network of providers, FORMS 5,412
OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS RELATING TO THE 5,413
DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF PROPOSED 5,414
CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR GROUP 5,415
CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING DATA, enrollment 5,416
projections, plan of operation, and any other changes have been 5,417
filed with the superintendent. 5,418
(2) Within ten calendar days after receipt of a complete 5,420
filing under division (C)(1) of this section, the superintendent 5,422
115
shall refer the appropriate jurisdictional issues to the director 5,423
of health pursuant to section 1751.04 of the Revised Code. 5,425
(3) Within seventy-five days after the superintendent's 5,427
receipt of a complete filing under division (C)(1) of this 5,429
section, the superintendent shall determine whether the plan for 5,430
expansion is lawful, fair, and reasonable. The superintendent 5,431
may not make a determination until the superintendent has 5,432
received the director's certification of compliance, which the 5,433
director shall furnish within forty-five days after referral 5,434
under division (C)(2) of this section. The director shall not 5,436
certify that the requirements of section 1751.04 of the Revised 5,437
Code are not met, unless the applicant has been given an 5,439
opportunity for a hearing as provided in division (D) of section 5,441
1751.04 of the Revised Code. The forty-five-day and 5,442
seventy-five-day review periods provided for in division (C)(3) 5,444
of this section shall cease to run as of the date on which the 5,445
notice of the applicant's right to request a hearing is mailed 5,446
and shall remain suspended until the director issues a final 5,447
certification. 5,448
(4) If the superintendent has not approved or disapproved 5,450
all or a portion of a service area expansion within the 5,451
seventy-five-day period provided for in division (C)(3) of this 5,453
section, the filing shall be deemed approved. 5,454
(5) Disapproval of all or a portion of the filing shall be 5,457
effected by written notice, which shall state the grounds for the 5,458
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 5,459
Sec. 1751.13. (A)(1)(a) A health insuring corporation 5,469
shall, either directly or indirectly, enter into contracts for 5,470
the provision of health care services with a sufficient number 5,471
and types of providers and health care facilities to ensure that 5,472
all covered health care services will be accessible to enrollees 5,473
from a contracted provider or health care facility. 5,474
(b) A health insuring corporation shall not refuse to 5,477
116
contract with a physician for the provision of health care
services or refuse to recognize a physician as a specialist on 5,478
the basis that the physician attended an educational program or a 5,480
residency program approved or certified by the American 5,481
Osteopathic Association. A health insuring corporation shall not 5,482
refuse to contract with a health care facility for the provision 5,483
of health care services on the basis that the health care 5,484
facility is certified or accredited by the American Osteopathic 5,486
Association or that the health care facility is an osteopathic 5,487
hospital as defined in section 3702.51 of the Revised Code. 5,490
(c) Nothing in division (A)(1)(b) of this section shall be 5,494
construed to require a health insuring corporation to make a 5,495
benefit payment under a closed panel plan to a physician or 5,496
health care facility with which the health insuring corporation 5,497
does not have a contract, provided that none of the bases set 5,498
forth in that division are used as a reason for failing to make a 5,499
benefit payment.
(2) When a health insuring corporation is unable to 5,501
provide a covered health care service from a contracted provider 5,502
or health care facility, the health insuring corporation must 5,503
provide that health care service from a noncontracted provider or 5,505
health care facility consistent with the terms of the enrollee's 5,506
policy, contract, certificate, or agreement. The health insuring 5,507
corporation shall either ensure that the health care service be 5,508
provided at no greater cost to the enrollee than if the enrollee 5,509
had obtained the health care service from a contracted provider 5,510
or health care facility, or make other arrangements acceptable to 5,511
the superintendent of insurance. 5,512
(3) Nothing in this section shall prohibit a health 5,514
insuring corporation from entering into contracts with 5,515
out-of-state providers or health care facilities that are 5,516
licensed, certified, accredited, or otherwise authorized in that 5,517
state. 5,518
(B)(1) A health insuring corporation shall, either 5,521
117
directly or indirectly, enter into contracts with all providers 5,522
and health care facilities through which health care services are 5,523
provided to its enrollees.
(2) A health insuring corporation, upon written request, 5,525
shall assist its contracted providers in finding stop-loss or 5,526
reinsurance carriers.
(C) A health insuring corporation shall file an annual 5,528
certificate with the superintendent certifying that all provider 5,529
contracts and contracts with health care facilities through which 5,530
health care services are being provided contain the following: 5,531
(1) A description of the method by which the provider or 5,533
health care facility will be notified of the specific health care 5,535
services for which the provider or health care facility will be 5,536
responsible, including any limitations or conditions on such 5,537
services;
(2) The specific hold harmless provision specifying 5,539
protection of enrollees set forth as follows: 5,540
"[Provider/Health Care Facility< agrees that in no event, 5,543
including but not limited to nonpayment by the health insuring 5,544
corporation, insolvency of the health insuring corporation, or 5,545
breach of this agreement, shall [Provide/Health Care Facility< 5,547
bill, charge, collect a deposit from, seek remuneration or 5,548
reimbursement from, or have any recourse against, a subscriber, 5,549
enrollee, person to whom health care services have been provided, 5,551
or person acting on behalf of the covered enrollee, for health 5,552
care services provided pursuant to this agreement. This does not 5,553
prohibit [Provider/Health Care Facility< from collecting 5,554
co-insurance, deductibles, or copayments as specifically provided 5,556
in the evidence of coverage, or fees for uncovered health care 5,557
services delivered on a fee-for-service basis to persons 5,558
referenced above, nor from any recourse against the health 5,559
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 5,561
facility to continue to provide covered health care services to 5,562
118
enrollees in the event of the health insuring corporation's 5,563
insolvency or discontinuance of operations. The provisions shall 5,565
require the provider or health care facility to continue to 5,566
provide covered health care services to enrollees as needed to 5,567
complete any medically necessary procedures commenced but 5,568
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A 5,569
MEDICALLY NECESSARY PROCEDURE SHALL INCLUDE THE RENDERING OF ALL 5,571
MEDICALLY NECESSARY FOLLOW-UP CARE FOR THAT PROCEDURE. If an 5,572
enrollee is receiving necessary inpatient care at a hospital, the 5,573
provisions may limit the required provision of covered health 5,574
care services relating to that inpatient care in accordance with 5,575
division (D)(3) of section 1751.11 of the Revised Code, and may 5,577
also limit such required provision of covered health care 5,578
services to the period ending thirty days after the health 5,579
insuring corporation's insolvency or discontinuance of 5,580
operations.
The provisions required by division (C)(3) of this section 5,583
shall not require any provider or health care facility to 5,584
continue to provide any covered health care service after the
occurrence of any of the following: 5,585
(a) The end of the thirty-day period following the entry 5,587
of a liquidation order under Chapter 3903. of the Revised Code; 5,589
(b) The end of the enrollee's period of coverage for a 5,591
contractual prepayment or premium; 5,592
(c) The enrollee obtains equivalent coverage with another 5,594
health insuring corporation or insurer, or the enrollee's 5,595
employer obtains such coverage for the enrollee; 5,596
(d) The enrollee or the enrollee's employer terminates 5,598
coverage under the contract; 5,599
(e) A liquidator effects a transfer of the health insuring 5,602
corporation's obligations under the contract under division 5,603
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 5,605
119
responsibilities of the health insuring corporation, and of the 5,606
contracted providers and health care facilities, with respect to 5,607
administrative policies and programs, including, but not limited 5,608
to, payments systems, utilization review, quality assurance, 5,609
assessment, and improvement programs, credentialing, 5,610
confidentiality requirements, and any applicable federal or state 5,611
programs; 5,612
(5) A provision regarding the availability and 5,614
confidentiality of those health records maintained by providers 5,615
and health care facilities to monitor and evaluate the quality of 5,617
care, to conduct evaluations and audits, and to determine on a 5,618
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 5,619
The provision shall include terms requiring the provider or 5,620
health care facility to make these health records available to 5,621
appropriate state and federal authorities involved in assessing 5,622
the quality of care or in investigating the grievances or 5,623
complaints of enrollees, and requiring the provider or health 5,624
care facility to comply with applicable state and federal laws 5,625
related to the confidentiality of medical or health records. 5,627
(6) A provision that states that contractual rights and 5,629
responsibilities may not be assigned or delegated by the provider 5,631
or health care facility without the prior written consent of the 5,632
health insuring corporation;
(7) A provision requiring the provider or health care 5,634
facility to maintain adequate professional liability and 5,635
malpractice insurance. The provision shall also require the 5,636
provider or health care facility to notify the health insuring 5,637
corporation not more than ten days after the provider's or health 5,639
care facility's receipt of notice of any reduction or
cancellation of such coverage. 5,640
(8) A provision requiring the provider or health care 5,642
facility to observe, protect, and promote the rights of enrollees 5,644
as patients;
120
(9) A provision requiring the provider or health care 5,646
facility to provide health care services without discrimination 5,647
on the basis of a patient's participation in the health care 5,648
plan, age, sex, ethnicity, religion, sexual preference, health 5,649
status, or disability, and without regard to the source of 5,650
payments made for health care services rendered to a patient. 5,651
This requirement shall not apply to circumstances when the 5,652
provider or health care facility appropriately does not render 5,653
services due to limitations arising from the provider's or health 5,655
care facility's lack of training, experience, or skill, or due to 5,656
licensing restrictions.
(10) A provision containing the specifics of any 5,658
obligation on the PRIMARY CARE provider or health care facility 5,659
to provide, or to arrange for the provision of, covered health 5,661
care services twenty-four hours per day, seven days per week; 5,662
(11) A provision setting forth procedures for the 5,664
resolution of disputes arising out of the contract; 5,665
(12) A provision stating that the hold harmless provision 5,667
required by division (C)(2) of this section shall survive the 5,669
termination of the contract with respect to services covered and 5,670
provided under the contract during the time the contract was in 5,671
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 5,672
(13) A provision requiring those terms that are used in 5,674
the contract and that are defined by this chapter, be used in the 5,676
contract in a manner consistent with those definitions. 5,677
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF 5,679
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 5,684
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 5,687
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 5,688
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 5,689
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 5,692
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 5,697
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 5,700
121
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 5,701
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 5,705
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 5,706
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, OR TO 5,707
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 5,708
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 5,709
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 5,710
(D)(1) No health insuring corporation contract with a 5,713
provider or health care facility shall contain any of the 5,714
following:
(a) A provision that directly or indirectly offers an 5,717
inducement to the provider or health care facility to reduce or 5,718
limit medically necessary health care services to a covered 5,719
enrollee;
(b) A provision that penalizes a provider or health care 5,722
facility that assists an enrollee to seek a reconsideration of 5,723
the health insuring corporation's decision to deny or limit 5,724
benefits to the enrollee; 5,725
(c) A provision that limits or otherwise restricts the 5,728
provider's or health care facility's ethical and legal
responsibility to fully advise enrollees about their medical 5,729
condition and about medically appropriate treatment options; 5,731
(d) A provision that penalizes a provider or health care 5,734
facility for principally advocating for medically necessary 5,735
health care services;
(e) A provision that penalizes a provider or health care 5,737
facility for providing information or testimony to a legislative 5,738
or regulatory body or agency. This shall not be construed to 5,739
prohibit a health insuring corporation from penalizing a provider 5,741
or health care facility that provides information or testimony 5,742
that is libelous or slanderous or that discloses trade secrets 5,743
which the provider or health care facility has no privilege or 5,744
permission to disclose.
(2) Nothing in this division shall be construed to 5,746
122
prohibit a health insuring corporation from doing either of the 5,747
following: 5,748
(a) Making a determination not to reimburse or pay for a 5,751
particular medical treatment or other health care service; 5,752
(b) Enforcing reasonable peer review or utilization review 5,755
protocols, or determining whether a particular provider or health 5,756
care facility has complied with these protocols. 5,757
(E) Any contract between a health insuring corporation and 5,760
an intermediary organization shall clearly specify that the 5,761
health insuring corporation must approve or disapprove the 5,762
participation of any provider or health care facility with which 5,763
the intermediary organization contracts. 5,764
(F) If an intermediary organization that is not a health 5,766
delivery network contracting solely with self-insured employers 5,767
subcontracts with a provider or health care facility, the 5,768
subcontract with the provider or health care facility shall do 5,769
all of the following:
(1) Contain the provisions required by divisions (C) and 5,772
(G) of this section, as made applicable to an intermediary 5,773
organization, without the inclusion of inducements or penalties 5,774
described in division (D) of this section; 5,775
(2) Acknowledge that the health insuring corporation is a 5,777
third-party beneficiary to the agreement; 5,778
(3) Acknowledge the health insuring corporation's role in 5,780
approving the participation of the provider or health care 5,781
facility, pursuant to division (E) of this section. 5,783
(G) Any provider contract or contract with a health care 5,786
facility shall clearly specify the health insuring corporation's 5,787
statutory responsibility to monitor and oversee the offering of 5,788
covered health care services to its enrollees. 5,789
(H)(1) A health insuring corporation shall maintain its 5,792
provider contracts and its contracts with health care facilities 5,793
at one or more of its places of business in this state, and shall 5,794
provide copies of these contracts to facilitate regulatory review 5,795
123
upon written notice by the superintendent of insurance. 5,796
(2) Any contract with an intermediary organization shall 5,798
include provisions requiring the intermediary organization to 5,799
provide the superintendent with regulatory access to all books, 5,800
records, financial information, and documents related to the 5,801
provision of health care services to subscribers and enrollees 5,802
under the contract. The contract shall require the intermediary 5,803
organization to maintain such books, records, financial 5,804
information, and documents at its principal place of business in 5,805
this state and to preserve them for at least three years in a 5,806
manner that facilitates regulatory review. 5,807
(I)(1) A health insuring corporation shall provide notice 5,809
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A 5,810
contract with FOR THE PROVISION OF HEALTH CARE SERVICES BETWEEN 5,812
THE HEALTH INSURING CORPORATION AND a primary care physician or 5,814
hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF 5,815
THE CONTRACT.
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 5,817
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE 5,818
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH 5,819
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE PRIMARY 5,821
CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF THE 5,822
SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE 5,823
PREVIOUS TWELVE MONTHS. 5,824
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 5,826
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR A 5,828
DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE 5,829
PREVIOUS TWELVE MONTHS. 5,830
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL 5,832
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A PRIMARY 5,834
CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE TERMINATION OF 5,835
THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION OF THE CONTRACT 5,836
124
TERMINATION IS MAILED TO A SUBSCRIBER AT THE SUBSCRIBER'S LAST 5,837
KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do not apply to 5,840
any health insuring corporation that, on June 4, 1997, holds a 5,841
certificate of authority or license to operate under Chapter 5,843
1740. of the Revised Code. 5,844
(K) Nothing in this section shall restrict the governing 5,846
body of a hospital from exercising the authority granted it 5,847
pursuant to section 3701.351 of the Revised Code. 5,848
Sec. 3924.10. (A) The board of directors of the Ohio 5,857
health reinsurance program shall design the SEHC plan OHC BASIC, 5,859
STANDARD, AND CARRIER REIMBURSEMENT PLANS which, when offered by 5,860
a carrier, is ARE eligible for reinsurance under the program. 5,862
The board shall establish the form and level of coverage to be 5,863
made available by carriers in their SEHC plan OHC PLANS. In 5,864
designing the plan PLANS the board shall also establish benefit 5,866
levels, deductibles, coinsurance factors, exclusions, and 5,867
limitations for the plan PLANS. The forms and levels of coverage 5,869
established by the board shall specify which components of a 5,870
health benefit plan PLANS offered by a carrier may be reinsured. 5,871
The SEHC plan is OHC PLANS ARE subject to division (C) of section 5,873
3924.02 of the Revised Code and to the provisions in Chapters 5,874
1751., 1753., 3923., and any other chapter of the Revised Code 5,876
that require coverage or the offer of coverage of a health care 5,877
service or benefit.
(B) The board shall adopt the SEHC plan OHC PLANS within 5,880
one hundred eighty days after its appointment THE EFFECTIVE DATE 5,881
OF THIS AMENDMENT. The plan PLANS may include cost containment 5,883
features including any of the following:
(1) Utilization review of health care services, including 5,885
review of the medical necessity of hospital and physician 5,886
services; 5,887
(2) Case management benefit alternatives; 5,889
(3) Selective contracting with hospitals, physicians, and 5,891
125
other health care providers; 5,892
(4) Reasonable benefit differentials applicable to 5,894
participating and nonparticipating providers; 5,895
(5) Employee assistance program options that provide 5,897
preventive and early intervention mental health and substance 5,898
abuse services; 5,899
(6) Other provisions for the cost-effective management of 5,901
the plan PLANS. 5,902
(C) An SEHC plan OHC PLANS established for use by health 5,906
insuring corporations shall be consistent with the basic method 5,909
of operation of such corporations.
(D) Each carrier shall certify to the superintendent of 5,911
insurance, in the form and manner prescribed by the 5,912
superintendent, that the SEHC plan OHC PLANS filed by the carrier 5,914
is ARE in substantial compliance with the provisions of the board 5,916
SEHC plan OHC PLANS. Upon receipt by the superintendent of the 5,918
certification, the carrier may use the certified plan PLANS. 5,919
(E) Each carrier shall, on and after sixty days after the 5,921
date that the program becomes operational and as a condition of 5,922
transacting business in this state, renew coverage provided to 5,923
any individual or group under its SEHC plan OHC PLANS. 5,925
Section 4. That all existing versions of sections 1751.02, 5,927
1751.03, 1751.13, and 3924.10 of the Revised Code are hereby 5,928
repealed. 5,929
Section 5. Sections 3 and 4 of this act shall take effect 5,931
October 1, 1998. 5,932
Section 6. That Section 3 of Am. Sub. S.B. 67 of the 122nd 5,934
General Assembly be amended to read as follows: 5,935
"Sec. 3. (A) The certificate of authority of every 5,937
prepaid dental plan organization, health care corporation, dental 5,938
care corporation, and health maintenance organization licensed to 5,940
operate under Chapter 1736., 1738., 1740., or 1742. of the 5,942
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 5,945
126
Chapter 1751. of the Revised Code. All assets and liabilities of 5,946
the prepaid dental plan organization, health care corporation, 5,947
dental care corporation, or health maintenance organization, 5,948
including all obligations under subscriber contracts delivered, 5,949
issued for delivery, or renewed prior to the effective date of 5,950
this section JUNE 4, 1997, shall be assumed by the successor 5,952
entity. Except as otherwise provided in division (B) of this 5,953
section, such entity shall, no later than January 1, 1998, comply 5,954
with Chapter 1751. of the Revised Code. 5,955
(B)(1) Each entity described in division (A) of this 5,957
section shall do both of the following: 5,958
(a) Comply with sections 1751.19 and 1751.26 of the 5,961
Revised Code no later than six months after the effective date of
this section JUNE 4, 1997. 5,963
(b) Comply with section 1751.28 of the Revised Code by 5,966
making annual deposits with the Superintendent of Insurance, no 5,967
later than the first day of January of each year, for up to three 5,968
years, beginning the first day of January immediately following 5,969
the effective date of this section INCREASING THE ENTITY'S NET 5,971
WORTH, ON THE FIRST DAY OF JANUARY IN EACH OF THE YEARS 1998, 5,972
1999, AND 2000, BY AN AMOUNT EQUAL TO AT LEAST ONE-THIRD OF ANY 5,974
DIFFERENCE BETWEEN THE ENTITY'S NET WORTH AS OF JUNE 4, 1997, AND 5,976
THE NET WORTH REQUIRED BY SECTION 1751.28 OF THE REVISED CODE. 5,977
EACH ENTITY SHALL ATTAIN THE NET WORTH REQUIRED BY SECTION 5,978
1751.28 OF THE REVISED CODE NO LATER THAN JANUARY 1, 2000. 5,980
(2) Every contract delivered, issued for delivery, or 5,982
renewed by an entity described in division (A) of this section 5,983
prior to the effective date of this section JUNE 4, 1997, shall 5,985
comply with section 1751.13 of the Revised Code no later than the 5,987
contract's first renewal date after the first day of January 5,988
immediately following the effective date of this section JUNE 4, 5,990
1997.
(3) Every contract delivered, issued for delivery, or 5,993
renewed by an entity described in division (A) of this section 5,994
127
prior to the effective date of this section JUNE 4, 1997, shall 5,995
comply with section 1751.31 of the Revised Code no later than 5,997
three months after the effective date of this section JUNE 4, 5,998
1997.
(4) An entity described in division (A) of this section 6,000
may comply with section 1751.27 of the Revised Code by making 6,001
annual deposits with the Superintendent of Insurance, not later 6,002
than the first day of January of each year, for up to three years 6,003
beginning the first day of January immediately following the 6,004
effective date of this section JUNE 4, 1997. An equal amount 6,006
shall be deposited each year until the total amount required 6,008
under section 1751.27 of the Revised Code has been deposited." 6,009
Section 7. That existing Section 3 of Am. Sub. S.B. 67 of 6,011
the 122nd General Assembly is hereby repealed. 6,012
Section 8. Section 3901.21 of the Revised Code is 6,014
presented in this act as a composite of the section as amended by 6,015
both Sub. H.B. 374 and Am. Sub. S.B. 70 of the 122nd General 6,016
Assembly, with the language of neither of the acts shown in 6,017
capital letters. Section 3924.08 of the Revised Code is
presented in this act as a composite of the section as amended by 6,019
both Sub. H.B. 374 and Am. Sub. S.B. 67 of the 122nd General 6,020
Assembly, with the new language of neither of the acts shown in 6,023
capital letters. This is in recognition of the principle stated 6,024
in division (B) of section 1.52 of the Revised Code that such 6,025
amendments are to be harmonized where not substantively 6,026
irreconcilable and constitutes a legislative finding that such is 6,027
the resulting version in effect prior to the effective date of 6,028
this act.