As Passed by the House 1
122nd General Assembly 4
Regular Session Am. H. B. No. 698 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-GARCIA 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, 1751.14, 1751.15, 1751.16, 1751.20, 14
1751.31, 1751.46, 1751.55, 1751.58, 1751.59, 15
1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 17
3923.021, 3923.122, 3923.57, 3923.571, 3923.58, 18
3924.01, 3924.03, 3924.033, 3924.08, 3924.09, 19
3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 20
and to enact sections 1751.141 and 1751.151, 23
and to repeal section 3924.05 of the Revised Code 24
and to amend Section 3 of Am. Sub. S.B. 67 of the 25
122nd General Assembly to conform provisions in 27
the Health Insuring Corporation Law and the
Sickness and Accident Insurance Law with the 28
Health Insurance Portability and Accountability 30
Act of 1996, to clarify other provisions in 32
these laws, to specify how health insuring
corporations are to bring their net worth into 33
compliance with the Health Insuring Corporation 34
Law, and to maintain the provisions of this act 36
on and after October 1, 1998, by amending the 38
versions of sections 1751.02, 1751.03, 1751.13,
and 3924.10 of the Revised Code that take effect 39
on that date. 40
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 42
Section 1. That sections 1739.01, 1751.01, 1751.02, 44
2
1751.03, 1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 1751.14, 45
1751.15, 1751.16, 1751.20, 1751.31, 1751.46, 1751.55, 1751.58, 46
1751.59, 1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 47
3923.122, 3923.57, 3923.571, 3923.58, 3924.01, 3924.03, 3924.033, 49
3924.08, 3924.09, 3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 50
be amended and sections 1751.141 and 1751.151 of the Revised Code 52
be enacted to read as follows:
Sec. 1739.01. As used in sections 1739.01 to 1739.22 of 61
the Revised Code: 62
(A) "Agreement" means a written agreement executed by 64
members of a multiple employer welfare arrangement that 65
establishes an arrangement, provides for its operation, and 66
through which each member agrees to assume and discharge all 67
liability under sections 1739.01 to 1739.22 of the Revised Code 68
relating to or arising out of the operation of the arrangement in 69
proportion to the ratio of the total number of covered employees 70
employed by the member at the time the liability arose to the 71
total number of covered employees employed by all members of the 72
arrangement at the time the liability arose. 73
(B) "Excess insurance" or "stop-loss insurance" means an 75
insurance policy purchased by a multiple employer welfare 76
arrangement under which it receives reimbursement for benefits it 77
pays in excess of a preset deductible or limit. 78
(C) "Fully-insured FULLY INSURED program" means a program 80
by which benefits are provided to members, employees of members, 82
or the dependents of such members or employees, through the 83
purchase of sickness and accident insurance from an insurance 84
company licensed to do business in this state or health services 85
purchased from a health maintenance organization INSURING 86
CORPORATION authorized to do business in this state. 88
(D) "Group self-insurance program" means a program by 90
which benefits are provided to members, employees of members, or 91
the dependents of such members or employees, other than through 92
sickness and accident insurance purchased from an insurance 93
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company licensed to do business in this state or health care 94
services purchased from a health maintenance organization 95
INSURING CORPORATION authorized to do business in this state. 96
(E) "Member" means an individual or an employer that is a 98
member of an organization sponsoring a multiple employer welfare 99
arrangement. 100
(F) "Multiple employer welfare arrangement" means an 102
employee welfare benefit plan, trust, or any other arrangement, 103
whether such plan, trust, or arrangement is subject to the 104
"Employee Retirement Income Security Act of 1974," 88 Stat. 829, 105
29 U.S.C.A. 1001, as amended, that is established or maintained 106
for the purpose of offering or providing, through group insurance 107
or group self-insurance programs, medical, surgical, or hospital 108
care or benefits, or benefits in the event of sickness, accident, 109
disability, or death, to the employees, and their dependents, of 110
two or more employers, or to two or more self-employed 111
individuals and their dependents. 112
(G) "Premium" means any type of consideration paid to a 114
multiple employer welfare arrangement by a member for coverage 115
under the arrangement. 116
(H) "Surplus" means the total assets of the multiple 118
employer welfare arrangement less its liabilities and reserves as 119
determined in accordance with the requirements of sections 120
1739.01 to 1739.21 of the Revised Code. 121
(I) "Third-party administrator" has the same meaning as 123
"administrator" in section 3959.01 of the Revised Code. 124
Sec. 1751.01. As used in this chapter: 133
(A) "Basic health care services" means the following 136
services when medically necessary: 137
(1) Physician's services, except when such services are 139
supplemental under division (B) of this section; 141
(2) Inpatient hospital services; 143
(3) Outpatient medical services; 145
(4) Emergency health services; 147
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(5) Urgent care services; 149
(6) Diagnostic laboratory services and diagnostic and 151
therapeutic radiologic services; 152
(7) Preventive health care services, including, but not 154
limited to, voluntary family planning services, infertility 155
services, periodic physical examinations, prenatal obstetrical 156
care, and well-child care. 157
"Basic health care services" does not include experimental 159
procedures. 160
A health insuring corporation shall not offer coverage for 162
a health care service, defined as a basic health care service by 163
this division, unless it offers coverage for all listed basic 164
health care services. However, this requirement does not apply 166
to the coverage of beneficiaries enrolled in Title XVIII of the 167
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 169
amended, pursuant to a medicare risk contract or medicare cost 170
contract, or to the coverage of beneficiaries enrolled in the 171
federal employee health benefits program pursuant to 5 U.S.C.A. 173
8905, or to the coverage of beneficiaries enrolled in Title XIX 174
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 176
301, as amended, known as the medical assistance program or 177
medicaid, provided by the Ohio department of human services under 178
Chapter 5111. of the Revised Code, or to the coverage of 180
beneficiaries under any federal health care program regulated by 181
a federal regulatory body, OR TO THE COVERAGE OF BENEFICIARIES 182
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE 183
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE 185
SERVICES.
(B) "Supplemental health care services" means any health 188
care services other than basic health care services that a health 189
insuring corporation may offer, alone or in combination with 190
either basic health care services or other supplemental health 191
care services, and includes:
(1) Services of facilities for intermediate or long-term 193
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care, or both; 194
(2) Dental care services; 196
(3) Vision care and optometric services including lenses 198
and frames; 199
(4) Podiatric care or foot care services; 201
(5) Mental health services including psychological 203
services; 204
(6) Short-term outpatient evaluative and 206
crisis-intervention mental health services; 207
(7) Medical or psychological treatment and referral 209
services for alcohol and drug abuse or addiction; 210
(8) Home health services; 212
(9) Prescription drug services; 214
(10) Nursing services; 216
(11) Services of a dietitian licensed under Chapter 4759. 219
of the Revised Code;
(12) Physical therapy services; 221
(13) Chiropractic services; 223
(14) Any other category of services approved by the 225
superintendent of insurance. 226
(C) "Specialty health care services" means one of the 228
supplemental health care services listed in division (B)(1) to 230
(13) of this section, when provided by a health insuring 231
corporation on an outpatient-only basis and not in combination 232
with other supplemental health care services.
(D) "Closed panel plan" means a health care plan that 234
requires enrollees to use participating providers. 235
(E) "Compensation" means remuneration for the provision of 238
health care services, determined on other than a fee-for-service 239
or discounted-fee-for-service basis.
(F) "Contractual periodic prepayment" means the formula 242
for determining the premium rate for all subscribers of a health 243
insuring corporation. 244
(G) "Corporation" means a corporation formed under Chapter 247
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1701. or 1702. of the Revised Code or the similar laws of another 249
state.
(H) "Emergency health services" means those health care 252
services that must be available on a seven-days-per-week, 253
twenty-four-hours-per-day basis in order to prevent jeopardy to 254
an enrollee's health status that would occur if such services 255
were not received as soon as possible, and includes, where 256
appropriate, provisions for transportation and indemnity payments 257
or service agreements for out-of-area coverage. 258
(I) "Enrollee" means any natural person who is entitled to 261
receive health care benefits provided by a health insuring 262
corporation.
(J) "Evidence of coverage" means any certificate, 265
agreement, policy, or contract issued to a subscriber that sets 266
out the coverage and other rights to which such person is 267
entitled under a health care plan. 268
(K) "Health care facility" means any facility, except a 271
health care practitioner's office, that provides preventive, 272
diagnostic, therapeutic, acute convalescent, rehabilitation, 273
mental health, mental retardation, intermediate care, or skilled 274
nursing services. 275
(L) "Health care services" means any BASIC, SUPPLEMENTAL, 278
AND SPECIALTY HEALTH CARE services involved in or incident to the 279
furnishing of preventive, diagnostic, therapeutic, or 280
rehabilitative care. 281
(M) "Health delivery network" means any group of providers 284
or health care facilities, or both, or any representative 285
thereof, that have entered into an agreement to offer health care 287
services in a panel rather than on an individual basis. 288
(N) "Health insuring corporation" means a corporation, as 291
defined in division (G) of this section, that, pursuant to a 292
policy, contract, certificate, or agreement, pays for, 293
reimburses, or provides, delivers, arranges for, or otherwise 294
makes available, basic health care services, supplemental health 295
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care services, or specialty health care services, or a 296
combination of basic health care services and either supplemental 297
health care services or specialty health care services, through 299
either an open panel plan or a closed panel plan. 300
"Health insuring corporation" does not include a limited 303
liability company formed pursuant to Chapter 1705. of the Revised 305
Code, AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED CODE 311
IF THAT INSURER OFFERS ONLY OPEN PANEL PLANS UNDER WHICH ALL 312
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING RECEIVE THEIR 313
COMPENSATION DIRECTLY FROM THE INSURER, a corporation formed by 314
or on behalf of a political subdivision or a department, office, 315
or institution of the state, or a public entity formed by or on 316
behalf of a board of county commissioners, a county board of 318
mental retardation and developmental disabilities, an alcohol and 320
drug addiction services board, a board of alcohol, drug 321
addiction, and mental health services, or a community mental 322
health board, as those terms are used in Chapters 340. and 5126. 323
of the Revised Code. Except as provided by division (D) of 326
section 1751.02 of the Revised Code, or as otherwise provided by 329
law, no board, commission, agency, or other entity under the 331
control of a political subdivision may accept insurance risk in 332
providing for health care services. However, nothing in this 333
division shall be construed as prohibiting such entities from 334
purchasing the services of a health insuring corporation or a 335
third-party administrator licensed under Chapter 3959. of the 336
Revised Code. 337
(O) "Intermediary organization" means a health delivery 340
network or other entity that contracts with licensed health 341
insuring corporations or self-insured employers, or both, to 342
provide health care services, and that enters into contractual 344
arrangements with other entities for the provision of health care 345
services for the purpose of fulfilling the terms of its contracts 346
with the health insuring corporations and self-insured employers. 347
(P) "Intermediate care" means residential care above the 350
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level of room and board for patients who require personal 351
assistance and health-related services, but who do not require 352
skilled nursing care.
(Q) "Medical record" means the personal information that 355
relates to an individual's physical or mental condition, medical 356
history, or medical treatment. 357
(R)(1) "Open panel plan" means a health care plan that 359
provides incentives for enrollees to use participating providers 360
and that also allows enrollees to use providers that are not 361
participating providers.
(2) No health insuring corporation may offer an open panel 364
plan, unless the health insuring corporation is also licensed as 365
an insurer under Title XXXIX of the Revised Code, the health 366
insuring corporation, on the effective date of this section JUNE 367
4, 1997, holds a certificate of authority or license to operate 369
under Chapter 1736. or 1740. of the Revised Code, or an insurer 370
licensed under Title XXXIX of the Revised Code is responsible for 372
the out-of-network risk as evidenced by both an evidence of
coverage filing under section 1751.11 of the Revised Code and a 374
policy and certificate filing under section 3923.02 of the 375
Revised Code. 376
(S) "PANEL" MEANS A GROUP OF PROVIDERS OR HEALTH CARE 378
FACILITIES THAT HAVE JOINED TOGETHER TO DELIVER HEALTH CARE 379
SERVICES THROUGH A CONTRACTUAL ARRANGEMENT WITH A HEALTH INSURING 381
CORPORATION, EMPLOYER GROUP, OR OTHER PAYOR.
(T) "Person" has the same meaning as in section 1.59 of 383
the Revised Code, and, unless the context otherwise requires, 384
includes any insurance company holding a certificate of authority 385
under Title XXXIX of the Revised Code, any subsidiary and 387
affiliate of an insurance company, and any government agency. 388
(T)(U) "Premium rate" means any set fee regularly paid by 391
a subscriber to a health insuring corporation. A "premium rate" 392
does not include a one-time membership fee, an annual
administrative fee, or a nominal access fee, paid to a managed 393
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health care system under which the recipient of health care 394
services remains solely responsible for any charges accessed for 395
those services by the provider or health care facility. 396
(U)(V) "Primary care provider" means a provider that is 399
designated by a health insuring corporation to supervise, 400
coordinate, or provide initial care or continuing care to an 401
enrollee, and that may be required by the health insuring 402
corporation to initiate a referral for specialty care and to 403
maintain supervision of the health care services rendered to the 404
enrollee.
(V)(W) "Provider" means any natural person or partnership 407
of natural persons who are licensed, certified, accredited, or 408
otherwise authorized in this state to furnish health care 409
services, or any professional association organized under Chapter 410
1785. of the Revised Code, provided that nothing in this chapter 412
or other provisions of law shall be construed to preclude a 413
health insuring corporation, health care practitioner, or 414
organized health care group associated with a health insuring 415
corporation from employing CERTIFIED nurse practitioners,
CERTIFIED NURSE ANESTHETISTS, CLINICAL NURSE SPECIALISTS, 416
CERTIFIED NURSE MIDWIVES, dietitians, physicians' assistants, 417
dental assistants, dental hygienists, optometric technicians, or 418
other allied health personnel who are licensed, certified, 419
accredited, or otherwise authorized in this state to furnish 420
health care services.
(W)(X) "Provider sponsored organization" means a 423
corporation, as defined in division (G) of this section, that is 424
at least eighty per cent owned or controlled by one or more 426
hospitals, as defined in section 3727.01 of the Revised Code, or 427
one or more physicians licensed to practice medicine or surgery 428
or osteopathic medicine and surgery under Chapter 4731. of the 429
Revised Code, or any combination of such physicians and 430
hospitals. Such control is presumed to exist if at least eighty 431
per cent of the voting rights or governance rights of a provider 432
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sponsored organization are directly or indirectly owned, 433
controlled, or otherwise held by any combination of the 434
physicians and hospitals described in this division. 435
(X)(Y) "Solicitation document" means the written materials 437
provided to prospective subscribers or enrollees, or both, and 439
used for advertising and marketing to induce enrollment in the 440
health care plans of a health insuring corporation. 441
(Y)(Z) "Subscriber" means a person who is responsible for 444
making payments to a health insuring corporation for 445
participation in a health care plan, or an enrollee whose 446
employment or other status is the basis of eligibility for 447
enrollment in a health insuring corporation.
(Z)(AA) "Urgent care services" means those health care 450
services that are appropriately provided for an unforeseen 451
condition of a kind that usually requires medical attention 452
without delay but that does not pose a threat to the life, limb, 453
or permanent health of the injured or ill person, and may include 455
such health care services provided out of the health insuring 456
corporation's approved service area pursuant to indemnity 457
payments or service agreements.
Sec. 1751.02. (A) Notwithstanding any law in this state 466
to the contrary, any corporation, as defined in section 1751.01 468
of the Revised Code, may apply to the superintendent of insurance 470
for a certificate of authority to establish and operate a health 471
insuring corporation. If the corporation applying for a 472
certificate of authority is a foreign corporation domiciled in a 473
state without laws similar to those of this chapter, the 475
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 476
chapter.
(B) No person shall establish, operate, or perform the 479
services of a health insuring corporation in this state without 481
obtaining a certificate of authority under this chapter. 482
(C) Except as provided by division (D) of this section, no 485
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political subdivision or department, office, or institution of 486
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 487
this state, shall establish, operate, or perform the services of 488
a health insuring corporation. Nothing in this section shall be 491
construed to preclude a board of county commissioners, a county 492
board of mental retardation and developmental disabilities, an 493
alcohol and drug addiction services board, a board of alcohol, 494
drug addiction, and mental health services, or a community mental 495
health board, or a public entity formed by or on behalf of any of 496
these boards, from using managed care techniques in carrying out 497
the board's or public entity's duties pursuant to the 498
requirements of Chapters 307., 329., 340., and 5126. of the 500
Revised Code. However, no such board or public entity may 502
operate so as to compete in the private sector with health 503
insuring corporations holding certificates of authority under 504
this chapter.
(D) A corporation formed by or on behalf of a publicly 506
owned, operated, or funded hospital or health care facility may 507
apply to the superintendent for a certificate of authority under 509
division (A) of this section to establish and operate a health 510
insuring corporation.
(E) A health insuring corporation shall operate in this 513
state in compliance with this chapter and with sections 3702.51 514
to 3702.62 of the Revised Code, and shall operate in conformity 517
with its filings with the superintendent under this chapter, 518
including filings made pursuant to sections 1751.03, 1751.11, 519
1751.12, and 1751.31 of the Revised Code. 521
(F) An insurer licensed under Title XXXIX of the Revised 525
Code need not obtain a certificate of authority as a health 526
insuring corporation to offer an open panel plan as long as the 527
providers and health care facilities participating in the open 528
panel plan receive their compensation directly from the insurer. 529
If the providers and health care facilities participating in the 530
12
open panel plan receive their compensation from any person other 531
than the insurer, or if the insurer offers a closed panel plan, 532
the insurer must obtain a certificate of authority as a health 533
insuring corporation.
(G) An intermediary organization need not obtain a 536
certificate of authority as a health insuring corporation, 537
regardless of the method of reimbursement to the intermediary 538
organization, as long as a health insuring corporation or a 540
self-insured employer maintains the ultimate responsibility to 541
assure delivery of all health care services required by the
contract between the health insuring corporation and the 542
subscriber and the laws of this state or between the self-insured 543
employer and its employees. 544
Nothing in this section shall be construed to require any 546
health care facility, provider, health delivery network, or 547
intermediary organization that contracts with a health insuring 548
corporation or self-insured employer, regardless of the method of 550
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 551
certificate of authority as a health insuring corporation under 552
this chapter, unless otherwise provided, in the case of contracts 554
with a self-insured employer, by operation of the "Employee 555
Retirement Income Security Act of 1974," 88 Stat. 829, 29 560
U.S.C.A. 1001, as amended. 562
(H) Any health delivery network doing business in this 565
state, INCLUDING ANY HEALTH DELIVERY NETWORK THAT IS FUNCTIONING 566
AS AN INTERMEDIARY ORGANIZATION DOING BUSINESS IN THIS STATE, 568
that is not required to obtain a certificate of authority under 569
this chapter shall certify to the superintendent annually, not 570
later than the first day of July, and shall provide a statement 572
signed by the highest ranking official which includes the 573
following information:
(1) The health delivery network's full name and the 575
address of its principal place of business; 576
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(2) A statement that the health delivery network is not 578
required to obtain a certificate of authority under this chapter 579
to conduct its business. 580
(I) The superintendent shall not issue a certificate of 583
authority to a health insuring corporation that is a provider 584
sponsored organization unless all health care plans to be offered 585
by the health insuring corporation provide basic health care 586
services. Substantially all of the physicians and hospitals with 587
ownership or control of the provider sponsored organization, as 588
defined in division (W)(X) of section 1751.01 of the Revised 590
Code, shall also be participating providers for the provision of 592
basic health care services for health care plans offered by the 593
provider sponsored organization. If a health insuring 594
corporation that is a provider sponsored organization offers 595
health care plans that do not provide basic health care services, 596
the health insuring corporation shall be deemed, for purposes of 597
section 1751.35 of the Revised Code, to have failed to 598
substantially comply with this chapter. 599
Except as specifically provided in this division and in 601
division (C) of section 1751.28 of the Revised Code, the 603
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 604
same manner that these provisions apply to all health insuring 605
corporations that are not provider sponsored organizations. 606
(J) Nothing in this section shall be construed to apply to 608
any multiple employer welfare arrangement operating pursuant to 609
Chapter 1739. of the Revised Code. 610
(K) Any person who violates division (B) of this section, 614
and any health delivery network that fails to comply with 615
division (H) of this section, is subject to the penalties set 616
forth in section 1751.45 of the Revised Code. 618
(L) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 621
1998.
Sec. 1751.03. (A) Each application for a certificate of 631
14
authority under this chapter shall be verified by an officer or 632
authorized representative of the applicant, shall be in a format 633
prescribed by the superintendent of insurance, and shall set 634
forth or be accompanied by the following: 635
(1) A certified copy of the applicant's articles of 637
incorporation and all amendments to the articles of 638
incorporation; 639
(2) A copy of any regulations adopted for the government 641
of the corporation, any bylaws, and any similar documents, and a 642
copy of all amendments to these regulations, bylaws, and 643
documents. The corporate secretary shall certify that these 644
regulations, bylaws, documents, and amendments have been properly 646
adopted or approved.
(3) A list of the names, addresses, and official positions 649
of the persons responsible for the conduct of the applicant, 650
including all members of the board, the principal officers, and 651
the person responsible for completing or filing financial 652
statements with the department of insurance, accompanied by a 653
completed original biographical affidavit and release of 654
information for each of these persons on forms acceptable to the 655
department;
(4) A full and complete disclosure of the extent and 657
nature of any contractual or other financial arrangement between 658
the applicant and any provider or a person listed in division 659
(A)(3) of this section, including, but not limited to, a full and 661
complete disclosure of the financial interest held by any such 662
provider or person in any health care facility, provider, or 663
insurer that has entered into a financial relationship with the 664
health insuring corporation; 665
(5) A description of the applicant, its facilities, and 667
its personnel, including, but not limited to, the location, hours 669
of operation, and telephone numbers of all contracted facilities; 670
(6) The applicant's projected annual enrollee population 672
over a three-year period; 673
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(7) A clear and specific description of the health care 675
plan or plans to be used by the applicant, including a 676
description of the proposed providers, procedures for accessing 677
care, and the form of all proposed and existing contracts 678
relating to the administration, delivery, or financing of health 679
care services; 680
(8) A copy of each type of evidence of coverage and 682
identification card or similar document to be issued to 683
subscribers; 684
(9) A copy of each type of individual or group policy, 686
contract, or agreement to be used; 687
(10) The schedule of the proposed contractual periodic 689
prepayments or premium rates, or both, accompanied by appropriate 690
supporting data; 691
(11) A financial plan which provides a three-year 693
projection of operating results, including the projected 694
expenses, income, and sources of working capital; 695
(12) The enrollee complaint procedure to be utilized as 697
required under section 1751.19 of the Revised Code; 700
(13) A description of the procedures and programs to be 702
implemented on an ongoing basis to assure the quality of health 703
care services delivered to enrollees; 704
(14) A statement describing the geographic area or areas 706
to be served, by county; 707
(15) A copy of all solicitation documents; 709
(16) A balance sheet and other financial statements 711
showing the applicant's assets, liabilities, income, and other 712
sources of financial support; 713
(17) A description of the nature and extent of any 715
reinsurance program to be implemented, and a demonstration that 716
errors and omission insurance and, if appropriate, fidelity 717
insurance, will be in place upon the applicant's receipt of a 718
certificate of authority; 719
(18) Copies of all proposed or in force related-party or 721
16
intercompany agreements with an explanation of the financial 722
impact of these agreements on the applicant. If the applicant 723
intends to enter into a contract for managerial or administrative 725
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 726
description of the person to provide these services. The 728
description shall include that person's experience in managing or 729
administering health care plans, a copy of that person's most 730
recent audited financial statement, and a completed biographical 731
affidavit on a form acceptable to the superintendent for each of 732
that person's principal officers and board members and for any 733
additional employee to be directly involved in providing 734
managerial or administrative services to the health insuring 735
corporation. If the person to provide managerial or 736
administrative services is affiliated with the health insuring 737
corporation, the contract must provide for payment for services 738
based on actual costs.
(19) A statement from the applicant's board that the 740
admitted assets of the applicant have not been and will not be 741
pledged or hypothecated; 742
(20) A statement from the applicant's board that the 744
applicant will submit monthly financial statements during the 745
first year of operations; 746
(21) The name and address of the applicant's Ohio 749
statutory agent for service of process, notice, or demand; 750
(22) Copies of all documents the applicant filed with the 752
secretary of state; 753
(23) The location of those books and records of the 755
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL 756
BE MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, 757
AND WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF 758
DOMICILE OR IN OHIO IF THE APPLICANT IS A FOREIGN CORPORATION; 759
(24) The applicant's federal identification number, 761
corporate address, and mailing address; 762
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(25) An internal and external organizational chart; 765
(26) A list of the assets representing the initial net 767
worth of the applicant; 768
(27) If the applicant has a parent company, the parent 770
company's guaranty, on a form acceptable to the superintendent, 771
that the applicant will maintain Ohio's minimum net worth. If no 774
parent company exists, a statement regarding the availability of 775
future funds if needed.
(28) The names and addresses of the applicant's actuary 777
and external auditors; 778
(29) If the applicant is a foreign corporation, a copy of 780
the most recent financial statements filed with the insurance 781
regulatory agency in the applicant's state of domicile; 782
(30) If the applicant is a foreign corporation, a 784
statement from the insurance regulatory agency of the applicant's 785
state of domicile stating that the regulatory agency has no 786
objection to the applicant applying for an Ohio license and that 787
the applicant is in good standing in the applicant's state of 788
domicile; 789
(31) Any other information that the superintendent may 791
require. 792
(B)(1) A health insuring corporation, unless otherwise 795
provided for in this chapter OR IN SECTION 3901.321 OF THE 796
REVISED CODE, shall file a timely notice with the superintendent 797
describing any change to the corporation's articles of 798
incorporation or regulations, or any major modification to its 799
operations as set out in the information required by division (A) 801
of this section that affects any of the following: 802
(a) The solvency of the health insuring corporation; 805
(b) The health insuring corporation's continued provision 808
of services that it has contracted to provide; 809
(c) The manner in which the health insuring corporation 812
conducts its business.
(2) If the change or modification is to be the result of 814
18
an action to be taken by the health insuring corporation, the 815
notice shall be filed with the superintendent prior to the health 816
insuring corporation taking the action. The action shall be 818
deemed approved if the superintendent does not disapprove it 819
within sixty days of filing. 820
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION (B)(1) OR 823
(2) OF THIS SECTION SHALL ALSO SERVE AS THE SUBMISSION OF A 824
NOTICE WHEN REQUIRED FOR THE SUPERINTENDENT'S REVIEW FOR PURPOSES 825
OF SECTION 3901.341 OF THE REVISED CODE, IF THE NOTICE CONTAINS 827
ALL OF THE INFORMATION THAT SECTION 3901.341 OF THE REVISED CODE 831
REQUIRES FOR SUCH SUBMISSIONS AND A COPY OF ANY WRITTEN 832
AGREEMENT. THE FILING OF SUCH A NOTICE, FOR THE PURPOSE OF 833
SATISFYING THIS DIVISION AND SECTION 3901.341 OF THE REVISED 836
CODE, SHALL BE SUBJECT TO THE SIXTY-DAY REVIEW PERIOD OF DIVISION 837
(B)(2) OF THIS SECTION. 838
(C)(1) No health insuring corporation shall expand its 841
approved service area until a copy of the request for expansion, 842
accompanied by documentation of the network of providers, FORMS 844
OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS RELATING TO THE 845
DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF PROPOSED 846
CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR GROUP 847
CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING DATA, enrollment 848
projections, plan of operation, and any other changes have been 849
filed with the superintendent. 850
(2) Within ten calendar days after receipt of a complete 852
filing under division (C)(1) of this section, the superintendent 854
shall refer the appropriate jurisdictional issues to the director 855
of health pursuant to section 1751.04 of the Revised Code. 857
(3) Within seventy-five days after the superintendent's 859
receipt of a complete filing under division (C)(1) of this 861
section, the superintendent shall determine whether the plan for 862
expansion is lawful, fair, and reasonable. The superintendent 863
may not make a determination until the superintendent has 864
received the director's certification of compliance, which the 865
19
director shall furnish within forty-five days after referral 866
under division (C)(2) of this section. The director shall not 868
certify that the requirements of section 1751.04 of the Revised 869
Code are not met, unless the applicant has been given an 871
opportunity for a hearing as provided in division (D) of section 873
1751.04 of the Revised Code. The forty-five-day and 874
seventy-five-day review periods provided for in division (C)(3) 876
of this section shall cease to run as of the date on which the 877
notice of the applicant's right to request a hearing is mailed 878
and shall remain suspended until the director issues a final 879
certification. 880
(4) If the superintendent has not approved or disapproved 882
all or a portion of a service area expansion within the 883
seventy-five-day period provided for in division (C)(3) of this 885
section, the filing shall be deemed approved. 886
(5) Disapproval of all or a portion of the filing shall be 889
effected by written notice, which shall state the grounds for the 890
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 891
(D) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 894
1998.
Sec. 1751.05. (A) The superintendent of insurance shall 904
issue or deny a certificate of authority to establish or operate 905
a health insuring corporation to any corporation filing an 906
application pursuant to section 1751.03 of the Revised Code 908
within forty-five days of the superintendent's receipt of the 909
certification from the director of health under division (C) of 910
section 1751.04 of the Revised Code. A certificate of authority 911
shall be issued upon payment of the application fee prescribed in 912
section 1751.44 of the Revised Code if the superintendent is 913
satisfied that the following conditions are met: 914
(1) The persons responsible for the conduct of the affairs 917
of the applicant are competent, trustworthy, and possess good 918
reputations.
20
(2) The director certifies, in accordance with division 920
(C) of section 1751.04 of the Revised Code, that the 921
organization's proposed plan of operation meets the requirements 922
of division (B) of that section and sections 3702.51 to 3702.62 924
of the Revised Code. If, after the director has certified 925
compliance, the application is amended in a manner that affects 926
its approval under section 1751.04 of the Revised Code, the 927
superintendent shall request the director to review and recertify 928
the amended plan of operation. Within forty-five days of receipt 929
of the amended plan from the superintendent, the director shall 930
certify to the superintendent, pursuant to section 1751.04 of the 931
Revised Code, whether or not the amended plan meets the 933
requirements of section 1751.04 of the Revised Code. The 934
superintendent's forty-five-day review period shall cease to run 935
as of the date on which the amended plan is transmitted to the 936
director and shall remain suspended until the superintendent 937
receives a new certification from the director.
(3) The applicant constitutes an appropriate mechanism to 939
effectively provide or arrange for the provision of the basic 940
health care services, supplemental health care services, or 941
specialty health care services to be provided to enrollees. 942
(4) The applicant is financially responsible, complies 944
with section 1751.28 of the Revised Code, and may reasonably be 946
expected to meet its obligations to enrollees and prospective 947
enrollees. In making this determination, the superintendent may 948
consider: 949
(a) The financial soundness of the applicant's 951
arrangements for health care services, including the applicant's 952
proposed contractual periodic prepayments or premiums and the use 953
of copayments or deductibles; 954
(b) The adequacy of working capital; 956
(c) Any agreement with an insurer, a government, or any 959
other person for insuring the payment of the cost of health care 960
services or providing for automatic applicability of an 961
21
alternative coverage in the event of discontinuance of the health 962
insuring corporation's operations; 963
(d) Any agreement with providers or health care facilities 965
for the provision of health care services; 966
(e) Any deposit of securities submitted in accordance with 969
section 1751.27 of the Revised Code as a guarantee that the 970
obligations will be performed. 971
(5) The applicant has submitted documentation of an 973
arrangement to provide health care services to its enrollees 974
until the expiration of the enrollees' contracts with the 975
applicant if a health care plan or the operations of the health 976
insuring corporation are discontinued prior to the expiration of 977
the enrollees' contracts. An arrangement to provide health care 978
services may be made by using any one, or any combination, of the 980
following methods:
(a) The maintenance of insolvency insurance; 982
(b) A provision in contracts with providers and health 985
care facilities, but no health insuring corporation shall rely 986
solely on such a provision for more than thirty days; 987
(c) An agreement with other health insuring corporations 990
or insurers, providing enrollees with automatic conversion rights 991
upon the discontinuation of a health care plan or the health 992
insuring corporation's operations; 993
(d) Such other methods as approved by the superintendent. 995
(6) Nothing in the applicant's proposed method of 997
operation, as shown by the information submitted pursuant to 998
section 1751.03 of the Revised Code or by independent 1,000
investigation, will cause harm to an enrollee or to the public at 1,002
large, as determined by the superintendent.
(7) Any deficiencies certified by the director have been 1,004
corrected. 1,005
(8) The applicant has deposited securities as set forth in 1,008
section 1751.27 of the Revised Code.
(B) If an applicant elects to fulfill the requirements of 1,011
22
division (A)(5) of this section through an agreement with other 1,013
health insuring corporations or insurers, the agreement shall 1,014
require those health insuring corporations or insurers to give 1,015
thirty days' notice to the superintendent prior to cancellation 1,016
or discontinuation of the agreement for any reason. 1,017
(C) A certificate of authority shall be denied only after 1,020
compliance with the requirements of section 1751.36 of the 1,021
Revised Code.
Sec. 1751.06. Upon obtaining a certificate of authority as 1,030
required under this chapter, a health insuring corporation may do 1,032
all of the following:
(A) Enroll individuals and their dependents in either of 1,034
the following circumstances: 1,035
(1) The individual resides or lives in the approved 1,037
service area.
(2) The individual's place of employment is located in the 1,040
approved service area.
(B) Contract with providers and health care facilities for 1,042
the health care services to which enrollees are entitled under 1,043
the terms of the health insuring corporation's health care 1,044
contracts;
(C) Contract with insurance companies authorized to do 1,047
business in this state for insurance, indemnity, or reimbursement 1,048
against the cost of providing emergency and nonemergency health 1,049
care services for enrollees, subject to the provisions set forth 1,050
in this chapter and the limitations set forth in the Revised 1,052
Code;
(D) Contract with any person pursuant to the requirements 1,054
of division (A)(18) of section 1751.03 of the Revised Code for 1,055
managerial or administrative services, or for data processing, 1,056
actuarial analysis, billing services, or any other services 1,057
authorized by the superintendent of insurance. However, a health 1,059
insuring corporation shall not enter into a contract for any of 1,060
the services listed in this division with an insurance company 1,061
23
that is not authorized to engage in the business of insurance in 1,062
this state.
(E) Accept from governmental agencies, private agencies, 1,064
corporations, associations, groups, individuals, or other 1,065
persons, payments covering all or part of the costs of planning, 1,066
development, construction, and the provision of health care 1,067
services;
(F) Purchase, lease, construct, renovate, operate, or 1,069
maintain health care facilities, and their ancillary equipment, 1,070
and any property necessary in the transaction of the business of 1,071
the health insuring corporation;
(G) In the employer group market, impose an affiliation 1,074
period of not more than sixty days, OR FOR LATE ENROLLEES AN
AFFILIATION PERIOD OF NOT MORE THAN NINETY DAYS, which period 1,075
begins on the individual's date of enrollment and runs 1,076
concurrently with any waiting period imposed under the coverage. 1,077
For purposes of this division, "affiliation period" means a 1,078
period of time which, under the terms of the coverage offered, 1,079
must expire before the coverage becomes effective. No health 1,080
care services or benefits need to be provided during an 1,081
affiliation period, and no periodic prepayments can be charged 1,082
for any coverage during that period. 1,083
(H) If a health insuring corporation offers coverage in 1,086
the small employer group market through a network plan, limit or 1,087
deny the coverage in accordance with section 3924.031 of the 1,088
Revised Code; 1,090
(I) Refuse to issue coverage in the small employer group 1,093
market pursuant to section 3924.032 of the Revised Code; 1,095
(J) Establish employer contribution rules or group 1,098
participation rules for the offering of coverage in connection 1,099
with a group contract in the small employer group market, as 1,100
provided in division (E)(1) of section 3924.03 of the Revised 1,102
Code. 1,103
Nothing in this section shall be construed as prohibiting a 1,105
24
health insuring corporation without other commercial enrollment 1,106
from contracting solely with federal health care programs 1,107
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 1,109
authority of a health insuring corporation to perform those 1,110
functions not otherwise prohibited by law. 1,111
Sec. 1751.11. (A) Every subscriber of a health insuring 1,121
corporation is entitled to an evidence of coverage for the health 1,122
care plan under which health care benefits are provided. 1,124
(B) Every subscriber of a health insuring corporation that 1,126
offers basic health care services is entitled to an 1,127
identification card or similar document that specifies the health 1,128
insuring corporation's name as stated in its articles of 1,129
incorporation, and any trade or fictitious names used by the 1,130
health insuring corporation. The identification card or document 1,131
shall list at least one telephone number that provides the 1,132
subscriber with access to health care on a 1,133
twenty-four-hour-per-day TWENTY-FOUR-HOURS-PER-DAY,
seven-day-per-week SEVEN-DAYS-PER-WEEK basis. 1,134
(C) No evidence of coverage, or amendment to the evidence 1,136
of coverage, shall be delivered, issued for delivery, renewed, or 1,137
used, until the form of the evidence of coverage or amendment has 1,138
been filed by the health insuring corporation with the 1,139
superintendent of insurance. If the superintendent does not 1,140
disapprove the evidence of coverage or amendment within sixty 1,141
days after it is filed it shall be deemed approved, unless the 1,142
superintendent sooner gives approval for the evidence of coverage 1,143
or amendment. With respect to an amendment to an approved 1,144
evidence of coverage, the superintendent only may disapprove 1,145
provisions amended or added to the evidence of coverage. If the 1,146
superintendent determines within the sixty-day period that any 1,147
evidence of coverage or amendment fails to meet the requirements 1,148
of this section, the superintendent shall so notify the health 1,149
insuring corporation and it shall be unlawful for the health 1,150
25
insuring corporation to use such evidence of coverage or 1,151
amendment. At any time, the superintendent, upon at least thirty 1,153
days' written notice to a health insuring corporation, may 1,154
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 1,155
section. Such disapproval shall be effected by a written order, 1,156
which shall state the grounds for disapproval and shall be issued 1,158
in accordance with Chapter 119. of the Revised Code. 1,160
(D) No evidence of coverage or amendment shall be 1,162
delivered, issued for delivery, renewed, or used: 1,163
(1) If it contains provisions or statements that are 1,165
inequitable, untrue, misleading, or deceptive; 1,166
(2) Unless it contains a clear, concise, and complete 1,168
statement of the following: 1,169
(a) The health care services and insurance or other 1,172
benefits, if any, to which the enrollee is entitled under the 1,173
health care plan;
(b) Any exclusions or limitations on the health care 1,176
services, type of health care services, benefits, or type of 1,177
benefits to be provided, including copayments or deductibles; 1,178
(c) The enrollee's personal financial obligation for 1,180
noncovered services; 1,181
(d) Where and in what manner general information and 1,184
information as to how services may be obtained is available, 1,185
including the telephone number; 1,186
(e) The premium rate with respect to individual and 1,188
conversion contracts, and relevant copayment provisions with 1,189
respect to all contracts. The statement of the premium rate, 1,190
however, may be contained in a separate insert. 1,191
(f) The method utilized by the health insuring corporation 1,194
for resolving enrollee complaints. 1,195
(3) Unless it provides for the continuation of an 1,197
enrollee's coverage, in the event that the enrollee's coverage 1,198
under the GROUP policy, contract, certificate, or agreement 1,199
26
terminates while the enrollee is receiving inpatient care in a 1,200
hospital. This continuation of coverage shall terminate at the 1,201
earliest occurrence of any of the following: 1,202
(a) The enrollee's discharge from the hospital; 1,204
(b) The determination by the enrollee's attending 1,206
physician that inpatient care is no longer medically indicated 1,207
for the enrollee;
(c) The enrollee's reaching the limit for contractual 1,209
benefits; 1,210
(d) THE EFFECTIVE DATE OF ANY NEW COVERAGE. 1,213
(4) Unless it contains a provision that states, in 1,215
substance, that the health insuring corporation is not a member 1,216
of any guaranty fund, and that in the event of the health 1,217
insuring corporation's insolvency, the enrollee is protected only 1,219
to the extent that the hold harmless provision required by
section 1751.13 of the Revised Code applies to the health care 1,221
services rendered; 1,222
(5) Unless it contains a provision that states, in 1,224
substance, that in the event of the insolvency of the health 1,225
insuring corporation, the enrollee may be financially responsible 1,227
for health care services rendered by a provider or health care 1,228
facility that is not under contract to the health insuring 1,229
corporation, whether or not the health insuring corporation 1,230
authorized the use of the provider or health care facility. 1,231
(E) Notwithstanding division (D) of this section, a health 1,235
insuring corporation may use an evidence of coverage that
provides for the coverage of beneficiaries enrolled in Title 1,237
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 1,238
U.S.C.A. 301, as amended, pursuant to a medicare risk contract or 1,240
medicare cost contract, or an evidence of coverage that provides 1,241
for the coverage of beneficiaries enrolled in the federal 1,242
employees health benefits program pursuant to 5 U.S.C.A. 8905, or 1,245
an evidence of coverage that provides for the coverage of 1,246
beneficiaries enrolled in Title XIX of the "Social Security Act," 1,248
27
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the 1,249
medical assistance program or medicaid, provided by the Ohio 1,251
department of human services under Chapter 5111. of the Revised 1,252
Code, or an evidence of coverage that provides for the coverage 1,253
of beneficiaries under any other federal health care program 1,254
regulated by a federal regulatory body, OR AN EVIDENCE OF 1,255
COVERAGE THAT PROVIDES FOR THE COVERAGE OF BENEFICIARIES UNDER 1,256
ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS 1,257
BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, 1,259
if both of the following apply: 1,261
(1) The evidence of coverage has been approved by the 1,263
United States department of health and human services, the United 1,265
States office of personnel management, or the Ohio department of 1,266
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,267
(2) The evidence of coverage is filed with the 1,269
superintendent of insurance prior to use and is accompanied by 1,270
documentation of approval from the United States department of 1,272
health and human services, the United States office of personnel 1,273
management, or the Ohio department of human services, OR THE 1,274
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,275
Sec. 1751.12. (A)(1) No contractual periodic prepayment 1,285
and no premium rate for nongroup and conversion policies for 1,286
health care services, or any amendment to them, may be used by 1,287
any health insuring corporation at any time until the contractual 1,288
periodic prepayment and premium rate, or amendment, have been 1,289
filed with the superintendent of insurance, and shall not be 1,290
effective until the expiration of sixty days after their filing 1,291
unless the superintendent sooner gives approval. THE FILING 1,292
SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE FORM 1,293
PRESCRIBED BY THE SUPERINTENDENT. The superintendent shall 1,295
disapprove the filing, if the superintendent determines within 1,296
the sixty-day period that the contractual periodic prepayment or 1,297
premium rate, or amendment, is not in accordance with sound 1,298
actuarial principles or is not reasonably related to the 1,299
28
applicable coverage and characteristics of the applicable class 1,300
of enrollees. The superintendent shall notify the health 1,301
insuring corporation of the disapproval, and it shall thereafter 1,302
be unlawful for the health insuring corporation to use the 1,303
contractual periodic prepayment or premium rate, or amendment. 1,304
(2) No contractual periodic prepayment for group policies 1,307
for health care services shall be used until the contractual 1,308
periodic prepayment has been filed with the superintendent. THE 1,309
FILING SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE 1,310
FORM PRESCRIBED BY THE SUPERINTENDENT. The superintendent may 1,312
reject a filing made under division (A)(2) of this section at any 1,313
time, with at least thirty days' written notice to a health 1,314
insuring corporation, if the contractual periodic prepayment is 1,315
not in accordance with sound actuarial principles or is not 1,317
reasonably related to the applicable coverage and characteristics 1,318
of the applicable class of enrollees. 1,319
(3) At any time, the superintendent, upon at least thirty 1,321
days' written notice to a health insuring corporation, may 1,322
withdraw the approval given under division (A)(1) of this 1,323
section, deemed or actual, of any contractual periodic prepayment 1,325
or premium rate, or amendment, based on information that either 1,326
of the following applies:
(a) The contractual periodic prepayment or premium rate, 1,329
or amendment, is not in accordance with sound actuarial 1,330
principles.
(b) The contractual periodic prepayment or premium rate, 1,333
or amendment, is not reasonably related to the applicable 1,334
coverage and characteristics of the applicable class of 1,335
enrollees.
(4) Any disapproval under division (A)(1) of this section, 1,337
any rejection of a filing made under division (A)(2) of this 1,339
section, or any withdrawal of approval under division (A)(3) of 1,340
this section, shall be effected by a written notice, which shall 1,341
state the specific basis for the disapproval, rejection, or 1,342
29
withdrawal and shall be issued in accordance with Chapter 119. of 1,343
the Revised Code. 1,344
(B) Notwithstanding division (A) of this section, a health 1,347
insuring corporation may use a contractual periodic prepayment or 1,348
premium rate for policies used for the coverage of beneficiaries 1,349
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 1,351
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 1,353
risk contract or medicare cost contract, or for policies used for 1,354
the coverage of beneficiaries enrolled in the federal employees 1,355
health benefits program pursuant to 5 U.S.C.A. 8905, or for 1,358
policies used for the coverage of beneficiaries enrolled in Title 1,359
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 1,361
U.S.C.A. 301, as amended, known as the medical assistance program 1,364
or medicaid, provided by the Ohio department of human services 1,365
under Chapter 5111. of the Revised Code, or for policies used for 1,366
the coverage of beneficiaries under any other federal health care 1,367
program regulated by a federal regulatory body, OR FOR POLICIES 1,369
USED FOR THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT 1,370
COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED 1,371
INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the 1,373
following apply: 1,374
(1) The contractual periodic prepayment or premium rate 1,376
has been approved by the United States department of health and 1,377
human services, the United States office of personnel management, 1,379
or the Ohio department of human services, OR THE DEPARTMENT OF 1,380
ADMINISTRATIVE SERVICES.
(2) The contractual periodic prepayment or premium rate is 1,382
filed with the superintendent prior to use and is accompanied by 1,383
documentation of approval from the United States department of 1,385
health and human services, the United States office of personnel 1,387
management, or the Ohio department of human services, OR THE 1,389
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,390
(C) The administrative expense portion of all contractual 1,393
periodic prepayment or premium rate filings submitted to the 1,394
30
superintendent for review must reflect the actual cost of 1,395
administering the product. The superintendent may require that 1,396
the administrative expense portion of the filings be itemized and 1,397
supported.
(D)(1) Copayments and deductibles must be reasonable and 1,400
must not be a barrier to the necessary utilization of services by 1,401
enrollees.
(2) A health insuring corporation may not impose copayment 1,404
charges on basic health care services that exceed thirty per cent 1,405
of the total cost of providing any single covered health care 1,406
service, except for physician office visits, emergency health 1,407
services, and urgent care services. The total cost of providing 1,408
a health care service is the cost to the health insuring 1,409
corporation of providing the health care service to its enrollees 1,411
as reduced by any applicable provider discount. An open panel 1,413
plan may not impose copayments on out-of-network benefits that 1,414
exceed fifty per cent of the total cost of providing any single 1,415
covered health care service.
(3) To ensure that copayments are not a barrier to the 1,417
utilization of basic health care services, a health insuring 1,418
corporation may not impose, in any contract year, on any 1,419
subscriber or enrollee, copayments that exceed two hundred per 1,420
cent of the total annual premium rate to the subscriber or 1,421
enrollees. This limitation of two hundred per cent does not 1,423
include any reasonable copayments that are not a barrier to the 1,424
necessary utilization of health care services by enrollees and 1,425
that are imposed on physician office visits, emergency health 1,426
services, urgent care services, supplemental health care 1,427
services, or specialty health care services.
(E) A health insuring corporation shall not impose 1,430
lifetime maximums on basic health care services. However, a 1,431
health insuring corporation may establish a benefit limit for 1,432
inpatient hospital services that are provided pursuant to a 1,433
policy, contract, certificate, or agreement for supplemental 1,434
31
health care services.
Sec. 1751.13. (A)(1) A health insuring corporation shall, 1,444
either directly or indirectly, enter into contracts for the 1,445
provision of health care services with a sufficient number and 1,446
types of providers and health care facilities to ensure that all 1,447
covered health care services will be accessible to enrollees from 1,448
a contracted provider or health care facility. 1,449
(2) When a health insuring corporation is unable to 1,451
provide a covered health care service from a contracted provider 1,452
or health care facility, the health insuring corporation must 1,453
provide that health care service from a noncontracted provider or 1,455
health care facility consistent with the terms of the enrollee's 1,456
policy, contract, certificate, or agreement. The health insuring 1,457
corporation shall either ensure that the health care service be 1,458
provided at no greater cost to the enrollee than if the enrollee 1,459
had obtained the health care service from a contracted provider 1,460
or health care facility, or make other arrangements acceptable to 1,461
the superintendent of insurance. 1,462
(3) Nothing in this section shall prohibit a health 1,464
insuring corporation from entering into contracts with 1,465
out-of-state providers or health care facilities that are 1,466
licensed, certified, accredited, or otherwise authorized in that 1,467
state. 1,468
(B)(1) A health insuring corporation shall, either 1,471
directly or indirectly, enter into contracts with all providers 1,472
and health care facilities through which health care services are 1,473
provided to its enrollees.
(2) A health insuring corporation, upon written request, 1,475
shall assist its contracted providers in finding stop-loss or 1,476
reinsurance carriers.
(C) A health insuring corporation shall file an annual 1,478
certificate with the superintendent certifying that all provider 1,479
contracts and contracts with health care facilities through which 1,480
health care services are being provided contain the following: 1,481
32
(1) A description of the method by which the provider or 1,483
health care facility will be notified of the specific health care 1,485
services for which the provider or health care facility will be 1,486
responsible, including any limitations or conditions on such 1,487
services;
(2) The specific hold harmless provision specifying 1,489
protection of enrollees set forth as follows: 1,490
"[Provider/Health Care Facility< agrees that in no event, 1,493
including but not limited to nonpayment by the health insuring 1,494
corporation, insolvency of the health insuring corporation, or 1,495
breach of this agreement, shall [Provider/Health Care Facility< 1,497
bill, charge, collect a deposit from, seek remuneration or 1,498
reimbursement from, or have any recourse against, a subscriber, 1,499
enrollee, person to whom health care services have been provided, 1,501
or person acting on behalf of the covered enrollee, for health 1,502
care services provided pursuant to this agreement. This does not 1,503
prohibit [Provider/Health Care Facility< from collecting 1,504
co-insurance, deductibles, or copayments as specifically provided 1,506
in the evidence of coverage, or fees for uncovered health care 1,507
services delivered on a fee-for-service basis to persons 1,508
referenced above, nor from any recourse against the health 1,509
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 1,511
facility to continue to provide covered health care services to 1,512
enrollees in the event of the health insuring corporation's 1,513
insolvency or discontinuance of operations. The provisions shall 1,515
require the provider or health care facility to continue to 1,516
provide covered health care services to enrollees as needed to 1,517
complete any medically necessary procedures commenced but 1,518
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A 1,519
MEDICALLY NECESSARY PROCEDURE SHALL INCLUDE THE RENDERING OF ALL 1,521
MEDICALLY NECESSARY FOLLOW-UP CARE FOR THAT PROCEDURE. If an 1,522
enrollee is receiving necessary inpatient care at a hospital, the 1,523
33
provisions may limit the required provision of covered health 1,524
care services relating to that inpatient care in accordance with 1,525
division (D)(3) of section 1751.11 of the Revised Code, and may 1,527
also limit such required provision of covered health care 1,528
services to the period ending thirty days after the health 1,529
insuring corporation's insolvency or discontinuance of 1,530
operations.
The provisions required by division (C)(3) of this section 1,533
shall not require any provider or health care facility to 1,534
continue to provide any covered health care service after the
occurrence of any of the following: 1,535
(a) The end of the thirty-day period following the entry 1,537
of a liquidation order under Chapter 3903. of the Revised Code; 1,539
(b) The end of the enrollee's period of coverage for a 1,541
contractual prepayment or premium; 1,542
(c) The enrollee obtains equivalent coverage with another 1,544
health insuring corporation or insurer, or the enrollee's 1,545
employer obtains such coverage for the enrollee; 1,546
(d) The enrollee or the enrollee's employer terminates 1,548
coverage under the contract; 1,549
(e) A liquidator effects a transfer of the health insuring 1,552
corporation's obligations under the contract under division 1,553
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 1,555
responsibilities of the health insuring corporation, and of the 1,556
contracted providers and health care facilities, with respect to 1,557
administrative policies and programs, including, but not limited 1,558
to, payments systems, utilization review, quality assessment and 1,559
improvement programs, credentialing, confidentiality 1,560
requirements, and any applicable federal or state programs; 1,562
(5) A provision regarding the availability and 1,564
confidentiality of those health records maintained by providers 1,565
and health care facilities to monitor and evaluate the quality of 1,567
care, to conduct evaluations and audits, and to determine on a 1,568
34
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 1,569
The provision shall include terms requiring the provider or 1,570
health care facility to make these health records available to 1,571
appropriate state and federal authorities involved in assessing 1,572
the quality of care or in investigating the grievances or 1,573
complaints of enrollees, and requiring the provider or health 1,574
care facility to comply with applicable state and federal laws 1,575
related to the confidentiality of medical or health records. 1,577
(6) A provision that states that contractual rights and 1,579
responsibilities may not be assigned or delegated by the provider 1,581
or health care facility without the prior written consent of the 1,582
health insuring corporation;
(7) A provision requiring the provider or health care 1,584
facility to maintain adequate professional liability and 1,585
malpractice insurance. The provision shall also require the 1,586
provider or health care facility to notify the health insuring 1,587
corporation not more than ten days after the provider's or health 1,589
care facility's receipt of notice of any reduction or
cancellation of such coverage. 1,590
(8) A provision requiring the provider or health care 1,592
facility to observe, protect, and promote the rights of enrollees 1,594
as patients;
(9) A provision requiring the provider or health care 1,596
facility to provide health care services without discrimination 1,597
on the basis of a patient's participation in the health care 1,598
plan, age, sex, ethnicity, religion, sexual preference, health 1,599
status, or disability, and without regard to the source of 1,600
payments made for health care services rendered to a patient. 1,601
This requirement shall not apply to circumstances when the 1,602
provider or health care facility appropriately does not render 1,603
services due to limitations arising from the provider's or health 1,605
care facility's lack of training, experience, or skill, or due to 1,606
licensing restrictions.
35
(10) A provision containing the specifics of any 1,608
obligation on the PRIMARY CARE provider or health care facility 1,609
to provide, or to arrange for the provision of, covered health 1,611
care services twenty-four hours per day, seven days per week; 1,612
(11) A provision setting forth procedures for the 1,614
resolution of disputes arising out of the contract; 1,615
(12) A provision stating that the hold harmless provision 1,617
required by division (C)(2) of this section shall survive the 1,619
termination of the contract with respect to services covered and 1,620
provided under the contract during the time the contract was in 1,621
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 1,622
(13) A provision requiring those terms that are used in 1,624
the contract and that are defined by this chapter, be used in the 1,626
contract in a manner consistent with those definitions. 1,627
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF 1,629
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 1,634
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 1,637
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 1,638
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 1,639
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 1,642
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 1,647
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 1,650
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 1,651
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 1,655
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 1,656
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, OR TO 1,657
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 1,658
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 1,659
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,660
(D) No health insuring corporation contract with a 1,663
provider or health care facility shall do either of the 1,664
following:
(1) Offer an inducement to the provider or health care 1,666
36
facility, directly or indirectly, to reduce or limit medically 1,667
necessary health care services to a covered enrollee; 1,668
(2) Penalize a provider or health care facility that 1,670
assists an enrollee to seek a reconsideration of the health 1,671
insuring corporation's decision to deny or limit benefits to the 1,672
enrollee. 1,673
(E) Any contract between a health insuring corporation and 1,676
an intermediary organization shall clearly specify that the 1,677
health insuring corporation must approve or disapprove the 1,678
participation of any provider or health care facility with which 1,679
the intermediary organization contracts. 1,680
(F) If an intermediary organization that is not a health 1,682
delivery network contracting solely with self-insured employers 1,683
subcontracts with a provider or health care facility, the 1,684
subcontract with the provider or health care facility shall do 1,685
all of the following:
(1) Contain the provisions required by divisions (C) and 1,688
(G) of this section, as made applicable to an intermediary 1,689
organization, without the inclusion of inducements or penalties 1,690
described in division (D) of this section; 1,691
(2) Acknowledge that the health insuring corporation is a 1,693
third-party beneficiary to the agreement; 1,694
(3) Acknowledge the health insuring corporation's role in 1,696
approving the participation of the provider or health care 1,697
facility, pursuant to division (E) of this section. 1,699
(G) Any provider contract or contract with a health care 1,702
facility shall clearly specify the health insuring corporation's 1,703
statutory responsibility to monitor and oversee the offering of 1,704
covered health care services to its enrollees. 1,705
(H)(1) A health insuring corporation shall maintain its 1,708
provider contracts and its contracts with health care facilities 1,709
at one or more of its places of business in this state, and shall 1,710
provide copies of these contracts to facilitate regulatory review 1,711
upon written notice by the superintendent of insurance. 1,712
37
(2) Any contract with an intermediary organization shall 1,714
include provisions requiring the intermediary organization to 1,715
provide the superintendent with regulatory access to all books, 1,716
records, financial information, and documents related to the 1,717
provision of health care services to subscribers and enrollees 1,718
under the contract. The contract shall require the intermediary 1,719
organization to maintain such books, records, financial 1,720
information, and documents at its principal place of business in 1,721
this state and to preserve them for at least three years in a 1,722
manner that facilitates regulatory review. 1,723
(I)(1) A health insuring corporation shall provide notice 1,725
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A 1,727
contract with FOR THE PROVISION OF HEALTH CARE SERVICES BETWEEN 1,728
THE HEALTH INSURING CORPORATION AND a primary care physician or 1,730
hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF
THE CONTRACT. 1,731
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 1,733
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE 1,734
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH 1,735
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE PRIMARY 1,737
CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF THE 1,738
SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE 1,739
PREVIOUS TWELVE MONTHS. 1,740
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 1,742
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR A 1,744
DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE 1,745
PREVIOUS TWELVE MONTHS. 1,746
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL 1,748
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A PRIMARY 1,750
CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE TERMINATION OF 1,751
THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION OF THE CONTRACT 1,752
TERMINATION IS MAILED TO A SUBSCRIBER AT THE SUBSCRIBER'S LAST 1,753
38
KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do not apply to 1,756
any health insuring corporation that, on the effective date of 1,757
this section JUNE 4, 1997, holds a certificate of authority or 1,758
license to operate under Chapter 1740. of the Revised Code. 1,760
(K) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 1,763
1998.
Sec. 1751.14. (A) Any policy, contract, or agreement for 1,773
health care services authorized by this chapter that is issued, 1,774
delivered, or renewed in this state and that provides that 1,775
coverage of an unmarried dependent child will terminate upon 1,776
attainment of the limiting age for dependent children specified 1,777
in the policy, contract, or agreement, shall also provide in 1,778
substance that attainment of the limiting age shall not operate 1,779
to terminate the coverage of the child if the child is and 1,780
continues to be both:
(1) Incapable of self-sustaining employment by reason of 1,782
mental retardation or physical handicap; 1,783
(2) Primarily dependent upon the subscriber for support 1,785
and maintenance. 1,786
(B) Proof of incapacity and dependence for purposes of 1,788
division (A) of this section shall be furnished to the health 1,789
insuring corporation within thirty-one days of the child's 1,791
attainment of the limiting age. Upon request, but not more 1,792
frequently than annually, the health insuring corporation may 1,793
require proof satisfactory to it of the continuance of such 1,794
incapacity and dependency.
(C) Nothing in this section shall be construed to require 1,797
a health insuring corporation to cover a dependent child who is 1,798
mentally retarded or physically handicapped if the policy, 1,799
contract, or agreement is underwritten on evidence of 1,800
insurability based on health factors set forth in the 1,801
application, or if the dependent child does not satisfy the 1,802
conditions of the policy, contract, or agreement as to any 1,803
39
requirement for evidence of insurability or any other provision 1,804
of the policy, contract, or agreement, satisfaction of which is 1,805
required for coverage thereunder to take effect. In any such 1,806
case, the terms of the policy, contract, or agreement shall apply 1,807
with regard to the coverage or exclusion of the dependent from 1,808
such coverage.
(D) This section does not apply to any health insuring 1,811
corporation, policy, contract, or agreement offering only 1,812
supplemental health care services or specialty health care
services. 1,813
Sec. 1751.141. A HEALTH INSURING CORPORATION SHALL PROVIDE 1,817
COVERAGE FOR A SUBSCRIBER'S DEPENDENT CHILDREN LIVING OUTSIDE THE 1,818
HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA IF A COURT 1,819
ORDER REQUIRES THE SUBSCRIBER TO PROVIDE HEALTH CARE COVERAGE TO 1,820
THE DEPENDENT CHILDREN.
Sec. 1751.15. (A) After a health insuring corporation has 1,829
furnished, directly or indirectly, basic health care services for 1,830
a period of twenty-four months, and if it currently meets the 1,831
financial requirements set forth in section 1751.28 of the 1,832
Revised Code and had net income as reported to the superintendent 1,833
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 1,834
less than thirty days during its month of licensure for 1,836
individuals who are not federally eligible individuals. 1,837
(B) During the open enrollment period described in 1,839
division (A) of this section, the health insuring corporation 1,840
shall accept applicants and their dependents in the order in 1,841
which they apply for enrollment and in accordance with any of the 1,842
following:
(1) Up to its capacity, as determined by the health 1,844
insuring corporation subject to review by the superintendent; 1,845
(2) If less than its capacity, one per cent of the health 1,847
insuring corporation's total number of subscribers residing in 1,848
this state as of the immediately preceding thirty-first day of 1,849
40
December. 1,850
(C) Where a health insuring corporation demonstrates to 1,852
the satisfaction of the superintendent that such open enrollment 1,853
would jeopardize its economic viability, the superintendent may 1,854
do any of the following:
(1) Waive the requirement for open enrollment; 1,856
(2) Impose a limit on the number of applicants and their 1,858
dependents that must be enrolled; 1,859
(3) Authorize such underwriting restrictions upon open 1,861
enrollment as are necessary to do any of the following: 1,862
(a) Preserve its financial stability; 1,864
(b) Prevent excessive adverse selection; 1,866
(c) Avoid unreasonably high or unmarketable charges for 1,868
coverage of health care services. 1,869
(D)(1) A request to the superintendent under division (C) 1,872
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 1,873
documentation, including financial data. In reviewing the 1,874
request, the superintendent may consider various factors, 1,875
including the size of the health insuring corporation, the health 1,876
insuring corporation's net worth and profitability, the health 1,877
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 1,878
(2) Any action taken by the superintendent under division 1,880
(C) of this section shall be effective for a period of not more 1,882
than one year. At the expiration of such time, a new 1,883
demonstration of the health insuring corporation's need for the 1,884
restriction, limit, or waiver shall be made before a new 1,885
restriction, limit, or waiver is granted by the superintendent. 1,886
(3) Irrespective of the granting of any restriction, 1,888
limit, or waiver by the superintendent, a health insuring 1,889
corporation may reject an applicant or a dependent of the 1,890
applicant during its open enrollment period if the applicant or 1,891
dependent: 1,892
41
(a) Was eligible for and was covered under any 1,894
employer-sponsored health care coverage, or if employer-sponsored 1,895
health care coverage was available at the time of open 1,896
enrollment;
(b) Is eligible for continuation coverage under state or 1,898
federal law; 1,899
(c) Is eligible for medicare, and the health insuring 1,901
corporation does not have an agreement on appropriate payment 1,902
mechanisms with the governmental agency administering the 1,903
medicare program.
(E) A health insuring corporation shall not be required 1,905
either to enroll applicants or their dependents who are confined 1,906
to a health care facility because of chronic illness, permanent 1,907
injury, or other infirmity that would cause economic impairment 1,908
to the health insuring corporation if such applicants or their 1,909
dependents were enrolled or to make the effective date of 1,910
benefits for applicants or their dependents enrolled under this 1,911
section earlier than ninety days after the date of enrollment. 1,912
(F) A health insuring corporation shall not be required to 1,914
cover the fees or costs, or both, for any basic health care 1,915
service related to a transplant of a body organ if the transplant 1,916
occurs within one year after the effective date of an enrollee's 1,917
coverage under this section. This limitation on coverage does 1,918
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 1,919
(G) Each health insuring corporation required to hold an 1,921
open enrollment pursuant to division (A) of this section shall 1,922
file with the superintendent, not later than sixty days prior to 1,923
the commencement of the proposed open enrollment period, the 1,924
following documents:
(1) The proposed public notice of open enrollment; 1,926
(2) The evidence of coverage approved pursuant to section 1,928
1751.11 of the Revised Code that will be used during open 1,930
enrollment;
42
(3) The contractual periodic prepayment and premium rate 1,932
approved pursuant to section 1751.12 of the Revised Code that 1,933
will be applicable during open enrollment; 1,934
(4) Any solicitation document approved pursuant to section 1,937
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 1,938
(5) A list of the proposed dates of publication of the 1,940
public notice, and the names of the newspapers in which the 1,941
notice will appear; 1,942
(6) Any request for a restriction, limit, or waiver with 1,944
respect to the open enrollment period, along with any supporting 1,945
documentation. 1,946
(H)(1) An open enrollment period shall not satisfy the 1,948
requirements of this section unless the health insuring 1,949
corporation provides adequate public notice in accordance with 1,950
divisions (H)(2) and (3) of this section. No public notice shall 1,951
be used until the form of the public notice has been filed by the 1,952
health insuring corporation with the superintendent. If the 1,953
superintendent does not disapprove the public notice within sixty 1,954
days after it is filed, it shall be deemed approved, unless the 1,955
superintendent sooner gives approval for the public notice. If 1,956
the superintendent determines within this sixty-day period that 1,957
the public notice fails to meet the requirements of this section, 1,958
the superintendent shall so notify the health insuring 1,959
corporation and it shall be unlawful for the health insuring 1,960
corporation to use the public notice. Such disapproval shall be 1,961
effected by a written order, which shall state the grounds for 1,962
disapproval and shall be issued in accordance with Chapter 119. 1,963
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 1,965
section shall be published in at least one newspaper of general 1,966
circulation in each county in the health insuring corporation's 1,967
service area, at least once in each of the two weeks immediately 1,968
preceding the month in which the open enrollment is to occur and 1,969
43
in each week of that month, or until the enrollment limitation is 1,970
reached, whichever occurs first. The notice published during the 1,971
last week of open enrollment shall appear not less than five days 1,972
before the end of the open enrollment period. It shall be at 1,973
least two newspaper columns wide or two and one-half inches wide, 1,975
whichever is larger. The first two lines of the text shall be 1,976
published in not less than twelve-point, boldface type. The 1,977
remainder of the text of the notice shall be published in not 1,978
less than eight-point type. The entire public notice shall be 1,979
surrounded by a continuous black line not less than one-eighth of 1,980
an inch wide.
(3) The following information shall be included in the 1,982
public notice provided under division (H)(2) of this section: 1,983
(a) The dates that open enrollment will be held and the 1,985
date coverage obtained under the open enrollment will become 1,986
effective;
(b) Notice that an applicant or the applicant's dependents 1,988
will not be denied coverage during open enrollment because of a 1,989
preexisting health condition, but that some limitations and 1,990
restrictions may apply;
(c) The address where a person may obtain an application; 1,992
(d) The telephone number that a person may call to request 1,994
an application or to ask questions; 1,996
(e) The date the first payment will be due; 1,998
(f) The actual rates or range of rates that will be 2,000
applicable for applicants; 2,001
(g) Any limitation granted by the superintendent on the 2,004
number of applications that will be accepted by the health 2,005
insuring corporation.
(4) Within thirty days after the end of an open enrollment 2,008
period, the health insuring corporation shall submit to the 2,009
superintendent proof of publication for the public notices, and 2,010
shall report the total number of applicants and their dependents 2,011
enrolled during the open enrollment period. 2,012
44
(I)(1) No health insuring corporation may employ any 2,014
scheme, plan, or device that restricts the ability of any person 2,015
to enroll during open enrollment. 2,016
(2) No health insuring corporation may require enrollment 2,018
to be made in person. Every health insuring corporation shall 2,019
permit application for coverage by mail. A representative of the 2,021
health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 2,022
operations of the health insuring corporation and to answer any 2,023
questions the applicant may have. Every health insuring 2,024
corporation shall make open enrollment applications and 2,025
solicitation documents readily available to any potential 2,026
applicant who requests such material. 2,027
(J) An application postmarked on the last day of an open 2,029
enrollment period shall qualify as a valid application, 2,030
regardless of the date on which it is received by the health 2,031
insuring corporation.
(K) This section does not apply to any health insuring 2,033
corporation that offers only supplemental health care services or 2,035
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 2,036
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 2,037
U.S.C.A. 301, as amended, and that has no other commercial 2,038
enrollment, or to any health insuring corporation that offers 2,039
plans only through other federal health care programs regulated 2,040
by federal regulatory bodies and that has no other commercial 2,041
enrollment, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 2,042
PLANS ONLY THROUGH CONTRACTS COVERING OFFICERS OR EMPLOYEES OF 2,043
THE STATE THAT HAVE BEEN ENTERED INTO BY THE DEPARTMENT OF 2,045
ADMINISTRATIVE SERVICES AND THAT HAS NO OTHER COMMERCIAL 2,046
ENROLLMENT.
(L) Each health insuring corporation shall accept 2,049
federally eligible individuals for open enrollment coverage as 2,050
provided in section 3923.581 of the Revised Code. A health 2,052
45
insuring corporation may reinsure coverage of any federally 2,053
eligible individual acquired under that section with the open 2,054
enrollment reinsurance program in accordance with division (G) of 2,056
section 3924.11 of the Revised Code. Fixed periodic prepayment 2,059
rates charged for coverage reinsured by the program shall be 2,060
established in accordance with section 3924.12 of the Revised 2,061
Code. 2,062
(M) As used in this section, "federally eligible 2,065
individual" means an eligible individual as defined in 45 C.F.R. 2,067
148.103. 2,068
Sec. 1751.151. AT LEAST ONCE IN EVERY TWELVE-MONTH 2,070
PERIOD, A HEALTH INSURING CORPORATION SHALL PROVIDE TO ALL LATE 2,072
ENROLLEES, AS DEFINED IN SECTION 3924.01 OF THE REVISED CODE, THE 2,075
OPTION TO ENROLL IN THE GROUP HEALTH CARE PLAN. THE ENROLLMENT 2,076
OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF THIRTY 2,077
CONSECUTIVE DAYS.
Sec. 1751.16. (A) Except as provided in division (F) of 2,086
this section, every group contract issued by a health insuring 2,087
corporation shall provide an option for conversion to an 2,088
individual contract issued on a direct-payment basis to any 2,089
subscriber covered by the group contract who terminates 2,090
employment or membership in the group, unless: 2,091
(1) Termination of the conversion option or contract is 2,093
based upon nonpayment of premium after reasonable notice in 2,094
writing has been given by the health insuring corporation to the 2,095
subscriber. 2,096
(2) The subscriber is, or is eligible to be, covered for 2,098
benefits at least comparable to the group contract under any of 2,099
the following: 2,100
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 2,102
(1935), 42 U.S.C.A. 301, as amended; 2,103
(b) Any act of congress or law under this or any other 2,105
state of the United States providing coverage at least comparable 2,106
to the benefits under division (A)(2)(a) of this section; 2,107
46
(c) Any policy of insurance or health care plan providing 2,109
coverage at least comparable to the benefits under division 2,110
(A)(2)(a) of this section. 2,111
(B)(1) The direct-payment contract offered by the health 2,113
insuring corporation pursuant to division (A) of this section 2,115
shall provide the following: 2,117
(a) In the case of an individual who is not a federally 2,120
eligible individual, benefits comparable to benefits in any of 2,121
the individual contracts then being issued to individual 2,122
subscribers by the health insuring corporation; 2,123
(b) In the case of a federally eligible individual, a 2,126
basic and standard plan established by the board of directors of 2,127
the Ohio health reinsurance program or plans substantially 2,128
similar to the basic and standard plan in benefit design and 2,129
scope of covered services. For purposes of division (B)(1)(b) of 2,131
this section, the superintendent of insurance shall determine 2,132
whether a plan is substantially similar to the basic or standard 2,133
plan in benefit design and scope of covered services. The 2,134
contractual periodic prepayments charged for such plans may not 2,135
exceed an amount that is two times the midpoint of the standard 2,136
rate charged any other individual of a group to which the 2,137
organization is currently accepting new business and for which 2,138
similar copayments and deductibles are applied. 2,139
(2) The direct payment contract offered pursuant to 2,141
division (A) of this section may include a coordination of 2,143
benefits provision as approved by the superintendent. 2,144
(3) For purposes of division (B) of this section 2,147
"federally eligible individual" means an eligible individual as 2,148
defined in 45 C.F.R. 148.103. 2,151
(C) The option for conversion shall be available: 2,153
(1) Upon the death of the subscriber, to the surviving 2,155
spouse with respect to such of the spouse and dependents as are 2,157
then covered by the group contract; 2,158
(2) To a child solely with respect to the child upon the 2,160
47
child's attaining the limiting age of coverage under the group 2,161
contract while covered as a dependent under the contract; 2,162
(3) Upon the divorce, dissolution, or annulment of the 2,164
marriage of the subscriber, to the divorced spouse, or, in the 2,165
event of annulment, to the former spouse of the subscriber. 2,167
(D) No health insuring corporation shall use age as the 2,169
basis for refusing to renew a converted contract. 2,170
(E) Written notice of the conversion option provided by 2,173
this section shall be given to the subscriber by the health 2,174
insuring corporation by mail. The notice shall be sent to the 2,175
subscriber's address in the records of the employer upon receipt 2,176
of notice from the employer of the event giving rise to the 2,177
conversion option. If the subscriber has not received notice of 2,178
the conversion privilege at least fifteen days prior to the 2,179
expiration of the thirty-day conversion period, then the 2,180
subscriber shall have an additional period within which to 2,181
exercise the privilege. This additional period shall expire 2,182
fifteen days after the subscriber receives notice, but in no 2,183
event shall the period extend beyond sixty days after the 2,184
expiration of the thirty-day conversion period. 2,185
(F) This section does not apply to any group contract 2,187
offering only supplemental health care services or specialty 2,188
health care services.
Sec. 1751.20. (A) No health insuring corporation, or 2,198
agent, employee, or representative of a health insuring 2,199
corporation, shall use any advertisement or solicitation 2,200
document, or shall engage in any activity, that is unfair, 2,201
untrue, misleading, or deceptive.
(B) No health insuring corporation shall use a name that 2,204
is deceptively similar to the name or description of any 2,205
insurance or surety corporation doing business in this state. 2,206
(C) All solicitation documents, advertisements, evidences 2,209
of coverage, and enrollee identification cards used by a health 2,210
insuring corporation shall contain the health insuring 2,211
48
corporation's name. The use of a trade name, an insurance group 2,212
designation, the name of a parent company, the name of a division 2,213
of an affiliated insurance company, a service mark, a slogan, a 2,214
symbol, or other device, without the name of the health insuring 2,215
corporation as stated in its articles of incorporation, shall not 2,216
satisfy this requirement if the usage would have the capacity and 2,217
tendency to mislead or deceive persons as to the true identity of 2,218
the health insuring corporation. 2,219
(D) No solicitation document or advertisement used by a 2,222
health insuring corporation shall contain any words, symbols, or 2,223
physical materials that are so similar in content, phraseology, 2,224
shape, color, or other characteristic to those used by an agency 2,225
of the federal government or this state, that prospective 2,226
enrollees may be led to believe that the solicitation document or 2,227
advertisement is connected with an agency of the federal 2,228
government or this state. 2,229
(E) A HEALTH INSURING CORPORATION THAT PROVIDES BASIC 2,231
HEALTH CARE SERVICES MAY USE THE PHRASE "HEALTH MAINTENANCE 2,233
ORGANIZATION" OR THE ABBREVIATION "HMO" IN ITS MARKETING NAME, 2,234
ADVERTISING, SOLICITATION DOCUMENTS, OR MARKETING LITERATURE, OR 2,236
IN REFERENCE TO THE PHRASE "DOING BUSINESS AS" OR THE
ABBREVIATION "DBA." 2,237
(F) This section does not apply to the coverage of 2,239
beneficiaries enrolled in Title XVIII of the "Social Security 2,241
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, pursuant 2,244
to a medicare risk contract or medicare cost contract, or to the 2,245
coverage of beneficiaries enrolled in the federal employee health 2,246
benefits program pursuant to 5 U.S.C.A. 8905, or to the coverage 2,248
of beneficiaries enrolled in Title XIX of the "Social Security 2,249
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as 2,251
the medical assistance program or medicaid, provided by the Ohio 2,252
department of human services under Chapter 5111. of the Revised 2,253
Code, or to the coverage of beneficiaries under any federal 2,255
health care program regulated by a federal regulatory body, OR TO 2,256
49
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 2,257
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 2,258
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,259
Sec. 1751.31. (A) Any changes in a health insuring 2,269
corporation's solicitation document shall be filed with the 2,270
superintendent of insurance. The superintendent, within sixty 2,271
days of filing, may disapprove any solicitation document or 2,272
amendment to it on any of the grounds stated in this section. 2,273
Such disapproval shall be effected by written notice to the 2,274
health insuring corporation. The notice shall state the grounds 2,275
for disapproval and shall be issued in accordance with Chapter 2,276
119. of the Revised Code. 2,277
(B) The solicitation document shall contain all 2,280
information necessary to enable a consumer to make an informed 2,281
choice as to whether or not to enroll in the health insuring 2,282
corporation. The information shall include a specific 2,283
description of the health care services to be available and the 2,284
approximate number and type of full-time equivalent medical 2,285
practitioners. The information shall be presented in the 2,286
solicitation document in a manner that is clear, concise, and 2,287
intelligible to prospective applicants in the proposed service 2,288
area.
(C) Every potential applicant whose subscription to a 2,291
health care plan is solicited shall receive, at or before the 2,292
time of solicitation, a solicitation document approved by the 2,293
superintendent.
(D) Notwithstanding division (A) of this section, a health 2,296
insuring corporation may use a solicitation document that the 2,297
corporation uses in connection with policies for beneficiaries of 2,298
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,300
U.S.C.A. 301, as amended, pursuant to a medicare risk contract or 2,302
medicare cost contract, or for policies for beneficiaries of the 2,303
federal employees health benefits program pursuant to 5 U.S.C.A. 2,305
8905, or for policies for beneficiaries of Title XIX of the 2,307
50
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 2,310
amended, known as the medical assistance program or medicaid, 2,311
provided by the Ohio department of human services under Chapter 2,312
5111. of the Revised Code, or for policies for beneficiaries of 2,313
any other federal health care program regulated by a federal 2,314
regulatory body, OR FOR POLICIES FOR BENEFICIARIES OF CONTRACTS 2,315
COVERING OFFICERS OR EMPLOYEES OF THE STATE ENTERED INTO BY THE 2,317
DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the following 2,318
apply: 2,319
(1) The solicitation document has been approved by the 2,321
United States department of health and human services, the United 2,322
States office of personnel management, or the Ohio department of 2,324
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,325
(2) The solicitation document is filed with the 2,327
superintendent of insurance prior to use and is accompanied by 2,328
documentation of approval from the United States department of 2,331
health and human services, the United States office of personnel 2,333
management, or the Ohio department of human services, OR THE 2,335
DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,336
(E) No health insuring corporation, or its agents or 2,339
representatives, shall use monetary or other valuable 2,340
consideration, engage in misleading or deceptive practices, or 2,341
make untrue, misleading, or deceptive representations to induce 2,342
enrollment. Nothing in this division shall prohibit incentive 2,343
forms of remuneration such as commission sales programs for the 2,344
health insuring corporation's employees and agents. 2,345
(F) Any person obligated for any part of a premium rate in 2,348
connection with an enrollment agreement, in addition to any right 2,349
otherwise available to revoke an offer, may cancel such agreement 2,350
within seventy-two hours after having signed the agreement or 2,351
offer to enroll. Cancellation occurs when written notice of the 2,352
cancellation is given to the health insuring corporation or its 2,353
agents or other representatives. A notice of cancellation mailed 2,354
to the health insuring corporation shall be considered to have 2,355
51
been filed on its postmark date. 2,356
(G) Nothing in this section shall prohibit healthy 2,358
lifestyle programs. 2,359
Sec. 1751.46. (A) The superintendent of insurance and the 2,369
director of health may contract with qualified persons to make 2,370
recommendations concerning the determinations required to be made 2,371
by the superintendent or the director relative to an expansion of 2,372
a service area pursuant to division (C) of section 1751.03 of the 2,374
Revised Code, an application for a certificate of authority 2,376
pursuant to sections 1751.04 and 1751.05 of the Revised Code, a 2,378
contractual periodic prepayment or premium rate pursuant to 2,379
section 1751.12 of the Revised Code, and an examination pursuant 2,381
to division (B) of section 1751.34 of the Revised Code. The 2,383
recommendations may be accepted in full or in part, or may be 2,384
rejected, by the superintendent or director. 2,385
THE TOTAL COST OF A CONTRACT WITH A QUALIFIED PERSON 2,387
PURSUANT TO THIS DIVISION SHALL BE BORNE BY THE HEALTH INSURING 2,388
CORPORATION THAT IS THE SUBJECT OF THE DETERMINATION REQUIRED TO 2,389
BE MADE BY THE SUPERINTENDENT OR THE DIRECTOR. 2,390
(B) No qualified person placed on contract by the 2,393
superintendent or the director pursuant to division (A) of this 2,395
section shall have a conflict of interest with the department of 2,396
insurance, the department of health, or the health insuring 2,397
corporation.
Sec. 1751.55. A health insuring corporation policy, 2,406
contract, or agreement shall not be construed to exclude illness 2,407
or injury upon the ground that the subscriber might have elected 2,408
to have such illness or injury covered by workers' compensation 2,409
under division (A)(3) of section 4123.01 CHAPTER 4123. of the 2,411
Revised Code unless the policy, contract, or agreement clearly 2,413
excludes work or occupational related illness or injury, or the 2,414
policy, contract, or agreement, or a separate writing signed by 2,415
the subscriber, informs the subscriber that such coverage is 2,416
excluded and may be available to the subscriber under workers' 2,417
52
compensation as the sole proprietor of a business, a member of a 2,418
partnership, or an officer of a family farm corporation. 2,419
Sec. 1751.58. Except as otherwise provided in section 2721 2,429
of the "Health Insurance Portability and Accountability Act of 2,433
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 2,439
as amended, the following conditions apply to all group health 2,440
insuring corporation contracts that are sold in connection with 2,441
an employment-related group health care plan and that are not 2,442
subject to section 3924.03 of the Revised Code: 2,444
(A)(1) Except as provided in section 2712(b) to (e) of the 2,448
"Health Insurance Portability and Accountability Act of 1996," if 2,452
a health insuring corporation offers coverage in the small or 2,453
large group market in connection with a group contract, the 2,454
organization shall renew or continue in force such coverage at 2,455
the option of the contract holder. 2,456
(2) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 2,459
TO RENEW THE COVERAGE OF ANY ELIGIBLE EMPLOYEE OR OF A DEPENDENT 2,460
OF AN ELIGIBLE EMPLOYEE UNDER THE GROUP CONTRACT IF THE EMPLOYEE 2,461
OR DEPENDENT, AS APPLICABLE, HAS PERFORMED AN ACT OR PRACTICE 2,462
THAT CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION 2,463
OF MATERIAL FACT UNDER THE TERMS OF THE COVERAGE AND IF THE 2,464
CANCELLATION OR NONRENEWAL IS NOT BASED, EITHER DIRECTLY OR 2,465
INDIRECTLY, ON ANY HEALTH STATUS-RELATED FACTOR IN RELATION TO 2,466
THE EMPLOYEE OR DEPENDENT.
(B) Such group contracts are subject to division 2,468
(E)(1)(A)(3) of section 3924.03 and sections 3924.033 and 3924.27 2,470
of the Revised Code. 2,471
(C) Such group contracts shall provide for the special 2,474
enrollment periods described in section 2701(f) of the "Health 2,476
Insurance Portability and Accountability Act of 1996." 2,480
Sec. 1751.59. (A) No individual or group health insuring 2,489
corporation policy, contract, or agreement that makes family 2,491
coverage available may be delivered, issued for delivery, or 2,493
renewed in this state, unless the policy, contract, or agreement
53
covers adopted children of the subscriber on the same basis as 2,494
other dependents. 2,495
(B) The coverage required by this section is subject to 2,497
the requirements and restrictions set forth in section 3924.51 of 2,499
the Revised Code. Coverage for dependent children living outside 2,501
the health insuring corporation's approved service area must be 2,502
provided if a court order requires the subscriber to provide 2,503
health care coverage.
Sec. 1751.60. (A) Except as provided for in divisions (E) 2,513
and (F) of this section, every provider or health care facility 2,515
that contracts with a health insuring corporation to provide 2,516
health care services to the health insuring corporation's 2,517
enrollees or subscribers shall seek compensation for covered 2,518
services solely from the health insuring corporation and not, 2,519
under any circumstances, from the enrollees or subscribers, 2,520
except for approved deductibles and copayments. 2,521
(B) No subscriber or enrollee of a health insuring 2,524
corporation is liable to any contracting provider or health care 2,525
facility for the cost of any covered health care services, if the 2,526
subscriber or enrollee has acted in accordance with the evidence 2,527
of coverage.
(C) Except as provided for in divisions (E) and (F) of 2,531
this section, every contract between a health insuring 2,532
corporation and provider or health care facility shall contain a 2,533
provision approved by the superintendent of insurance requiring 2,534
the provider or health care facility to seek compensation solely 2,535
from the health insuring corporation and not, under any 2,536
circumstances, from the subscriber or enrollee, except for 2,537
approved deductibles and copayments. 2,538
(D) Nothing in this section shall be construed as 2,541
preventing a provider or health care facility from billing the 2,542
enrollee or subscriber of a health insuring corporation for 2,543
noncovered services.
(E) Upon application by a health insuring corporation and 2,546
54
a provider or health care facility, the superintendent may waive 2,547
the requirements of divisions (A) and (C) of this section when, 2,549
in addition to the reserve requirements contained in section 2,550
1751.28 of the Revised Code, the health insuring corporation 2,553
provides sufficient assurances to the superintendent that the 2,554
provider or health care facility has been provided with financial 2,555
guarantees. No waiver of the requirements of divisions (A) and 2,556
(C) of this section is effective as to enrollees or subscribers 2,558
for whom the health insuring corporation is compensated under a 2,559
provider agreement or risk contract entered into pursuant to 2,560
Chapter 5111. or 5115. of the Revised Code. 2,563
(F) The requirements of divisions (A) to (C) of this 2,567
section apply only to health care services provided to an 2,568
enrollee or subscriber prior to the effective date of a 2,569
termination of a contract between the health insuring corporation 2,570
and the provider or health care facility. 2,571
Sec. 1751.62. (A) As used in this section, "screening 2,581
mammography" means a radiologic examination utilized to detect 2,582
unsuspected breast cancer at an early stage in an asymptomatic 2,583
woman and includes the x-ray examination of the breast using 2,584
equipment that is dedicated specifically for mammography, 2,585
including the x-ray tube, filter, compression device, screens, 2,586
film, and cassettes, and that has an average radiation exposure 2,587
delivery of less than one rad mid-breast. "Screening 2,588
mammography" includes two views for each breast. The term also 2,589
includes the professional interpretation of the film. 2,590
"Screening mammography" does not include diagnostic 2,592
mammography. 2,593
(B) Every individual or group health insuring corporation 2,596
policy, contract, or agreement providing basic health care 2,597
services that is delivered, issued for delivery, or renewed in 2,598
this state shall provide benefits for the expenses of both of the 2,599
following: 2,600
(1) Screening mammography to detect the presence of breast 2,603
55
cancer in adult women;
(2) Cytologic screening for the presence of cervical 2,605
cancer. 2,606
(C) The benefits provided under division (B)(1) of this 2,610
section shall cover expenses in accordance with all of the 2,611
following:
(1) If a woman is at least thirty-five years of age but 2,613
under forty years of age, one screening mammography; 2,614
(2) If a woman is at least forty years of age but under 2,616
fifty years of age, either of the following: 2,617
(a) One screening mammography every two years; 2,620
(b) If a licensed physician has determined that the woman 2,623
has risk factors to breast cancer, one screening mammography 2,624
every year.
(3) If a woman is at least fifty years of age but under 2,626
sixty-five years of age, one screening mammography every year. 2,628
(D)(1) The benefits provided under division (B)(1) of this 2,632
section shall not exceed eighty-five dollars per year unless a 2,633
lower amount is established pursuant to a provider contract. 2,634
(2) The benefit paid in accordance with division (D)(1) of 2,637
this section shall constitute full payment. No institutional or 2,638
professional health care provider shall seek or receive 2,639
remuneration in excess of the payment made in accordance with 2,640
division (D)(1) of this section, except for approved deductibles 2,642
and copayments.
(E) The benefits provided under division (B)(1) of this 2,646
section shall be provided only for screening mammographies that 2,647
are performed in a health care facility or mobile mammography 2,648
screening unit that is accredited under the American college of 2,649
radiology mammography accreditation program or in a hospital as 2,650
defined in section 3727.01 of the Revised Code. 2,652
(F) The benefits provided under divisions (B)(1) and (2) 2,656
of this section shall be provided according to the terms of the 2,657
subscriber contract.
56
(G) The benefits provided under division (B)(2) of this 2,661
section shall be provided only for cytologic screenings that are 2,662
processed and interpreted in a laboratory certified by the 2,663
college of American pathologists or in a hospital as defined in 2,664
section 3727.01 of the Revised Code. 2,666
Sec. 1907.161. (A) As used in this section, "health care 2,676
coverage" means sickness and accident insurance or other coverage 2,677
of hospitalization, surgical care, major medical care,
disability, dental care, eye care, medical care, hearing aids, 2,678
and prescription drugs or any combination of those benefits or 2,679
services.
(B) The board of county commissioners, after consultation 2,682
with the judges of the county court, shall negotiate and contract 2,683
for, purchase, or otherwise procure group health care coverage
for the judges and their spouses and dependents from insurance 2,684
companies authorized to engage in the business of insurance in 2,685
this state under Title XXXIA XXXIX of the Revised Code, medical 2,687
care corporations organized under Chapter 1737. of the Revised
Code, health care corporations organized under Chapter 1738. of 2,689
the Revised Code, or health maintenance organizations INSURING 2,690
CORPORATIONS organized under Chapter 1742. 1751. of the Revised 2,692
Code, except that, if the county provides group health care 2,694
coverage for its employees, the group health care coverage 2,695
required by this section shall be provided, if possible, through 2,696
the policy or plan under which the group health care coverage is 2,697
provided for the county employees.
(C) The portion of the costs, premiums, or charges for the 2,700
group health care coverage procured pursuant to division (B) of 2,701
this section that is not paid by the judges of the county court, 2,702
or all of the costs, premiums, or charges for the group health 2,703
care coverage if the judges will not be paying any portion of 2,704
those costs, premiums, or charges, shall be paid out of the
county treasury. 2,705
Sec. 2305.252. (A) As used in this section: 2,714
57
(1) "Review board, committee, risk management personnel, 2,716
or corporation" means any of the following: 2,717
(a) A peer review committee of a hospital, a nonprofit 2,719
health care corporation that is a member of the hospital or of 2,720
which the hospital is a member, or a community mental health 2,721
center;
(b) A board or committee of a hospital or of a nonprofit 2,723
health care corporation that is a member of the hospital or of 2,724
which the hospital is a member reviewing professional 2,725
qualifications or activities of the hospital medical staff or 2,726
applicants for admission to the medical staff;
(c) A utilization committee of a state or local society 2,728
composed of doctors of medicine or doctors of osteopathic 2,729
medicine and surgery or doctors of podiatric medicine; 2,730
(d) A peer review committee of nursing home providers or 2,732
administrators, including a corporation engaged in performing the 2,733
functions of a peer review committee of nursing home providers or 2,734
administrators, or a corporation engaged in performing the 2,735
functions of another type of peer review or professional 2,737
standards review committee;
(e) A peer review committee, professional standards review 2,739
committee, or arbitration committee of a state or local society 2,740
composed of doctors of medicine, doctors of osteopathic medicine 2,741
and surgery, doctors of dentistry, doctors of optometry, doctors 2,742
of podiatric medicine, psychologists, or registered pharmacists; 2,743
(f) A peer review committee of a health maintenance 2,745
organization INSURING CORPORATION that has at least a two-thirds 2,747
majority of member physicians in active practice and that 2,748
conducts professional credentialing and quality review activities 2,749
involving the competence or professional conduct of health care
providers, which conduct adversely affects, or could adversely 2,750
affect, the health or welfare of any patient. For purposes of 2,751
this division, "health maintenance organization INSURING 2,752
CORPORATION" includes wholly-owned WHOLLY OWNED subsidiaries of a 2,753
58
health maintenance organization INSURING CORPORATION. 2,754
(g) A peer review committee of any insurer authorized 2,756
under Title XXXIX of the Revised Code to do the business of 2,757
sickness and accident insurance in this state that has at least a 2,758
two-thirds majority of physicians in active practice and that 2,759
conducts professional credentialing and quality review activities 2,760
involving the competence or professional conduct of health care 2,761
providers, which conduct adversely affects, or could adversely
affect, the health or welfare of any patient; 2,762
(h) A peer review committee of any insurer authorized 2,764
under Title XXXIX of the Revised Code to do the business of 2,765
sickness and accident insurance in this state that has at least a 2,766
two-thirds majority of physicians in active practice and that 2,767
conducts professional credentialing and quality review activities 2,768
involving the competence or professional conduct of a health care 2,769
facility that has contracted with the insurer to provide health
care services to insureds, which conduct adversely affects, or 2,770
could adversely affect, the health or welfare of any patient; 2,771
(i) A peer review committee of an insurer authorized under 2,773
Title XXXIX of the Revised Code to do the business of medical 2,774
professional liability insurance in this state and that conducts 2,775
professional quality review activities involving the competence 2,776
or professional conduct of health care providers, which conduct 2,777
adversely affects, or could affect, the health or welfare of any 2,778
patient;
(j) A peer review committee of a health care entity. 2,780
(2) "Peer review committee" means a utilization review 2,782
committee, quality assurance committee, quality improvement 2,783
committee, tissue committee, credentialing committee, and any 2,784
other committee that conducts professional credentialing and 2,785
quality review activities involving the competence or
professional conduct of health care practitioners. 2,786
(3) "Health care entity" means a government entity, a 2,788
for-profit or nonprofit corporation, a limited liability company, 2,789
59
a partnership, a professional corporation, a state or local 2,790
society as described in division (A)(1)(c) of this section, or 2,791
other health care organization, including, but not limited to, 2,792
health care entities described in division (A)(1) of this 2,793
section, whether acting on its own behalf or on behalf of or in 2,794
affiliation with other health care entities, that conducts, as 2,795
part of its purpose, professional credentialing and quality
review activities involving the competence or professional 2,796
conduct of health care practitioners. 2,797
(4) "Incident report or risk management report" means a 2,800
report of an incident involving injury or potential injury to a
patient as a result of patient care by a health care entity that 2,801
is prepared by or for the use of a review board, committee, risk 2,802
management personnel, or corporation and is within the scope of 2,803
the functions of that review board, committee, risk management 2,804
personnel, or corporation.
(5) "Tort action" means a civil action for damages for 2,807
injury, death, or loss to a patient of a health care entity. 2,808
"Tort action" includes a product liability claim but does not 2,809
include a civil action for a breach of contract or another 2,810
agreement between persons.
(B) Notwithstanding any contrary provision of section 2,813
149.43, 1742.141 1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 2,814
of the Revised Code, an incident report or risk management report 2,816
and the contents of an incident report or risk management report 2,817
are not subject to discovery in, and are not admissible in 2,818
evidence in the trial of, a tort action. An individual who
prepares or has knowledge of the contents of an incident report 2,819
or risk management report shall not testify and shall not be 2,820
required to testify in a tort action as to the contents of the 2,821
report. This division does not prohibit or limit the discovery 2,822
or admissibility of testimony or evidence relating to patient 2,823
care that is within a person's personal knowledge. 2,824
(C) Except as specified in division (B) of this section, 2,827
60
this section does not affect any provision of section 1742.141 2,828
1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 of the Revised 2,830
Code that describes, imposes, or confers an immunity from tort or 2,831
other civil liability, a forfeiture of an immunity from tort or 2,832
other civil liability, a requirement of confidentiality, a 2,833
limitation upon the use of information, data, reports, or 2,834
records, tort or other civil liability, or a limitation upon 2,835
discovery of matter, introduction into evidence of matter, or 2,836
testimony pertaining to matter in a tort or other civil action. 2,837
This section does not affect a privileged communication between 2,838
an attorney and the attorney's client under section 2317.02 of 2,839
the Revised Code.
(D) This section shall be considered to be purely remedial 2,841
in operation and shall be applied in a remedial manner in any 2,842
civil action in which this section is relevant, whether the civil 2,843
action is pending in court or commenced on or after the effective 2,844
date of this section JANUARY 27, 1997, regardless of when the 2,845
cause of action accrued and notwithstanding any other section of 2,846
the Revised Code or prior rule of law of this state. 2,847
Sec. 3901.21. The following are hereby defined as unfair 2,856
and deceptive acts or practices in the business of insurance: 2,857
(A) Making, issuing, circulating, or causing or permitting 2,859
to be made, issued, or circulated, or preparing with intent to so 2,860
use, any estimate, illustration, circular, or statement 2,861
misrepresenting the terms of any policy issued or to be issued or 2,862
the benefits or advantages promised thereby or the dividends or 2,863
share of the surplus to be received thereon, or making any false 2,864
or misleading statements as to the dividends or share of surplus 2,865
previously paid on similar policies, or making any misleading 2,866
representation or any misrepresentation as to the financial 2,867
condition of any insurer as shown by the last preceding verified 2,868
statement made by it to the insurance department of this state, 2,869
or as to the legal reserve system upon which any life insurer 2,870
operates, or using any name or title of any policy or class of 2,871
61
policies misrepresenting the true nature thereof, or making any 2,872
misrepresentation or incomplete comparison to any person for the 2,873
purpose of inducing or tending to induce such person to purchase, 2,874
amend, lapse, forfeit, change, or surrender insurance. 2,875
Any written statement concerning the premiums for a policy 2,877
which refers to the net cost after credit for an assumed 2,878
dividend, without an accurate written statement of the gross 2,879
premiums, cash values, and dividends based on the insurer's 2,880
current dividend scale, which are used to compute the net cost 2,881
for such policy, and a prominent warning that the rate of 2,882
dividend is not guaranteed, is a misrepresentation for the 2,883
purposes of this division. 2,884
(B) Making, publishing, disseminating, circulating, or 2,886
placing before the public or causing, directly or indirectly, to 2,887
be made, published, disseminated, circulated, or placed before 2,888
the public, in a newspaper, magazine, or other publication, or in 2,889
the form of a notice, circular, pamphlet, letter, or poster, or 2,890
over any radio station, or in any other way, or preparing with 2,891
intent to so use, an advertisement, announcement, or statement 2,892
containing any assertion, representation, or statement, with 2,893
respect to the business of insurance or with respect to any 2,894
person in the conduct of the person's insurance business, which 2,896
is untrue, deceptive, or misleading. 2,897
(C) Making, publishing, disseminating, or circulating, 2,899
directly or indirectly, or aiding, abetting, or encouraging the 2,900
making, publishing, disseminating, or circulating, or preparing 2,901
with intent to so use, any statement, pamphlet, circular, 2,902
article, or literature, which is false as to the financial 2,903
condition of an insurer and which is calculated to injure any 2,904
person engaged in the business of insurance. 2,905
(D) Filing with any supervisory or other public official, 2,907
or making, publishing, disseminating, circulating, or delivering 2,908
to any person, or placing before the public, or causing directly 2,909
or indirectly to be made, published, disseminated, circulated, 2,910
62
delivered to any person, or placed before the public, any false 2,911
statement of financial condition of an insurer. 2,912
Making any false entry in any book, report, or statement of 2,914
any insurer with intent to deceive any agent or examiner lawfully 2,915
appointed to examine into its condition or into any of its 2,916
affairs, or any public official to whom such insurer is required 2,917
by law to report, or who has authority by law to examine into its 2,918
condition or into any of its affairs, or, with like intent, 2,919
willfully omitting to make a true entry of any material fact 2,920
pertaining to the business of such insurer in any book, report, 2,921
or statement of such insurer, or mutilating, destroying, 2,922
suppressing, withholding, or concealing any of its records. 2,923
(E) Issuing or delivering or permitting agents, officers, 2,925
or employees to issue or deliver agency company stock or other 2,926
capital stock or benefit certificates or shares in any common-law 2,927
corporation or securities or any special or advisory board 2,928
contracts or other contracts of any kind promising returns and 2,929
profits as an inducement to insurance. 2,930
(F) Making or permitting any unfair discrimination among 2,932
individuals of the same class and equal expectation of life in 2,933
the rates charged for any contract of life insurance or of life 2,934
annuity or in the dividends or other benefits payable thereon, or 2,935
in any other of the terms and conditions of such contract. 2,936
(G)(1) Except as otherwise expressly provided by law, 2,938
knowingly permitting or offering to make or making any contract 2,939
of life insurance, life annuity or accident and health insurance, 2,940
or agreement as to such contract other than as plainly expressed 2,941
in the contract issued thereon, or paying or allowing, or giving 2,942
or offering to pay, allow, or give, directly or indirectly, as 2,943
inducement to such insurance, or annuity, any rebate of premiums 2,944
payable on the contract, or any special favor or advantage in the 2,945
dividends or other benefits thereon, or any valuable 2,946
consideration or inducement whatever not specified in the 2,947
contract; or giving, or selling, or purchasing, or offering to 2,948
63
give, sell, or purchase, as inducement to such insurance or 2,949
annuity or in connection therewith, any stocks, bonds, or other 2,950
securities, or other obligations of any insurance company or 2,951
other corporation, association, or partnership, or any dividends 2,952
or profits accrued thereon, or anything of value whatsoever not 2,953
specified in the contract. 2,954
(2) Nothing in division (F) or division (G)(1) of this 2,956
section shall be construed as prohibiting any of the following 2,957
practices: (a) in the case of any contract of life insurance or 2,958
life annuity, paying bonuses to policyholders or otherwise 2,959
abating their premiums in whole or in part out of surplus 2,960
accumulated from nonparticipating insurance, provided that any 2,961
such bonuses or abatement of premiums shall be fair and equitable 2,962
to policyholders and for the best interests of the company and 2,963
its policyholders; (b) in the case of life insurance policies 2,964
issued on the industrial debit plan, making allowance to 2,965
policyholders who have continuously for a specified period made 2,966
premium payments directly to an office of the insurer in an 2,967
amount which fairly represents the saving in collection expenses; 2,968
(c) readjustment of the rate of premium for a group insurance 2,969
policy based on the loss or expense experience thereunder, at the 2,970
end of the first or any subsequent policy year of insurance 2,971
thereunder, which may be made retroactive only for such policy 2,972
year. 2,973
(H) Making, issuing, circulating, or causing or permitting 2,975
to be made, issued, or circulated, or preparing with intent to so 2,976
use, any statement to the effect that a policy of life insurance 2,977
is, is the equivalent of, or represents shares of capital stock 2,978
or any rights or options to subscribe for or otherwise acquire 2,979
any such shares in the life insurance company issuing that policy 2,980
or any other company. 2,981
(I) Making, issuing, circulating, or causing or permitting 2,983
to be made, issued or circulated, or preparing with intent to so 2,984
issue, any statement to the effect that payments to a 2,985
64
policyholder of the principal amounts of a pure endowment are 2,986
other than payments of a specific benefit for which specific 2,987
premiums have been paid. 2,988
(J) Making, issuing, circulating, or causing or permitting 2,990
to be made, issued, or circulated, or preparing with intent to so 2,991
use, any statement to the effect that any insurance company was 2,992
required to change a policy form or related material to comply 2,993
with Title XXXIX of the Revised Code or any regulation of the 2,994
superintendent of insurance, for the purpose of inducing or 2,995
intending to induce any policyholder or prospective policyholder 2,996
to purchase, amend, lapse, forfeit, change, or surrender 2,997
insurance. 2,998
(K) Aiding or abetting another to violate this section. 3,000
(L) Refusing to issue any policy of insurance, or 3,002
canceling or declining to renew such policy because of the sex or 3,003
marital status of the applicant, prospective insured, insured, or 3,004
policyholder. 3,005
(M) Making or permitting any unfair discrimination between 3,007
individuals of the same class and of essentially the same hazard 3,008
in the amount of premium, policy fees, or rates charged for any 3,009
policy or contract of insurance, other than life insurance, or in 3,010
the benefits payable thereunder, or in underwriting standards and 3,011
practices or eligibility requirements, or in any of the terms or 3,012
conditions of such contract, or in any other manner whatever. 3,013
(N) Refusing to make available disability income insurance 3,015
solely because the applicant's principal occupation is that of 3,016
managing a household. 3,017
(O) Refusing, when offering maternity benefits under any 3,019
individual or group sickness and accident insurance policy, to 3,020
make maternity benefits available to the policyholder for the 3,021
individual or individuals to be covered under any comparable 3,022
policy to be issued for delivery in this state, including family 3,023
members if the policy otherwise provides coverage for family 3,024
members. Nothing in this division shall be construed to prohibit 3,025
65
an insurer from imposing a reasonable waiting period for such 3,026
benefits under an A NONFEDERALLY ELIGIBLE individual sickness and 3,028
accident insurance policy OR A NONEMPLOYER-RELATED GROUP SICKNESS 3,029
AND ACCIDENT INSURANCE POLICY, but in no event shall such waiting 3,031
period exceed two hundred seventy days.
(P) Using, or permitting to be used, a pattern settlement 3,033
as the basis of any offer of settlement. As used in this 3,034
division, "pattern settlement" means a method by which liability 3,035
is routinely imputed to a claimant without an investigation of 3,036
the particular occurrence upon which the claim is based and by 3,037
using a predetermined formula for the assignment of liability 3,038
arising out of occurrences of a similar nature. Nothing in this 3,039
division shall be construed to prohibit an insurer from 3,040
determining a claimant's liability by applying formulas or 3,041
guidelines to the facts and circumstances disclosed by the 3,042
insurer's investigation of the particular occurrence upon which a 3,043
claim is based. 3,044
(Q) Refusing to insure, or refusing to continue to insure, 3,046
or limiting the amount, extent, or kind of life or sickness and 3,047
accident insurance or annuity coverage available to an 3,048
individual, or charging an individual a different rate for the 3,049
same coverage solely because of blindness or partial blindness. 3,050
With respect to all other conditions, including the underlying 3,051
cause of blindness or partial blindness, persons who are blind or 3,052
partially blind shall be subject to the same standards of sound 3,053
actuarial principles or actual or reasonably anticipated 3,054
actuarial experience as are sighted persons. Refusal to insure 3,055
includes, but is not limited to, denial by an insurer of 3,056
disability insurance coverage on the grounds that the policy 3,057
defines "disability" as being presumed in the event that the 3,058
eyesight of the insured is lost. However, an insurer may exclude 3,059
from coverage disabilities consisting solely of blindness or 3,060
partial blindness when such conditions existed at the time the 3,061
policy was issued. To the extent that the provisions of this 3,062
66
division may appear to conflict with any provision of section 3,063
3999.16 of the Revised Code, this division applies. 3,064
(R)(1) Directly or indirectly offering to sell, selling, 3,066
or delivering, issuing for delivery, renewing, or using or 3,067
otherwise marketing any policy of insurance or insurance product 3,068
in connection with or in any way related to the grant of a 3,069
student loan guaranteed in whole or in part by an agency or 3,070
commission of this state or the United States, except insurance 3,071
that is required under federal or state law as a condition for 3,072
obtaining such a loan and the premium for which is included in 3,073
the fees and charges applicable to the loan; or, in the case of 3,074
an insurer or insurance agent, knowingly permitting any lender 3,075
making such loans to engage in such acts or practices in 3,076
connection with the insurer's or agent's insurance business. 3,077
(2) Except in the case of a violation of division (G) of 3,079
this section, division (R)(1) of this section does not apply to 3,080
either of the following: 3,081
(a) Acts or practices of an insurer, its agents, 3,083
representatives, or employees in connection with the grant of a 3,084
guaranteed student loan to its insured or the insured's spouse or 3,085
dependent children where such acts or practices take place more 3,086
than ninety days after the effective date of the insurance; 3,087
(b) Acts or practices of an insurer, its agents, 3,089
representatives, or employees in connection with the 3,090
solicitation, processing, or issuance of an insurance policy or 3,091
product covering the student loan borrower or the borrower's 3,092
spouse or dependent children, where such acts or practices take 3,094
place more than one hundred eighty days after the date on which 3,095
the borrower is notified that the student loan was approved. 3,096
(S) Denying coverage, under any health insurance or health 3,098
care policy, contract, or plan providing family coverage, to any 3,099
natural or adopted child of the named insured or subscriber 3,100
solely on the basis that the child does not reside in the 3,101
household of the named insured or subscriber. 3,102
67
(T)(1) Using any underwriting standard or engaging in any 3,104
other act or practice that, directly or indirectly, due solely to 3,105
any health status-related factor in relation to one or more 3,106
individuals, does either of the following:
(a) Terminates or fails to renew an existing individual 3,108
policy, contract, or plan of health benefits, or a health benefit 3,109
plan issued to an employer, for which an individual would 3,110
otherwise be eligible;
(b) With respect to a health benefit plan issued to an 3,112
employer, excludes or causes the exclusion of an individual from 3,113
coverage under an existing employer-provided policy, contract, or 3,114
plan of health benefits.
(2) The superintendent of insurance may adopt rules in 3,116
accordance with Chapter 119. of the Revised Code for purposes of 3,117
implementing division (T)(1) of this section. 3,118
(3) For purposes of division (T)(1) of this section, 3,121
"health status-related factor" means any of the following: 3,122
(a) Health status; 3,124
(b) Medical condition, including both physical and mental 3,127
illnesses;
(c) Claims experience; 3,129
(d) Receipt of health care; 3,131
(e) Medical history; 3,133
(f) Genetic information; 3,135
(g) Evidence of insurability, including conditions arising 3,138
out of acts of domestic violence;
(h) Disability. 3,140
(U) With respect to a health benefit plan issued to a 3,142
small employer, as those terms are defined in section 3924.01 of 3,143
the Revised Code, negligently or willfully placing coverage for 3,144
adverse risks with a certain carrier, as defined in section 3,145
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 3,147
or practice that, directly or indirectly, causes or results in 3,148
68
the placing of coverage for adverse risks with another carrier, 3,149
as defined in section 3924.01 of the Revised Code. 3,150
(W) Failing to comply with section 3923.23, 3923.231, 3,152
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 3,153
in any unfair, discriminatory reimbursement practice. 3,154
(X) Intentionally establishing an unfair premium for, or 3,156
misrepresenting the cost of, any insurance policy financed under 3,157
a premium finance agreement of an insurance premium finance 3,158
company. 3,159
(Y)(1)(a) Limiting coverage under, refusing to issue, 3,161
canceling, or refusing to renew, any individual policy or 3,162
contract of life insurance, or limiting coverage under or 3,163
refusing to issue any individual policy or contract of health 3,164
insurance, for the reason that the insured or applicant for 3,165
insurance is or has been a victim of domestic violence; 3,166
(b) Adding a surcharge or rating factor to a premium of 3,168
any individual policy or contract of life or health insurance for 3,169
the reason that the insured or applicant for insurance is or has 3,170
been a victim of domestic violence; 3,171
(c) Denying coverage under, or limiting coverage under, 3,173
any policy or contract of life or health insurance, for the 3,174
reason that a claim under the policy or contract arises from an 3,175
incident of domestic violence;
(d) Inquiring, directly or indirectly, of an insured 3,177
under, or of an applicant for, a policy or contract of life or 3,178
health insurance, as to whether the insured or applicant is or 3,179
has been a victim of domestic violence, or inquiring as to 3,180
whether the insured or applicant has sought shelter or protection 3,181
from domestic violence or has sought medical or psychological
treatment as a victim of domestic violence. 3,182
(2) Nothing in division (Y)(1) of this section shall be 3,184
construed to prohibit an insurer from inquiring as to, or from 3,185
underwriting or rating a risk on the basis of, a person's 3,186
physical or mental condition, even if the condition has been 3,187
69
caused by domestic violence, provided that all of the following 3,188
apply:
(a) The insurer routinely considers the condition in 3,190
underwriting or in rating risks, and does so in the same manner 3,191
for a victim of domestic violence as for an insured or applicant 3,192
who is not a victim of domestic violence; 3,193
(b) The insurer does not refuse to issue any policy or 3,195
contract of life or health insurance or cancel or refuse to renew 3,197
any policy or contract of life insurance, solely on the basis of
the condition, except where such refusal to issue, cancellation, 3,198
or refusal to renew is based on sound actuarial principles or is 3,199
related to actual or reasonably anticipated experience; 3,200
(c) The insurer does not consider a person's status as 3,202
being or as having been a victim of domestic violence, in itself, 3,203
to be a physical or mental condition; 3,204
(d) The underwriting or rating of a risk on the basis of 3,206
the condition is not used to evade the intent of division (Y)(1) 3,208
of this section, or of any other provision of the Revised Code. 3,210
(3)(a) Nothing in division (Y)(1) of this section shall be 3,213
construed to prohibit an insurer from refusing to issue a policy 3,214
or contract of life insurance insuring the life of a person who 3,215
is or has been a victim of domestic violence if the person who 3,216
committed the act of domestic violence is the applicant for the 3,217
insurance or would be the owner of the insurance policy or 3,218
contract.
(b) Nothing in division (Y)(2) of this section shall be 3,221
construed to permit an insurer to cancel or refuse to renew any 3,222
policy or contract of health insurance in violation of the 3,223
"Health Insurance Portability and Accountability Act of 1996," 3,224
110 Stat. 1955, 42 U.S.C.A. 300gg-41(b), as amended, or in a 3,226
manner that violates or is inconsistent with any provision of the 3,227
Revised Code that implements the "Health Insurance Portability 3,229
and Accountability Act of 1996." 3,230
(4) An insurer is immune from any civil or criminal 3,233
70
liability that otherwise might be incurred or imposed as a result
of any action taken by the insurer to comply with division (Y) of 3,235
this section.
(5) As used in division (Y) of this section, "domestic 3,238
violence" means any of the following acts: 3,239
(a) Knowingly causing or attempting to cause physical harm 3,241
to a family or household member; 3,243
(b) Recklessly causing serious physical harm to a family 3,245
or household member; 3,247
(c) Knowingly causing, by threat of force, a family or 3,249
household member to believe that the person will cause imminent 3,250
physical harm to the family or household member. 3,251
For the purpose of division (Y)(5) of this section, "family 3,255
or household member" has the same meaning as in section 2919.25
of the Revised Code. 3,256
Nothing in division (Y)(5) of this section shall be 3,259
construed to require, as a condition to the application of 3,260
division (Y) of this section, that the act described in division 3,262
(Y)(5) of this section be the basis of a criminal prosecution. 3,264
With respect to private passenger automobile insurance, no 3,266
insurer shall charge different premium rates to persons residing 3,267
within the limits of any municipal corporation based solely on 3,268
the location of the residence of the insured within those limits. 3,269
The enumeration in sections 3901.19 to 3901.26 of the 3,271
Revised Code of specific unfair or deceptive acts or practices in 3,272
the business of insurance is not exclusive or restrictive or 3,273
intended to limit the powers of the superintendent of insurance 3,274
to adopt rules to implement this section, or to take action under 3,275
other sections of the Revised Code. 3,276
This section does not prohibit the sale of shares of any 3,278
investment company registered under the "Investment Company Act 3,279
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 3,280
policies, annuities, or other contracts described in section 3,281
3907.15 of the Revised Code. 3,282
71
As used in this section, "estimate," "statement," 3,284
"representation," "misrepresentation," "advertisement," or 3,285
"announcement" includes oral or written occurrences. 3,286
Sec. 3923.021. (A) As used in this section, "benefits 3,295
provided are not unreasonable in relation to the premium charged" 3,296
means the rates were calculated in accordance with sound 3,297
actuarial principles. 3,298
(B) With respect to any filing, made pursuant to section 3,300
3923.02 of the Revised Code, of any premium rates for any 3,301
individual policy of sickness and accident insurance or for any 3,302
indorsement or rider pertaining thereto, the superintendent of 3,303
insurance may, within thirty days after filing: 3,304
(1) Disapprove such filing after finding that the benefits 3,307
provided are unreasonable in relation to the premium charged. 3,308
Such disapproval shall be effected by written order of the 3,309
superintendent, a copy of which shall be mailed to the insurer 3,310
that has made the filing. In the order, the superintendent shall 3,311
specify the reasons for the disapproval and state that a hearing 3,313
will be held within fifteen days after requested in writing by 3,314
the insurer. If a hearing is so requested, the superintendent 3,315
shall also give such public notice as the superintendent 3,316
considers appropriate. The superintendent, within fifteen days 3,318
after the commencement of any hearing, shall issue a written 3,319
order, a copy of which shall be mailed to the insurer that has 3,320
made the filing, either affirming the prior disapproval or 3,321
approving such filing after finding that the benefits provided 3,322
are not unreasonable in relation to the premium charged. 3,324
(2) Set a date for a public hearing to commence no later 3,326
than forty days after the filing. The superintendent shall give 3,327
the insurer making the filing twenty days' written notice of the 3,328
hearing and shall give such public notice as the superintendent 3,330
considers appropriate. The superintendent, within twenty days 3,331
after the commencement of a hearing, shall issue a written order, 3,332
a copy of which shall be mailed to the insurer that has made the 3,333
72
filing, either approving such filing if the superintendent finds 3,334
that the benefits provided are not unreasonable in relation to 3,336
the premium charged, or disapproving such filing if the 3,337
superintendent finds that the benefits provided are unreasonable 3,339
in relation to the premium charged. This division does not apply 3,340
to any insurer organized or transacting the business of insurance 3,341
under Chapter 3907. or 3909. of the Revised Code. 3,342
(3) Take no action, in which case such filing shall be 3,344
deemed to be approved and shall become effective upon the 3,345
thirty-first day after such filing, unless the superintendent has 3,346
previously given to the insurer a written approval. 3,347
(C) At any time after any filing has been approved 3,349
pursuant to this section, the superintendent may, after a hearing 3,350
of which at least twenty days' written notice has been given to 3,351
the insurer that has made such filing and for which such public 3,352
notice as the superintendent considers appropriate has been 3,353
given, withdraw approval of such filing after finding that the 3,355
benefits provided are unreasonable in relation to the premium 3,357
charged. Such withdrawal of approval shall be effected by 3,358
written order of the superintendent, a copy of which shall be 3,359
mailed to the insurer that has made the filing, which shall state 3,360
the ground for such withdrawal and the date, not less than forty 3,361
days after the date of such order, when the withdrawal or 3,362
approval shall become effective. 3,363
(D) The superintendent may retain at the insurer's expense 3,365
such attorneys, actuaries, accountants, and other experts not 3,366
otherwise a part of the superintendent's staff as shall be 3,367
reasonably necessary to assist in the preparation for and conduct 3,368
of any public hearing under this section. The expense for 3,369
retaining such experts and the expenses of the department of 3,370
insurance incurred in connection with such public hearing shall 3,371
be assessed against the insurer in an amount not to exceed one 3,372
one-hundredth of one per cent of the sum of premiums earned plus 3,373
net realized investment gain or loss of such insurer as reflected 3,374
73
in the most current annual statement on file with the 3,375
superintendent. Any person retained shall be under the direction 3,376
and control of the superintendent and shall act in a purely 3,377
advisory capacity. 3,378
(E) This section does not apply to any filing of any 3,380
premium rate or rating formula for individual sickness and 3,381
accident insurance policies offered in accordance with division 3,382
(L) of section 3923.58 of the Revised Code, or for any amendment 3,384
thereto.
Sec. 3923.122. (A) Every policy of group sickness and 3,393
accident insurance providing hospital, surgical, or medical 3,394
expense coverage for other than specific diseases or accidents 3,395
only, and delivered, issued for delivery, or renewed in this 3,396
state on or after January 1, 1976, shall include a provision 3,397
giving each insured the option to convert to the following: 3,398
(1) In the case of an individual who is not a federally 3,401
eligible individual, any of the individual policies of hospital, 3,402
surgical, or medical expense insurance then being issued by the 3,403
insurer with benefit limits not to exceed those in effect under 3,404
the group policy;
(2) In the case of a federally eligible individual, a 3,406
basic or standard plan established by the board of directors of 3,407
the Ohio health reinsurance program or plans substantially 3,408
similar to the basic and standard plan in benefit design and 3,409
scope of covered services. For purposes of division (A)(2) of 3,410
this section, the superintendent of insurance shall determine 3,411
whether a plan is substantially similar to the basic or standard 3,412
plan in benefit design and scope of covered services. 3,413
(B) An option for conversion to an individual policy shall 3,415
be available without evidence of insurability to every insured, 3,416
including any person eligible under division (D) of this section, 3,417
who terminates employment or membership in the group holding the 3,419
policy after having been continuously insured thereunder for at 3,420
least one year.
74
Upon receipt of the insured's written application and upon 3,422
payment of at least the first quarterly premium not later than 3,423
thirty-one days after the termination of coverage under the group 3,424
policy, the insurer shall issue a converted policy on a form then 3,425
available for conversion. The premium shall be in accordance 3,426
with the insurer's table of premium rates in effect on the later 3,427
of the following dates: 3,428
(1) The effective date of the converted policy; 3,430
(2) The date of application therefor; and shall be 3,432
applicable to the class of risk to which each person covered 3,434
belongs and to the form and amount of the policy at the person's 3,435
then attained age. However, premiums charged federally eligible 3,436
individuals may not exceed an amount that is two times the 3,438
midpoint of the standard rate charged any other individual of a 3,439
group to which the insurer is currently accepting new business 3,440
and for which similar copayments and deductibles are applied. 3,441
At the election of the insurer, a separate converted policy 3,443
may be issued to cover any dependent of an employee or member of 3,444
the group. 3,445
Except as provided in division (H) of this section, any 3,447
converted policy shall become effective as of the day following 3,448
the date of termination of insurance under the group policy. 3,449
Any probationary or waiting period set forth in the 3,451
converted policy is deemed to commence on the effective date of 3,452
the insured's coverage under the group policy. 3,453
(C) No insurer shall be required to issue a converted 3,455
policy to any person who is, or is eligible to be, covered for 3,456
benefits at least comparable to the group policy under: 3,457
(1) Title XVIII of the Social Security Act, as amended or 3,459
superseded; 3,460
(2) Any act of congress or law under this or any other 3,462
state of the United States that duplicates coverage offered under 3,463
division (C)(1) of this section; 3,464
(3) Any policy that duplicates coverage offered under 3,466
75
division (C)(1) of this section; 3,467
(4) Any other group sickness and accident insurance 3,469
providing hospital, surgical, or medical expense coverage for 3,470
other than specific diseases or accidents only. 3,471
(D) The option for conversion shall be available: 3,473
(1) Upon the death of the employee or member, to the 3,475
surviving spouse with respect to such of the spouse and 3,476
dependents as are then covered by the group policy; 3,477
(2) To a child solely with respect to the child upon 3,479
attaining the limiting age of coverage under the group policy 3,480
while covered as a dependent thereunder; 3,481
(3) Upon the divorce, dissolution, or annulment of the 3,483
marriage of the employee or member, to the divorced spouse, or 3,484
former spouse in the event of annulment, of such employee or 3,485
member, or upon the legal separation of the spouse from such 3,486
employee or member, to the spouse. 3,487
Persons possessing the option for conversion pursuant to 3,489
this division shall be considered members for the purposes of 3,490
division (H) of this section. 3,491
(E) If coverage is continued under a group policy on an 3,493
employee following retirement prior to the time the employee is, 3,495
or is eligible to be, covered by Title XVIII of the Social 3,496
Security Act, the employee may elect, in lieu of the continuance 3,497
of group insurance, to have the same conversion rights as would 3,499
apply had the employee's insurance terminated at retirement by 3,501
reason of termination of employment. 3,502
(F) If the insurer and the group policyholder agree upon 3,504
one or more additional plans of benefits to be available for 3,505
converted policies, the applicant for the converted policy may 3,506
elect such a plan in lieu of a converted policy. 3,507
(G) The converted policy may contain provisions for 3,509
avoiding duplication of benefits provided pursuant to divisions 3,510
(C)(1), (2), (3), and (4) of this section or provided under any 3,511
other insured or noninsured plan or program. 3,512
76
(H) If an employee or member becomes entitled to obtain a 3,514
converted policy pursuant to this section, and if the employee or 3,515
member has not received notice of the conversion privilege at 3,516
least fifteen days prior to the expiration of the thirty-one-day 3,517
conversion period provided in division (B) of this section, then 3,518
the employee or member has an additional period within which to 3,519
exercise the privilege. This additional period shall expire 3,520
fifteen days after the employee or member receives notice, but in 3,521
no event shall the period extend beyond sixty days after the 3,522
expiration of the thirty-one-day conversion period. 3,523
Written notice presented to the employee or member, or 3,525
mailed by the policyholder to the last known address of the 3,526
employee or member as indicated on its records, constitutes 3,527
notice for the purpose of this division. In the case of a person 3,528
who is eligible for a converted policy under division (D)(2) or 3,529
(D)(3) of this section, a policyholder shall not be responsible 3,530
for presenting or mailing such notice, unless such policyholder 3,531
has actual knowledge of the person's eligibility for a converted 3,532
policy. 3,533
If an additional period is allowed by an employee or member 3,535
for the exercise of a conversion privilege, and if written 3,536
application for the converted policy, accompanied by at least the 3,537
first quarterly premium, is made after the expiration of the 3,538
thirty-one-day conversion period, but within the additional 3,539
period allowed an employee or member in accordance with this 3,540
division, the effective date of the converted policy shall be the 3,541
date of application. 3,542
(I) The converted policy may provide: 3,544
(1) That THAT any hospital, surgical, or medical expense 3,546
benefits otherwise payable with respect to any person may be 3,547
reduced by the amount of any such benefits payable under the 3,548
group policy for the same loss after termination of coverage; 3,549
(2) For termination of coverage on any person who is, or 3,551
is eligible to be, covered pursuant to division (C) of this 3,552
77
section; 3,553
(3) That the insurer may request information in advance of 3,555
any premium due date of the policy as to whether the insured is, 3,556
or is eligible to be, covered pursuant to division (C) of this 3,557
section. If the insured is, or is eligible to be, covered, and 3,558
the insured fails to furnish the details of the insured's 3,560
coverage or eligibility to the insurer within thirty-one days 3,561
after the date of the request, the benefits payable under the 3,562
converted policy may be based on the hospital, surgical, or 3,563
medical expenses actually incurred after excluding expenses to 3,564
the extent of the amount of benefits for which the insured is, or 3,565
is eligible to be, covered pursuant to division (C) of this 3,566
section.
(J) The converted policy may contain: 3,568
(1) Any exclusion, reduction, or limitation contained in 3,570
the group policy or customarily used in individual policies 3,571
issued by the insurer; 3,572
(2) Any provision permitted in this section; 3,574
(3) Any other provision not prohibited by law. 3,576
Any provision required or permitted in this section may be 3,578
made a part of any converted policy by means of an endorsement or 3,579
rider. 3,580
(K) The time limit specified in a converted policy for 3,582
certain defenses with respect to any person who was covered by a 3,583
group policy shall commence on the effective date of such 3,584
person's coverage under the group policy. 3,585
(L) No insurer shall use deterioration of health as the 3,587
basis for refusing to renew a converted policy. 3,588
(M) No insurer shall use age as the basis for refusing to 3,590
renew a converted policy. 3,591
(N) A converted policy made available pursuant to this 3,593
section shall, if delivery of the policy is to be made in this 3,594
state, comply with this section. If delivery of a converted 3,595
policy is to be made in another state, it may be on a form 3,596
78
offered by the insurer in the jurisdiction where the delivery is 3,597
to be made and which provides benefits substantially in 3,598
compliance with those required in a policy delivered in this 3,599
state. 3,600
(O) As used in this section, "federally eligible 3,603
individual" means an eligible individual as defined in 45 C.F.R. 3,605
148.103. 3,606
Sec. 3923.57. Notwithstanding any provision of this 3,615
chapter, every individual policy of sickness and accident 3,616
insurance that is delivered, issued for delivery, or renewed in 3,617
this state is subject to the following conditions, as applicable: 3,618
(A) Pre-existing conditions provisions shall not exclude 3,620
or limit coverage for a period beyond twelve months following the 3,621
policyholder's effective date of coverage and may only relate to 3,622
conditions during the six months immediately preceding the 3,623
effective date of coverage. 3,624
(B) In determining whether a pre-existing conditions 3,626
provision applies to a policyholder or dependent, each policy 3,627
shall credit the time the policyholder or dependent was covered 3,628
under a previous policy, contract, or plan if the previous 3,630
coverage was continuous to a date not more than thirty days prior 3,632
to the effective date of the new coverage, exclusive of any 3,633
applicable service waiting period under the policy. 3,634
(C)(1) Except as otherwise provided in division (C) of 3,637
this section, an insurer that provides an individual sickness and 3,638
accident insurance policy to an individual shall renew or 3,639
continue in force such coverage at the option of the individual. 3,640
(2) An insurer may nonrenew or discontinue coverage of an 3,643
individual in the individual market based only on one or more of 3,644
the following reasons:
(a) The individual failed to pay premiums or contributions 3,647
in accordance with the terms of the policy or the insurer has not 3,648
received timely premium payments.
(b) The individual performed an act or practice that 3,651
79
constitutes fraud or made an intentional misrepresentation of 3,652
material fact under the terms of the policy.
(c) The insurer is ceasing to offer coverage in the 3,655
individual market in accordance with division (D) of this section 3,656
and the applicable laws of this state. 3,657
(d) If the insurer offers coverage in the market through a 3,660
network plan, the individual no longer resides, lives, or works 3,661
in the service area, or in an area for which the insurer is 3,662
authorized to do business; provided, however, that such coverage 3,663
is terminated uniformly without regard to any health 3,664
status-related factor of covered individuals.
(e) If the coverage is made available in the individual 3,667
market only through one or more bona fide associations, the 3,668
membership of the individual in the association, on the basis of 3,669
which the coverage is provided, ceases; provided, however, that 3,670
such coverage is terminated under division (C)(2)(e) of this 3,673
section uniformly without regard to any health status-related 3,674
factor of covered individuals.
AN INSURER OFFERING COVERAGE TO INDIVIDUALS SOLELY THROUGH 3,676
MEMBERSHIP IN A BONA FIDE ASSOCIATION SHALL NOT BE DEEMED, BY 3,677
VIRTUE OF THAT OFFERING, TO BE IN THE INDIVIDUAL MARKET FOR 3,678
PURPOSES OF SECTIONS 3923.58 AND 3923.581 OF THE REVISED CODE. 3,679
SUCH AN INSURER SHALL NOT BE REQUIRED TO ACCEPT APPLICANTS FOR 3,681
COVERAGE IN THE INDIVIDUAL MARKET PURSUANT TO SECTIONS 3923.58
AND 3923.581 OF THE REVISED CODE UNLESS THE INSURER ALSO OFFERS 3,683
COVERAGE TO INDIVIDUALS OTHER THAN THROUGH BONA FIDE
ASSOCIATIONS.
(3) An insurer may cancel or decide not to renew the 3,685
coverage of a dependent of an individual if the dependent has 3,686
performed an act or practice that constitutes fraud or made an 3,687
intentional misrepresentation of material fact under the terms of 3,688
the coverage and if the cancellation or nonrenewal is not based, 3,689
either directly or indirectly, on any health status-related 3,690
factor in relation to the dependent.
80
(D)(1) If an insurer decides to discontinue offering a 3,693
particular type of health insurance coverage offered in the 3,694
individual market, coverage of such type may be discontinued by 3,695
the insurer if the insurer does all of the following: 3,696
(a) Provides notice to each individual provided coverage 3,699
of this type in such market of the discontinuation at least 3,700
ninety days prior to the date of the discontinuation of the 3,701
coverage;
(b) Offers to each individual provided coverage of this 3,704
type in such market, the option to purchase any other individual 3,705
health insurance coverage currently being offered by the insurer 3,706
for individuals in that market;
(c) In exercising the option to discontinue coverage of 3,709
this type and in offering the option of coverage under division 3,710
(D)(1)(b) of this section, acts uniformly without regard to any 3,712
health status-related factor of covered individuals or of 3,713
individuals who may become eligible for such coverage. 3,714
(2) If an insurer elects to discontinue offering all 3,716
health insurance coverage in the individual market in this state, 3,718
health insurance coverage may be discontinued by the insurer only 3,719
if both of the following apply:
(a) The insurer provides notice to the department of 3,722
insurance and to each individual of the discontinuation at least 3,723
one hundred eighty days prior to the date of the expiration of 3,724
the coverage.
(b) All health insurance delivered or issued for delivery 3,727
in this state in such market is discontinued and coverage under 3,728
that health insurance in that market is not renewed. 3,729
(3) In the event of a discontinuation under division 3,731
(D)(2) of this section in the individual market, the insurer 3,733
shall not provide for the issuance of any health insurance 3,734
coverage in the market and this state during the five-year period 3,735
beginning on the date of the discontinuation of the last health 3,736
insurance coverage not so renewed. 3,737
81
(E) Nothwithstanding NOTWITHSTANDING divisions (C) and (D) 3,740
of this section, an insurer may, at the time of coverage renewal,
modify the health insurance coverage for a policy form offered to 3,742
individuals in the individual market if the modification is 3,743
consistent with the law of this state and effective on a uniform 3,744
basis among all individuals with that policy form. 3,745
(F) Such policies are subject to sections 2743 and 2747 of 3,748
the "Health Insurance Portability and Accountability Act of 3,752
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 3,758
and 300gg-47, as amended. 3,759
(G) Sections 3924.031 and 3924.032 of the Revised Code 3,763
shall apply to sickness and accident insurance policies offered 3,764
in the individual market in the same manner as they apply to 3,765
health benefit plans offered in the small employer market. 3,766
In accordance with 45 C.F.R. 148.102, divisions (C) to (G) 3,771
of this section also apply to all group sickness and accident 3,772
insurance policies that are not sold in connection with an 3,773
employment-related group health plan and that provide more than 3,774
short-term, limited duration coverage. 3,775
In applying divisions (C) to (G) of this section with 3,779
respect to health insurance coverage that is made available by an 3,781
insurer in the individual market to individuals only through one 3,782
or more associations, the term "individual" includes the
association of which the individual is a member. 3,783
For purposes of this section, any policy issued pursuant to 3,785
division (C) of section 3923.13 of the Revised Code in connection 3,788
with a public or private college or university student health
insurance program is considered to be issued to a bona fide 3,789
association and is not subject to divisions (C) to (G) of this 3,791
section.
As used in this section, "bona fide association" has the 3,794
same meaning as in section 3924.03 of the Revised Code, and 3,796
"health status-related factor" and "network plan" have the same 3,797
meanings as in section 3924.031 of the Revised Code. 3,799
82
This section does not apply to any policy that provides 3,801
coverage for specific diseases or accidents only, or to any 3,802
hospital indemnity, medicare supplement, long-term care, 3,803
disability income, one-time-limited-duration policy of no longer 3,804
than six months, or other policy that offers only supplemental 3,805
benefits. 3,806
Sec. 3923.571. Except as otherwise provided in section 3,816
2721 of the "Health Insurance Portability and Accountability Act 3,821
of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 3,826
300gg-21, as amended, the following conditions apply to all group 3,828
policies of sickness and accident insurance that are sold in
connection with an employment-related group health plan and that 3,829
are not subject to section 3924.03 of the Revised Code: 3,830
(A) Any such policy shall comply with the requirements of 3,832
division (A) of section 3924.03 and section 3924.033 of the 3,833
Revised Code. 3,834
(B)(1) Except as provided in section 2712(b) to (e) of the 3,838
"Health Insurance Portability and Accountability Act of 1996," if 3,842
an insurer offers coverage in the small or large group market in 3,843
connection with a group policy, the insurer shall renew or 3,844
continue in force such coverage at the option of the 3,845
policyholder.
(2) An insurer may cancel or decide not to renew the 3,847
coverage of an employee or of a dependent of an employee if the 3,848
employee or dependent, as applicable, has performed an act or 3,849
practice that constitutes fraud or made an intentional 3,850
misrepresentation of material fact under the terms of the
coverage and if the cancellation or nonrenewal is not based, 3,851
either directly or indirectly, on any health status-related 3,852
factor in relation to the employee or dependent. 3,853
As used in division (B)(2) of this section, "health 3,856
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 3,858
(C)(1) No such policy, or insurer offering health 3,860
83
insurance coverage in connection with such a policy, shall 3,862
require any individual, as a condition of coverage or continued 3,863
coverage under the policy, to pay a premium or contribution that 3,864
is greater than the premium or contribution for a similarly 3,865
situated individual covered under the policy on the basis of any 3,866
health status-related factor in relation to the individual or to 3,867
an individual covered under the policy as a dependent of the 3,868
individual. 3,869
(2) Nothing in division (C)(1) of this section shall be 3,872
construed to restrict the amount that an employer may be charged 3,873
for coverage under a group policy, or to prevent a group policy, 3,874
and an insurer offering group health insurance coverage, from 3,875
establishing premium discounts or rebates or modifying otherwise 3,876
applicable copayments or deductibles in return for adherence to 3,877
programs of health promotion and disease prevention. 3,878
(D) Such policies shall provide for the special enrollment 3,881
periods described in section 2701(f) of the "Health Insurance 3,884
Portability and Accountability Act of 1996." 3,887
(E) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, A HEALTH 3,889
INSURING CORPORATION SHALL PROVIDE TO ALL LATE ENROLLEES, AS 3,890
DEFINED IN SECTION 3924.01 OF THE REVISED CODE, THE OPTION TO 3,893
ENROLL IN THE GROUP HEALTH CARE PLAN. THE ENROLLMENT OPTION 3,894
SHALL BE PROVIDED FOR A MINIMUM PERIOD OF THIRTY CONSECUTIVE 3,895
DAYS. ANY PRE-EXISTING CONDITION EXCLUSION PERIOD MUST START ON 3,896
THE DATE OF APPLICATION. 3,897
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 3,906
of the Revised Code: 3,907
(1) "Health benefit plan" and "MEWA" have the same 3,910
meanings as in section 3924.01 of the Revised Code. 3,911
(2) "Insurer" means any sickness and accident insurance 3,913
company authorized to do business in this state, or MEWA 3,916
authorized to issue insured health benefit plans in this state. 3,917
"Insurer" does not include any health insuring corporation that
is owned or operated by an insurer. 3,919
84
(3) "Pre-existing conditions provision" means a policy 3,922
provision that excludes or limits coverage for charges or 3,923
expenses incurred during a specified period following the 3,924
insured's effective date of coverage as to a condition which, 3,925
during a specified period immediately preceding the effective 3,926
date of coverage, had manifested itself in such a manner as would 3,928
cause an ordinarily prudent person to seek medical advice,
diagnosis, care, or treatment or for which medical advice, 3,929
diagnosis, care, or treatment was recommended or received, or a 3,930
pregnancy existing on the effective date of coverage. 3,931
(B) Beginning in January of each year, insurers in the 3,934
business of issuing individual policies of sickness and accident 3,935
insurance as contemplated by section 3923.021 of the Revised 3,936
Code, except individual policies issued pursuant to section 3,938
3923.122 of the Revised Code, shall accept applicants for open 3,942
enrollment coverage, as set forth in this division, in the order 3,944
in which they apply for coverage and subject to the limitation 3,945
set forth in division (G) of this section. Insurers shall accept 3,946
for coverage pursuant to this section individuals to whom both of 3,949
the following conditions apply:
(1) The individual is not applying for coverage as an 3,951
employee of an employer, as a member of an association, or as a 3,952
member of any other group. 3,953
(2) The individual is not covered, and is not eligible for 3,955
coverage, under any other private or public health benefits 3,956
arrangement, including the medicare program established under 3,957
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 3,958
U.S.C.A. 301, as amended, or any other act of congress or law of 3,959
this or any other state of the United States that provides 3,960
benefits comparable to the benefits provided under this section, 3,961
any medicare supplement policy, or any continuation of coverage 3,963
policy under state or federal law.
(C) An insurer shall offer to any individual accepted 3,966
under this section the small employer health care plan BASIC AND 3,967
85
STANDARD PLANS established by the board of directors of the Ohio 3,969
health reinsurance program under division (A) of section 3924.10 3,971
of the Revised Code or a health benefit plan PLANS that is ARE 3,973
substantially similar to the small employer health care plan 3,974
BASIC AND STANDARD PLANS in benefit plan design and scope of 3,975
covered services.
An insurer may offer other health benefit plans in addition 3,977
to, but not in lieu of, the plan PLANS required to be offered 3,978
under this division. These additional A BASIC health benefit 3,980
plans PLAN shall provide, at a minimum, the coverage provided by 3,982
the small employer OHIO health care BASIC plan or any health 3,983
benefit plan that is substantially similar to the small employer 3,984
OHIO health care BASIC plan in benefit plan design and scope of 3,986
covered services. A STANDARD HEALTH BENEFIT PLAN SHALL PROVIDE, 3,987
AT A MINIMUM, THE COVERAGE PROVIDED BY THE OHIO HEALTH CARE 3,988
STANDARD PLAN OR ANY HEALTH BENEFIT PLAN THAT IS SUBSTANTIALLY 3,989
SIMILAR TO THE OHIO HEALTH CARE STANDARD PLAN IN BENEFIT PLAN 3,990
DESIGN AND SCOPE OF COVERED SERVICES.
For purposes of this division, the superintendent of 3,992
insurance shall determine whether a health benefit plan is 3,993
substantially similar to the small employer OHIO health care plan 3,995
BASIC AND STANDARD PLANS in benefit plan design and scope of 3,997
covered services. 3,998
(D) Health benefit plans issued under this section may 4,000
establish pre-existing conditions provisions that exclude or 4,001
limit coverage for a period of up to twelve months following the 4,002
individual's effective date of coverage and that may relate only 4,003
to conditions during the six months immediately preceding the 4,004
effective date of coverage. 4,005
(E) Premiums charged to individuals under this section may 4,008
not exceed an amount that is two and one-half times the highest 4,009
rate charged any other individual to which the insurer is
currently accepting new business, and for which similar 4,010
copayments and deductibles are applied. 4,011
86
(F) In offering health benefit plans under this section, 4,013
an insurer may require the purchase of health benefit plans that 4,014
condition the reimbursement of health services upon the use of a 4,015
specific network of providers. 4,016
(G)(1) In no event shall an insurer be required to accept 4,018
annually under this section individuals who, in the aggregate, 4,019
would cause the insurer to have a total number of new insureds 4,022
that is more than one-half per cent of its total number of 4,023
insured individuals in this state per year, as contemplated by 4,024
section 3923.021 of the Revised Code, calculated as of the 4,025
immediately preceding thirty-first day of December and excluding 4,026
the insurer's medicare supplement policies and conversion or 4,027
continuation of coverage policies under state or federal law and 4,028
any policies described in division (M)(L) of this section. 4,029
(2) An officer of the insurer shall certify to the 4,031
department of insurance when it has met the enrollment limit set 4,032
forth in division (G)(1) of this section. Upon providing such 4,033
certification, the insurer shall be relieved of its open 4,034
enrollment requirement under this section for the remainder of 4,035
the calendar year. 4,036
(H) An insurer shall not be required to accept under this 4,038
section applicants who, at the time of enrollment, are confined 4,039
to a health care facility because of chronic illness, permanent 4,040
injury, or other infirmity that would cause economic impairment 4,041
to the insurer if the applicants were accepted, or to make the 4,042
effective date of benefits for individuals accepted under this 4,044
section earlier than ninety days after the date of acceptance. 4,045
(I) The requirements of this section do not apply to any 4,047
insurer that is currently in a state of supervision, insolvency, 4,048
or liquidation. If an insurer demonstrates to the satisfaction 4,049
of the superintendent that the requirements of this section would 4,051
place the insurer in a state of supervision, insolvency, or 4,052
liquidation, the superintendent may waive or modify the 4,053
requirements of division (B) or (G) of this section. The actions
87
of the superintendent under this division shall be effective for 4,055
a period of not more than one year. At the expiration of such 4,056
time, a new showing of need for a waiver or modification by the 4,057
insurer shall be made before a new waiver or modification is 4,058
issued or imposed.
(J) No hospital, health care facility, or health care 4,060
practitioner, and no person who employs any health care 4,061
practitioner, shall balance bill any individual or dependent of 4,062
an individual for any health care supplies or services provided 4,063
to the individual or dependent who is insured under a policy 4,065
issued under this section. The hospital, health care facility, 4,067
or health care practitioner, or any person that employs the 4,068
health care practitioner, shall accept payments made to it by the 4,069
insurer under the terms of the policy or contract insuring or 4,070
covering such individual as payment in full for such health care 4,071
supplies or services. 4,072
As used in this division, "hospital" has the same meaning 4,074
as in section 3727.01 of the Revised Code; "health care 4,075
practitioner" has the same meaning as in section 4769.01 of the 4,076
Revised Code; and "balance bill" means charging or collecting an 4,077
amount in excess of the amount reimbursable or payable under the 4,078
policy or health care service contract issued to an individual 4,079
under this section for such health care supply or service. 4,080
"Balance bill" does not include charging for or collecting 4,081
copayments or deductibles required by the policy or contract. 4,082
(K) An insurer shall pay an agent a commission in the 4,084
amount of five per cent of the premium charged for initial 4,085
placement or for otherwise securing the issuance of a policy or 4,086
contract issued to an individual under this section, and four per 4,088
cent of the premium charged for the renewal of such a policy or 4,089
contract. The superintendent may adopt, in accordance with 4,090
Chapter 119. of the Revised Code, such rules as are necessary to 4,091
enforce this division.
(L) Individuals accepted for coverage under this section 4,093
88
may be issued contracts and certificates subject to the 4,094
requirements of section 3923.12 of the Revised Code. The 4,095
coverage issued to such individuals is not subject to the 4,096
requirements of section 3923.021 of the Revised Code. 4,097
(M) This section does not apply to any policy that 4,099
provides coverage for specific diseases or accidents only, or to 4,101
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 4,103
than six months, or other policy that offers only supplemental 4,104
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 4,113
the Revised Code: 4,114
(A) "Actuarial certification" means a written statement 4,116
prepared by a member of the American academy of actuaries, or by 4,117
any other person acceptable to the superintendent of insurance, 4,118
that states that, based upon the person's examination, a carrier 4,119
offering health benefit plans to small employers is in compliance 4,120
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 4,121
certification" shall include a review of the appropriate records 4,122
of, and the actuarial assumptions and methods used by, the 4,123
carrier relative to establishing premium rates for the health 4,124
benefit plans. 4,125
(B) "Adjusted average market premium price" means the 4,127
average market premium price as determined by the board of 4,129
directors of the Ohio health reinsurance program either on the 4,130
basis of the arithmetic mean of all carriers' premium rates for 4,132
an SEHC OHC plan sold to groups with similar case characteristics 4,134
by all carriers selling SEHC OHC plans in the state, or on any 4,136
other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 4,138
plan that is issued by a carrier and that covers at least two but 4,139
no more than fifty employees of a small employer, the lowest 4,141
premium rate for a new or existing business prescribed by the 4,142
carrier for the same or similar coverage under a plan or 4,143
89
arrangement covering any small employer with similar case 4,144
characteristics.
(D) "Carrier" means any sickness and accident insurance 4,146
company or health insuring corporation authorized to issue health 4,149
benefit plans in this state or a MEWA. A sickness and accident 4,151
insurance company that owns or operates a health insuring 4,152
corporation, either as a separate corporation or as a line of 4,154
business, shall be considered as a separate carrier from that 4,155
health insuring corporation for purposes of sections 3924.01 to 4,157
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 4,159
employer, the geographic area in which the employees work; the 4,160
age and sex of the individual employees and their dependents; the 4,161
appropriate industry classification as determined by the carrier; 4,162
the number of employees and dependents; and such other objective 4,163
criteria as may be established by the carrier. "Case 4,164
characteristics" does not include claims experience, health 4,165
status, or duration of coverage from the date of issue. 4,166
(F) "Dependent" means the spouse or child of an eligible 4,168
employee, subject to applicable terms of the health benefits plan 4,169
covering the employee. 4,170
(G) "Eligible employee" means an employee who works a 4,172
normal work week of twenty-five or more hours. "Eligible 4,173
employee" does not include a temporary or substitute employee, or 4,175
a seasonal employee who works only part of the calendar year on 4,176
the basis of natural or suitable times or circumstances. 4,177
(H) "Health benefit plan" means any hospital or medical 4,179
expense policy or certificate or any health plan provided by a 4,181
carrier, that is delivered, issued for delivery, renewed, or used 4,183
in this state on or after the date occurring six months after 4,184
November 24, 1995. "Health benefit plan" does not include 4,186
policies covering only accident, credit, dental, disability 4,187
income, long-term care, hospital indemnity, medicare supplement, 4,188
specified disease, or vision care; coverage under a 4,189
90
one-time-limited-duration policy of no longer than six months; 4,191
coverage issued as a supplement to liability insurance; insurance 4,192
arising out of a workers' compensation or similar law; automobile 4,193
medical-payment insurance; or insurance under which benefits are 4,194
payable with or without regard to fault and which is statutorily 4,195
required to be contained in any liability insurance policy or 4,196
equivalent self-insurance.
(I) "Late enrollee" means an eligible employee or 4,198
dependent who enrolls in a small employer's health benefit plan 4,201
other than during the first period in which the employee or 4,202
dependent is eligible to enroll under the plan or during a 4,204
special enrollment period described in section 2701(f) of the 4,205
"Health Insurance Portability and Accountability Act of 1996," 4,210
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg, as 4,216
amended.
(J) "MEWA" means any "multiple employer welfare 4,218
arrangement" as defined in section 3 of the "Federal Employee 4,219
Retirement Income Security Act of 1974," 88 Stat. 832, 29 4,220
U.S.C.A. 1001, as amended, except for any arrangement which is 4,221
fully insured as defined in division (b)(6)(D) of section 514 of 4,222
that act. 4,223
(K) "Midpoint rate" means, for small employers with 4,225
similar case characteristics and plan designs and as determined 4,226
by the applicable carrier for a rating period, the arithmetic 4,227
average of the applicable base premium rate and the corresponding 4,228
highest premium rate. 4,229
(L) "Pre-existing conditions provision" means a policy 4,231
provision that excludes or limits coverage for charges or 4,233
expenses incurred during a specified period following the 4,234
insured's enrollment date as to a condition for which medical 4,236
advice, diagnosis, care, or treatment was recommended or received 4,237
during a specified period immediately preceding the enrollment 4,240
date. Genetic information shall not be treated as such a 4,241
condition in the absence of a diagnosis of the condition related 4,242
91
to such information. 4,243
For purposes of this division, "enrollment date" means, 4,245
with respect to an individual covered under a group health 4,246
benefit plan, the date of enrollment of the individual in the 4,247
plan or, if earlier, the first day of the waiting period for such 4,249
enrollment.
(M) "Service waiting period" means the period of time 4,251
after employment begins before an employee is eligible to be 4,252
covered for benefits under the terms of any applicable health 4,254
benefit plan offered by the small employer.
(N)(1) "Small employer" means, in connection with a group 4,258
health benefit plan and with respect to a calendar year and a
plan year, an employer who employed an average of at least two 4,259
but no more than fifty eligible employees on business days during 4,261
the preceding calendar year and who employs at least two 4,263
employees on the first day of the plan year.
(2) For purposes of division (N)(1) of this section, all 4,266
persons treated as a single employer under subsection (b), (c), 4,267
(m), or (o) of section 414 of the "Internal Revenue Code of 4,271
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be 4,275
considered one employer. In the case of an employer that was not 4,276
in existence throughout the preceding calendar year, the 4,277
determination of whether the employer is a small or large 4,278
employer shall be based on the average number of eligible 4,279
employees that it is reasonably expected the employer will employ 4,280
on business days in the current calendar year. Any reference in 4,281
division (N) of this section to an "employer" includes any 4,283
predecessor of the employer. Except as otherwise specifically 4,284
provided, provisions of sections 3924.01 to 3924.14 of the 4,285
Revised Code that apply to a small employer that has a health 4,286
benefit plan shall continue to apply until the plan anniversary 4,287
following the date the employer no longer meets the requirements 4,288
of this division.
(O) "SEHC OHC plan" means an Ohio small employer health 4,292
92
care plan, which is a health benefit THE BASIC, STANDARD, OR 4,293
CARRIER REIMBURSEMENT plan for small individuals and employers 4,295
AND INDIVIDUALS established by the board in accordance with 4,296
section 3924.10 of the Revised Code. 4,297
Sec. 3924.03. Except as otherwise provided in section 2721 4,306
of the "Health Insurance Portability and Accountability Act of 4,312
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 4,318
as amended, health benefit plans covering small employers are 4,319
subject to the following conditions, as applicable:
(A)(1) Pre-existing conditions provisions shall not 4,321
exclude or limit coverage for a period beyond twelve months, or 4,322
eighteen months in the case of a late enrollee, following the 4,323
individual's enrollment date and may only relate to a physical or 4,326
mental condition, regardless of the cause of the condition, for 4,328
which medical advice, diagnosis, care, or treatment was 4,329
recommended or received within the six months immediately
preceding the enrollment date. 4,331
Division (A)(1) of this section is subject to the 4,334
exceptions set forth in section 2701(d) of the "Health Insurance 4,337
Portability and Accountability Act of 1996." 4,340
(2) The period of any such pre-existing condition 4,342
exclusion shall be reduced by the aggregate of the periods of 4,343
creditable coverage, if any, applicable to the employee or 4,344
dependent as of the enrollment date. 4,345
(3) A period of creditable coverage shall not be counted, 4,348
with respect to enrollment of an individual under a group health 4,349
benefit plan, if, after that period and before the enrollment 4,350
date, there was a sixty-three-day period during all of which the 4,351
individual was not covered under any creditable coverage. 4,352
Subsections (c)(2) to (4) and (e) of section 2701 of the "Health 4,354
Insurance Portability and Accountability Act of 1996" apply with 4,358
respect to crediting previous coverage. 4,359
(4) As used in division (A) of this section: 4,362
(a) "Creditable coverage" has the same meaning as in 4,365
93
section 2701(c)(1) of the "Health Insurance Portability and 4,368
Accountability Act of 1996." 4,370
(b) "Enrollment date" means, with respect to an individual 4,373
covered under a group health benefit plan, the date of enrollment 4,374
of the individual in the plan or, if earlier, the first day of 4,375
the waiting period for such enrollment.
(B)(1) Except as provided in section 2712(b) to (e) of the 4,378
"Health Insurance Portability and Accountability Act of 1996," if 4,379
a carrier offers coverage in the small employer market in 4,380
connection with a group health benefit plan, the carrier shall 4,381
renew or continue in force such coverage at the option of the 4,382
plan sponsor of the plan. 4,383
(2) A carrier may cancel or decide not to renew the 4,385
coverage of any eligible employee or of a dependent of an 4,386
eligible employee if the employee or dependent, as applicable, 4,388
has performed an act or practice that constitutes fraud or made 4,389
an intentional misrepresentation of material fact under the terms 4,390
of the coverage and if the cancellation or nonrenewal is not
based, either directly or indirectly, on any health 4,391
status-related factor in relation to the employee or dependent. 4,392
As used in division (B)(2) of this section, "health 4,395
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 4,396
(C) A carrier shall not exclude any eligible employee or 4,398
dependent, who would otherwise be covered under a health benefit 4,399
plan, on the basis of any actual or expected health condition of 4,401
the employee or dependent.
If, prior to November 24, 1995, a carrier excluded an 4,405
eligible employee or dependent, other than a late enrollee, on 4,406
the basis of an actual or expected health condition, the carrier 4,407
shall, upon the initial renewal of the coverage on or after that 4,408
date, extend coverage to the employee or dependent if all other 4,409
eligibility requirements are met.
(D) No health benefit plan issued by a carrier shall limit 4,412
94
or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 4,414
medical condition, or accident, except for pre-existing 4,415
conditions as permitted under division (A) of this section. If a 4,416
health benefit plan that is delivered or issued for delivery 4,418
prior to April 14, 1993, contains such limitations or exclusions, 4,420
by use of a rider or amendment applicable to a specific 4,421
individual, the plan shall eliminate the use of such riders or 4,422
amendments within eighteen months after April 14, 1993. 4,423
(E)(1) Except as provided in sections 3924.031 and 4,426
3924.032 of the Revised Code, and subject to such rules as may be 4,429
adopted by the superintendent of insurance in accordance with
Chapter 119. of the Revised Code, a carrier shall offer and make 4,431
available every health benefit plan that it is actively marketing 4,432
to every small employer that applies to the carrier for such 4,433
coverage.
Division (E)(1) of this section does not apply to a health 4,436
benefit plan that a carrier makes available in the small employer 4,437
market only through one or more bona fide associations. 4,438
Division (E)(1) of this section shall not be construed to 4,441
preclude a carrier from establishing employer contribution rules 4,442
or group participation rules for the offering of coverage in 4,443
connection with a group health benefit plan in the small employer 4,444
market, as allowed under the law of this state. As used in 4,445
division (E)(1) of this section, "employer contribution rule" 4,447
means a requirement relating to the minimum level or amount of 4,448
employer contribution toward the premium for enrollment of 4,449
employees and dependents and "group participation rule" means a 4,450
requirement relating to the minimum number of employees or 4,451
dependents that must be enrolled in relation to a specified 4,452
percentage or number of eligible individuals or employees of an 4,453
employer.
(2) Each health benefit plan, at the time of initial group 4,455
enrollment, shall make coverage available to all the eligible 4,456
95
employees of a small employer without a service waiting period. 4,457
The decision of whether to impose a service waiting period shall 4,459
be made by the small employer. Such waiting periods shall not be 4,460
greater than ninety days. 4,461
(3) Each health benefit plan shall provide for the special 4,464
enrollment periods described in section 2701(f) of the "Health 4,466
Insurance Portability and Accountability Act of 1996." 4,470
(4) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, A HEALTH 4,472
INSURING CORPORATION SHALL PROVIDE TO ALL LATE ENROLLEES THE 4,473
OPTION TO ENROLL IN THE GROUP HEALTH CARE PLAN. THE ENROLLMENT 4,474
OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF THIRTY 4,475
CONSECUTIVE DAYS. ANY PRE-EXISTING CONDITION EXCLUSION PERIOD 4,476
MUST START ON THE DATE OF APPLICATION. 4,477
(F) The benefit structure of any health benefit plan may, 4,480
at the time of coverage renewal, be changed by the carrier to 4,482
make it consistent with the benefit structure contained in health 4,483
benefit plans being marketed to new small employer groups. If 4,484
the health benefit plan is available in the small employer market 4,486
other than only through one or more bona fide associations, the 4,487
modification must be consistent with the law of this state and 4,488
effective on a uniform basis among small employer group plans. 4,489
(G) A carrier may obtain any facts and information 4,491
necessary to apply this section, or supply those facts and 4,492
information to any other third-party payer, without the consent 4,493
of the beneficiary. Each person claiming benefits under a health 4,494
benefit plan shall provide any facts and information necessary to 4,495
apply this section. 4,496
For purposes of this section, "bona fide association" means 4,499
an association that has been actively in existence for at least 4,500
five years; has been formed and maintained in good faith for 4,501
purposes other than obtaining insurance; does not condition 4,502
membership in the association on any health status-related 4,503
factor, as defined in section 3924.031 of the Revised Code, 4,505
relating to an individual, including an employee or dependent; 4,506
96
makes health insurance coverage offered through the association 4,507
available to all members regardless of any health status-related 4,508
factor, as defined in section 3924.031 of the Revised Code, 4,511
relating to such members or to individuals eligible for coverage 4,512
through a member; does not make health insurance coverage offered 4,513
through the association available other than in connection with a 4,514
member of the association; and meets any other requirement 4,515
imposed by the superintendent. To maintain its status as a "bona 4,516
fide association," each association shall annually certify to the 4,517
superintendent that it meets the requirements of this paragraph. 4,518
Sec. 3924.033. (A) Each carrier, in connection with the 4,528
offering of a health benefit plan to a small employer, shall 4,529
disclose to the employer, as part of its solicitation and sales 4,530
materials, that the information described in division (B) of this 4,531
section is available upon request. 4,532
(B) A carrier shall provide the following information to a 4,535
small employer upon request: 4,536
(1) The provisions of the plan concerning the carrier's 4,539
right to change premium rates and the factors that may affect 4,540
changes in premium rates;
(2) The provisions of the plan relating to renewability of 4,543
coverage;
(3) The provisions of the plan relating to any 4,545
pre-existing condition exclusion; 4,546
(4) The benefits and premiums available under all health 4,549
benefit plans for which the employer is qualified.
(C) The information described in division (B) of this 4,553
section shall be provided in a manner determined to be
understandable by the average small employer, and in a manner 4,554
sufficient to reasonably inform a small employer regarding the 4,555
employer's rights and obligations under the health benefit plan. 4,557
(D) Nothing in this section requires a carrier to disclose 4,560
any information that is by law proprietary and trade secret 4,561
information.
97
Sec. 3924.08. (A) The board of directors of the Ohio 4,571
health reinsurance program shall consist of nine appointed 4,573
members who shall serve staggered terms as determined by the 4,574
initial board for its members and by the plan of operation of the 4,575
program for members of subsequent boards. Within thirty days 4,576
after April 14, 1993, the members of the board shall be
appointed, as follows: 4,577
(1) The chairperson of the senate committee having 4,579
jurisdiction over insurance shall appoint the following members: 4,580
(a) Two member carriers that are small employer carriers; 4,582
(b) One member carrier that is a health insuring 4,584
corporation predominantly in the small employer market; 4,585
(c) One representative of providers of health care. 4,587
(2) The chairperson of the committee in the house of 4,589
representatives having jurisdiction over insurance shall appoint 4,590
the following members: 4,591
(a) One member carrier that is a small employer carrier; 4,593
(b) One member carrier whose principal health insurance 4,595
business is in the large employer market; 4,596
(c) One representative of an employer with fifty or fewer 4,598
employees; 4,599
(d) One representative of consumers in this state. 4,601
(3) The superintendent of insurance shall appoint a 4,603
representative of a member carrier operating in the small 4,605
employer market who is a fellow of the society of actuaries. 4,606
The superintendent, a member of the house of 4,608
representatives appointed by the speaker of the house of 4,609
representatives, and a member of the senate appointed by the 4,610
president of the senate, shall be ex-officio members of the 4,611
board. The membership of all boards subsequent to the initial 4,612
board shall reflect the distribution described in division (A) of 4,614
this section.
The chairperson of the initial board and each subsequent 4,616
board shall represent a small employer member carrier and shall 4,617
98
be elected by a majority of the voting members of the board. 4,618
Each chairperson shall serve for the maximum duration established 4,619
in the plan of operation. 4,620
(B) Within one hundred eighty days after the appointment 4,622
of the initial board, the board shall establish a plan of 4,623
operation and, thereafter, any amendments to the plan that are 4,624
necessary or suitable, to assure the fair, reasonable, and 4,625
equitable administration of the program. The board shall, 4,626
immediately upon adoption, provide to the superintendent copies 4,627
of the plan of operation and all subsequent amendments to it. 4,628
(C) The plan of operation shall establish rules, 4,630
conditions, and procedures for all of the following: 4,631
(1) The handling and accounting of assets and moneys of 4,633
the program and for an annual fiscal reporting to the 4,634
superintendent; 4,635
(2) Filling vacancies on the board; 4,637
(3) Selecting an administering insurer, which shall be a 4,639
carrier as defined in section 3924.01 of the Revised Code, and 4,640
setting forth the powers and duties of the administering insurer; 4,641
(4) Reinsuring risks in accordance with sections 3924.07 4,643
to 3924.14 of the Revised Code; 4,644
(5) Collecting assessments subject to section 3924.13 of 4,646
the Revised Code from all members to provide for claims reinsured 4,647
by the program and for administrative expenses incurred or 4,648
estimated to be incurred during the period for which the 4,649
assessment is made; 4,650
(6) Providing protection for carriers from the financial 4,652
risk associated with small employers that present poor credit 4,653
risks; 4,654
(7) Establishing standards for the coverage of small 4,656
employers that have a high turnover of employees; 4,657
(8) Establishing an appeals process for carriers to seek 4,659
relief when a carrier has experienced an unfair share of 4,660
administrative and credit risks; 4,661
99
(9) Establishing the adjusted average market premium 4,663
prices for use by the SEHC OHC plan for individuals, for groups 4,665
of two to twenty-five employees, and for groups of twenty-six to 4,667
fifty employees that are offered in the state; 4,668
(10) Establishing participation standards at issue and 4,670
renewal for reinsured cases; 4,671
(11) Reinsuring risks and collecting assessments in 4,673
accordance with division (G) of section 3924.11 of the Revised 4,674
Code; 4,675
(12) Any additional matters as determined by the board. 4,677
Sec. 3924.09. The Ohio health reinsurance program shall 4,687
have the general powers and authority granted under the laws of 4,688
the state to insurance companies licensed to transact sickness 4,689
and accident insurance, except the power to issue insurance. The 4,690
board of directors of the program also shall have the specific 4,691
authority to do all of the following:
(A) Enter into contracts as are necessary or proper to 4,693
carry out the provisions and purposes of sections 3924.07 to 4,694
3924.14 of the Revised Code, including the authority to enter 4,695
into contracts with similar programs of other states for the 4,696
joint performance of common functions, or with persons or other 4,697
organizations for the performance of administrative functions; 4,698
(B) Sue or be sued, including taking any legal actions 4,700
necessary or proper for recovery of any assessments for, on 4,701
behalf of, or against any program or board member; 4,702
(C) Take such legal action as is necessary to avoid the 4,704
payment of improper claims against the program; 4,705
(D) Design the SEHC OHC plan which, when offered by a 4,708
carrier, is eligible for reinsurance and issue reinsurance 4,709
policies in accordance with the requirements of sections 3924.07 4,710
to 3924.14 of the Revised Code; 4,711
(E) Establish rules, conditions, and procedures pertaining 4,713
to the reinsurance of members' risks by the program; 4,714
(F) Establish appropriate rates, rate schedules, rate 4,716
100
adjustments, rate classifications, and any other actuarial 4,717
functions appropriate to the operation of the program; 4,718
(G) Assess members in accordance with division (G) of 4,721
section 3924.11 and the provisions of section 3924.13 of the 4,722
Revised Code, and make such advance interim assessments as may be 4,723
reasonable and necessary for organizational and interim operating 4,724
expenses. Any interim assessments shall be credited as offsets 4,725
against any regular assessments due following the close of the 4,726
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 4,728
other committees if necessary to provide technical assistance 4,729
with respect to the operation of the program, policy and other 4,730
contract design, and any other function within the authority of 4,731
the program; 4,732
(I) Borrow money to effect the purposes of the program. 4,734
Any notes or other evidence of indebtedness of the program not in 4,735
default shall be legal investments for carriers and may be 4,736
carried as admitted assets. 4,737
(J) Reinsure risks, collect assessments, and otherwise 4,739
carry out its duties under division (G) of section 3924.11 of the 4,740
Revised Code; 4,741
(K) Study the operation of the Ohio health reinsurance 4,743
program and the open enrollment reinsurance program and, based on 4,745
its findings, make legislative recommendations to the general 4,746
assembly for improvements in the effectiveness, operation, and 4,747
integrity of the programs;
(L) Design a basic and standard plan for purposes of 4,749
sections 1751.16, 3923.122, and 3923.581 of the Revised Code. 4,750
Sec. 3924.10. (A) The board of directors of the Ohio 4,759
health reinsurance program shall design the SEHC plan OHC BASIC, 4,761
STANDARD, AND CARRIER REIMBURSEMENT PLANS which, when offered by 4,762
a carrier, is ARE eligible for reinsurance under the program. 4,763
The board shall establish the form and level of coverage to be 4,764
made available by carriers in their SEHC plan OHC PLANS. In 4,765
101
designing the plan PLANS the board shall also establish benefit 4,768
levels, deductibles, coinsurance factors, exclusions, and 4,769
limitations for the plan PLANS. The forms and levels of coverage 4,771
established by the board shall specify which components of a 4,772
health benefit plan PLANS offered by a carrier may be reinsured. 4,773
The SEHC plan is OHC PLANS ARE subject to division (C) of section 4,775
3924.02 of the Revised Code and to the provisions in Chapters 4,776
1751., 3923., and any other chapter of the Revised Code that 4,778
require coverage or the offer of coverage of a health care 4,779
service or benefit.
(B) The board shall adopt the SEHC plan OHC PLANS within 4,782
one hundred eighty days after its appointment THE EFFECTIVE DATE 4,783
OF THIS AMENDMENT. The plan PLANS may include cost containment 4,785
features including any of the following:
(1) Utilization review of health care services, including 4,787
review of the medical necessity of hospital and physician 4,788
services; 4,789
(2) Case management benefit alternatives; 4,791
(3) Selective contracting with hospitals, physicians, and 4,793
other health care providers; 4,794
(4) Reasonable benefit differentials applicable to 4,796
participating and nonparticipating providers; 4,797
(5) Employee assistance program options that provide 4,799
preventive and early intervention mental health and substance 4,800
abuse services; 4,801
(6) Other provisions for the cost-effective management of 4,803
the plan PLANS. 4,804
(C) An SEHC plan OHC PLANS established for use by health 4,808
insuring corporations shall be consistent with the basic method 4,811
of operation of such corporations.
(D) Each carrier shall certify to the superintendent of 4,813
insurance, in the form and manner prescribed by the 4,814
superintendent, that the SEHC plan OHC PLANS filed by the carrier 4,817
is ARE in substantial compliance with the provisions of the board 4,819
102
SEHC plan OHC PLANS. Upon receipt by the superintendent of the 4,821
certification, the carrier may use the certified plan PLANS. 4,822
(E) Each carrier shall, on and after sixty days after the 4,824
date that the program becomes operational and as a condition of 4,825
transacting business in this state, renew coverage provided to 4,826
any individual or group under its SEHC plan OHC PLANS. 4,828
(F) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER 1, 4,831
1998.
Sec. 3924.11. Any member of the Ohio health reinsurance 4,841
program may reinsure small employer groups or individuals in 4,842
accordance with the following conditions and limitations: 4,843
(A) With respect to eligible employees and their 4,845
dependents who are hired subsequent to the commencement of the 4,846
employer's coverage by a carrier and who are not late enrollees, 4,847
and with respect to employees of an employer who are otherwise 4,848
eligible for insurance but were excluded by the carrier's 4,849
underwriting and who are not late enrollees, coverage may be 4,850
reinsured in any of the following ways: 4,851
(1) Except in the case of late enrollees, within sixty 4,853
days after the commencement of their coverage under the plan; 4,854
(2) In the case of late enrollees who were not eligible to 4,857
enroll during a special enrollment period described in section 4,858
2701(f) of the "Health Insurance Portability and Accountability 4,860
Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 4,863
300gg-42, as amended, eighteen months after the date the late 4,865
enrollee becomes a member of the small employer's plan; 4,866
(3) In the case of late enrollees who were eligible to 4,868
enroll during a special enrollment period described in section 4,869
2701(f) of the "Health Insurance Portability and Accountability 4,871
Act of 1996," as amended, within sixty days after the 4,873
commencement of their coverage under the plan A SMALL EMPLOYER 4,875
GROUP OR INDIVIDUAL MAY BE REINSURED WITHIN SIXTY DAYS AFTER THE 4,876
COMMENCEMENT OF THE GROUP'S OR INDIVIDUAL'S COVERAGE UNDER THE 4,877
PLAN.
103
(B)(1) The carrier may reinsure either the entire eligible 4,880
group or any eligible individual, in accordance with the premium 4,882
rates established in section 3924.12 of the Revised Code, upon 4,884
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 4,887
dependents of an eligible employee, who were previously excluded 4,888
from group coverage for medical reasons, and shall reinsure such 4,889
employees or dependents within sixty days after the carrier is 4,890
required to include them in the group coverage.
(C) With respect to an SEHC OHC plan, the program shall 4,893
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 4,895
the program shall reinsure the level of coverage provided up to, 4,896
but not exceeding, the level of coverage provided in an SEHC OHC 4,898
CARRIER REIMBURSEMENT plan. In the coverage provided to small 4,899
employers, carriers shall be required to use high-cost care 4,900
management, hospital precertification techniques, and other cost 4,901
containment mechanisms established by the program. 4,902
(E) A carrier may not reinsure existing business, except 4,904
pursuant to division (A) of this section. 4,905
(F) If an employer group is covered under a plan other 4,907
than an SEHC OHC CARRIER REIMBURSEMENT plan and the carrier 4,909
chooses to reinsure the group subsequent to the initial coverage 4,910
period, or if a new individual joins the group and the carrier 4,911
wants to reinsure that individual, the carrier shall not force 4,912
the employer to change to an SEHC OHC CARRIER REIMBURSEMENT plan. 4,913
The carrier shall allow the employer to maintain the same benefit 4,915
plan and reinsure only that portion of the plan that is 4,916
consistent with an SEHC OHC CARRIER REIMBURSEMENT plan. 4,917
(G) With respect to coverage provided to an individual 4,919
acquired under section 3923.58 or a federally eligible individual 4,921
acquired under section 3923.581 of the Revised Code, the 4,922
following conditions and limitations apply: 4,923
(1) Within sixty days after the commencement of the 4,926
104
initial coverage, any carrier may reinsure coverage of such an 4,927
individual with the open enrollment reinsurance program in 4,929
accordance with division (G) of this section. Premium rates 4,930
charged for coverage reinsured by the program shall be 4,932
established in accordance with section 3924.12 of the Revised 4,933
Code.
(2) The board of directors of the Ohio health reinsurance 4,936
program shall establish the open enrollment reinsurance fund for 4,937
coverage provided under section 3923.58 of the Revised Code and, 4,938
with respect to federally eligible individuals, coverage provided 4,940
under section 3923.581 of the Revised Code. The fund shall be 4,941
maintained separately from any reinsurance fund established for 4,942
small employer OHIO health care plans issued pursuant to sections 4,943
3924.07 to 3924.14 of the Revised Code. The board shall 4,944
calculate, on a retrospective basis, the amount needed for 4,945
maintenance of the open enrollment reinsurance fund and, on the 4,946
basis of that calculation, shall determine the amount to be 4,947
assessed each carrier that is required to provide open enrollment 4,948
coverage. 4,949
Assessments shall be apportioned by the board among all 4,951
carriers participating in the open enrollment reinsurance program 4,952
in proportion to their respective shares of the total premiums, 4,953
net of reinsurance premiums paid by a carrier for open enrollment 4,954
coverage and net of reinsurance premiums paid by the carrier for 4,955
all other individual health benefit plans, earned in this state 4,957
from all health benefit plans covering individuals that are
issued by all such carriers during the calendar year coinciding 4,960
with or ending during the fiscal year of the open enrollment 4,961
program, or on any other equitable basis reflecting coverage of 4,962
individuals in this state as may be provided in the plan of 4,963
operation adopted by the board. In no event shall the assessment 4,964
of any carrier under this section exceed, on an annual basis, 4,966
three per cent of its Ohio premiums for health benefit plans 4,967
covering individuals as reported on its most recent annual 4,968
105
statement filed with the superintendent of insurance. 4,969
The board shall submit its determination of the amount of 4,971
the assessment to the superintendent for review of the accuracy 4,973
of the calculation of the assessment. Upon approval by the 4,974
superintendent, each carrier shall, within thirty days after 4,975
receipt of the notice of assessment, submit the assessment to the 4,976
board for purposes of the open enrollment reinsurance fund. 4,977
(3) If the assessments made and collected pursuant to 4,979
division (G)(2) of this section are not sufficient to pay the 4,980
claims reinsured under division (G) of this section and the 4,981
allocated administrative expenses, incurred or estimated to be 4,982
incurred during the period for which the assessment was made, the 4,983
secretary of the board shall immediately notify the 4,984
superintendent, and the superintendent shall suspend the 4,985
operation of open enrollment under section 3923.58 of the Revised 4,986
Code and, with respect to federally eligible individuals, under 4,987
section 3923.581 of the Revised Code until the board has 4,988
collected in subsequent years through assessments made pursuant 4,989
to division (G)(2) of this section an amount sufficient to pay 4,990
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 4,992
under section 3923.58 of the Revised Code may elect not to 4,994
participate in the open enrollment reinsurance program under 4,995
division (G) of this section by filing an application with the 4,996
superintendent and obtaining the superintendent's approval. In 4,997
determining whether to approve an application, the superintendent 4,998
shall consider whether the carrier meets all of the following 4,999
standards: 5,000
(i) Demonstration by the carrier of a substantial and 5,002
established market presence; 5,003
(ii) Demonstrated experience in the individual market and 5,006
history of rating and underwriting individual plans; 5,007
(iii) Commitment to comply with the requirements of 5,009
section 3923.58 of the Revised Code; 5,010
106
(iv) Financial ability to assume and manage the risk of 5,012
enrolling open enrollment individuals without the need for, or 5,014
protection of, reinsurance.
(b) A carrier whose application for nonparticipation has 5,016
been rejected by the superintendent may appeal the decision in 5,017
accordance with Chapter 119. of the Revised Code. A carrier that 5,018
has received approval of the superintendent not to participate in 5,019
the open enrollment reinsurance program shall, on or before the 5,020
first day of December, annually certify to the superintendent 5,021
that it continues to meet the standards described in division 5,022
(G)(4)(a) of this section. 5,023
(c) In any year subsequent to the year in which its 5,025
application not to participate has been approved, a carrier may 5,026
elect to participate in the open enrollment reinsurance program 5,027
by giving notice to the superintendent and board on or before the 5,028
thirty-first day of December. If, after a period of 5,029
nonparticipation, a carrier elects to participate in the open 5,030
enrollment reinsurance program, the carrier retains the risks it 5,031
assumed during the period when it was not participating. 5,032
(d) The superintendent may, at any time, authorize a 5,034
carrier to modify an election not to participate if the risk from 5,035
the carrier's open enrollment business jeopardizes the financial 5,036
condition of the carrier. If the superintendent authorizes the 5,037
carrier to again participate in the open enrollment reinsurance 5,038
program, the carrier shall retain the risks it assumed during the 5,039
period of nonparticipation. 5,040
(5)(a) The open enrollment reinsurance program shall be 5,043
operated separately from the Ohio health reinsurance program. 5,044
(b) A carrier's election to participate in the open 5,046
enrollment reinsurance program under division (G) of this section 5,048
shall not be construed as an election to participate in the Ohio 5,049
health reinsurance program under section 3924.07 of the Revised 5,050
Code.
Sec. 3999.22. (A) As used in this section: 5,059
107
(1) "Claim" means any attempt to cause a health care 5,061
insurer to make payment of a health care benefit. 5,062
(2) "Health care benefit" means the right under a contract 5,064
or a certificate or policy of insurance to have a payment made by 5,065
a health care insurer for a specified health care service. 5,066
(3) "Health care insurer" means any person that is 5,068
authorized to do the business of sickness and accident 5,070
insurance;, any prepaid dental plan, medical care corporation, 5,071
health care corporation, dental care corporation, or health 5,072
maintenance organization; INSURING CORPORATION, and any legal 5,073
entity that is self-insured and provides health care benefits to 5,075
its employees or members.
(B) No person shall knowingly solicit, offer, pay, or 5,077
receive any kickback, bribe, or rebate, directly or indirectly, 5,078
overtly or covertly, in cash or in kind, in return for referring 5,079
an individual for the furnishing of health care services or goods 5,080
for which whole or partial reimbursement is or may be made by a 5,081
health care insurer, except as authorized by the health care or 5,082
health insurance contract, policy, or plan. This division does 5,083
not apply to any of the following: 5,084
(1) Deductibles, copayments, or similar amounts owed by 5,086
the person covered by the health care or health insurance 5,087
contract, policy, or plan; 5,088
(2) Discounts or similar reductions in prices; 5,090
(3) Any amount paid within a bona fide legal entity, or 5,092
within legal entities under common ownership or control, 5,093
including any amount paid to an employee in a bona fide 5,094
employment relationship; 5,095
(4) Any amount paid as part of a bona fide lease, 5,097
management, or other business contract. 5,098
(C) Nothing in this section shall be construed to apply to 5,100
any of the following: 5,101
(1) A provider who provides goods or services requested by 5,103
an individual that are not covered by the individual's health 5,104
108
care or health insurance contract, policy, or plan; 5,105
(2) A provider who, in good faith, provides goods or 5,107
services ordered by another health care provider; 5,108
(3) A provider who, in good faith, resubmits a claim 5,110
previously submitted that has not been paid or denied within 5,111
thirty days of the original submission, if the provider notifies 5,112
the payor or returns any duplicate payment within sixty days 5,113
after receipt of the duplicate payment; 5,114
(4) A provider who, in good faith, makes a diagnosis that 5,116
differs from the interpretation of a diagnosis reached by a 5,117
health care insurer in the payment of claims. 5,118
(D) Whoever violates this section is guilty of a felony of 5,120
the fifth degree on a first offense and a felony of the fourth 5,121
degree on each subsequent offense. 5,122
Sec. 5112.01. As used in sections 5112.02 to 5112.21 of 5,131
the Revised Code:
(A)(1) "Hospital" means a nonfederal hospital to which 5,133
either of the following applies: 5,134
(a) The hospital is registered under section 3701.07 of 5,136
the Revised Code as a general medical and surgical hospital or a 5,137
pediatric general hospital, and provides inpatient hospital 5,138
services, as defined in 42 C.F.R. 440.10; 5,139
(b) The hospital is recognized under the medicare program 5,141
established by Title XVIII of the "Social Security Act," 49 Stat. 5,143
620 (1935), 42 U.S.C.A. 301, as amended, as a cancer hospital and 5,145
is exempt from the medicare prospective payment system. 5,146
"Hospital" does not include a hospital operated by a health 5,148
maintenance organization INSURING CORPORATION that has been 5,149
issued a certificate of authority under section 1742.05 1751.05 5,151
of the Revised Code or a hospital that does not charge patients 5,153
for services.
(2) "Disproportionate share hospital" means a hospital 5,155
that meets the definition of a disproportionate share hospital in 5,156
rules adopted under section 5112.03 of the Revised Code. 5,157
109
(B) "Bad debt," "charity care," "courtesy care," and 5,159
"contractual allowances" have the same meanings given these terms 5,160
in regulations adopted under Title XVIII of the "Social Security 5,162
Act." 5,163
(C) "Cost reporting period" means the twelve-month period 5,165
used by a hospital in reporting costs for purposes of Title XVIII 5,167
of the "Social Security Act." 5,168
(D) "Governmental hospital" means a county hospital with 5,170
more than five hundred registered beds or a state-owned and 5,172
-operated hospital with more than five hundred registered beds. 5,173
(E) "Indigent care pool" means the sum of the following: 5,175
(1) The total of assessments to be paid in a program year 5,177
by all hospitals under section 5112.06 of the Revised Code, less 5,178
the assessments deposited into the legislative budget services 5,179
fund under section 5112.19 of the Revised Code; 5,181
(2) The total amount of intergovernmental transfers 5,183
required to be made in the same program year by governmental 5,184
hospitals under section 5112.07 of the Revised Code, less the 5,185
amount of transfers deposited into the legislative budget 5,187
services fund under section 5112.19 of the Revised Code; 5,188
(3) The total amount of federal matching funds that will 5,190
be made available in the same program year as a result of 5,191
payments the department of human services makes to hospitals 5,192
under section 5112.08 of the Revised Code. 5,193
(F) "Intergovernmental transfer" means any transfer of 5,195
money by a governmental hospital under section 5112.07 of the 5,196
Revised Code.
(G) "Medical assistance program" means the program of 5,198
medical assistance established under section 5111.01 of the 5,199
Revised Code and Title XIX of the "Social Security Act." 5,200
(H) "Program year" means a period beginning the first day 5,202
of October, or a later date designated in rules adopted under 5,203
section 5112.03 of the Revised Code, and ending the thirtieth day 5,204
of September, or an earlier date designated in rules adopted 5,205
110
under that section. 5,206
(I) "Registered beds" means the total number of hospital 5,208
beds registered with the department of health, as reported in the 5,209
most recent "directory of registered hospitals" published by the 5,210
department of health. 5,211
(J) "Total facility costs" means the total costs for all 5,213
services rendered to all patients, including the direct, 5,214
indirect, and overhead cost to the hospital of all services, 5,215
supplies, equipment, and capital related to the care of patients, 5,216
regardless of whether patients are enrolled in a health 5,217
maintenance organization INSURING CORPORATION, excluding costs 5,218
associated with providing skilled nursing services in 5,220
distinct-part nursing facility units, as shown on the hospital's 5,221
cost report filed under section 5112.04 of the Revised Code. 5,222
Effective October 1, 1993, if rules adopted under section 5112.03 5,223
of the Revised Code so provide, "total facility costs" may 5,224
exclude costs associated with providing care to recipients of any 5,225
of the governmental programs listed in division (B) of that 5,226
section.
(K) "Uncompensated care" means bad debt and charity care. 5,228
Sec. 5112.08. The director of human services shall adopt 5,237
rules under section 5112.03 of the Revised Code establishing a 5,238
methodology to pay hospitals that is sufficient to expend all 5,239
money in the indigent care pool. Under the rules: 5,240
(A) The department of human services shall classify 5,242
similar hospitals into groups and allocate funds for distribution 5,243
within each group. 5,244
(B) The department shall establish a method of allocating 5,246
funds to each group of hospitals, taking into consideration the 5,247
relative amount of indigent care provided by each group. The 5,248
amount to be allocated to each group shall be based on any 5,249
combination of the following indicators of indigent care that the 5,250
director considers appropriate: 5,251
(1) Total costs, volume, or proportion of services to 5,253
111
recipients of the medical assistance program, including 5,254
recipients enrolled in health maintenance organizations INSURING 5,255
CORPORATIONS; 5,256
(2) Total costs, volume, or proportion of services to 5,258
low-income patients in addition to recipients of the medical 5,259
assistance program, which may include recipients of Title V of 5,261
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 5,263
as amended, general assistance established under Chapter 5113. of 5,264
the Revised Code, and disability assistance established under 5,265
Chapter 5115. of the Revised Code; 5,266
(3) The amount of uncompensated care provided by the 5,268
hospitals; 5,269
(4) Other factors that the director considers to be 5,271
appropriate indicators of indigent care. 5,272
(C) The department shall distribute funds to hospitals in 5,274
each group in a manner that first may provide for an additional 5,275
payment to individual hospitals that provide a high proportion of 5,276
indigent care in relation to the total care provided by the 5,277
hospital or in relation to other hospitals. The department shall 5,278
establish a formula to distribute the remainder of the funds 5,279
allocated to the group to all hospitals in the group. The 5,280
formula shall be consistent with section 1923 of the "Social 5,281
Security Act," 42 U.S.C.A. 1396r-4, as amended, and shall be 5,284
based on any combination of the indicators of indigent care 5,285
listed in division (B) of this section that the director 5,287
considers appropriate.
(D) The department shall make payments to each hospital in 5,289
installments not later than ten working days after the deadline 5,290
established in rules for each hospital to pay an installment on 5,291
its assessment under section 5112.06 of the Revised Code. In the 5,292
case of a governmental hospital that makes intergovernmental 5,293
transfers, the department shall pay an installment under this 5,294
section not later than ten working days after the earlier of that 5,295
deadline or the deadline established in rules for the 5,296
112
governmental hospital to pay an installment on its 5,297
intergovernmental transfer. If the amount in the hospital care 5,298
assurance program fund and the hospital care assurance match fund 5,299
created under section 5112.18 of the Revised Code is insufficient 5,300
to make the total payments for which hospitals are eligible to 5,301
receive in any period, the department shall reduce the amount of 5,302
each payment by the percentage by which the amount is 5,303
insufficient. The department shall pay hospitals any amounts not 5,304
paid in the period in which they are due as soon as moneys are 5,305
available in the funds. 5,306
Section 2. That existing sections 1739.01, 1751.01, 5,308
1751.02, 1751.03, 1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 5,309
1751.14, 1751.15, 1751.16, 1751.20, 1751.31, 1751.46, 1751.55, 5,310
1751.58, 1751.59, 1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 5,311
3923.021, 3923.122, 3923.57, 3923.571, 3923.58, 3924.01, 3924.03, 5,313
3924.033, 3924.08, 3924.09, 3924.10, 3924.11, 3999.22, 5112.01, 5,314
and 5112.08 and section 3924.05 of the Revised Code are hereby 5,317
repealed.
Section 3. That sections 1751.02, 1751.03, 1751.13, and 5,319
3924.10 of the Revised Code, as amended by Am. Sub. H.B. 361 of 5,320
the 122nd General Assembly, be amended to read as follows: 5,321
Sec. 1751.02. (A) Notwithstanding any law in this state 5,330
to the contrary, any corporation, as defined in section 1751.01 5,332
of the Revised Code, may apply to the superintendent of insurance 5,334
for a certificate of authority to establish and operate a health 5,335
insuring corporation. If the corporation applying for a 5,336
certificate of authority is a foreign corporation domiciled in a 5,337
state without laws similar to those of this chapter, the 5,339
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 5,340
chapter.
(B) No person shall establish, operate, or perform the 5,343
services of a health insuring corporation in this state without 5,345
obtaining a certificate of authority under this chapter. 5,346
113
(C) Except as provided by division (D) of this section, no 5,349
political subdivision or department, office, or institution of 5,350
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 5,351
this state, shall establish, operate, or perform the services of 5,352
a health insuring corporation. Nothing in this section shall be 5,355
construed to preclude a board of county commissioners, a county 5,356
board of mental retardation and developmental disabilities, an 5,357
alcohol and drug addiction services board, a board of alcohol, 5,358
drug addiction, and mental health services, or a community mental 5,359
health board, or a public entity formed by or on behalf of any of 5,360
these boards, from using managed care techniques in carrying out 5,361
the board's or public entity's duties pursuant to the 5,362
requirements of Chapters 307., 329., 340., and 5126. of the 5,364
Revised Code. However, no such board or public entity may 5,366
operate so as to compete in the private sector with health 5,367
insuring corporations holding certificates of authority under 5,368
this chapter.
(D) A corporation formed by or on behalf of a publicly 5,370
owned, operated, or funded hospital or health care facility may 5,371
apply to the superintendent for a certificate of authority under 5,373
division (A) of this section to establish and operate a health 5,374
insuring corporation.
(E) A health insuring corporation shall operate in this 5,377
state in compliance with this chapter and Chapter 1753. of the 5,378
Revised Code, and with sections 3702.51 to 3702.62 of the Revised 5,380
Code, and shall operate in conformity with its filings with the 5,382
superintendent under this chapter, including filings made 5,383
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 5,384
the Revised Code. 5,386
(F) An insurer licensed under Title XXXIX of the Revised 5,390
Code need not obtain a certificate of authority as a health 5,391
insuring corporation to offer an open panel plan as long as the 5,392
providers and health care facilities participating in the open 5,393
114
panel plan receive their compensation directly from the insurer. 5,394
If the providers and health care facilities participating in the 5,395
open panel plan receive their compensation from any person other 5,396
than the insurer, or if the insurer offers a closed panel plan, 5,397
the insurer must obtain a certificate of authority as a health 5,398
insuring corporation.
(G) An intermediary organization need not obtain a 5,401
certificate of authority as a health insuring corporation, 5,402
regardless of the method of reimbursement to the intermediary 5,403
organization, as long as a health insuring corporation or a 5,405
self-insured employer maintains the ultimate responsibility to 5,406
assure delivery of all health care services required by the
contract between the health insuring corporation and the 5,407
subscriber and the laws of this state or between the self-insured 5,408
employer and its employees. 5,409
Nothing in this section shall be construed to require any 5,411
health care facility, provider, health delivery network, or 5,412
intermediary organization that contracts with a health insuring 5,413
corporation or self-insured employer, regardless of the method of 5,415
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 5,416
certificate of authority as a health insuring corporation under 5,417
this chapter, unless otherwise provided, in the case of contracts 5,419
with a self-insured employer, by operation of the "Employee 5,420
Retirement Income Security Act of 1974," 88 Stat. 829, 29 5,425
U.S.C.A. 1001, as amended. 5,427
(H) Any health delivery network doing business in this 5,430
state, INCLUDING ANY HEALTH DELIVERY NETWORK THAT IS FUNCTIONING 5,431
AS AN INTERMEDIARY ORGANIZATION DOING BUSINESS IN THIS STATE, 5,433
that is not required to obtain a certificate of authority under 5,434
this chapter shall certify to the superintendent annually, not 5,435
later than the first day of July, and shall provide a statement 5,437
signed by the highest ranking official which includes the 5,438
following information:
115
(1) The health delivery network's full name and the 5,440
address of its principal place of business; 5,441
(2) A statement that the health delivery network is not 5,443
required to obtain a certificate of authority under this chapter 5,444
to conduct its business. 5,445
(I) The superintendent shall not issue a certificate of 5,448
authority to a health insuring corporation that is a provider 5,449
sponsored organization unless all health care plans to be offered 5,450
by the health insuring corporation provide basic health care 5,451
services. Substantially all of the physicians and hospitals with 5,452
ownership or control of the provider sponsored organization, as 5,453
defined in division (W)(X) of section 1751.01 of the Revised 5,455
Code, shall also be participating providers for the provision of 5,457
basic health care services for health care plans offered by the 5,458
provider sponsored organization. If a health insuring 5,459
corporation that is a provider sponsored organization offers 5,460
health care plans that do not provide basic health care services, 5,461
the health insuring corporation shall be deemed, for purposes of 5,462
section 1751.35 of the Revised Code, to have failed to 5,463
substantially comply with this chapter. 5,464
Except as specifically provided in this division and in 5,466
division (C) of section 1751.28 of the Revised Code, the 5,468
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 5,469
same manner that these provisions apply to all health insuring 5,470
corporations that are not provider sponsored organizations. 5,471
(J) Nothing in this section shall be construed to apply to 5,473
any multiple employer welfare arrangement operating pursuant to 5,474
Chapter 1739. of the Revised Code. 5,475
(K) Any person who violates division (B) of this section, 5,479
and any health delivery network that fails to comply with 5,480
division (H) of this section, is subject to the penalties set 5,481
forth in section 1751.45 of the Revised Code. 5,483
Sec. 1751.03. (A) Each application for a certificate of 5,493
116
authority under this chapter shall be verified by an officer or 5,494
authorized representative of the applicant, shall be in a format 5,495
prescribed by the superintendent of insurance, and shall set 5,496
forth or be accompanied by the following: 5,497
(1) A certified copy of the applicant's articles of 5,499
incorporation and all amendments to the articles of 5,500
incorporation; 5,501
(2) A copy of any regulations adopted for the government 5,503
of the corporation, any bylaws, and any similar documents, and a 5,504
copy of all amendments to these regulations, bylaws, and 5,505
documents. The corporate secretary shall certify that these 5,506
regulations, bylaws, documents, and amendments have been properly 5,508
adopted or approved.
(3) A list of the names, addresses, and official positions 5,511
of the persons responsible for the conduct of the applicant, 5,512
including all members of the board, the principal officers, and 5,513
the person responsible for completing or filing financial 5,514
statements with the department of insurance, accompanied by a 5,515
completed original biographical affidavit and release of 5,516
information for each of these persons on forms acceptable to the 5,517
department;
(4) A full and complete disclosure of the extent and 5,519
nature of any contractual or other financial arrangement between 5,520
the applicant and any provider or a person listed in division 5,521
(A)(3) of this section, including, but not limited to, a full and 5,523
complete disclosure of the financial interest held by any such 5,524
provider or person in any health care facility, provider, or 5,525
insurer that has entered into a financial relationship with the 5,526
health insuring corporation; 5,527
(5) A description of the applicant, its facilities, and 5,529
its personnel, including, but not limited to, the location, hours 5,531
of operation, and telephone numbers of all contracted facilities; 5,532
(6) The applicant's projected annual enrollee population 5,534
over a three-year period; 5,535
117
(7) A clear and specific description of the health care 5,537
plan or plans to be used by the applicant, including a 5,538
description of the proposed providers, procedures for accessing 5,539
care, and the form of all proposed and existing contracts 5,540
relating to the administration, delivery, or financing of health 5,541
care services; 5,542
(8) A copy of each type of evidence of coverage and 5,544
identification card or similar document to be issued to 5,545
subscribers; 5,546
(9) A copy of each type of individual or group policy, 5,548
contract, or agreement to be used; 5,549
(10) The schedule of the proposed contractual periodic 5,551
prepayments or premium rates, or both, accompanied by appropriate 5,552
supporting data; 5,553
(11) A financial plan which provides a three-year 5,555
projection of operating results, including the projected 5,556
expenses, income, and sources of working capital; 5,557
(12) The enrollee complaint procedure to be utilized as 5,559
required under section 1751.19 of the Revised Code; 5,562
(13) A description of the procedures and programs to be 5,564
implemented on an ongoing basis to assure the quality of health 5,565
care services delivered to enrollees, including, if applicable, a 5,566
description of a quality assurance program complying with the 5,568
requirements of sections 1751.73 to 1751.75 of the Revised Code;
(14) A statement describing the geographic area or areas 5,570
to be served, by county; 5,571
(15) A copy of all solicitation documents; 5,573
(16) A balance sheet and other financial statements 5,575
showing the applicant's assets, liabilities, income, and other 5,576
sources of financial support; 5,577
(17) A description of the nature and extent of any 5,579
reinsurance program to be implemented, and a demonstration that 5,580
errors and omission insurance and, if appropriate, fidelity 5,581
insurance, will be in place upon the applicant's receipt of a 5,582
118
certificate of authority; 5,583
(18) Copies of all proposed or in force related-party or 5,585
intercompany agreements with an explanation of the financial 5,586
impact of these agreements on the applicant. If the applicant 5,587
intends to enter into a contract for managerial or administrative 5,589
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 5,590
description of the person to provide these services. The 5,592
description shall include that person's experience in managing or 5,593
administering health care plans, a copy of that person's most 5,594
recent audited financial statement, and a completed biographical 5,595
affidavit on a form acceptable to the superintendent for each of 5,596
that person's principal officers and board members and for any 5,597
additional employee to be directly involved in providing 5,598
managerial or administrative services to the health insuring 5,599
corporation. If the person to provide managerial or 5,600
administrative services is affiliated with the health insuring 5,601
corporation, the contract must provide for payment for services 5,602
based on actual costs.
(19) A statement from the applicant's board that the 5,604
admitted assets of the applicant have not been and will not be 5,605
pledged or hypothecated; 5,606
(20) A statement from the applicant's board that the 5,608
applicant will submit monthly financial statements during the 5,609
first year of operations; 5,610
(21) The name and address of the applicant's Ohio 5,613
statutory agent for service of process, notice, or demand; 5,614
(22) Copies of all documents the applicant filed with the 5,616
secretary of state; 5,617
(23) The location of those books and records of the 5,619
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL 5,620
BE MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, 5,621
AND WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF 5,623
DOMICILE OR IN OHIO IF THE APPLICANT IS A FOREIGN CORPORATION; 5,625
119
(24) The applicant's federal identification number, 5,627
corporate address, and mailing address; 5,628
(25) An internal and external organizational chart; 5,631
(26) A list of the assets representing the initial net 5,633
worth of the applicant; 5,634
(27) If the applicant has a parent company, the parent 5,636
company's guaranty, on a form acceptable to the superintendent, 5,637
that the applicant will maintain Ohio's minimum net worth. If no 5,640
parent company exists, a statement regarding the availability of 5,641
future funds if needed.
(28) The names and addresses of the applicant's actuary 5,643
and external auditors; 5,644
(29) If the applicant is a foreign corporation, a copy of 5,646
the most recent financial statements filed with the insurance 5,647
regulatory agency in the applicant's state of domicile; 5,648
(30) If the applicant is a foreign corporation, a 5,650
statement from the insurance regulatory agency of the applicant's 5,651
state of domicile stating that the regulatory agency has no 5,652
objection to the applicant applying for an Ohio license and that 5,653
the applicant is in good standing in the applicant's state of 5,654
domicile; 5,655
(31) Any other information that the superintendent may 5,657
require. 5,658
(B)(1) A health insuring corporation, unless otherwise 5,661
provided for in this chapter OR IN SECTION 3901.321 OF THE 5,663
REVISED CODE, shall file a timely notice with the superintendent 5,665
describing any change to the corporation's articles of 5,666
incorporation or regulations, or any major modification to its 5,667
operations as set out in the information required by division (A) 5,669
of this section that affects any of the following: 5,670
(a) The solvency of the health insuring corporation; 5,673
(b) The health insuring corporation's continued provision 5,676
of services that it has contracted to provide; 5,677
(c) The manner in which the health insuring corporation 5,680
120
conducts its business.
(2) If the change or modification is to be the result of 5,682
an action to be taken by the health insuring corporation, the 5,683
notice shall be filed with the superintendent prior to the health 5,684
insuring corporation taking the action. The action shall be 5,686
deemed approved if the superintendent does not disapprove it 5,687
within sixty days of filing. 5,688
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION (B)(1) OR 5,691
(2) OF THIS SECTION SHALL ALSO SERVE AS THE SUBMISSION OF A 5,692
NOTICE WHEN REQUIRED FOR THE SUPERINTENDENT'S REVIEW FOR PURPOSES 5,693
OF SECTION 3901.341 OF THE REVISED CODE, IF THE NOTICE CONTAINS 5,695
ALL OF THE INFORMATION THAT SECTION 3901.341 OF THE REVISED CODE 5,699
REQUIRES FOR SUCH SUBMISSIONS AND A COPY OF ANY WRITTEN 5,700
AGREEMENT. THE FILING OF SUCH A NOTICE, FOR THE PURPOSE OF 5,701
SATISFYING THIS DIVISION AND SECTION 3901.341 OF THE REVISED 5,704
CODE, SHALL BE SUBJECT TO THE SIXTY-DAY REVIEW PERIOD OF DIVISION 5,705
(B)(2) OF THIS SECTION. 5,706
(C)(1) No health insuring corporation shall expand its 5,709
approved service area until a copy of the request for expansion, 5,710
accompanied by documentation of the network of providers, FORMS 5,712
OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS RELATING TO THE 5,713
DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF PROPOSED 5,714
CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR GROUP 5,715
CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING DATA, enrollment 5,716
projections, plan of operation, and any other changes have been 5,717
filed with the superintendent. 5,718
(2) Within ten calendar days after receipt of a complete 5,720
filing under division (C)(1) of this section, the superintendent 5,722
shall refer the appropriate jurisdictional issues to the director 5,723
of health pursuant to section 1751.04 of the Revised Code. 5,725
(3) Within seventy-five days after the superintendent's 5,727
receipt of a complete filing under division (C)(1) of this 5,729
section, the superintendent shall determine whether the plan for 5,730
expansion is lawful, fair, and reasonable. The superintendent 5,731
121
may not make a determination until the superintendent has 5,732
received the director's certification of compliance, which the 5,733
director shall furnish within forty-five days after referral 5,734
under division (C)(2) of this section. The director shall not 5,736
certify that the requirements of section 1751.04 of the Revised 5,737
Code are not met, unless the applicant has been given an 5,739
opportunity for a hearing as provided in division (D) of section 5,741
1751.04 of the Revised Code. The forty-five-day and 5,742
seventy-five-day review periods provided for in division (C)(3) 5,744
of this section shall cease to run as of the date on which the 5,745
notice of the applicant's right to request a hearing is mailed 5,746
and shall remain suspended until the director issues a final 5,747
certification. 5,748
(4) If the superintendent has not approved or disapproved 5,750
all or a portion of a service area expansion within the 5,751
seventy-five-day period provided for in division (C)(3) of this 5,753
section, the filing shall be deemed approved. 5,754
(5) Disapproval of all or a portion of the filing shall be 5,757
effected by written notice, which shall state the grounds for the 5,758
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 5,759
Sec. 1751.13. (A)(1)(a) A health insuring corporation 5,769
shall, either directly or indirectly, enter into contracts for 5,770
the provision of health care services with a sufficient number 5,771
and types of providers and health care facilities to ensure that 5,772
all covered health care services will be accessible to enrollees 5,773
from a contracted provider or health care facility. 5,774
(b) A health insuring corporation shall not refuse to 5,777
contract with a physician for the provision of health care
services or refuse to recognize a physician as a specialist on 5,778
the basis that the physician attended an educational program or a 5,780
residency program approved or certified by the American 5,781
Osteopathic Association. A health insuring corporation shall not 5,782
refuse to contract with a health care facility for the provision 5,783
122
of health care services on the basis that the health care 5,784
facility is certified or accredited by the American Osteopathic 5,786
Association or that the health care facility is an osteopathic 5,787
hospital as defined in section 3702.51 of the Revised Code. 5,790
(c) Nothing in division (A)(1)(b) of this section shall be 5,794
construed to require a health insuring corporation to make a 5,795
benefit payment under a closed panel plan to a physician or 5,796
health care facility with which the health insuring corporation 5,797
does not have a contract, provided that none of the bases set 5,798
forth in that division are used as a reason for failing to make a 5,799
benefit payment.
(2) When a health insuring corporation is unable to 5,801
provide a covered health care service from a contracted provider 5,802
or health care facility, the health insuring corporation must 5,803
provide that health care service from a noncontracted provider or 5,805
health care facility consistent with the terms of the enrollee's 5,806
policy, contract, certificate, or agreement. The health insuring 5,807
corporation shall either ensure that the health care service be 5,808
provided at no greater cost to the enrollee than if the enrollee 5,809
had obtained the health care service from a contracted provider 5,810
or health care facility, or make other arrangements acceptable to 5,811
the superintendent of insurance. 5,812
(3) Nothing in this section shall prohibit a health 5,814
insuring corporation from entering into contracts with 5,815
out-of-state providers or health care facilities that are 5,816
licensed, certified, accredited, or otherwise authorized in that 5,817
state. 5,818
(B)(1) A health insuring corporation shall, either 5,821
directly or indirectly, enter into contracts with all providers 5,822
and health care facilities through which health care services are 5,823
provided to its enrollees.
(2) A health insuring corporation, upon written request, 5,825
shall assist its contracted providers in finding stop-loss or 5,826
reinsurance carriers.
123
(C) A health insuring corporation shall file an annual 5,828
certificate with the superintendent certifying that all provider 5,829
contracts and contracts with health care facilities through which 5,830
health care services are being provided contain the following: 5,831
(1) A description of the method by which the provider or 5,833
health care facility will be notified of the specific health care 5,835
services for which the provider or health care facility will be 5,836
responsible, including any limitations or conditions on such 5,837
services;
(2) The specific hold harmless provision specifying 5,839
protection of enrollees set forth as follows: 5,840
"[Provider/Health Care Facility< agrees that in no event, 5,843
including but not limited to nonpayment by the health insuring 5,844
corporation, insolvency of the health insuring corporation, or 5,845
breach of this agreement, shall [Provide/Health Care Facility< 5,847
bill, charge, collect a deposit from, seek remuneration or 5,848
reimbursement from, or have any recourse against, a subscriber, 5,849
enrollee, person to whom health care services have been provided, 5,851
or person acting on behalf of the covered enrollee, for health 5,852
care services provided pursuant to this agreement. This does not 5,853
prohibit [Provider/Health Care Facility< from collecting 5,854
co-insurance, deductibles, or copayments as specifically provided 5,856
in the evidence of coverage, or fees for uncovered health care 5,857
services delivered on a fee-for-service basis to persons 5,858
referenced above, nor from any recourse against the health 5,859
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 5,861
facility to continue to provide covered health care services to 5,862
enrollees in the event of the health insuring corporation's 5,863
insolvency or discontinuance of operations. The provisions shall 5,865
require the provider or health care facility to continue to 5,866
provide covered health care services to enrollees as needed to 5,867
complete any medically necessary procedures commenced but 5,868
unfinished at the time of the health insuring corporation's
124
insolvency or discontinuance of operations. THE COMPLETION OF A 5,869
MEDICALLY NECESSARY PROCEDURE SHALL INCLUDE THE RENDERING OF ALL 5,871
MEDICALLY NECESSARY FOLLOW-UP CARE FOR THAT PROCEDURE. If an 5,872
enrollee is receiving necessary inpatient care at a hospital, the 5,873
provisions may limit the required provision of covered health 5,874
care services relating to that inpatient care in accordance with 5,875
division (D)(3) of section 1751.11 of the Revised Code, and may 5,877
also limit such required provision of covered health care 5,878
services to the period ending thirty days after the health 5,879
insuring corporation's insolvency or discontinuance of 5,880
operations.
The provisions required by division (C)(3) of this section 5,883
shall not require any provider or health care facility to 5,884
continue to provide any covered health care service after the
occurrence of any of the following: 5,885
(a) The end of the thirty-day period following the entry 5,887
of a liquidation order under Chapter 3903. of the Revised Code; 5,889
(b) The end of the enrollee's period of coverage for a 5,891
contractual prepayment or premium; 5,892
(c) The enrollee obtains equivalent coverage with another 5,894
health insuring corporation or insurer, or the enrollee's 5,895
employer obtains such coverage for the enrollee; 5,896
(d) The enrollee or the enrollee's employer terminates 5,898
coverage under the contract; 5,899
(e) A liquidator effects a transfer of the health insuring 5,902
corporation's obligations under the contract under division 5,903
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 5,905
responsibilities of the health insuring corporation, and of the 5,906
contracted providers and health care facilities, with respect to 5,907
administrative policies and programs, including, but not limited 5,908
to, payments systems, utilization review, quality assurance, 5,909
assessment, and improvement programs, credentialing, 5,910
confidentiality requirements, and any applicable federal or state 5,911
125
programs; 5,912
(5) A provision regarding the availability and 5,914
confidentiality of those health records maintained by providers 5,915
and health care facilities to monitor and evaluate the quality of 5,917
care, to conduct evaluations and audits, and to determine on a 5,918
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 5,919
The provision shall include terms requiring the provider or 5,920
health care facility to make these health records available to 5,921
appropriate state and federal authorities involved in assessing 5,922
the quality of care or in investigating the grievances or 5,923
complaints of enrollees, and requiring the provider or health 5,924
care facility to comply with applicable state and federal laws 5,925
related to the confidentiality of medical or health records. 5,927
(6) A provision that states that contractual rights and 5,929
responsibilities may not be assigned or delegated by the provider 5,931
or health care facility without the prior written consent of the 5,932
health insuring corporation;
(7) A provision requiring the provider or health care 5,934
facility to maintain adequate professional liability and 5,935
malpractice insurance. The provision shall also require the 5,936
provider or health care facility to notify the health insuring 5,937
corporation not more than ten days after the provider's or health 5,939
care facility's receipt of notice of any reduction or
cancellation of such coverage. 5,940
(8) A provision requiring the provider or health care 5,942
facility to observe, protect, and promote the rights of enrollees 5,944
as patients;
(9) A provision requiring the provider or health care 5,946
facility to provide health care services without discrimination 5,947
on the basis of a patient's participation in the health care 5,948
plan, age, sex, ethnicity, religion, sexual preference, health 5,949
status, or disability, and without regard to the source of 5,950
payments made for health care services rendered to a patient. 5,951
126
This requirement shall not apply to circumstances when the 5,952
provider or health care facility appropriately does not render 5,953
services due to limitations arising from the provider's or health 5,955
care facility's lack of training, experience, or skill, or due to 5,956
licensing restrictions.
(10) A provision containing the specifics of any 5,958
obligation on the PRIMARY CARE provider or health care facility 5,959
to provide, or to arrange for the provision of, covered health 5,961
care services twenty-four hours per day, seven days per week; 5,962
(11) A provision setting forth procedures for the 5,964
resolution of disputes arising out of the contract; 5,965
(12) A provision stating that the hold harmless provision 5,967
required by division (C)(2) of this section shall survive the 5,969
termination of the contract with respect to services covered and 5,970
provided under the contract during the time the contract was in 5,971
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 5,972
(13) A provision requiring those terms that are used in 5,974
the contract and that are defined by this chapter, be used in the 5,976
contract in a manner consistent with those definitions. 5,977
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF 5,979
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 5,984
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 5,987
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 5,988
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 5,989
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 5,992
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 5,997
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 6,000
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 6,001
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 6,005
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 6,006
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, OR TO 6,007
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 6,008
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 6,009
127
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 6,010
(D)(1) No health insuring corporation contract with a 6,013
provider or health care facility shall contain any of the 6,014
following:
(a) A provision that directly or indirectly offers an 6,017
inducement to the provider or health care facility to reduce or 6,018
limit medically necessary health care services to a covered 6,019
enrollee;
(b) A provision that penalizes a provider or health care 6,022
facility that assists an enrollee to seek a reconsideration of 6,023
the health insuring corporation's decision to deny or limit 6,024
benefits to the enrollee; 6,025
(c) A provision that limits or otherwise restricts the 6,028
provider's or health care facility's ethical and legal
responsibility to fully advise enrollees about their medical 6,029
condition and about medically appropriate treatment options; 6,031
(d) A provision that penalizes a provider or health care 6,034
facility for principally advocating for medically necessary 6,035
health care services;
(e) A provision that penalizes a provider or health care 6,037
facility for providing information or testimony to a legislative 6,038
or regulatory body or agency. This shall not be construed to 6,039
prohibit a health insuring corporation from penalizing a provider 6,041
or health care facility that provides information or testimony 6,042
that is libelous or slanderous or that discloses trade secrets 6,043
which the provider or health care facility has no privilege or 6,044
permission to disclose.
(2) Nothing in this division shall be construed to 6,046
prohibit a health insuring corporation from doing either of the 6,047
following: 6,048
(a) Making a determination not to reimburse or pay for a 6,051
particular medical treatment or other health care service; 6,052
(b) Enforcing reasonable peer review or utilization review 6,055
protocols, or determining whether a particular provider or health 6,056
128
care facility has complied with these protocols. 6,057
(E) Any contract between a health insuring corporation and 6,060
an intermediary organization shall clearly specify that the 6,061
health insuring corporation must approve or disapprove the 6,062
participation of any provider or health care facility with which 6,063
the intermediary organization contracts. 6,064
(F) If an intermediary organization that is not a health 6,066
delivery network contracting solely with self-insured employers 6,067
subcontracts with a provider or health care facility, the 6,068
subcontract with the provider or health care facility shall do 6,069
all of the following:
(1) Contain the provisions required by divisions (C) and 6,072
(G) of this section, as made applicable to an intermediary 6,073
organization, without the inclusion of inducements or penalties 6,074
described in division (D) of this section; 6,075
(2) Acknowledge that the health insuring corporation is a 6,077
third-party beneficiary to the agreement; 6,078
(3) Acknowledge the health insuring corporation's role in 6,080
approving the participation of the provider or health care 6,081
facility, pursuant to division (E) of this section. 6,083
(G) Any provider contract or contract with a health care 6,086
facility shall clearly specify the health insuring corporation's 6,087
statutory responsibility to monitor and oversee the offering of 6,088
covered health care services to its enrollees. 6,089
(H)(1) A health insuring corporation shall maintain its 6,092
provider contracts and its contracts with health care facilities 6,093
at one or more of its places of business in this state, and shall 6,094
provide copies of these contracts to facilitate regulatory review 6,095
upon written notice by the superintendent of insurance. 6,096
(2) Any contract with an intermediary organization shall 6,098
include provisions requiring the intermediary organization to 6,099
provide the superintendent with regulatory access to all books, 6,100
records, financial information, and documents related to the 6,101
provision of health care services to subscribers and enrollees 6,102
129
under the contract. The contract shall require the intermediary 6,103
organization to maintain such books, records, financial 6,104
information, and documents at its principal place of business in 6,105
this state and to preserve them for at least three years in a 6,106
manner that facilitates regulatory review. 6,107
(I)(1) A health insuring corporation shall provide notice 6,109
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A 6,110
contract with FOR THE PROVISION OF HEALTH CARE SERVICES BETWEEN 6,112
THE HEALTH INSURING CORPORATION AND a primary care physician or 6,114
hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF 6,115
THE CONTRACT.
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 6,117
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE 6,118
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH 6,119
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE PRIMARY 6,121
CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF THE 6,122
SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE 6,123
PREVIOUS TWELVE MONTHS. 6,124
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 6,126
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR A 6,128
DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE 6,129
PREVIOUS TWELVE MONTHS. 6,130
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL 6,132
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A PRIMARY 6,134
CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE TERMINATION OF 6,135
THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION OF THE CONTRACT 6,136
TERMINATION IS MAILED TO A SUBSCRIBER AT THE SUBSCRIBER'S LAST 6,137
KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do not apply to 6,140
any health insuring corporation that, on June 4, 1997, holds a 6,141
certificate of authority or license to operate under Chapter 6,143
1740. of the Revised Code. 6,144
130
(K) Nothing in this section shall restrict the governing 6,146
body of a hospital from exercising the authority granted it 6,147
pursuant to section 3701.351 of the Revised Code. 6,148
Sec. 3924.10. (A) The board of directors of the Ohio 6,157
health reinsurance program shall design the SEHC plan OHC BASIC, 6,159
STANDARD, AND CARRIER REIMBURSEMENT PLANS which, when offered by 6,160
a carrier, is ARE eligible for reinsurance under the program. 6,162
The board shall establish the form and level of coverage to be 6,163
made available by carriers in their SEHC plan OHC PLANS. In 6,164
designing the plan PLANS the board shall also establish benefit 6,166
levels, deductibles, coinsurance factors, exclusions, and 6,167
limitations for the plan PLANS. The forms and levels of coverage 6,169
established by the board shall specify which components of a 6,170
health benefit plan PLANS offered by a carrier may be reinsured. 6,171
The SEHC plan is OHC PLANS ARE subject to division (C) of section 6,173
3924.02 of the Revised Code and to the provisions in Chapters 6,174
1751., 1753., 3923., and any other chapter of the Revised Code 6,176
that require coverage or the offer of coverage of a health care 6,177
service or benefit.
(B) The board shall adopt the SEHC plan OHC PLANS within 6,180
one hundred eighty days after its appointment THE EFFECTIVE DATE 6,181
OF THIS AMENDMENT. The plan PLANS may include cost containment 6,183
features including any of the following:
(1) Utilization review of health care services, including 6,185
review of the medical necessity of hospital and physician 6,186
services; 6,187
(2) Case management benefit alternatives; 6,189
(3) Selective contracting with hospitals, physicians, and 6,191
other health care providers; 6,192
(4) Reasonable benefit differentials applicable to 6,194
participating and nonparticipating providers; 6,195
(5) Employee assistance program options that provide 6,197
preventive and early intervention mental health and substance 6,198
abuse services; 6,199
131
(6) Other provisions for the cost-effective management of 6,201
the plan PLANS. 6,202
(C) An SEHC plan OHC PLANS established for use by health 6,206
insuring corporations shall be consistent with the basic method 6,209
of operation of such corporations.
(D) Each carrier shall certify to the superintendent of 6,211
insurance, in the form and manner prescribed by the 6,212
superintendent, that the SEHC plan OHC PLANS filed by the carrier 6,214
is ARE in substantial compliance with the provisions of the board 6,216
SEHC plan OHC PLANS. Upon receipt by the superintendent of the 6,218
certification, the carrier may use the certified plan PLANS. 6,219
(E) Each carrier shall, on and after sixty days after the 6,221
date that the program becomes operational and as a condition of 6,222
transacting business in this state, renew coverage provided to 6,223
any individual or group under its SEHC plan OHC PLANS. 6,225
Section 4. That all existing versions of sections 1751.02, 6,227
1751.03, 1751.13, and 3924.10 of the Revised Code are hereby 6,228
repealed. 6,229
Section 5. Sections 3 and 4 of this act shall take effect 6,231
October 1, 1998. 6,232
Section 6. That Section 3 of Am. Sub. S.B. 67 of the 122nd 6,234
General Assembly be amended to read as follows: 6,235
"Sec. 3. (A) The certificate of authority of every 6,237
prepaid dental plan organization, health care corporation, dental 6,238
care corporation, and health maintenance organization licensed to 6,240
operate under Chapter 1736., 1738., 1740., or 1742. of the 6,242
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 6,245
Chapter 1751. of the Revised Code. All assets and liabilities of 6,246
the prepaid dental plan organization, health care corporation, 6,247
dental care corporation, or health maintenance organization, 6,248
including all obligations under subscriber contracts delivered, 6,249
issued for delivery, or renewed prior to the effective date of 6,250
this section JUNE 4, 1997, shall be assumed by the successor 6,252
132
entity. Except as otherwise provided in division (B) of this 6,253
section, such entity shall, no later than January 1, 1998, comply 6,254
with Chapter 1751. of the Revised Code. 6,255
(B)(1) Each entity described in division (A) of this 6,257
section shall do both of the following: 6,258
(a) Comply with sections 1751.19 and 1751.26 of the 6,261
Revised Code no later than six months after the effective date of
this section JUNE 4, 1997. 6,263
(b) Comply with section 1751.28 of the Revised Code by 6,266
making annual deposits with the Superintendent of Insurance, no 6,267
later than the first day of January of each year, for up to three 6,268
years, beginning the first day of January immediately following 6,269
the effective date of this section INCREASING THE ENTITY'S NET 6,271
WORTH, ON THE FIRST DAY OF JANUARY IN EACH OF THE YEARS 1998, 6,272
1999, AND 2000, BY AN AMOUNT EQUAL TO AT LEAST ONE-THIRD OF ANY 6,274
DIFFERENCE BETWEEN THE ENTITY'S NET WORTH AS OF JUNE 4, 1997, AND 6,276
THE NET WORTH REQUIRED BY SECTION 1751.28 OF THE REVISED CODE. 6,277
EACH ENTITY SHALL ATTAIN THE NET WORTH REQUIRED BY SECTION 6,278
1751.28 OF THE REVISED CODE NO LATER THAN JANUARY 1, 2000. 6,280
(2) Every contract delivered, issued for delivery, or 6,282
renewed by an entity described in division (A) of this section 6,283
prior to the effective date of this section JUNE 4, 1997, shall 6,285
comply with section 1751.13 of the Revised Code no later than the 6,287
contract's first renewal date after the first day of January 6,288
immediately following the effective date of this section JUNE 4, 6,290
1997.
(3) Every contract delivered, issued for delivery, or 6,293
renewed by an entity described in division (A) of this section 6,294
prior to the effective date of this section JUNE 4, 1997, shall 6,295
comply with section 1751.31 of the Revised Code no later than 6,297
three months after the effective date of this section JUNE 4, 6,298
1997.
(4) An entity described in division (A) of this section 6,300
may comply with section 1751.27 of the Revised Code by making 6,301
133
annual deposits with the Superintendent of Insurance, not later 6,302
than the first day of January of each year, for up to three years 6,303
beginning the first day of January immediately following the 6,304
effective date of this section JUNE 4, 1997. An equal amount 6,306
shall be deposited each year until the total amount required 6,308
under section 1751.27 of the Revised Code has been deposited." 6,309
Section 7. That existing Section 3 of Am. Sub. S.B. 67 of 6,311
the 122nd General Assembly is hereby repealed. 6,312
Section 8. Section 3901.21 of the Revised Code is 6,314
presented in this act as a composite of the section as amended by 6,315
both Sub. H.B. 374 and Am. Sub. S.B. 70 of the 122nd General 6,316
Assembly, with the language of neither of the acts shown in 6,317
capital letters. Section 3924.08 of the Revised Code is
presented in this act as a composite of the section as amended by 6,319
both Sub. H.B. 374 and Am. Sub. S.B. 67 of the 122nd General 6,320
Assembly, with the new language of neither of the acts shown in 6,323
capital letters. This is in recognition of the principle stated 6,324
in division (B) of section 1.52 of the Revised Code that such 6,325
amendments are to be harmonized where not substantively 6,326
irreconcilable and constitutes a legislative finding that such is 6,327
the resulting version in effect prior to the effective date of 6,328
this act.