As Passed by the Senate 1
122nd General Assembly 4
Regular Session Sub. H. B. No. 698 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-GARCIA-SENATORS SUHADOLNIK-DRAKE 8
_________________________________________________________________ 10
A B I L L
To amend sections 1701.03, 1705.03, 1705.04, 12
1705.53, 1739.01, 1751.01, 1751.02, 1751.03, 13
1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 14
1751.14, 1751.15, 1751.16, 1751.20, 1751.31, 16
1751.32, 1751.46, 1751.55, 1751.58, 1751.59,
1751.60, 1751.62, 1751.81, 1785.01, 1785.02, 17
1785.03, 1785.08, 1907.161, 2305.252, 3701.75, 18
3901.21, 3901.38, 3917.01, 3917.06, 3923.021, 19
3923.122, 3923.57, 3923.571, 3923.58, 3924.01, 20
3924.03, 3924.033, 3924.08, 3924.09, 3924.10, 22
3924.11, 3924.13, 3999.22, 4715.22, 4715.39,
4723.16, 4725.114, 4729.161, 4731.226, 4731.65, 24
4732.28, 4734.091, 4755.471, 5111.25, 5111.251,
5111.264, 5111.81, 5112.01, 5112.08, 5725.18, and 25
5729.03, to enact sections 5.2217, 1751.141, 27
1751.321, 3701.18, 3702.141, and 4503.104, and to 28
repeal sections 3924.05, 5111.75, 5111.77, 29
5111.771, and 5111.811 of the Revised Code and to 31
amend Section 3 of Am. Sub. S.B. 67 of the 122nd 32
General Assembly, Section 6 of Am. Sub. S.B. 154
of the 122nd General Assembly, and Section 194 of 33
Am. Sub. H.B. 215 of the 122nd General Assembly 34
to conform provisions in the Health Insuring
Corporation Law and the Sickness and Accident 36
Insurance Law with the Health Insurance 37
Portability and Accountability Act of 1996, to 38
revise other provisions in these laws, to specify 40
how health insuring corporations are to bring 41
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their net worth into compliance with the Health 42
Insuring Corporation Law, to revise the premium 43
tax imposed on domestic and foreign insurance 44
companies that operate a health insuring
corporation as a line of business, to make 45
related revisions in the phase-in schedule for 46
the tax, to authorize a form of group life 47
insurance as conversion coverage for certain 48
former employees and members, to remove the
coverage limitation on group term life insurance 49
insuring the spouse and dependent children of an 50
insured employee or member, to add a member to 51
the committee created under Am. Sub. S.B. 154 of 52
the 122nd General Assembly to study the 53
continuing education requirements for insurance
agents, to revise the standards for using 54
electronic signatures in records of health care 55
facilities, to specify when certain existing
health care facilities are required to improve 57
the structure or fixtures of the facility in
order to comply with the safety and 58
quality-of-care standards and quality-of-care 59
data reporting requirements established by the 60
Director of Health, to extend the Department of 61
Health's study of cardiac catheterization
performed without an on-site open-heart surgery 62
service, to create the Save Our Sight Fund to 63
support eye health and safety programs for
children, to require the Registrar of Motor 64
Vehicles and deputy registrars to request
contributions to the fund from applicants for 65
motor vehicle registration and renewal, to
require the Department of Health to develop 66
informational materials on eye care and safety, 67
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to allow a dentist to authorize a dental
hygienist to provide dental hygiene services when 68
the dentist is not physically present if certain
conditions are met, to authorize the State Dental 69
Board to adopt rules allowing certified dental 70
assistants to polish the clinical crowns of
teeth, to designate June as "Prostate Cancer 71
Awareness Month," to authorize mechanotherapists 72
to engage in their practice with certain other 73
health care professionals in a combined form of a
professional corporation, limited liability 74
company, partnership, or professional 75
association, and to change the manner of 76
determining the amount of the per day, per
patient reimbursement that the Department of 77
Human Services pays for the reasonable capital
costs of eligible nursing facilities and 78
intermediate care facilities for the mentally
retarded, in specified circumstances in which 79
there is a transfer or lease between related 80
parties.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 82
Section 1. That sections 1701.03, 1705.03, 1705.04, 84
1705.53, 1739.01, 1751.01, 1751.02, 1751.03, 1751.05, 1751.06, 86
1751.11, 1751.12, 1751.13, 1751.14, 1751.15, 1751.16, 1751.20, 87
1751.31, 1751.32, 1751.46, 1751.55, 1751.58, 1751.59, 1751.60,
1751.62, 1751.81, 1785.01, 1785.02, 1785.03, 1785.08, 1907.161, 88
2305.252, 3701.75, 3901.21, 3901.38, 3917.01, 3917.06, 3923.021, 90
3923.122, 3923.57, 3923.571, 3923.58, 3924.01, 3924.03, 3924.033, 93
3924.08, 3924.09, 3924.10, 3924.11, 3924.13, 3999.22, 4715.22, 94
4715.39, 4723.16, 4725.114, 4729.161, 4731.226, 4731.65, 4732.28, 96
4734.091, 4755.471, 5111.25, 5111.251, 5111.264, 5111.81, 97
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5112.01, 5112.08, 5725.18, and 5729.03 be amended and sections 99
5.2217, 1751.141, 1751.321, 3701.18, 3702.141, and 4503.104 of 100
the Revised Code be enacted to read as follows:
Sec. 5.2217. THE MONTH OF JUNE SHALL BE DESIGNATED AS 103
"PROSTATE CANCER AWARENESS MONTH."
Sec. 1701.03. (A) A corporation may be formed under this 112
chapter for any purpose or combination of purposes for which 113
individuals lawfully may associate themselves, except that, if 114
the Revised Code contains special provisions pertaining to the 115
formation of any designated type of corporation other than a 116
professional association, as defined in section 1785.01 of the 117
Revised Code, a corporation of that type shall be formed in 118
accordance with the special provisions. 119
(B) On and after July 1, 1994, a corporation may be formed 122
under this chapter for the purpose of carrying on the practice of 123
any profession, including, but not limited to, a corporation for 124
the purpose of providing public accounting or certified public 125
accounting services, a corporation for the erection, owning, and 126
conducting of a sanitarium for receiving and caring for patients, 127
medical and hygienic treatment of patients, and instruction of 128
nurses in the treatment of disease and in hygiene, a corporation 129
for the purpose of providing architectural, landscape 130
architectural, professional engineering, or surveying services or 131
any combination of those types of services, and a corporation for 132
the purpose of providing a combination of the professional 133
services, as defined in section 1785.01 of the Revised Code, of 134
optometrists authorized under Chapter 4725. of the Revised Code, 135
chiropractors authorized under Chapter 4734. of the Revised Code,
psychologists authorized under Chapter 4732. of the Revised Code, 137
registered or licensed practical nurses authorized under Chapter 138
4723. of the Revised Code, pharmacists authorized under Chapter 140
4729. of the Revised Code, physical therapists authorized under 143
sections 4755.40 to 4755.53 of the Revised Code, 145
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 OF THE
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REVISED CODE, and doctors of medicine and surgery, osteopathic 147
medicine and surgery, or podiatric medicine and surgery 148
authorized under Chapter 4731. of the Revised Code. This chapter 149
does not restrict, limit, or otherwise affect the authority or 150
responsibilities of any agency, board, commission, department, 151
office, or other entity to license, register, and otherwise 152
regulate the professional conduct of individuals or organizations 153
of any kind rendering professional services, as defined in 154
section 1785.01 of the Revised Code, in this state or to regulate 155
the practice of any profession that is within the jurisdiction of 156
the agency, board, commission, department, office, or other 157
entity, notwithstanding that an individual is a director, 158
officer, employee, or other agent of a corporation formed under 159
this chapter and is rendering professional services or engaging 160
in the practice of a profession through a corporation formed 161
under this chapter or that the organization is a corporation 162
formed under this chapter. 163
(C) Nothing in division (A) or (B) of this section 165
precludes the organization of a professional association in 166
accordance with this chapter and Chapter 1785. of the Revised 167
Code or the formation of a limited liability company under 168
Chapter 1705. of the Revised Code with respect to a business, as 169
defined in section 1705.01 of the Revised Code. 170
(D) No corporation formed for the purpose of providing a 174
combination of the professional services, as defined in section 175
1785.01 of the Revised Code, of optometrists authorized under
Chapter 4725. of the Revised Code, chiropractors authorized under 176
Chapter 4734. of the Revised Code, psychologists authorized under 177
Chapter 4732. of the Revised Code, registered or licensed 178
practical nurses authorized under Chapter 4723. of the Revised
Code, pharmacists authorized under Chapter 4729. of the Revised 181
Code, physical therapists authorized under sections 4755.40 to 183
4755.53 of the Revised Code, MECHANOTHERAPISTS AUTHORIZED UNDER 185
SECTION 4731.151 OF THE REVISED CODE, and doctors of medicine and 187
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surgery, osteopathic medicine and surgery, or podiatric medicine 188
and surgery authorized under Chapter 4731. of the Revised Code 189
shall control the professional clinical judgment exercised within 190
accepted and prevailing standards of practice of a licensed, 192
certificated, or otherwise legally authorized optometrist,
chiropractor, psychologist, nurse, pharmacist, physical 193
therapist, MECHANOTHERAPIST, or doctor of medicine and surgery, 195
osteopathic medicine and surgery, or podiatric medicine and 198
surgery in rendering care, treatment, or professional advice to 199
an individual patient.
This division does not prevent a hospital, as defined in 201
section 3727.01 of the Revised Code, insurer, as defined in 203
section 3999.36 of the Revised Code, or intermediary 205
organization, as defined in section 1751.01 of the Revised Code, 207
from entering into a contract with a corporation described in 208
this division that includes a provision requiring utilization 209
review, quality assurance, peer review, or other performance or
quality standards. Those activities shall not be construed as 210
controlling the professional clinical judgment of an individual 211
practitioner listed in this division. 212
Sec. 1705.03. (A) A limited liability company may sue and 221
be sued.
(B) Unless otherwise provided in its articles of 223
organization, a limited liability company may take property of 224
any description or any interest in property of any description by 225
gift, devise, or bequest and may make donations for the public 226
welfare or for charitable, scientific, or educational purposes.
(C) In carrying out the purposes stated in its articles of 228
organization or operating agreement and subject to limitations 230
prescribed by law or in its articles of organization or its 231
operating agreement, a limited liability company may do all of
the following: 232
(1) Purchase or otherwise acquire, lease as lessee or 234
lessor, invest in, hold, use, encumber, sell, exchange, transfer, 235
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and dispose of property of any description or any interest in 236
property of any description;
(2) Make contracts; 238
(3) Form or acquire the control of other domestic or 240
foreign limited liability companies; 241
(4) Be a shareholder, partner, member, associate, or 243
participant in other profit or nonprofit enterprises or ventures; 244
(5) Conduct its affairs in this state and elsewhere; 246
(6) Render in this state and elsewhere a professional 248
service, the kinds of professional services authorized under 250
Chapters 4703. and 4733. of the Revised Code, or a combination of 251
the professional services of optometrists authorized under 252
Chapter 4725. of the Revised Code, chiropractors authorized under 253
Chapter 4734. of the Revised Code, psychologists authorized under 254
Chapter 4732. of the Revised Code, registered or licensed 255
practical nurses authorized under Chapter 4723. of the Revised 257
Code, pharmacists authorized under Chapter 4729. of the Revised 260
Code, physical therapists authorized under sections 4755.40 to 262
4755.53 of the Revised Code, MECHANOTHERAPISTS AUTHORIZED UNDER 264
SECTION 4731.151 OF THE REVISED CODE, and doctors of medicine and 265
surgery, osteopathic medicine and surgery, or podiatric medicine 266
and surgery authorized under Chapter 4731. of the Revised Code; 267
(7) Borrow money; 269
(8) Issue, sell, and pledge its notes, bonds, and other 271
evidences of indebtedness; 272
(9) Secure any of its obligations by mortgage, pledge, or 274
deed of trust of all or any of its property; 275
(10) Guarantee or secure obligations of any person; 277
(11) Do all things permitted by law and exercise all 279
authority within or incidental to the purposes stated in its 280
articles of organization.
(D) In addition to the authority conferred by division (C) 282
of this section and irrespective of the purposes stated in its 283
articles of organization or operating agreement but subject to 285
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any limitations stated in those articles or its operating
agreement, a limited liability company may invest funds not 286
currently needed in its business in any securities if the 287
investment does not cause the company to acquire control of 288
another enterprise whose activities and operations are not 289
incidental to the purposes stated in the articles of organization
of the company. 290
(E)(1) No lack of authority or limitation upon the 292
authority of a limited liability company shall be asserted in any 293
action except as follows:
(a) By the state in an action by it against the company; 295
(b) By or on behalf of the company in an action against a 297
manager, an officer, or any member as a member; 298
(c) By a member as a member in an action against the 300
company, a manager, an officer, or any member as a member; 301
(d) In an action involving an alleged improper issue of a 303
membership interest in the company. 304
(2) Division (E)(1) of this section applies to any action 306
commenced in this state upon any contract made in this state by a 307
foreign limited liability company. 308
Sec. 1705.04. (A) One or more persons, without regard to 317
residence, domicile, or state of organization, may form a limited 318
liability company. The company is formed when one or more 320
persons or their authorized representative signs and files with 321
the secretary of state articles of organization that set forth 322
all of the following: 323
(1) The name of the company; 325
(2) Except as provided in division (B) of this section, 327
the period of its duration, which may be perpetual; 328
(3) The address to which interested persons may direct 330
requests for copies of any operating agreement and any bylaws of 331
the company; 332
(4) Any other provisions that are from the operating 334
agreement or that are not inconsistent with applicable law and 335
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that the members elect to set out in the articles for the 336
regulation of the affairs of the company. 337
(B) If the articles of organization or operating agreement 339
do not set forth the period of the duration of the limited 341
liability company, its duration shall be perpetual. 342
(C) If a limited liability company is formed under this 344
chapter for the purpose of rendering a professional service, the 346
kinds of professional services authorized under Chapters 4703. 347
and 4733. of the Revised Code, or a combination of the
professional services of optometrists authorized under Chapter 348
4725. of the Revised Code, chiropractors authorized under Chapter 349
4734. of the Revised Code, psychologists authorized under Chapter 352
4732. of the Revised Code, registered or licensed practical 353
nurses authorized under Chapter 4723. of the Revised Code, 354
pharmacists authorized under Chapter 4729. of the Revised Code, 355
physical therapists authorized under sections 4755.40 to 4755.53 356
of the Revised Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 357
4731.151 OF THE REVISED CODE, and doctors of medicine and 359
surgery, osteopathic medicine and surgery, or podiatric medicine 360
and surgery authorized under Chapter 4731. of the Revised Code, 361
the following apply:
(1) Each member, employee, or other agent of the company 363
who renders a professional service in this state and, if the 364
management of the company is not reserved to its members, each 365
manager of the company who renders a professional service in this 366
state shall be licensed, certificated, or otherwise legally 368
authorized to render in this state the same kind of professional 369
service; if applicable, the kinds of professional services 370
authorized under Chapters 4703. and 4733. of the Revised Code; 371
or, if applicable, any of the kinds of professional services of 372
optometrists authorized under Chapter 4725. of the Revised Code, 373
chiropractors authorized under Chapter 4734. of the Revised Code, 374
psychologists authorized under Chapter 4732. of the Revised Code, 376
registered or licensed practical nurses authorized under Chapter 378
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4723. of the Revised Code, pharmacists authorized under Chapter
4729. of the Revised Code, physical therapists authorized under 380
sections 4755.40 to 4755.53 of the Revised Code,
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 OF THE 381
REVISED CODE, or doctors of medicine and surgery, osteopathic 382
medicine and surgery, or podiatric medicine and surgery 383
authorized under Chapter 4731. of the Revised Code. 384
(2) Each member, employee, or other agent of the company 386
who renders a professional service in another state and, if the 387
management of the company is not reserved to its members, each 388
manager of the company who renders a professional service in 389
another state shall be licensed, certificated, or otherwise 391
legally authorized to render that professional service in the 392
other state.
(D) Except for the provisions of this chapter pertaining 394
to the personal liability of members, employees, or other agents 395
of a limited liability company and, if the management of the 396
company is not reserved to its members, the personal liability of 397
managers of the company, this chapter does not restrict, limit, 398
or otherwise affect the authority or responsibilities of any 399
agency, board, commission, department, office, or other entity to 400
license, certificate, register, and otherwise regulate the 401
professional conduct of individuals or organizations of any kind 403
rendering professional services in this state or to regulate the 404
practice of any profession that is within the jurisdiction of the 405
agency, board, commission, department, office, or other entity, 406
notwithstanding that the individual is a member or manager of a 407
limited liability company and is rendering the professional 408
services or engaging in the practice of the profession through 409
the limited liability company or that the organization is a 410
limited liability company. 411
(E) No limited liability company formed for the purpose of 415
providing a combination of the professional services, as defined
in section 1785.01 of the Revised Code, of optometrists 416
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authorized under Chapter 4725. of the Revised Code, chiropractors 417
authorized under Chapter 4734. of the Revised Code, psychologists 418
authorized under Chapter 4732. of the Revised Code, registered or 420
licensed practical nurses authorized under Chapter 4723. of the
Revised Code, pharmacists authorized under Chapter 4729. of the 421
Revised Code, physical therapists authorized under sections 422
4755.40 to 4755.53 of the Revised Code, MECHANOTHERAPISTS 423
AUTHORIZED UNDER SECTION 4731.151 OF THE REVISED CODE, and 424
doctors of medicine and surgery, osteopathic medicine and 425
surgery, or podiatric medicine and surgery authorized under 426
Chapter 4731. of the Revised Code shall control the professional 429
clinical judgment exercised within accepted and prevailing
standards of practice of a licensed, certificated, or otherwise 430
legally authorized optometrist, chiropractor, psychologist, 431
nurse, pharmacist, physical therapist, MECHANOTHERAPIST, or 432
doctor of medicine and surgery, osteopathic medicine and surgery, 435
or podiatric medicine and surgery in rendering care, treatment, 437
or professional advice to an individual patient. 438
This division does not prevent a hospital, as defined in 440
section 3727.01 of the Revised Code, insurer, as defined in 442
section 3999.36 of the Revised Code, or intermediary 444
organization, as defined in section 1751.01 of the Revised Code, 446
from entering into a contract with a limited liability company 447
described in this division that includes a provision requiring 448
utilization review, quality assurance, peer review, or other
performance or quality standards. Those activities shall not be 449
construed as controlling the professional clinical judgment of an 450
individual practitioner listed in this division. 451
Sec. 1705.53. Subject to any contrary provisions of the 460
Ohio Constitution, the laws of the state under which a foreign 461
limited liability company is organized govern its organization 462
and internal affairs and the liability of its members. A foreign 463
limited liability company may not be denied a certificate of 464
registration as a foreign limited liability company in this state 465
12
because of any difference between the laws of the state under
which it is organized and the laws of this state. However, a 466
foreign limited liability company that applies for registration 467
under this chapter to render a professional service in this 468
state, as a condition to obtaining and maintaining a certificate 469
of registration, shall comply with the requirements of division 470
(C) of section 1705.04 of the Revised Code and shall comply with 471
the requirements of Chapters 4703. and 4733. of the Revised Code 472
if the kinds of professional services authorized under those 473
chapters are to be rendered or with the requirements of Chapters 475
4723., 4725., 4729., 4731., 4732., 4734., and 4755. of the 477
Revised Code if a combination of the professional services of
optometrists authorized under Chapter 4725. of the Revised Code, 480
chiropractors authorized under Chapter 4734. of the Revised Code, 481
psychologists authorized under Chapter 4732. of the Revised Code, 483
registered or licensed practical nurses authorized under Chapter 485
4723. of the Revised Code, pharmacists authorized under Chapter 487
4729. of the Revised Code, physical therapists authorized under 490
sections 4755.40 to 4755.53 of the Revised Code, 492
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 OF THE
REVISED CODE, and doctors of medicine and surgery, osteopathic 494
medicine and surgery, or podiatric medicine and surgery
authorized under Chapter 4731. of the Revised Code are to be 495
rendered.
Sec. 1739.01. As used in sections 1739.01 to 1739.22 of 504
the Revised Code: 505
(A) "Agreement" means a written agreement executed by 507
members of a multiple employer welfare arrangement that 508
establishes an arrangement, provides for its operation, and 509
through which each member agrees to assume and discharge all 510
liability under sections 1739.01 to 1739.22 of the Revised Code 511
relating to or arising out of the operation of the arrangement in 512
proportion to the ratio of the total number of covered employees 513
employed by the member at the time the liability arose to the 514
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total number of covered employees employed by all members of the 515
arrangement at the time the liability arose. 516
(B) "Excess insurance" or "stop-loss insurance" means an 518
insurance policy purchased by a multiple employer welfare 519
arrangement under which it receives reimbursement for benefits it 520
pays in excess of a preset deductible or limit. 521
(C) "Fully-insured FULLY INSURED program" means a program 523
by which benefits are provided to members, employees of members, 525
or the dependents of such members or employees, through the 526
purchase of sickness and accident insurance from an insurance 527
company licensed to do business in this state or health services 528
purchased from a health maintenance organization INSURING 529
CORPORATION authorized to do business in this state. 531
(D) "Group self-insurance program" means a program by 533
which benefits are provided to members, employees of members, or 534
the dependents of such members or employees, other than through 535
sickness and accident insurance purchased from an insurance 536
company licensed to do business in this state or health care 537
services purchased from a health maintenance organization 538
INSURING CORPORATION authorized to do business in this state. 539
(E) "Member" means an individual or an employer that is a 541
member of an organization sponsoring a multiple employer welfare 542
arrangement. 543
(F) "Multiple employer welfare arrangement" means an 545
employee welfare benefit plan, trust, or any other arrangement, 546
whether such plan, trust, or arrangement is subject to the 547
"Employee Retirement Income Security Act of 1974," 88 Stat. 829, 548
29 U.S.C.A. 1001, as amended, that is established or maintained 549
for the purpose of offering or providing, through group insurance 550
or group self-insurance programs, medical, surgical, or hospital 551
care or benefits, or benefits in the event of sickness, accident, 552
disability, or death, to the employees, and their dependents, of 553
two or more employers, or to two or more self-employed 554
individuals and their dependents. 555
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(G) "Premium" means any type of consideration paid to a 557
multiple employer welfare arrangement by a member for coverage 558
under the arrangement. 559
(H) "Surplus" means the total assets of the multiple 561
employer welfare arrangement less its liabilities and reserves as 562
determined in accordance with the requirements of sections 563
1739.01 to 1739.21 of the Revised Code. 564
(I) "Third-party administrator" has the same meaning as 566
"administrator" in section 3959.01 of the Revised Code. 567
Sec. 1751.01. As used in this chapter: 576
(A) "Basic health care services" means the following 579
services when medically necessary: 580
(1) Physician's services, except when such services are 582
supplemental under division (B) of this section; 584
(2) Inpatient hospital services; 586
(3) Outpatient medical services; 588
(4) Emergency health services; 590
(5) Urgent care services; 592
(6) Diagnostic laboratory services and diagnostic and 594
therapeutic radiologic services; 595
(7) Preventive health care services, including, but not 597
limited to, voluntary family planning services, infertility 598
services, periodic physical examinations, prenatal obstetrical 599
care, and well-child care. 600
"Basic health care services" does not include experimental 602
procedures. 603
A health insuring corporation shall not offer coverage for 605
a health care service, defined as a basic health care service by 606
this division, unless it offers coverage for all listed basic 607
health care services. However, this requirement does not apply 609
to the coverage of beneficiaries enrolled in Title XVIII of the 610
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 612
amended, pursuant to a medicare risk contract or medicare cost 613
contract, or to the coverage of beneficiaries enrolled in the 614
15
federal employee health benefits program pursuant to 5 U.S.C.A. 616
8905, or to the coverage of beneficiaries enrolled in Title XIX 617
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 619
301, as amended, known as the medical assistance program or 620
medicaid, provided by the Ohio department of human services under 621
Chapter 5111. of the Revised Code, or to the coverage of 623
beneficiaries under any federal health care program regulated by 624
a federal regulatory body, OR TO THE COVERAGE OF BENEFICIARIES 625
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE 626
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE 628
SERVICES.
(B) "Supplemental health care services" means any health 631
care services other than basic health care services that a health 632
insuring corporation may offer, alone or in combination with 633
either basic health care services or other supplemental health 634
care services, and includes:
(1) Services of facilities for intermediate or long-term 636
care, or both; 637
(2) Dental care services; 639
(3) Vision care and optometric services including lenses 641
and frames; 642
(4) Podiatric care or foot care services; 644
(5) Mental health services including psychological 646
services; 647
(6) Short-term outpatient evaluative and 649
crisis-intervention mental health services; 650
(7) Medical or psychological treatment and referral 652
services for alcohol and drug abuse or addiction; 653
(8) Home health services; 655
(9) Prescription drug services; 657
(10) Nursing services; 659
(11) Services of a dietitian licensed under Chapter 4759. 662
of the Revised Code;
(12) Physical therapy services; 664
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(13) Chiropractic services; 666
(14) Any other category of services approved by the 668
superintendent of insurance. 669
(C) "Specialty health care services" means one of the 671
supplemental health care services listed in division (B)(1) to 673
(13) of this section, when provided by a health insuring 674
corporation on an outpatient-only basis and not in combination 675
with other supplemental health care services.
(D) "Closed panel plan" means a health care plan that 677
requires enrollees to use participating providers. 678
(E) "Compensation" means remuneration for the provision of 681
health care services, determined on other than a fee-for-service 682
or discounted-fee-for-service basis.
(F) "Contractual periodic prepayment" means the formula 685
for determining the premium rate for all subscribers of a health 686
insuring corporation. 687
(G) "Corporation" means a corporation formed under Chapter 690
1701. or 1702. of the Revised Code or the similar laws of another 692
state.
(H) "Emergency health services" means those health care 695
services that must be available on a seven-days-per-week, 696
twenty-four-hours-per-day basis in order to prevent jeopardy to 697
an enrollee's health status that would occur if such services 698
were not received as soon as possible, and includes, where 699
appropriate, provisions for transportation and indemnity payments 700
or service agreements for out-of-area coverage. 701
(I) "Enrollee" means any natural person who is entitled to 704
receive health care benefits provided by a health insuring 705
corporation.
(J) "Evidence of coverage" means any certificate, 708
agreement, policy, or contract issued to a subscriber that sets 709
out the coverage and other rights to which such person is 710
entitled under a health care plan. 711
(K) "Health care facility" means any facility, except a 714
17
health care practitioner's office, that provides preventive, 715
diagnostic, therapeutic, acute convalescent, rehabilitation, 716
mental health, mental retardation, intermediate care, or skilled 717
nursing services. 718
(L) "Health care services" means any BASIC, SUPPLEMENTAL, 721
AND SPECIALTY HEALTH CARE services involved in or incident to the 722
furnishing of preventive, diagnostic, therapeutic, or 723
rehabilitative care. 724
(M) "Health delivery network" means any group of providers 727
or health care facilities, or both, or any representative 728
thereof, that have entered into an agreement to offer health care 730
services in a panel rather than on an individual basis. 731
(N) "Health insuring corporation" means a corporation, as 734
defined in division (G) of this section, that, pursuant to a 735
policy, contract, certificate, or agreement, pays for, 736
reimburses, or provides, delivers, arranges for, or otherwise 737
makes available, basic health care services, supplemental health 738
care services, or specialty health care services, or a 739
combination of basic health care services and either supplemental 740
health care services or specialty health care services, through 742
either an open panel plan or a closed panel plan. 743
"Health insuring corporation" does not include a limited 746
liability company formed pursuant to Chapter 1705. of the Revised 748
Code, AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED CODE 754
IF THAT INSURER OFFERS ONLY OPEN PANEL PLANS UNDER WHICH ALL 755
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING RECEIVE THEIR 756
COMPENSATION DIRECTLY FROM THE INSURER, a corporation formed by 757
or on behalf of a political subdivision or a department, office, 758
or institution of the state, or a public entity formed by or on 759
behalf of a board of county commissioners, a county board of 761
mental retardation and developmental disabilities, an alcohol and 763
drug addiction services board, a board of alcohol, drug 764
addiction, and mental health services, or a community mental 765
health board, as those terms are used in Chapters 340. and 5126. 766
18
of the Revised Code. Except as provided by division (D) of 769
section 1751.02 of the Revised Code, or as otherwise provided by 772
law, no board, commission, agency, or other entity under the 774
control of a political subdivision may accept insurance risk in 775
providing for health care services. However, nothing in this 776
division shall be construed as prohibiting such entities from 777
purchasing the services of a health insuring corporation or a 778
third-party administrator licensed under Chapter 3959. of the 779
Revised Code. 780
(O) "Intermediary organization" means a health delivery 783
network or other entity that contracts with licensed health 784
insuring corporations or self-insured employers, or both, to 785
provide health care services, and that enters into contractual 787
arrangements with other entities for the provision of health care 788
services for the purpose of fulfilling the terms of its contracts 789
with the health insuring corporations and self-insured employers. 790
(P) "Intermediate care" means residential care above the 793
level of room and board for patients who require personal 794
assistance and health-related services, but who do not require 795
skilled nursing care.
(Q) "Medical record" means the personal information that 798
relates to an individual's physical or mental condition, medical 799
history, or medical treatment. 800
(R)(1) "Open panel plan" means a health care plan that 802
provides incentives for enrollees to use participating providers 803
and that also allows enrollees to use providers that are not 804
participating providers.
(2) No health insuring corporation may offer an open panel 807
plan, unless the health insuring corporation is also licensed as 808
an insurer under Title XXXIX of the Revised Code, the health 809
insuring corporation, on the effective date of this section JUNE 810
4, 1997, holds a certificate of authority or license to operate 812
under Chapter 1736. or 1740. of the Revised Code, or an insurer 813
licensed under Title XXXIX of the Revised Code is responsible for 815
19
the out-of-network risk as evidenced by both an evidence of
coverage filing under section 1751.11 of the Revised Code and a 817
policy and certificate filing under section 3923.02 of the 818
Revised Code. 819
(S) "PANEL" MEANS A GROUP OF PROVIDERS OR HEALTH CARE 821
FACILITIES THAT HAVE JOINED TOGETHER TO DELIVER HEALTH CARE 822
SERVICES THROUGH A CONTRACTUAL ARRANGEMENT WITH A HEALTH INSURING 824
CORPORATION, EMPLOYER GROUP, OR OTHER PAYOR.
(T) "Person" has the same meaning as in section 1.59 of 826
the Revised Code, and, unless the context otherwise requires, 827
includes any insurance company holding a certificate of authority 828
under Title XXXIX of the Revised Code, any subsidiary and 830
affiliate of an insurance company, and any government agency. 831
(T)(U) "Premium rate" means any set fee regularly paid by 834
a subscriber to a health insuring corporation. A "premium rate" 835
does not include a one-time membership fee, an annual
administrative fee, or a nominal access fee, paid to a managed 836
health care system under which the recipient of health care 837
services remains solely responsible for any charges accessed for 838
those services by the provider or health care facility. 839
(U)(V) "Primary care provider" means a provider that is 842
designated by a health insuring corporation to supervise, 843
coordinate, or provide initial care or continuing care to an 844
enrollee, and that may be required by the health insuring 845
corporation to initiate a referral for specialty care and to 846
maintain supervision of the health care services rendered to the 847
enrollee.
(V)(W) "Provider" means any natural person or partnership 850
of natural persons who are licensed, certified, accredited, or 851
otherwise authorized in this state to furnish health care 852
services, or any professional association organized under Chapter 853
1785. of the Revised Code, provided that nothing in this chapter 855
or other provisions of law shall be construed to preclude a 856
health insuring corporation, health care practitioner, or 857
20
organized health care group associated with a health insuring 858
corporation from employing CERTIFIED nurse practitioners,
CERTIFIED NURSE ANESTHETISTS, CLINICAL NURSE SPECIALISTS, 859
CERTIFIED NURSE MIDWIVES, dietitians, physicians' assistants, 860
dental assistants, dental hygienists, optometric technicians, or 861
other allied health personnel who are licensed, certified, 862
accredited, or otherwise authorized in this state to furnish 863
health care services.
(W)(X) "Provider sponsored organization" means a 866
corporation, as defined in division (G) of this section, that is 867
at least eighty per cent owned or controlled by one or more 869
hospitals, as defined in section 3727.01 of the Revised Code, or 870
one or more physicians licensed to practice medicine or surgery 871
or osteopathic medicine and surgery under Chapter 4731. of the 872
Revised Code, or any combination of such physicians and 873
hospitals. Such control is presumed to exist if at least eighty 874
per cent of the voting rights or governance rights of a provider 875
sponsored organization are directly or indirectly owned, 876
controlled, or otherwise held by any combination of the 877
physicians and hospitals described in this division. 878
(X)(Y) "Solicitation document" means the written materials 880
provided to prospective subscribers or enrollees, or both, and 882
used for advertising and marketing to induce enrollment in the 883
health care plans of a health insuring corporation. 884
(Y)(Z) "Subscriber" means a person who is responsible for 887
making payments to a health insuring corporation for 888
participation in a health care plan, or an enrollee whose 889
employment or other status is the basis of eligibility for 890
enrollment in a health insuring corporation.
(Z)(AA) "Urgent care services" means those health care 893
services that are appropriately provided for an unforeseen 894
condition of a kind that usually requires medical attention 895
without delay but that does not pose a threat to the life, limb, 896
or permanent health of the injured or ill person, and may include 898
21
such health care services provided out of the health insuring 899
corporation's approved service area pursuant to indemnity 900
payments or service agreements.
Sec. 1751.02. (A) Notwithstanding any law in this state 909
to the contrary, any corporation, as defined in section 1751.01 911
of the Revised Code, may apply to the superintendent of insurance 913
for a certificate of authority to establish and operate a health 914
insuring corporation. If the corporation applying for a 915
certificate of authority is a foreign corporation domiciled in a 916
state without laws similar to those of this chapter, the 918
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 919
chapter.
(B) No person shall establish, operate, or perform the 922
services of a health insuring corporation in this state without 924
obtaining a certificate of authority under this chapter. 925
(C) Except as provided by division (D) of this section, no 928
political subdivision or department, office, or institution of 929
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 930
this state, shall establish, operate, or perform the services of 931
a health insuring corporation. Nothing in this section shall be 934
construed to preclude a board of county commissioners, a county 935
board of mental retardation and developmental disabilities, an 936
alcohol and drug addiction services board, a board of alcohol, 937
drug addiction, and mental health services, or a community mental 938
health board, or a public entity formed by or on behalf of any of 939
these boards, from using managed care techniques in carrying out 940
the board's or public entity's duties pursuant to the 941
requirements of Chapters 307., 329., 340., and 5126. of the 943
Revised Code. However, no such board or public entity may 945
operate so as to compete in the private sector with health 946
insuring corporations holding certificates of authority under 947
this chapter.
22
(D) A corporation formed by or on behalf of a publicly 949
owned, operated, or funded hospital or health care facility may 950
apply to the superintendent for a certificate of authority under 952
division (A) of this section to establish and operate a health 953
insuring corporation.
(E) A health insuring corporation shall operate in this 956
state in compliance with this chapter and Chapter 1753. of the 957
Revised Code, and with sections 3702.51 to 3702.62 of the Revised 959
Code, and shall operate in conformity with its filings with the 961
superintendent under this chapter, including filings made 962
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 963
the Revised Code. 965
(F) An insurer licensed under Title XXXIX of the Revised 969
Code need not obtain a certificate of authority as a health 970
insuring corporation to offer an open panel plan as long as the 971
providers and health care facilities participating in the open 972
panel plan receive their compensation directly from the insurer. 973
If the providers and health care facilities participating in the 974
open panel plan receive their compensation from any person other 975
than the insurer, or if the insurer offers a closed panel plan, 976
the insurer must obtain a certificate of authority as a health 977
insuring corporation.
(G) An intermediary organization need not obtain a 980
certificate of authority as a health insuring corporation, 981
regardless of the method of reimbursement to the intermediary 982
organization, as long as a health insuring corporation or a 984
self-insured employer maintains the ultimate responsibility to 985
assure delivery of all health care services required by the
contract between the health insuring corporation and the 986
subscriber and the laws of this state or between the self-insured 987
employer and its employees. 988
Nothing in this section shall be construed to require any 990
health care facility, provider, health delivery network, or 991
intermediary organization that contracts with a health insuring 992
23
corporation or self-insured employer, regardless of the method of 994
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 995
certificate of authority as a health insuring corporation under 996
this chapter, unless otherwise provided, in the case of contracts 998
with a self-insured employer, by operation of the "Employee 999
Retirement Income Security Act of 1974," 88 Stat. 829, 29 1,004
U.S.C.A. 1001, as amended. 1,006
(H) Any health delivery network doing business in this 1,009
state, INCLUDING ANY HEALTH DELIVERY NETWORK THAT IS FUNCTIONING 1,010
AS AN INTERMEDIARY ORGANIZATION DOING BUSINESS IN THIS STATE, 1,012
that is not required to obtain a certificate of authority under 1,013
this chapter shall certify to the superintendent annually, not 1,014
later than the first day of July, and shall provide a statement 1,016
signed by the highest ranking official which includes the 1,017
following information:
(1) The health delivery network's full name and the 1,019
address of its principal place of business; 1,020
(2) A statement that the health delivery network is not 1,022
required to obtain a certificate of authority under this chapter 1,023
to conduct its business. 1,024
(I) The superintendent shall not issue a certificate of 1,027
authority to a health insuring corporation that is a provider 1,028
sponsored organization unless all health care plans to be offered 1,029
by the health insuring corporation provide basic health care 1,030
services. Substantially all of the physicians and hospitals with 1,031
ownership or control of the provider sponsored organization, as 1,032
defined in division (W)(X) of section 1751.01 of the Revised 1,034
Code, shall also be participating providers for the provision of 1,036
basic health care services for health care plans offered by the 1,037
provider sponsored organization. If a health insuring 1,038
corporation that is a provider sponsored organization offers 1,039
health care plans that do not provide basic health care services, 1,040
the health insuring corporation shall be deemed, for purposes of 1,041
24
section 1751.35 of the Revised Code, to have failed to 1,042
substantially comply with this chapter. 1,043
Except as specifically provided in this division and in 1,045
division (C) of section 1751.28 of the Revised Code, the 1,047
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 1,048
same manner that these provisions apply to all health insuring 1,049
corporations that are not provider sponsored organizations. 1,050
(J) Nothing in this section shall be construed to apply to 1,052
any multiple employer welfare arrangement operating pursuant to 1,053
Chapter 1739. of the Revised Code. 1,054
(K) Any person who violates division (B) of this section, 1,058
and any health delivery network that fails to comply with 1,059
division (H) of this section, is subject to the penalties set 1,060
forth in section 1751.45 of the Revised Code. 1,062
Sec. 1751.03. (A) Each application for a certificate of 1,072
authority under this chapter shall be verified by an officer or 1,073
authorized representative of the applicant, shall be in a format 1,074
prescribed by the superintendent of insurance, and shall set 1,075
forth or be accompanied by the following: 1,076
(1) A certified copy of the applicant's articles of 1,078
incorporation and all amendments to the articles of 1,079
incorporation; 1,080
(2) A copy of any regulations adopted for the government 1,082
of the corporation, any bylaws, and any similar documents, and a 1,083
copy of all amendments to these regulations, bylaws, and 1,084
documents. The corporate secretary shall certify that these 1,085
regulations, bylaws, documents, and amendments have been properly 1,087
adopted or approved.
(3) A list of the names, addresses, and official positions 1,090
of the persons responsible for the conduct of the applicant, 1,091
including all members of the board, the principal officers, and 1,092
the person responsible for completing or filing financial 1,093
statements with the department of insurance, accompanied by a 1,094
25
completed original biographical affidavit and release of 1,095
information for each of these persons on forms acceptable to the 1,096
department;
(4) A full and complete disclosure of the extent and 1,098
nature of any contractual or other financial arrangement between 1,099
the applicant and any provider or a person listed in division 1,100
(A)(3) of this section, including, but not limited to, a full and 1,102
complete disclosure of the financial interest held by any such 1,103
provider or person in any health care facility, provider, or 1,104
insurer that has entered into a financial relationship with the 1,105
health insuring corporation; 1,106
(5) A description of the applicant, its facilities, and 1,108
its personnel, including, but not limited to, the location, hours 1,110
of operation, and telephone numbers of all contracted facilities; 1,111
(6) The applicant's projected annual enrollee population 1,113
over a three-year period; 1,114
(7) A clear and specific description of the health care 1,116
plan or plans to be used by the applicant, including a 1,117
description of the proposed providers, procedures for accessing 1,118
care, and the form of all proposed and existing contracts 1,119
relating to the administration, delivery, or financing of health 1,120
care services; 1,121
(8) A copy of each type of evidence of coverage and 1,123
identification card or similar document to be issued to 1,124
subscribers; 1,125
(9) A copy of each type of individual or group policy, 1,127
contract, or agreement to be used; 1,128
(10) The schedule of the proposed contractual periodic 1,130
prepayments or premium rates, or both, accompanied by appropriate 1,131
supporting data; 1,132
(11) A financial plan which provides a three-year 1,134
projection of operating results, including the projected 1,135
expenses, income, and sources of working capital; 1,136
(12) The enrollee complaint procedure to be utilized as 1,138
26
required under section 1751.19 of the Revised Code; 1,141
(13) A description of the procedures and programs to be 1,143
implemented on an ongoing basis to assure the quality of health 1,144
care services delivered to enrollees, including, if applicable, a 1,145
description of a quality assurance program complying with the 1,147
requirements of sections 1751.73 to 1751.75 of the Revised Code;
(14) A statement describing the geographic area or areas 1,149
to be served, by county; 1,150
(15) A copy of all solicitation documents; 1,152
(16) A balance sheet and other financial statements 1,154
showing the applicant's assets, liabilities, income, and other 1,155
sources of financial support; 1,156
(17) A description of the nature and extent of any 1,158
reinsurance program to be implemented, and a demonstration that 1,159
errors and omission insurance and, if appropriate, fidelity 1,160
insurance, will be in place upon the applicant's receipt of a 1,161
certificate of authority; 1,162
(18) Copies of all proposed or in force related-party or 1,164
intercompany agreements with an explanation of the financial 1,165
impact of these agreements on the applicant. If the applicant 1,166
intends to enter into a contract for managerial or administrative 1,168
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 1,169
description of the person to provide these services. The 1,171
description shall include that person's experience in managing or 1,172
administering health care plans, a copy of that person's most 1,173
recent audited financial statement, and a completed biographical 1,174
affidavit on a form acceptable to the superintendent for each of 1,175
that person's principal officers and board members and for any 1,176
additional employee to be directly involved in providing 1,177
managerial or administrative services to the health insuring 1,178
corporation. If the person to provide managerial or 1,179
administrative services is affiliated with the health insuring 1,180
corporation, the contract must provide for payment for services 1,181
27
based on actual costs.
(19) A statement from the applicant's board that the 1,183
admitted assets of the applicant have not been and will not be 1,184
pledged or hypothecated; 1,185
(20) A statement from the applicant's board that the 1,187
applicant will submit monthly financial statements during the 1,188
first year of operations; 1,189
(21) The name and address of the applicant's Ohio 1,192
statutory agent for service of process, notice, or demand; 1,193
(22) Copies of all documents the applicant filed with the 1,195
secretary of state; 1,196
(23) The location of those books and records of the 1,198
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL 1,199
BE MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, 1,200
AND WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF 1,202
DOMICILE OR IN OHIO IF THE APPLICANT IS A FOREIGN CORPORATION; 1,204
(24) The applicant's federal identification number, 1,206
corporate address, and mailing address; 1,207
(25) An internal and external organizational chart; 1,210
(26) A list of the assets representing the initial net 1,212
worth of the applicant; 1,213
(27) If the applicant has a parent company, the parent 1,215
company's guaranty, on a form acceptable to the superintendent, 1,216
that the applicant will maintain Ohio's minimum net worth. If no 1,219
parent company exists, a statement regarding the availability of 1,220
future funds if needed.
(28) The names and addresses of the applicant's actuary 1,222
and external auditors; 1,223
(29) If the applicant is a foreign corporation, a copy of 1,225
the most recent financial statements filed with the insurance 1,226
regulatory agency in the applicant's state of domicile; 1,227
(30) If the applicant is a foreign corporation, a 1,229
statement from the insurance regulatory agency of the applicant's 1,230
state of domicile stating that the regulatory agency has no 1,231
28
objection to the applicant applying for an Ohio license and that 1,232
the applicant is in good standing in the applicant's state of 1,233
domicile; 1,234
(31) Any other information that the superintendent may 1,236
require. 1,237
(B)(1) A health insuring corporation, unless otherwise 1,240
provided for in this chapter OR IN SECTION 3901.321 OF THE 1,242
REVISED CODE, shall file a timely notice with the superintendent 1,244
describing any change to the corporation's articles of 1,245
incorporation or regulations, or any major modification to its 1,246
operations as set out in the information required by division (A) 1,248
of this section that affects any of the following: 1,249
(a) The solvency of the health insuring corporation; 1,252
(b) The health insuring corporation's continued provision 1,255
of services that it has contracted to provide; 1,256
(c) The manner in which the health insuring corporation 1,259
conducts its business.
(2) If the change or modification is to be the result of 1,261
an action to be taken by the health insuring corporation, the 1,262
notice shall be filed with the superintendent prior to the health 1,263
insuring corporation taking the action. The action shall be 1,265
deemed approved if the superintendent does not disapprove it 1,266
within sixty days of filing. 1,267
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION (B)(1) OR 1,270
(2) OF THIS SECTION SHALL ALSO SERVE AS THE SUBMISSION OF A 1,271
NOTICE WHEN REQUIRED FOR THE SUPERINTENDENT'S REVIEW FOR PURPOSES 1,272
OF SECTION 3901.341 OF THE REVISED CODE, IF THE NOTICE CONTAINS 1,274
ALL OF THE INFORMATION THAT SECTION 3901.341 OF THE REVISED CODE 1,278
REQUIRES FOR SUCH SUBMISSIONS AND A COPY OF ANY WRITTEN 1,279
AGREEMENT. THE FILING OF SUCH A NOTICE, FOR THE PURPOSE OF 1,280
SATISFYING THIS DIVISION AND SECTION 3901.341 OF THE REVISED 1,283
CODE, SHALL BE SUBJECT TO THE SIXTY-DAY REVIEW PERIOD OF DIVISION 1,284
(B)(2) OF THIS SECTION. 1,285
(C)(1) No health insuring corporation shall expand its 1,288
29
approved service area until a copy of the request for expansion, 1,289
accompanied by documentation of the network of providers, FORMS 1,291
OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS RELATING TO THE 1,292
DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF PROPOSED 1,293
CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR GROUP 1,294
CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING DATA, enrollment 1,295
projections, plan of operation, and any other changes have been 1,296
filed with the superintendent. 1,297
(2) Within ten calendar days after receipt of a complete 1,299
filing under division (C)(1) of this section, the superintendent 1,301
shall refer the appropriate jurisdictional issues to the director 1,302
of health pursuant to section 1751.04 of the Revised Code. 1,304
(3) Within seventy-five days after the superintendent's 1,306
receipt of a complete filing under division (C)(1) of this 1,308
section, the superintendent shall determine whether the plan for 1,309
expansion is lawful, fair, and reasonable. The superintendent 1,310
may not make a determination until the superintendent has 1,311
received the director's certification of compliance, which the 1,312
director shall furnish within forty-five days after referral 1,313
under division (C)(2) of this section. The director shall not 1,315
certify that the requirements of section 1751.04 of the Revised 1,316
Code are not met, unless the applicant has been given an 1,318
opportunity for a hearing as provided in division (D) of section 1,320
1751.04 of the Revised Code. The forty-five-day and 1,321
seventy-five-day review periods provided for in division (C)(3) 1,323
of this section shall cease to run as of the date on which the 1,324
notice of the applicant's right to request a hearing is mailed 1,325
and shall remain suspended until the director issues a final 1,326
certification. 1,327
(4) If the superintendent has not approved or disapproved 1,329
all or a portion of a service area expansion within the 1,330
seventy-five-day period provided for in division (C)(3) of this 1,332
section, the filing shall be deemed approved. 1,333
(5) Disapproval of all or a portion of the filing shall be 1,336
30
effected by written notice, which shall state the grounds for the 1,337
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 1,338
Sec. 1751.05. (A) The superintendent of insurance shall 1,348
issue or deny a certificate of authority to establish or operate 1,349
a health insuring corporation to any corporation filing an 1,350
application pursuant to section 1751.03 of the Revised Code 1,352
within forty-five days of the superintendent's receipt of the 1,353
certification from the director of health under division (C) of 1,354
section 1751.04 of the Revised Code. A certificate of authority 1,355
shall be issued upon payment of the application fee prescribed in 1,356
section 1751.44 of the Revised Code if the superintendent is 1,357
satisfied that the following conditions are met: 1,358
(1) The persons responsible for the conduct of the affairs 1,361
of the applicant are competent, trustworthy, and possess good 1,362
reputations.
(2) The director certifies, in accordance with division 1,364
(C) of section 1751.04 of the Revised Code, that the 1,365
organization's proposed plan of operation meets the requirements 1,366
of division (B) of that section and sections 3702.51 to 3702.62 1,368
of the Revised Code. If, after the director has certified 1,369
compliance, the application is amended in a manner that affects 1,370
its approval under section 1751.04 of the Revised Code, the 1,371
superintendent shall request the director to review and recertify 1,372
the amended plan of operation. Within forty-five days of receipt 1,373
of the amended plan from the superintendent, the director shall 1,374
certify to the superintendent, pursuant to section 1751.04 of the 1,375
Revised Code, whether or not the amended plan meets the 1,377
requirements of section 1751.04 of the Revised Code. The 1,378
superintendent's forty-five-day review period shall cease to run 1,379
as of the date on which the amended plan is transmitted to the 1,380
director and shall remain suspended until the superintendent 1,381
receives a new certification from the director.
(3) The applicant constitutes an appropriate mechanism to 1,383
31
effectively provide or arrange for the provision of the basic 1,384
health care services, supplemental health care services, or 1,385
specialty health care services to be provided to enrollees. 1,386
(4) The applicant is financially responsible, complies 1,388
with section 1751.28 of the Revised Code, and may reasonably be 1,390
expected to meet its obligations to enrollees and prospective 1,391
enrollees. In making this determination, the superintendent may 1,392
consider: 1,393
(a) The financial soundness of the applicant's 1,395
arrangements for health care services, including the applicant's 1,396
proposed contractual periodic prepayments or premiums and the use 1,397
of copayments or deductibles; 1,398
(b) The adequacy of working capital; 1,400
(c) Any agreement with an insurer, a government, or any 1,403
other person for insuring the payment of the cost of health care 1,404
services or providing for automatic applicability of an 1,405
alternative coverage in the event of discontinuance of the health 1,406
insuring corporation's operations; 1,407
(d) Any agreement with providers or health care facilities 1,409
for the provision of health care services; 1,410
(e) Any deposit of securities submitted in accordance with 1,413
section 1751.27 of the Revised Code as a guarantee that the 1,414
obligations will be performed. 1,415
(5) The applicant has submitted documentation of an 1,417
arrangement to provide health care services to its enrollees 1,418
until the expiration of the enrollees' contracts with the 1,419
applicant if a health care plan or the operations of the health 1,420
insuring corporation are discontinued prior to the expiration of 1,421
the enrollees' contracts. An arrangement to provide health care 1,422
services may be made by using any one, or any combination, of the 1,424
following methods:
(a) The maintenance of insolvency insurance; 1,426
(b) A provision in contracts with providers and health 1,429
care facilities, but no health insuring corporation shall rely 1,430
32
solely on such a provision for more than thirty days; 1,431
(c) An agreement with other health insuring corporations 1,434
or insurers, providing enrollees with automatic conversion rights 1,435
upon the discontinuation of a health care plan or the health 1,436
insuring corporation's operations; 1,437
(d) Such other methods as approved by the superintendent. 1,439
(6) Nothing in the applicant's proposed method of 1,441
operation, as shown by the information submitted pursuant to 1,442
section 1751.03 of the Revised Code or by independent 1,444
investigation, will cause harm to an enrollee or to the public at 1,446
large, as determined by the superintendent.
(7) Any deficiencies certified by the director have been 1,448
corrected. 1,449
(8) The applicant has deposited securities as set forth in 1,452
section 1751.27 of the Revised Code.
(B) If an applicant elects to fulfill the requirements of 1,455
division (A)(5) of this section through an agreement with other 1,457
health insuring corporations or insurers, the agreement shall 1,458
require those health insuring corporations or insurers to give 1,459
thirty days' notice to the superintendent prior to cancellation 1,460
or discontinuation of the agreement for any reason. 1,461
(C) A certificate of authority shall be denied only after 1,464
compliance with the requirements of section 1751.36 of the 1,465
Revised Code.
Sec. 1751.06. Upon obtaining a certificate of authority as 1,474
required under this chapter, a health insuring corporation may do 1,476
all of the following:
(A) Enroll individuals and their dependents in either of 1,478
the following circumstances: 1,479
(1) The individual resides or lives in the approved 1,481
service area.
(2) The individual's place of employment is located in the 1,484
approved service area.
(B) Contract with providers and health care facilities for 1,486
33
the health care services to which enrollees are entitled under 1,487
the terms of the health insuring corporation's health care 1,488
contracts;
(C) Contract with insurance companies authorized to do 1,491
business in this state for insurance, indemnity, or reimbursement 1,492
against the cost of providing emergency and nonemergency health 1,493
care services for enrollees, subject to the provisions set forth 1,494
in this chapter and the limitations set forth in the Revised 1,496
Code;
(D) Contract with any person pursuant to the requirements 1,498
of division (A)(18) of section 1751.03 of the Revised Code for 1,499
managerial or administrative services, or for data processing, 1,500
actuarial analysis, billing services, or any other services 1,501
authorized by the superintendent of insurance. However, a health 1,503
insuring corporation shall not enter into a contract for any of 1,504
the services listed in this division with an insurance company 1,505
that is not authorized to engage in the business of insurance in 1,506
this state.
(E) Accept from governmental agencies, private agencies, 1,508
corporations, associations, groups, individuals, or other 1,509
persons, payments covering all or part of the costs of planning, 1,510
development, construction, and the provision of health care 1,511
services;
(F) Purchase, lease, construct, renovate, operate, or 1,513
maintain health care facilities, and their ancillary equipment, 1,514
and any property necessary in the transaction of the business of 1,515
the health insuring corporation;
(G) In the employer group market, impose an affiliation 1,518
period of not more than sixty days, OR FOR LATE ENROLLEES AN
AFFILIATION PERIOD OF NOT MORE THAN NINETY DAYS, which period 1,519
begins on the individual's date of enrollment and runs 1,520
concurrently with any waiting period imposed under the coverage. 1,521
For purposes of this division, "affiliation period" means a 1,522
period of time which, under the terms of the coverage offered, 1,523
34
must expire before the coverage becomes effective. No health 1,524
care services or benefits need to be provided during an 1,525
affiliation period, and no periodic prepayments can be charged 1,526
for any coverage during that period. 1,527
(H) If a health insuring corporation offers coverage in 1,530
the small employer group market through a network plan, limit or 1,531
deny the coverage in accordance with section 3924.031 of the 1,532
Revised Code; 1,534
(I) Refuse to issue coverage in the small employer group 1,537
market pursuant to section 3924.032 of the Revised Code; 1,539
(J) Establish employer contribution rules or group 1,542
participation rules for the offering of coverage in connection 1,543
with a group contract in the small employer group market, as 1,544
provided in division (E)(1) of section 3924.03 of the Revised 1,546
Code. 1,547
Nothing in this section shall be construed as prohibiting a 1,549
health insuring corporation without other commercial enrollment 1,550
from contracting solely with federal health care programs 1,551
regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the 1,553
authority of a health insuring corporation to perform those 1,554
functions not otherwise prohibited by law. 1,555
Sec. 1751.11. (A) Every subscriber of a health insuring 1,565
corporation is entitled to an evidence of coverage for the health 1,566
care plan under which health care benefits are provided. 1,568
(B) Every subscriber of a health insuring corporation that 1,570
offers basic health care services is entitled to an 1,571
identification card or similar document that specifies the health 1,572
insuring corporation's name as stated in its articles of 1,573
incorporation, and any trade or fictitious names used by the 1,574
health insuring corporation. The identification card or document 1,575
shall list at least one telephone number that provides the 1,576
subscriber with access to health care on a 1,577
twenty-four-hour-per-day TWENTY-FOUR-HOURS-PER-DAY,
35
seven-day-per-week SEVEN-DAYS-PER-WEEK basis. 1,578
(C) No evidence of coverage, or amendment to the evidence 1,580
of coverage, shall be delivered, issued for delivery, renewed, or 1,581
used, until the form of the evidence of coverage or amendment has 1,582
been filed by the health insuring corporation with the 1,583
superintendent of insurance. If the superintendent does not 1,584
disapprove the evidence of coverage or amendment within sixty 1,585
days after it is filed it shall be deemed approved, unless the 1,586
superintendent sooner gives approval for the evidence of coverage 1,587
or amendment. With respect to an amendment to an approved 1,588
evidence of coverage, the superintendent only may disapprove 1,589
provisions amended or added to the evidence of coverage. If the 1,590
superintendent determines within the sixty-day period that any 1,591
evidence of coverage or amendment fails to meet the requirements 1,592
of this section, the superintendent shall so notify the health 1,593
insuring corporation and it shall be unlawful for the health 1,594
insuring corporation to use such evidence of coverage or 1,595
amendment. At any time, the superintendent, upon at least thirty 1,597
days' written notice to a health insuring corporation, may 1,598
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 1,599
section. Such disapproval shall be effected by a written order, 1,600
which shall state the grounds for disapproval and shall be issued 1,602
in accordance with Chapter 119. of the Revised Code. 1,604
(D) No evidence of coverage or amendment shall be 1,606
delivered, issued for delivery, renewed, or used: 1,607
(1) If it contains provisions or statements that are 1,609
inequitable, untrue, misleading, or deceptive; 1,610
(2) Unless it contains a clear, concise, and complete 1,612
statement of the following: 1,613
(a) The health care services and insurance or other 1,616
benefits, if any, to which the enrollee is entitled under the 1,617
health care plan;
(b) Any exclusions or limitations on the health care 1,620
36
services, type of health care services, benefits, or type of 1,621
benefits to be provided, including copayments or deductibles; 1,622
(c) The enrollee's personal financial obligation for 1,624
noncovered services; 1,625
(d) Where and in what manner general information and 1,628
information as to how services may be obtained is available, 1,629
including the telephone number; 1,630
(e) The premium rate with respect to individual and 1,632
conversion contracts, and relevant copayment provisions with 1,633
respect to all contracts. The statement of the premium rate, 1,634
however, may be contained in a separate insert. 1,635
(f) The method utilized by the health insuring corporation 1,638
for resolving enrollee complaints. 1,639
(3) Unless it provides for the continuation of an 1,641
enrollee's coverage, in the event that the enrollee's coverage 1,642
under the GROUP policy, contract, certificate, or agreement 1,643
terminates while the enrollee is receiving inpatient care in a 1,644
hospital. This continuation of coverage shall terminate at the 1,645
earliest occurrence of any of the following: 1,646
(a) The enrollee's discharge from the hospital; 1,648
(b) The determination by the enrollee's attending 1,650
physician that inpatient care is no longer medically indicated 1,651
for the enrollee; HOWEVER, NOTHING IN DIVISION (D)(3)(b) OF THIS 1,654
SECTION PRECLUDES A HEALTH INSURING CORPORATION FROM ENGAGING IN 1,655
UTILIZATION REVIEW AS DESCRIBED IN THE EVIDENCE OF COVERAGE. 1,656
(c) The enrollee's reaching the limit for contractual 1,658
benefits; 1,659
(d) THE EFFECTIVE DATE OF ANY NEW COVERAGE. 1,662
(4) Unless it contains a provision that states, in 1,664
substance, that the health insuring corporation is not a member 1,665
of any guaranty fund, and that in the event of the health 1,666
insuring corporation's insolvency, the enrollee is protected only 1,668
to the extent that the hold harmless provision required by
section 1751.13 of the Revised Code applies to the health care 1,670
37
services rendered; 1,671
(5) Unless it contains a provision that states, in 1,673
substance, that in the event of the insolvency of the health 1,674
insuring corporation, the enrollee may be financially responsible 1,676
for health care services rendered by a provider or health care 1,677
facility that is not under contract to the health insuring 1,678
corporation, whether or not the health insuring corporation 1,679
authorized the use of the provider or health care facility. 1,680
(E) Notwithstanding division DIVISIONS (C) AND (D) of this 1,683
section, a health insuring corporation may use an evidence of 1,684
coverage that provides for the coverage of beneficiaries enrolled 1,685
in Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 1,687
42 U.S.C.A. 301, as amended, pursuant to a medicare risk contract 1,689
or medicare cost contract, or an evidence of coverage that 1,690
provides for the coverage of beneficiaries enrolled in the 1,691
federal employees health benefits program pursuant to 5 U.S.C.A. 1,693
8905, or an evidence of coverage that provides for the coverage 1,694
of beneficiaries enrolled in Title XIX of the "Social Security 1,696
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as 1,698
the medical assistance program or medicaid, provided by the Ohio 1,700
department of human services under Chapter 5111. of the Revised 1,701
Code, or an evidence of coverage that provides for the coverage 1,702
of beneficiaries under any other federal health care program 1,703
regulated by a federal regulatory body, OR AN EVIDENCE OF 1,704
COVERAGE THAT PROVIDES FOR THE COVERAGE OF BENEFICIARIES UNDER 1,705
ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS 1,706
BEEN ENTERED INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, 1,708
if both of the following apply: 1,710
(1) The evidence of coverage has been approved by the 1,712
United States department of health and human services, the United 1,714
States office of personnel management, or the Ohio department of 1,715
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,716
(2) The evidence of coverage is filed with the 1,718
superintendent of insurance prior to use and is accompanied by 1,719
38
documentation of approval from the United States department of 1,721
health and human services, the United States office of personnel 1,722
management, or the Ohio department of human services, OR THE 1,723
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,724
Sec. 1751.12. (A)(1) No contractual periodic prepayment 1,734
and no premium rate for nongroup and conversion policies for 1,735
health care services, or any amendment to them, may be used by 1,736
any health insuring corporation at any time until the contractual 1,737
periodic prepayment and premium rate, or amendment, have been 1,738
filed with the superintendent of insurance, and shall not be 1,739
effective until the expiration of sixty days after their filing 1,740
unless the superintendent sooner gives approval. THE FILING 1,741
SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE FORM 1,742
PRESCRIBED BY THE SUPERINTENDENT. The superintendent shall 1,744
disapprove the filing, if the superintendent determines within 1,745
the sixty-day period that the contractual periodic prepayment or 1,746
premium rate, or amendment, is not in accordance with sound 1,747
actuarial principles or is not reasonably related to the 1,748
applicable coverage and characteristics of the applicable class 1,749
of enrollees. The superintendent shall notify the health 1,750
insuring corporation of the disapproval, and it shall thereafter 1,751
be unlawful for the health insuring corporation to use the 1,752
contractual periodic prepayment or premium rate, or amendment. 1,753
(2) No contractual periodic prepayment for group policies 1,756
for health care services shall be used until the contractual 1,757
periodic prepayment has been filed with the superintendent. THE 1,758
FILING SHALL BE ACCOMPANIED BY AN ACTUARIAL CERTIFICATION IN THE 1,759
FORM PRESCRIBED BY THE SUPERINTENDENT. The superintendent may 1,761
reject a filing made under division (A)(2) of this section at any 1,762
time, with at least thirty days' written notice to a health 1,763
insuring corporation, if the contractual periodic prepayment is 1,764
not in accordance with sound actuarial principles or is not 1,766
reasonably related to the applicable coverage and characteristics 1,767
of the applicable class of enrollees. 1,768
39
(3) At any time, the superintendent, upon at least thirty 1,770
days' written notice to a health insuring corporation, may 1,771
withdraw the approval given under division (A)(1) of this 1,772
section, deemed or actual, of any contractual periodic prepayment 1,774
or premium rate, or amendment, based on information that either 1,775
of the following applies:
(a) The contractual periodic prepayment or premium rate, 1,778
or amendment, is not in accordance with sound actuarial 1,779
principles.
(b) The contractual periodic prepayment or premium rate, 1,782
or amendment, is not reasonably related to the applicable 1,783
coverage and characteristics of the applicable class of 1,784
enrollees.
(4) Any disapproval under division (A)(1) of this section, 1,786
any rejection of a filing made under division (A)(2) of this 1,788
section, or any withdrawal of approval under division (A)(3) of 1,789
this section, shall be effected by a written notice, which shall 1,790
state the specific basis for the disapproval, rejection, or 1,791
withdrawal and shall be issued in accordance with Chapter 119. of 1,792
the Revised Code. 1,793
(B) Notwithstanding division (A) of this section, a health 1,796
insuring corporation may use a contractual periodic prepayment or 1,797
premium rate for policies used for the coverage of beneficiaries 1,798
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 1,800
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 1,802
risk contract or medicare cost contract, or for policies used for 1,803
the coverage of beneficiaries enrolled in the federal employees 1,804
health benefits program pursuant to 5 U.S.C.A. 8905, or for 1,807
policies used for the coverage of beneficiaries enrolled in Title 1,808
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 1,810
U.S.C.A. 301, as amended, known as the medical assistance program 1,813
or medicaid, provided by the Ohio department of human services 1,814
under Chapter 5111. of the Revised Code, or for policies used for 1,815
the coverage of beneficiaries under any other federal health care 1,816
40
program regulated by a federal regulatory body, OR FOR POLICIES 1,818
USED FOR THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT 1,819
COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED 1,820
INTO BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the 1,822
following apply: 1,823
(1) The contractual periodic prepayment or premium rate 1,825
has been approved by the United States department of health and 1,826
human services, the United States office of personnel management, 1,828
or the Ohio department of human services, OR THE DEPARTMENT OF 1,829
ADMINISTRATIVE SERVICES.
(2) The contractual periodic prepayment or premium rate is 1,831
filed with the superintendent prior to use and is accompanied by 1,832
documentation of approval from the United States department of 1,834
health and human services, the United States office of personnel 1,836
management, or the Ohio department of human services, OR THE 1,838
DEPARTMENT OF ADMINISTRATIVE SERVICES. 1,839
(C) The administrative expense portion of all contractual 1,842
periodic prepayment or premium rate filings submitted to the 1,843
superintendent for review must reflect the actual cost of 1,844
administering the product. The superintendent may require that 1,845
the administrative expense portion of the filings be itemized and 1,846
supported.
(D)(1) Copayments and deductibles must be reasonable and 1,849
must not be a barrier to the necessary utilization of services by 1,850
enrollees.
(2) A health insuring corporation may not impose copayment 1,853
charges on basic health care services that exceed thirty per cent 1,854
of the total cost of providing any single covered health care 1,855
service, except for physician office visits, emergency health 1,856
services, and urgent care services. The total cost of providing 1,857
a health care service is the cost to the health insuring 1,858
corporation of providing the health care service to its enrollees 1,860
as reduced by any applicable provider discount. An open panel 1,862
plan may not impose copayments on out-of-network benefits that 1,863
41
exceed fifty per cent of the total cost of providing any single 1,864
covered health care service.
(3) To ensure that copayments are not a barrier to the 1,866
utilization of basic health care services, a health insuring 1,867
corporation may not impose, in any contract year, on any 1,869
subscriber or enrollee, copayments that exceed two hundred per 1,870
cent of the total annual premium rate to the subscriber or 1,871
enrollees. This limitation of two hundred per cent does not 1,874
include any reasonable copayments that are not a barrier to the 1,875
necessary utilization of health care services by enrollees and 1,876
that are imposed on physician office visits, emergency health 1,877
services, urgent care services, supplemental health care 1,878
services, or specialty health care services.
(E) A health insuring corporation shall not impose 1,881
lifetime maximums on basic health care services. However, a 1,882
health insuring corporation may establish a benefit limit for 1,883
inpatient hospital services that are provided pursuant to a 1,884
policy, contract, certificate, or agreement for supplemental 1,885
health care services.
Sec. 1751.13. (A)(1)(a) A health insuring corporation 1,895
shall, either directly or indirectly, enter into contracts for 1,896
the provision of health care services with a sufficient number 1,897
and types of providers and health care facilities to ensure that 1,898
all covered health care services will be accessible to enrollees 1,899
from a contracted provider or health care facility. 1,900
(b) A health insuring corporation shall not refuse to 1,903
contract with a physician for the provision of health care
services or refuse to recognize a physician as a specialist on 1,904
the basis that the physician attended an educational program or a 1,906
residency program approved or certified by the American 1,907
Osteopathic Association. A health insuring corporation shall not 1,908
refuse to contract with a health care facility for the provision 1,909
of health care services on the basis that the health care 1,910
facility is certified or accredited by the American Osteopathic 1,912
42
Association or that the health care facility is an osteopathic 1,913
hospital as defined in section 3702.51 of the Revised Code. 1,916
(c) Nothing in division (A)(1)(b) of this section shall be 1,920
construed to require a health insuring corporation to make a 1,921
benefit payment under a closed panel plan to a physician or 1,922
health care facility with which the health insuring corporation 1,923
does not have a contract, provided that none of the bases set 1,924
forth in that division are used as a reason for failing to make a 1,925
benefit payment.
(2) When a health insuring corporation is unable to 1,927
provide a covered health care service from a contracted provider 1,928
or health care facility, the health insuring corporation must 1,929
provide that health care service from a noncontracted provider or 1,931
health care facility consistent with the terms of the enrollee's 1,932
policy, contract, certificate, or agreement. The health insuring 1,933
corporation shall either ensure that the health care service be 1,934
provided at no greater cost to the enrollee than if the enrollee 1,935
had obtained the health care service from a contracted provider 1,936
or health care facility, or make other arrangements acceptable to 1,937
the superintendent of insurance. 1,938
(3) Nothing in this section shall prohibit a health 1,940
insuring corporation from entering into contracts with 1,941
out-of-state providers or health care facilities that are 1,942
licensed, certified, accredited, or otherwise authorized in that 1,943
state. 1,944
(B)(1) A health insuring corporation shall, either 1,947
directly or indirectly, enter into contracts with all providers 1,948
and health care facilities through which health care services are 1,949
provided to its enrollees.
(2) A health insuring corporation, upon written request, 1,951
shall assist its contracted providers in finding stop-loss or 1,952
reinsurance carriers.
(C) A health insuring corporation shall file an annual 1,954
certificate with the superintendent certifying that all provider 1,955
43
contracts and contracts with health care facilities through which 1,956
health care services are being provided contain the following: 1,957
(1) A description of the method by which the provider or 1,959
health care facility will be notified of the specific health care 1,961
services for which the provider or health care facility will be 1,962
responsible, including any limitations or conditions on such 1,963
services;
(2) The specific hold harmless provision specifying 1,965
protection of enrollees set forth as follows: 1,966
"[Provider/Health Care Facility< agrees that in no event, 1,969
including but not limited to nonpayment by the health insuring 1,970
corporation, insolvency of the health insuring corporation, or 1,971
breach of this agreement, shall [Provide PROVIDER/Health Care 1,972
Facility< bill, charge, collect a deposit from, seek remuneration 1,974
or reimbursement from, or have any recourse against, a 1,975
subscriber, enrollee, person to whom health care services have 1,976
been provided, or person acting on behalf of the covered 1,977
enrollee, for health care services provided pursuant to this 1,978
agreement. This does not prohibit [Provider/Health Care 1,980
Facility< from collecting co-insurance, deductibles, or 1,981
copayments as specifically provided in the evidence of coverage, 1,982
or fees for uncovered health care services delivered on a 1,983
fee-for-service basis to persons referenced above, nor from any 1,984
recourse against the health insuring corporation or its 1,985
successor."
(3) Provisions requiring the provider or health care 1,987
facility to continue to provide covered health care services to 1,988
enrollees in the event of the health insuring corporation's 1,989
insolvency or discontinuance of operations. The provisions shall 1,991
require the provider or health care facility to continue to 1,992
provide covered health care services to enrollees as needed to 1,993
complete any medically necessary procedures commenced but 1,994
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A 1,995
44
MEDICALLY NECESSARY PROCEDURE SHALL INCLUDE THE RENDERING OF ALL 1,997
COVERED HEALTH CARE SERVICES THAT CONSTITUTE MEDICALLY NECESSARY 1,998
FOLLOW-UP CARE FOR THAT PROCEDURE. If an enrollee is receiving 2,000
necessary inpatient care at a hospital, the provisions may limit 2,001
the required provision of covered health care services relating 2,002
to that inpatient care in accordance with division (D)(3) of 2,003
section 1751.11 of the Revised Code, and may also limit such 2,004
required provision of covered health care services to the period 2,005
ending thirty days after the health insuring corporation's 2,006
insolvency or discontinuance of operations. 2,007
The provisions required by division (C)(3) of this section 2,010
shall not require any provider or health care facility to 2,011
continue to provide any covered health care service after the
occurrence of any of the following: 2,012
(a) The end of the thirty-day period following the entry 2,014
of a liquidation order under Chapter 3903. of the Revised Code; 2,016
(b) The end of the enrollee's period of coverage for a 2,018
contractual prepayment or premium; 2,019
(c) The enrollee obtains equivalent coverage with another 2,021
health insuring corporation or insurer, or the enrollee's 2,022
employer obtains such coverage for the enrollee; 2,023
(d) The enrollee or the enrollee's employer terminates 2,025
coverage under the contract; 2,026
(e) A liquidator effects a transfer of the health insuring 2,029
corporation's obligations under the contract under division 2,030
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 2,032
responsibilities of the health insuring corporation, and of the 2,033
contracted providers and health care facilities, with respect to 2,034
administrative policies and programs, including, but not limited 2,035
to, payments systems, utilization review, quality assurance, 2,036
assessment, and improvement programs, credentialing, 2,037
confidentiality requirements, and any applicable federal or state 2,038
programs; 2,039
45
(5) A provision regarding the availability and 2,041
confidentiality of those health records maintained by providers 2,042
and health care facilities to monitor and evaluate the quality of 2,044
care, to conduct evaluations and audits, and to determine on a 2,045
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 2,046
The provision shall include terms requiring the provider or 2,047
health care facility to make these health records available to 2,048
appropriate state and federal authorities involved in assessing 2,049
the quality of care or in investigating the grievances or 2,050
complaints of enrollees, and requiring the provider or health 2,051
care facility to comply with applicable state and federal laws 2,052
related to the confidentiality of medical or health records. 2,054
(6) A provision that states that contractual rights and 2,056
responsibilities may not be assigned or delegated by the provider 2,058
or health care facility without the prior written consent of the 2,059
health insuring corporation;
(7) A provision requiring the provider or health care 2,061
facility to maintain adequate professional liability and 2,062
malpractice insurance. The provision shall also require the 2,063
provider or health care facility to notify the health insuring 2,064
corporation not more than ten days after the provider's or health 2,066
care facility's receipt of notice of any reduction or
cancellation of such coverage. 2,067
(8) A provision requiring the provider or health care 2,069
facility to observe, protect, and promote the rights of enrollees 2,071
as patients;
(9) A provision requiring the provider or health care 2,073
facility to provide health care services without discrimination 2,074
on the basis of a patient's participation in the health care 2,075
plan, age, sex, ethnicity, religion, sexual preference, health 2,076
status, or disability, and without regard to the source of 2,077
payments made for health care services rendered to a patient. 2,078
This requirement shall not apply to circumstances when the 2,079
46
provider or health care facility appropriately does not render 2,080
services due to limitations arising from the provider's or health 2,082
care facility's lack of training, experience, or skill, or due to 2,083
licensing restrictions.
(10) A provision containing the specifics of any 2,085
obligation on the PRIMARY CARE provider or health care facility 2,086
to provide, or to arrange for the provision of, covered health 2,088
care services twenty-four hours per day, seven days per week; 2,089
(11) A provision setting forth procedures for the 2,091
resolution of disputes arising out of the contract; 2,092
(12) A provision stating that the hold harmless provision 2,094
required by division (C)(2) of this section shall survive the 2,096
termination of the contract with respect to services covered and 2,097
provided under the contract during the time the contract was in 2,098
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 2,099
(13) A provision requiring those terms that are used in 2,101
the contract and that are defined by this chapter, be used in the 2,103
contract in a manner consistent with those definitions. 2,104
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF 2,106
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 2,111
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 2,114
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 2,115
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 2,116
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 2,119
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 2,124
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 2,127
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 2,128
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 2,132
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 2,133
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, OR TO 2,134
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 2,135
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 2,136
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,137
47
(D)(1) No health insuring corporation contract with a 2,140
provider or health care facility shall contain any of the 2,141
following:
(a) A provision that directly or indirectly offers an 2,144
inducement to the provider or health care facility to reduce or 2,145
limit medically necessary health care services to a covered 2,146
enrollee;
(b) A provision that penalizes a provider or health care 2,149
facility that assists an enrollee to seek a reconsideration of 2,150
the health insuring corporation's decision to deny or limit 2,151
benefits to the enrollee; 2,152
(c) A provision that limits or otherwise restricts the 2,155
provider's or health care facility's ethical and legal
responsibility to fully advise enrollees about their medical 2,156
condition and about medically appropriate treatment options; 2,158
(d) A provision that penalizes a provider or health care 2,161
facility for principally advocating for medically necessary 2,162
health care services;
(e) A provision that penalizes a provider or health care 2,164
facility for providing information or testimony to a legislative 2,165
or regulatory body or agency. This shall not be construed to 2,166
prohibit a health insuring corporation from penalizing a provider 2,168
or health care facility that provides information or testimony 2,169
that is libelous or slanderous or that discloses trade secrets 2,170
which the provider or health care facility has no privilege or 2,171
permission to disclose.
(2) Nothing in this division shall be construed to 2,173
prohibit a health insuring corporation from doing either of the 2,174
following: 2,175
(a) Making a determination not to reimburse or pay for a 2,178
particular medical treatment or other health care service; 2,179
(b) Enforcing reasonable peer review or utilization review 2,182
protocols, or determining whether a particular provider or health 2,183
care facility has complied with these protocols. 2,184
48
(E) Any contract between a health insuring corporation and 2,187
an intermediary organization shall clearly specify that the 2,188
health insuring corporation must approve or disapprove the 2,189
participation of any provider or health care facility with which 2,190
the intermediary organization contracts. 2,191
(F) If an intermediary organization that is not a health 2,193
delivery network contracting solely with self-insured employers 2,194
subcontracts with a provider or health care facility, the 2,195
subcontract with the provider or health care facility shall do 2,196
all of the following:
(1) Contain the provisions required by divisions (C) and 2,199
(G) of this section, as made applicable to an intermediary 2,200
organization, without the inclusion of inducements or penalties 2,201
described in division (D) of this section; 2,202
(2) Acknowledge that the health insuring corporation is a 2,204
third-party beneficiary to the agreement; 2,205
(3) Acknowledge the health insuring corporation's role in 2,207
approving the participation of the provider or health care 2,208
facility, pursuant to division (E) of this section. 2,210
(G) Any provider contract or contract with a health care 2,213
facility shall clearly specify the health insuring corporation's 2,214
statutory responsibility to monitor and oversee the offering of 2,215
covered health care services to its enrollees. 2,216
(H)(1) A health insuring corporation shall maintain its 2,219
provider contracts and its contracts with health care facilities 2,220
at one or more of its places of business in this state, and shall 2,221
provide copies of these contracts to facilitate regulatory review 2,222
upon written notice by the superintendent of insurance. 2,223
(2) Any contract with an intermediary organization THAT 2,225
ACCEPTS COMPENSATION shall include provisions requiring the 2,227
intermediary organization to provide the superintendent with 2,228
regulatory access to all books, records, financial information, 2,229
and documents related to the provision of health care services to 2,230
subscribers and enrollees under the contract. The contract shall 2,231
49
require the intermediary organization to maintain such books, 2,232
records, financial information, and documents at its principal 2,233
place of business in this state and to preserve them for at least 2,234
three years in a manner that facilitates regulatory review. 2,235
(I)(1) A health insuring corporation shall provide notice 2,237
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A 2,238
contract with FOR THE PROVISION OF HEALTH CARE SERVICES BETWEEN 2,240
THE HEALTH INSURING CORPORATION AND a primary care physician or 2,242
hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF 2,243
THE CONTRACT.
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 2,245
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE 2,246
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH 2,247
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE PRIMARY 2,249
CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF THE 2,250
SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE 2,251
PREVIOUS TWELVE MONTHS. 2,252
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE 2,254
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR A 2,256
DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE 2,257
PREVIOUS TWELVE MONTHS. 2,258
(2) THE HEALTH INSURING CORPORATION SHALL PAY, IN 2,260
ACCORDANCE WITH THE TERMS OF THE CONTRACT, FOR ALL COVERED HEALTH 2,262
CARE SERVICES RENDERED TO AN ENROLLEE BY A PRIMARY CARE PHYSICIAN 2,263
OR HOSPITAL BETWEEN THE DATE OF THE TERMINATION OF THE CONTRACT 2,264
AND FIVE DAYS AFTER THE NOTIFICATION OF THE CONTRACT TERMINATION 2,265
IS MAILED TO A SUBSCRIBER AT THE SUBSCRIBER'S LAST KNOWN ADDRESS. 2,266
(J) Divisions (A) and (B) of this section do not apply to 2,269
any health insuring corporation that, on June 4, 1997, holds a 2,270
certificate of authority or license to operate under Chapter 2,272
1740. of the Revised Code. 2,273
(K) Nothing in this section shall restrict the governing 2,275
50
body of a hospital from exercising the authority granted it 2,276
pursuant to section 3701.351 of the Revised Code. 2,277
Sec. 1751.14. (A) Any policy, contract, or agreement for 2,287
health care services authorized by this chapter that is issued, 2,288
delivered, or renewed in this state and that provides that 2,289
coverage of an unmarried dependent child will terminate upon 2,290
attainment of the limiting age for dependent children specified 2,291
in the policy, contract, or agreement, shall also provide in 2,292
substance that attainment of the limiting age shall not operate 2,293
to terminate the coverage of the child if the child is and 2,294
continues to be both:
(1) Incapable of self-sustaining employment by reason of 2,296
mental retardation or physical handicap; 2,297
(2) Primarily dependent upon the subscriber for support 2,299
and maintenance. 2,300
(B) Proof of incapacity and dependence for purposes of 2,302
division (A) of this section shall be furnished to the health 2,303
insuring corporation within thirty-one days of the child's 2,305
attainment of the limiting age. Upon request, but not more 2,306
frequently than annually, the health insuring corporation may 2,307
require proof satisfactory to it of the continuance of such 2,308
incapacity and dependency.
(C) Nothing in this section shall be construed to require 2,311
a health insuring corporation to cover a dependent child who is 2,312
mentally retarded or physically handicapped if the policy, 2,313
contract, or agreement is underwritten on evidence of 2,314
insurability based on health factors set forth in the 2,315
application, or if the dependent child does not satisfy the 2,316
conditions of the policy, contract, or agreement as to any 2,317
requirement for evidence of insurability or any other provision 2,318
of the policy, contract, or agreement, satisfaction of which is 2,319
required for coverage thereunder to take effect. In any such 2,320
case, the terms of the policy, contract, or agreement shall apply 2,321
with regard to the coverage or exclusion of the dependent from 2,322
51
such coverage.
(D) This section does not apply to any health insuring 2,325
corporation, policy, contract, or agreement offering only 2,327
supplemental health care services or specialty health care
services. 2,328
Sec. 1751.141. A HEALTH INSURING CORPORATION SHALL PROVIDE 2,331
COVERAGE, IN ACCORDANCE WITH THE TERMS OF THE CONTRACT, FOR A
SUBSCRIBER'S DEPENDENT CHILDREN LIVING OUTSIDE THE HEALTH 2,333
INSURING CORPORATION'S APPROVED SERVICE AREA IF A COURT ORDER 2,334
REQUIRES THE SUBSCRIBER TO PROVIDE HEALTH CARE COVERAGE TO THE 2,335
DEPENDENT CHILDREN.
Sec. 1751.15. (A) After a health insuring corporation has 2,344
furnished, directly or indirectly, basic health care services for 2,345
a period of twenty-four months, and if it currently meets the 2,346
financial requirements set forth in section 1751.28 of the 2,347
Revised Code and had net income as reported to the superintendent 2,348
of insurance for at least one of the preceding four calendar
quarters, it shall hold an annual open enrollment period of not 2,349
less than thirty days during its month of licensure for 2,351
individuals who are not federally eligible individuals AT THE 2,352
TIME THEY APPLY FOR ENROLLMENT.
(B) During the open enrollment period described in 2,354
division (A) of this section, the health insuring corporation 2,355
shall accept applicants and their dependents in the order in 2,356
which they apply for enrollment and in accordance with any of the 2,357
following:
(1) Up to its capacity, as determined by the health 2,359
insuring corporation subject to review by the superintendent; 2,360
(2) If less than its capacity, one per cent of the health 2,362
insuring corporation's total number of subscribers residing in 2,363
this state as of the immediately preceding thirty-first day of 2,364
December. 2,365
(C) Where a health insuring corporation demonstrates to 2,367
the satisfaction of the superintendent that such open enrollment 2,368
52
would jeopardize its economic viability, the superintendent may 2,369
do any of the following:
(1) Waive the requirement for open enrollment; 2,371
(2) Impose a limit on the number of applicants and their 2,373
dependents that must be enrolled; 2,374
(3) Authorize such underwriting restrictions upon open 2,376
enrollment as are necessary to do any of the following: 2,377
(a) Preserve its financial stability; 2,379
(b) Prevent excessive adverse selection; 2,381
(c) Avoid unreasonably high or unmarketable charges for 2,383
coverage of health care services. 2,384
(D)(1) A request to the superintendent under division (C) 2,387
of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting 2,388
documentation, including financial data. In reviewing the 2,389
request, the superintendent may consider various factors, 2,390
including the size of the health insuring corporation, the health 2,391
insuring corporation's net worth and profitability, the health 2,392
insuring corporation's delivery system structure, and the effect
on profitability of prior open enrollments. 2,393
(2) Any action taken by the superintendent under division 2,395
(C) of this section shall be effective for a period of not more 2,397
than one year. At the expiration of such time, a new 2,398
demonstration of the health insuring corporation's need for the 2,399
restriction, limit, or waiver shall be made before a new 2,400
restriction, limit, or waiver is granted by the superintendent. 2,401
(3) Irrespective of the granting of any restriction, 2,403
limit, or waiver by the superintendent, a health insuring 2,404
corporation may reject an applicant or a dependent of the 2,405
applicant during its open enrollment period if the applicant or 2,406
dependent: 2,407
(a) Was eligible for and was covered under any 2,409
employer-sponsored health care coverage, or if employer-sponsored 2,410
health care coverage was available at the time of open 2,411
53
enrollment;
(b) Is eligible for continuation coverage under state or 2,413
federal law; 2,414
(c) Is eligible for medicare, and the health insuring 2,416
corporation does not have an agreement on appropriate payment 2,417
mechanisms with the governmental agency administering the 2,418
medicare program.
(E) A health insuring corporation shall not be required 2,420
either to enroll applicants or their dependents who are confined 2,421
to a health care facility because of chronic illness, permanent 2,422
injury, or other infirmity that would cause economic impairment 2,423
to the health insuring corporation if such applicants or their 2,424
dependents were enrolled or to make the effective date of 2,425
benefits for applicants or their dependents enrolled under this 2,426
section earlier than ninety days after the date of enrollment. 2,427
(F) A health insuring corporation shall not be required to 2,429
cover the fees or costs, or both, for any basic health care 2,430
service related to a transplant of a body organ if the transplant 2,431
occurs within one year after the effective date of an enrollee's 2,432
coverage under this section. This limitation on coverage does 2,433
not apply to a newly born child who meets the requirements for
coverage under section 1751.61 of the Revised Code. 2,434
(G) Each health insuring corporation required to hold an 2,436
open enrollment pursuant to division (A) of this section shall 2,437
file with the superintendent, not later than sixty days prior to 2,438
the commencement of the proposed open enrollment period, the 2,439
following documents:
(1) The proposed public notice of open enrollment; 2,441
(2) The evidence of coverage approved pursuant to section 2,443
1751.11 of the Revised Code that will be used during open 2,445
enrollment;
(3) The contractual periodic prepayment and premium rate 2,447
approved pursuant to section 1751.12 of the Revised Code that 2,448
will be applicable during open enrollment; 2,449
54
(4) Any solicitation document approved pursuant to section 2,452
1751.31 of the Revised Code to be sent to applicants, including
the application form that will be used during open enrollment; 2,453
(5) A list of the proposed dates of publication of the 2,455
public notice, and the names of the newspapers in which the 2,456
notice will appear; 2,457
(6) Any request for a restriction, limit, or waiver with 2,459
respect to the open enrollment period, along with any supporting 2,460
documentation. 2,461
(H)(1) An open enrollment period shall not satisfy the 2,463
requirements of this section unless the health insuring 2,464
corporation provides adequate public notice in accordance with 2,465
divisions (H)(2) and (3) of this section. No public notice shall 2,466
be used until the form of the public notice has been filed by the 2,467
health insuring corporation with the superintendent. If the 2,468
superintendent does not disapprove the public notice within sixty 2,469
days after it is filed, it shall be deemed approved, unless the 2,470
superintendent sooner gives approval for the public notice. If 2,471
the superintendent determines within this sixty-day period that 2,472
the public notice fails to meet the requirements of this section, 2,473
the superintendent shall so notify the health insuring 2,474
corporation and it shall be unlawful for the health insuring 2,475
corporation to use the public notice. Such disapproval shall be 2,476
effected by a written order, which shall state the grounds for 2,477
disapproval and shall be issued in accordance with Chapter 119. 2,478
of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this 2,480
section shall be published in at least one newspaper of general 2,481
circulation in each county in the health insuring corporation's 2,482
service area, at least once in each of the two weeks immediately 2,483
preceding the month in which the open enrollment is to occur and 2,484
in each week of that month, or until the enrollment limitation is 2,485
reached, whichever occurs first. The notice published during the 2,486
last week of open enrollment shall appear not less than five days 2,487
55
before the end of the open enrollment period. It shall be at 2,488
least two newspaper columns wide or two and one-half inches wide, 2,490
whichever is larger. The first two lines of the text shall be 2,491
published in not less than twelve-point, boldface type. The 2,492
remainder of the text of the notice shall be published in not 2,493
less than eight-point type. The entire public notice shall be 2,494
surrounded by a continuous black line not less than one-eighth of 2,495
an inch wide.
(3) The following information shall be included in the 2,497
public notice provided under division (H)(2) of this section: 2,498
(a) The dates that open enrollment will be held and the 2,500
date coverage obtained under the open enrollment will become 2,501
effective;
(b) Notice that an applicant or the applicant's dependents 2,503
will not be denied coverage during open enrollment because of a 2,504
preexisting health condition, but that some limitations and 2,505
restrictions may apply;
(c) The address where a person may obtain an application; 2,507
(d) The telephone number that a person may call to request 2,509
an application or to ask questions; 2,511
(e) The date the first payment will be due; 2,513
(f) The actual rates or range of rates that will be 2,515
applicable for applicants; 2,516
(g) Any limitation granted by the superintendent on the 2,519
number of applications that will be accepted by the health 2,520
insuring corporation.
(4) Within thirty days after the end of an open enrollment 2,523
period, the health insuring corporation shall submit to the 2,524
superintendent proof of publication for the public notices, and 2,525
shall report the total number of applicants and their dependents 2,526
enrolled during the open enrollment period. 2,527
(I)(1) No health insuring corporation may employ any 2,529
scheme, plan, or device that restricts the ability of any person 2,530
to enroll during open enrollment. 2,531
56
(2) No health insuring corporation may require enrollment 2,533
to be made in person. Every health insuring corporation shall 2,534
permit application for coverage by mail. A representative of the 2,536
health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the 2,537
operations of the health insuring corporation and to answer any 2,538
questions the applicant may have. Every health insuring 2,539
corporation shall make open enrollment applications and 2,540
solicitation documents readily available to any potential 2,541
applicant who requests such material. 2,542
(J) An application postmarked on the last day of an open 2,544
enrollment period shall qualify as a valid application, 2,545
regardless of the date on which it is received by the health 2,546
insuring corporation.
(K) This section does not apply to any health insuring 2,548
corporation that offers only supplemental health care services or 2,550
specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title 2,551
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 2,552
U.S.C.A. 301, as amended, and that has no other commercial 2,553
enrollment, or to any health insuring corporation that offers 2,554
plans only through other federal health care programs regulated 2,555
by federal regulatory bodies and that has no other commercial 2,556
enrollment, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 2,557
PLANS ONLY THROUGH CONTRACTS COVERING OFFICERS OR EMPLOYEES OF 2,558
THE STATE THAT HAVE BEEN ENTERED INTO BY THE DEPARTMENT OF 2,560
ADMINISTRATIVE SERVICES AND THAT HAS NO OTHER COMMERCIAL 2,561
ENROLLMENT.
(L) Each health insuring corporation shall accept 2,564
federally eligible individuals for open enrollment coverage as 2,565
provided in section 3923.581 of the Revised Code. A health 2,567
insuring corporation may reinsure coverage of any federally 2,568
eligible individual acquired under that section with the open 2,569
enrollment reinsurance program in accordance with division (G) of 2,571
57
section 3924.11 of the Revised Code. Fixed periodic prepayment 2,574
rates charged for coverage reinsured by the program shall be 2,575
established in accordance with section 3924.12 of the Revised 2,576
Code. 2,577
(M) As used in this section, "federally eligible 2,580
individual" means an eligible individual as defined in 45 C.F.R. 2,582
148.103. 2,583
Sec. 1751.16. (A) Except as provided in division (F) of 2,592
this section, every group contract issued by a health insuring 2,593
corporation shall provide an option for conversion to an 2,594
individual contract issued on a direct-payment basis to any 2,595
subscriber covered by the group contract who terminates 2,596
employment or membership in the group, unless: 2,597
(1) Termination of the conversion option or contract is 2,599
based upon nonpayment of premium after reasonable notice in 2,600
writing has been given by the health insuring corporation to the 2,601
subscriber. 2,602
(2) The subscriber is, or is eligible to be, covered for 2,604
benefits at least comparable to the group contract under any of 2,605
the following: 2,606
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 2,608
(1935), 42 U.S.C.A. 301, as amended; 2,609
(b) Any act of congress or law under this or any other 2,611
state of the United States providing coverage at least comparable 2,612
to the benefits under division (A)(2)(a) of this section; 2,613
(c) Any policy of insurance or health care plan providing 2,615
coverage at least comparable to the benefits under division 2,616
(A)(2)(a) of this section. 2,617
(B)(1) The direct-payment contract offered by the health 2,619
insuring corporation pursuant to division (A) of this section 2,621
shall provide the following: 2,623
(a) In the case of an individual who is not a federally 2,626
eligible individual, benefits comparable to benefits in any of 2,627
the individual contracts then being issued to individual 2,628
58
subscribers by the health insuring corporation; 2,629
(b) In the case of a federally eligible individual, a 2,632
basic and standard plan established by the board of directors of 2,633
the Ohio health reinsurance program or plans substantially 2,634
similar to the basic and standard plan in benefit design and 2,635
scope of covered services. For purposes of division (B)(1)(b) of 2,637
this section, the superintendent of insurance shall determine 2,638
whether a plan is substantially similar to the basic or standard 2,639
plan in benefit design and scope of covered services. The 2,640
contractual periodic prepayments charged for such plans may not 2,641
exceed an amount that is two times the midpoint of the standard 2,642
rate charged any other individual of a group to which the 2,643
organization is currently accepting new business and for which 2,644
similar copayments and deductibles are applied. 2,645
(2) The direct payment contract offered pursuant to 2,647
division (A) of this section may include a coordination of 2,649
benefits provision as approved by the superintendent. 2,650
(3) For purposes of division (B) of this section 2,653
"federally eligible individual" means an eligible individual as 2,654
defined in 45 C.F.R. 148.103. 2,657
(C) The option for conversion shall be available: 2,659
(1) Upon the death of the subscriber, to the surviving 2,661
spouse with respect to such of the spouse and dependents as are 2,663
then covered by the group contract; 2,664
(2) To a child solely with respect to the child upon the 2,666
child's attaining the limiting age of coverage under the group 2,667
contract while covered as a dependent under the contract; 2,668
(3) Upon the divorce, dissolution, or annulment of the 2,670
marriage of the subscriber, to the divorced spouse, or, in the 2,671
event of annulment, to the former spouse of the subscriber. 2,673
(D) No health insuring corporation shall use age as the 2,675
basis for refusing to renew a converted contract. 2,676
(E) Written notice of the conversion option provided by 2,679
this section shall be given to the subscriber by the health 2,680
59
insuring corporation by mail. The notice shall be sent to the 2,681
subscriber's address in the records of the employer upon receipt 2,682
of notice from the employer of the event giving rise to the 2,683
conversion option. If the subscriber has not received notice of 2,684
the conversion privilege at least fifteen days prior to the 2,685
expiration of the thirty-day conversion period, then the 2,686
subscriber shall have an additional period within which to 2,687
exercise the privilege. This additional period shall expire 2,688
fifteen days after the subscriber receives notice, but in no 2,689
event shall the period extend beyond sixty days after the 2,690
expiration of the thirty-day conversion period. 2,691
(F) This section does not apply to any group contract 2,693
offering only supplemental health care services or specialty 2,694
health care services.
Sec. 1751.20. (A) No health insuring corporation, or 2,704
agent, employee, or representative of a health insuring 2,705
corporation, shall use any advertisement or solicitation 2,706
document, or shall engage in any activity, that is unfair, 2,707
untrue, misleading, or deceptive.
(B) No health insuring corporation shall use a name that 2,710
is deceptively similar to the name or description of any 2,711
insurance or surety corporation doing business in this state. 2,712
(C) All solicitation documents, advertisements, evidences 2,715
of coverage, and enrollee identification cards used by a health 2,716
insuring corporation shall contain the health insuring 2,717
corporation's name. The use of a trade name, an insurance group 2,718
designation, the name of a parent company, the name of a division 2,719
of an affiliated insurance company, a service mark, a slogan, a 2,720
symbol, or other device, without the name of the health insuring 2,721
corporation as stated in its articles of incorporation, shall not 2,722
satisfy this requirement if the usage would have the capacity and 2,723
tendency to mislead or deceive persons as to the true identity of 2,724
the health insuring corporation. 2,725
(D) No solicitation document or advertisement used by a 2,728
60
health insuring corporation shall contain any words, symbols, or 2,729
physical materials that are so similar in content, phraseology, 2,730
shape, color, or other characteristic to those used by an agency 2,731
of the federal government or this state, that prospective 2,732
enrollees may be led to believe that the solicitation document or 2,733
advertisement is connected with an agency of the federal 2,734
government or this state. 2,735
(E) A HEALTH INSURING CORPORATION THAT PROVIDES BASIC 2,737
HEALTH CARE SERVICES MAY USE THE PHRASE "HEALTH MAINTENANCE 2,739
ORGANIZATION" OR THE ABBREVIATION "HMO" IN ITS MARKETING NAME, 2,740
ADVERTISING, SOLICITATION DOCUMENTS, OR MARKETING LITERATURE, OR 2,742
IN REFERENCE TO THE PHRASE "DOING BUSINESS AS" OR THE
ABBREVIATION "DBA." 2,743
(F) This section does not apply to the coverage of 2,745
beneficiaries enrolled in Title XVIII of the "Social Security 2,747
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, pursuant 2,750
to a medicare risk contract or medicare cost contract, or to the 2,751
coverage of beneficiaries enrolled in the federal employee health 2,752
benefits program pursuant to 5 U.S.C.A. 8905, or to the coverage 2,754
of beneficiaries enrolled in Title XIX of the "Social Security 2,755
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as 2,757
the medical assistance program or medicaid, provided by the Ohio 2,758
department of human services under Chapter 5111. of the Revised 2,759
Code, or to the coverage of beneficiaries under any federal 2,761
health care program regulated by a federal regulatory body, OR TO 2,762
THE COVERAGE OF BENEFICIARIES UNDER ANY CONTRACT COVERING 2,763
OFFICERS OR EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO BY 2,764
THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,765
Sec. 1751.31. (A) Any changes in a health insuring 2,775
corporation's solicitation document shall be filed with the 2,776
superintendent of insurance. The superintendent, within sixty 2,777
days of filing, may disapprove any solicitation document or 2,778
amendment to it on any of the grounds stated in this section. 2,779
Such disapproval shall be effected by written notice to the 2,780
61
health insuring corporation. The notice shall state the grounds 2,781
for disapproval and shall be issued in accordance with Chapter 2,782
119. of the Revised Code. 2,783
(B) The solicitation document shall contain all 2,786
information necessary to enable a consumer to make an informed 2,787
choice as to whether or not to enroll in the health insuring 2,788
corporation. The information shall include a specific 2,789
description of the health care services to be available and the 2,790
approximate number and type of full-time equivalent medical 2,791
practitioners. The information shall be presented in the 2,792
solicitation document in a manner that is clear, concise, and 2,793
intelligible to prospective applicants in the proposed service 2,794
area.
(C) Every potential applicant whose subscription to a 2,797
health care plan is solicited shall receive, at or before the 2,798
time of solicitation, a solicitation document approved by the 2,799
superintendent.
(D) Notwithstanding division (A) of this section, a health 2,802
insuring corporation may use a solicitation document that the 2,803
corporation uses in connection with policies for beneficiaries of 2,804
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 2,806
U.S.C.A. 301, as amended, pursuant to a medicare risk contract or 2,808
medicare cost contract, or for policies for beneficiaries of the 2,809
federal employees health benefits program pursuant to 5 U.S.C.A. 2,811
8905, or for policies for beneficiaries of Title XIX of the 2,813
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 2,816
amended, known as the medical assistance program or medicaid, 2,817
provided by the Ohio department of human services under Chapter 2,818
5111. of the Revised Code, or for policies for beneficiaries of 2,819
any other federal health care program regulated by a federal 2,820
regulatory body, OR FOR POLICIES FOR BENEFICIARIES OF CONTRACTS 2,821
COVERING OFFICERS OR EMPLOYEES OF THE STATE ENTERED INTO BY THE 2,823
DEPARTMENT OF ADMINISTRATIVE SERVICES, if both of the following 2,824
apply: 2,825
62
(1) The solicitation document has been approved by the 2,827
United States department of health and human services, the United 2,828
States office of personnel management, or the Ohio department of 2,830
human services, OR THE DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,831
(2) The solicitation document is filed with the 2,833
superintendent of insurance prior to use and is accompanied by 2,834
documentation of approval from the United States department of 2,837
health and human services, the United States office of personnel 2,839
management, or the Ohio department of human services, OR THE 2,841
DEPARTMENT OF ADMINISTRATIVE SERVICES. 2,842
(E) No health insuring corporation, or its agents or 2,845
representatives, shall use monetary or other valuable 2,846
consideration, engage in misleading or deceptive practices, or 2,847
make untrue, misleading, or deceptive representations to induce 2,848
enrollment. Nothing in this division shall prohibit incentive 2,849
forms of remuneration such as commission sales programs for the 2,850
health insuring corporation's employees and agents. 2,851
(F) Any person obligated for any part of a premium rate in 2,854
connection with an enrollment agreement, in addition to any right 2,855
otherwise available to revoke an offer, may cancel such agreement 2,856
within seventy-two hours after having signed the agreement or 2,857
offer to enroll. Cancellation occurs when written notice of the 2,858
cancellation is given to the health insuring corporation or its 2,859
agents or other representatives. A notice of cancellation mailed 2,860
to the health insuring corporation shall be considered to have 2,861
been filed on its postmark date. 2,862
(G) Nothing in this section shall prohibit healthy 2,864
lifestyle programs. 2,865
Sec. 1751.32. Each health insuring corporation, annually, 2,874
on or before the first day of March, shall file a report with the 2,876
superintendent of insurance and the director of health, covering 2,877
the preceding calendar year.
The report shall be verified by an officer of the health 2,879
insuring corporation, shall be in the form the superintendent 2,880
63
prescribes, and shall include: 2,881
(A) A financial statement of the health insuring 2,884
corporation, including its balance sheet and receipts and 2,885
disbursements for the preceding year, which reflect, at a 2,886
minimum:
(1) All premium rate and other payments received for 2,888
health care services rendered; 2,889
(2) Expenditures with respect to all categories of 2,891
providers, facilities, insurance companies, and other persons 2,892
engaged to fulfill obligations of the health insuring corporation 2,894
arising out of its health care policies, contracts, certificates, 2,895
and agreements;
(3) Expenditures for capital improvements or additions 2,897
thereto, including, but not limited to, construction, renovation, 2,899
or purchase of facilities and equipment.
(B) A description of the enrollee population and 2,902
composition, group and nongroup;
(C) A summary of enrollee written complaints and their 2,905
disposition;
(D) A statement of the number of subscriber policies, 2,908
contracts, certificates, and agreements that have been terminated 2,909
by action of the health insuring corporation, including the 2,910
number of enrollees affected; 2,911
(E) A summary of the information compiled pursuant to 2,914
division (B)(5) of section 1751.04 of the Revised Code; 2,915
(F) A current report of the names and addresses of the 2,918
persons responsible for the conduct of the affairs of the health 2,919
insuring corporation as required by section 1751.03 of the 2,920
Revised Code. Additionally, the report shall include the amount 2,922
of wages, expense reimbursements, and other payments to these 2,923
persons for services to the health insuring corporation, and 2,924
shall include a full disclosure of the financial interests 2,925
related to the operations of the health insuring corporation 2,926
acquired by these persons during the preceding year. 2,927
64
(G) An audit report certified by an independent certified 2,930
public accountant in the form prescribed by the superintendent by 2,931
rule;
(H) An actuarial opinion in the form prescribed by the 2,934
superintendent by rule;
(I)(H) Any other information relating to the performance 2,937
of the health insuring corporation that is necessary to enable 2,938
the superintendent to carry out the superintendent's duties under 2,939
this chapter.
Sec. 1751.321. EACH HEALTH INSURING CORPORATION, ANNUALLY, 2,942
ON OR BEFORE THE FIRST DAY OF JUNE, SHALL FILE WITH THE 2,943
SUPERINTENDENT OF INSURANCE AND THE DIRECTOR OF HEALTH AN AUDIT 2,944
REPORT CERTIFIED BY AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT 2,945
COVERING THE PRECEDING CALENDAR YEAR. THE REPORT SHALL BE 2,946
VERIFIED BY AN OFFICER OF THE HEALTH INSURING CORPORATION AND 2,947
SHALL BE IN THE FORM PRESCRIBED BY THE SUPERINTENDENT BY RULE. 2,948
Sec. 1751.46. (A) The superintendent of insurance and the 2,958
director of health may contract with qualified persons to make 2,959
recommendations concerning the determinations required to be made 2,960
by the superintendent or the director relative to an expansion of 2,961
a service area pursuant to division (C) of section 1751.03 of the 2,963
Revised Code, an application for a certificate of authority 2,965
pursuant to sections 1751.04 and 1751.05 of the Revised Code, a 2,967
contractual periodic prepayment or premium rate pursuant to 2,968
section 1751.12 of the Revised Code, and an examination pursuant 2,970
to division (B) of section 1751.34 of the Revised Code. The 2,972
recommendations may be accepted in full or in part, or may be 2,973
rejected, by the superintendent or director. 2,974
THE TOTAL COST OF A CONTRACT WITH A QUALIFIED PERSON 2,976
PURSUANT TO THIS DIVISION SHALL REPRESENT THE FAIR MARKET VALUE 2,977
OF THE SERVICES PROVIDED AND SHALL BE BORNE BY THE HEALTH 2,978
INSURING CORPORATION THAT IS THE SUBJECT OF THE DETERMINATION 2,979
REQUIRED TO BE MADE BY THE SUPERINTENDENT OR THE DIRECTOR. 2,980
(B) No qualified person placed on contract by the 2,983
65
superintendent or the director pursuant to division (A) of this 2,985
section shall have a conflict of interest with the department of 2,986
insurance, the department of health, or the health insuring 2,987
corporation.
Sec. 1751.55. A health insuring corporation policy, 2,996
contract, or agreement shall not be construed to exclude illness 2,997
or injury upon the ground that the subscriber might have elected 2,998
to have such illness or injury covered by workers' compensation 2,999
under division (A)(3) of section 4123.01 CHAPTER 4123. of the 3,001
Revised Code unless the policy, contract, or agreement clearly 3,003
excludes work or occupational related illness or injury, or the 3,004
policy, contract, or agreement, or a separate writing signed by 3,005
the subscriber, informs the subscriber that such coverage is 3,006
excluded and may be available to the subscriber under workers' 3,007
compensation as the sole proprietor of a business, a member of a 3,008
partnership, or an officer of a family farm corporation. 3,009
Sec. 1751.58. Except as otherwise provided in section 2721 3,019
of the "Health Insurance Portability and Accountability Act of 3,023
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 3,029
as amended, the following conditions apply to all group health 3,030
insuring corporation contracts that are sold in connection with 3,031
an employment-related group health care plan and that are not 3,032
subject to section 3924.03 of the Revised Code: 3,034
(A)(1) Except as provided in section 2712(b) to (e) of the 3,038
"Health Insurance Portability and Accountability Act of 1996," if 3,042
a health insuring corporation offers coverage in the small or 3,043
large group market in connection with a group contract, the 3,044
organization CORPORATION shall renew or continue in force such 3,045
coverage at the option of the contract holder. 3,047
(2) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 3,050
TO RENEW THE COVERAGE OF ANY ELIGIBLE EMPLOYEE OR OF A DEPENDENT 3,051
OF AN ELIGIBLE EMPLOYEE UNDER THE GROUP CONTRACT IN ACCORDANCE 3,052
WITH DIVISION (B) OF SECTION 1751.18 OF THE REVISED CODE.
(B) Such group contracts are subject to division 3,054
66
(E)(1)(A)(3) of section 3924.03 and sections 3924.033 and 3924.27 3,056
of the Revised Code. 3,057
(C) Such group contracts shall provide for the special 3,060
enrollment periods described in section 2701(f) of the "Health 3,062
Insurance Portability and Accountability Act of 1996." 3,066
(D) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, A HEALTH 3,069
INSURING CORPORATION SHALL PROVIDE TO ALL LATE ENROLLEES, AS 3,070
DEFINED IN SECTION 3924.01 OF THE REVISED CODE, WHO ARE 3,072
IDENTIFIED BY THE CONTRACT HOLDER, THE OPTION TO ENROLL IN THE 3,073
GROUP CONTRACT. THE ENROLLMENT OPTION SHALL BE PROVIDED FOR A 3,074
MINIMUM PERIOD OF THIRTY CONSECUTIVE DAYS. ALL DELAYS OF 3,075
COVERAGE IMPOSED UNDER THE GROUP CONTRACT, INCLUDING ANY 3,076
AFFILIATION PERIOD, SHALL BEGIN ON THE DATE THE HEALTH INSURING 3,077
CORPORATION RECEIVES NOTICE OF THE LATE ENROLLEE'S APPLICATION OR 3,078
REQUEST FOR COVERAGE, AND SHALL RUN CONCURRENTLY WITH EACH OTHER. 3,079
Sec. 1751.59. (A) No individual or group health insuring 3,088
corporation policy, contract, or agreement that makes family 3,090
coverage available may be delivered, issued for delivery, or 3,092
renewed in this state, unless the policy, contract, or agreement
covers adopted children of the subscriber on the same basis as 3,093
other dependents. 3,094
(B) The coverage required by this section is subject to 3,096
the requirements and restrictions set forth in section 3924.51 of 3,098
the Revised Code. Coverage for dependent children living outside 3,100
the health insuring corporation's approved service area must be 3,101
provided if a court order requires the subscriber to provide 3,102
health care coverage.
Sec. 1751.60. (A) Except as provided for in divisions (E) 3,112
and (F) of this section, every provider or health care facility 3,114
that contracts with a health insuring corporation to provide 3,115
health care services to the health insuring corporation's 3,116
enrollees or subscribers shall seek compensation for covered 3,117
services solely from the health insuring corporation and not, 3,118
under any circumstances, from the enrollees or subscribers, 3,119
67
except for approved deductibles and copayments. 3,120
(B) No subscriber or enrollee of a health insuring 3,123
corporation is liable to any contracting provider or health care 3,124
facility for the cost of any covered health care services, if the 3,125
subscriber or enrollee has acted in accordance with the evidence 3,126
of coverage.
(C) Except as provided for in divisions (E) and (F) of 3,130
this section, every contract between a health insuring 3,131
corporation and provider or health care facility shall contain a 3,132
provision approved by the superintendent of insurance requiring 3,133
the provider or health care facility to seek compensation solely 3,134
from the health insuring corporation and not, under any 3,135
circumstances, from the subscriber or enrollee, except for 3,136
approved deductibles and copayments. 3,137
(D) Nothing in this section shall be construed as 3,140
preventing a provider or health care facility from billing the 3,141
enrollee or subscriber of a health insuring corporation for 3,142
noncovered services.
(E) Upon application by a health insuring corporation and 3,145
a provider or health care facility, the superintendent may waive 3,146
the requirements of divisions (A) and (C) of this section when, 3,148
in addition to the reserve requirements contained in section 3,149
1751.28 of the Revised Code, the health insuring corporation 3,152
provides sufficient assurances to the superintendent that the 3,153
provider or health care facility has been provided with financial 3,154
guarantees. No waiver of the requirements of divisions (A) and 3,155
(C) of this section is effective as to enrollees or subscribers 3,157
for whom the health insuring corporation is compensated under a 3,158
provider agreement or risk contract entered into pursuant to 3,159
Chapter 5111. or 5115. of the Revised Code. 3,162
(F) The requirements of divisions (A) to (C) of this 3,166
section apply only to health care services provided to an 3,167
enrollee or subscriber prior to the effective date of a 3,168
termination of a contract between the health insuring corporation 3,169
68
and the provider or health care facility. 3,170
Sec. 1751.62. (A) As used in this section, "screening 3,180
mammography" means a radiologic examination utilized to detect 3,181
unsuspected breast cancer at an early stage in an asymptomatic 3,182
woman and includes the x-ray examination of the breast using 3,183
equipment that is dedicated specifically for mammography, 3,184
including the x-ray tube, filter, compression device, screens, 3,185
film, and cassettes, and that has an average radiation exposure 3,186
delivery of less than one rad mid-breast. "Screening 3,187
mammography" includes two views for each breast. The term also 3,188
includes the professional interpretation of the film. 3,189
"Screening mammography" does not include diagnostic 3,191
mammography. 3,192
(B) Every individual or group health insuring corporation 3,195
policy, contract, or agreement providing basic health care 3,196
services that is delivered, issued for delivery, or renewed in 3,197
this state shall provide benefits for the expenses of both of the 3,198
following: 3,199
(1) Screening mammography to detect the presence of breast 3,202
cancer in adult women;
(2) Cytologic screening for the presence of cervical 3,204
cancer. 3,205
(C) The benefits provided under division (B)(1) of this 3,209
section shall cover expenses in accordance with all of the 3,210
following:
(1) If a woman is at least thirty-five years of age but 3,212
under forty years of age, one screening mammography; 3,213
(2) If a woman is at least forty years of age but under 3,215
fifty years of age, either of the following: 3,216
(a) One screening mammography every two years; 3,219
(b) If a licensed physician has determined that the woman 3,222
has risk factors to breast cancer, one screening mammography 3,223
every year.
(3) If a woman is at least fifty years of age but under 3,225
69
sixty-five years of age, one screening mammography every year. 3,227
(D)(1) The benefits provided under division (B)(1) of this 3,231
section shall not exceed eighty-five dollars per year unless a 3,232
lower amount is established pursuant to a provider contract. 3,233
(2) The benefit paid in accordance with division (D)(1) of 3,236
this section shall constitute full payment. No institutional or 3,237
professional health care provider shall seek or receive 3,238
remuneration in excess of the payment made in accordance with 3,239
division (D)(1) of this section, except for approved deductibles 3,241
and copayments.
(E) The benefits provided under division (B)(1) of this 3,245
section shall be provided only for screening mammographies that 3,246
are performed in a health care facility or mobile mammography 3,247
screening unit that is accredited under the American college of 3,248
radiology mammography accreditation program or in a hospital as 3,249
defined in section 3727.01 of the Revised Code. 3,251
(F) The benefits provided under divisions (B)(1) and (2) 3,255
of this section shall be provided according to the terms of the 3,256
subscriber contract.
(G) The benefits provided under division (B)(2) of this 3,260
section shall be provided only for cytologic screenings that are 3,261
processed and interpreted in a laboratory certified by the 3,262
college of American pathologists or in a hospital as defined in 3,263
section 3727.01 of the Revised Code. 3,265
Sec. 1751.81. (A) As used in this section: 3,274
(1) "Enrollee" includes the representative of an enrollee. 3,276
(2) "Necessary information" includes the results of any 3,278
face-to-face clinical evaluation or second opinion that may be 3,280
required.
(B) A health insuring corporation shall maintain written 3,282
procedures for making utilization review determinations and for 3,284
notifying enrollees, and participating providers and health care 3,286
facilities acting on behalf of enrollees, of its determinations. 3,287
(C) For initial determinations, a health insuring 3,289
70
corporation shall make the determination within two business days 3,291
after obtaining all necessary information regarding a proposed 3,293
admission, procedure, or health care service requiring a review 3,294
determination. 3,295
(1) In the case of a determination to certify an 3,297
admission, procedure, or health care service, the health insuring 3,298
corporation shall notify the provider or health care facility 3,299
rendering the health care service by telephone OR FACSIMILE 3,300
within three business days after making the initial 3,301
certification, and shall provide written or electronic 3,303
confirmation of the telephone notification to the enrollee and 3,304
the provider or health care facility within two business days 3,305
after making the telephone notification. 3,306
(2) In the case of an adverse determination, the health 3,308
insuring corporation shall notify the provider or health care 3,310
facility rendering the health care service by telephone within 3,311
three business days after making the adverse determination, and 3,312
shall provide written or electronic confirmation of the telephone 3,313
notification to the enrollee and the provider or health care 3,314
facility within one business day after making the telephone 3,315
notification.
(D) For concurrent review determinations, a health 3,317
insuring corporation shall make the determination within one 3,319
business day after obtaining all necessary information. 3,320
(1) In the case of a determination to certify an extended 3,322
stay or additional health care services, the health insuring 3,323
corporation shall notify the provider or health care facility 3,324
rendering the health care service by telephone OR FACSIMILE 3,325
within one business day after making the certification, and shall 3,328
provide written or electronic confirmation to the enrollee and
the provider or health care facility within one business day 3,329
after the telephone notification. The written notification shall 3,330
include the number of extended days or next review date, the new 3,331
total number of days of health care services approved, and the 3,333
71
date of admission or initiation of health care services.
(2) In the case of an adverse determination, the health 3,335
insuring corporation shall notify the provider or health care 3,336
facility rendering the health care service by telephone within 3,337
one business day after making the adverse determination, and 3,338
shall provide written or electronic confirmation to the enrollee 3,339
and the provider or health care facility within one business day 3,340
after the telephone notification. The health care service to the 3,341
enrollee shall be continued, with standard copayments and 3,343
deductibles, if applicable, until the enrollee has been notified 3,344
of the determination. 3,345
(E) For retrospective review determinations, a health 3,347
insuring corporation shall make the determination within thirty 3,350
business days after receiving all necessary information. 3,351
(1) In the case of a certification, the health insuring 3,353
corporation may notify the enrollee and the provider or health 3,355
care facility rendering the health care service in writing. 3,356
(2) In the case of an adverse determination, the health 3,358
insuring corporation shall notify the enrollee and the provider 3,360
or health care facility rendering the health care service, in 3,361
writing, within five business days after making the adverse 3,362
determination.
(F) The time frames set forth in divisions (C), (D), and 3,365
(E) of this section for determinations and notifications shall 3,366
prevail unless the seriousness of the medical condition of the 3,367
enrollee otherwise requires a more timely response from the
health insuring corporation. The health insuring corporation 3,368
shall maintain written procedures for making expedited 3,370
utilization review determinations and notifications of enrollees 3,371
and providers or health care facilities when warranted by the 3,372
medical condition of the enrollee. 3,373
(G) A written notification of an adverse determination 3,375
shall include the principal reason or reasons for the 3,376
determination, instructions for initiating an appeal or 3,377
72
reconsideration of the determination, and instructions for 3,378
requesting a written statement of the clinical rationale used to 3,379
make the determination. A health insuring corporation shall
provide the clinical rationale for an adverse determination in 3,381
writing to any party who received notice of the adverse 3,383
determination and who follows the instructions for a request. 3,384
(H) A health insuring corporation shall have written 3,386
procedures to address the failure or inability of a health care 3,389
facility, provider, or enrollee to provide all necessary 3,391
information for review. If the health care facility, provider,
or enrollee will not release necessary information, the health 3,393
insuring corporation may deny certification. 3,394
Sec. 1785.01. As used in this chapter: 3,403
(A) "Professional service" means any type of professional 3,405
service that may be performed only pursuant to a license, 3,406
certificate, or other legal authorization issued pursuant to 3,407
Chapter 4701., 4703., 4705., 4715., 4723., 4725., 4729., 4731., 3,409
4732., 4733., 4734., or 4741., sections 4755.01 to 4755.12, or 3,412
4755.40 to 4755.56 of the Revised Code to certified public 3,414
accountants, licensed public accountants, architects, attorneys, 3,415
dentists, nurses, optometrists, pharmacists, doctors of medicine 3,417
and surgery, doctors of osteopathic medicine and surgery, doctors 3,418
of podiatric medicine and surgery, practitioners of the limited 3,419
branches of medicine or surgery specified in section 4731.15 of 3,420
the Revised Code, MECHANOTHERAPISTS, psychologists, professional 3,421
engineers, chiropractors, veterinarians, occupational therapists, 3,423
and physical therapists. 3,424
(B) "Professional association" means an association 3,426
organized under this chapter for the sole purpose of rendering 3,427
one of the professional services authorized under Chapter 4701., 3,428
4703., 4705., 4715., 4723., 4725., 4729., 4731., 4732., 4733., 3,429
4734., or 4741., sections 4755.01 to 4755.12, or 4755.40 to 3,431
4755.56 of the Revised Code, a combination of the professional 3,433
services authorized under Chapters 4703. and 4733. of the Revised 3,434
73
Code, or a combination of the professional services of 3,435
optometrists authorized under Chapter 4725. of the Revised Code,
chiropractors authorized under Chapter 4734. of the Revised Code, 3,436
psychologists authorized under Chapter 4732. of the Revised Code, 3,438
registered or licensed practical nurses authorized under Chapter 3,440
4723. of the Revised Code, pharmacists authorized under Chapter 3,441
4729. of the Revised Code, physical therapists authorized under 3,442
sections 4755.40 to 4755.53 of the Revised Code, 3,443
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 OF THE 3,444
REVISED CODE, and doctors of medicine and surgery, osteopathic 3,445
medicine and surgery, or podiatric medicine and surgery 3,446
authorized under Chapter 4731. of the Revised Code.
Sec. 1785.02. An individual or group of individuals each 3,455
of whom is licensed, certificated, or otherwise legally 3,456
authorized to render within this state the same kind of 3,457
professional service, a group of individuals each of whom is 3,459
licensed, certificated, or otherwise legally authorized to render 3,461
within this state the professional service authorized under
Chapter 4703. or 4733. of the Revised Code, or a group of 3,463
individuals each of whom is licensed, certificated, or otherwise 3,464
legally authorized to render within this state the professional 3,465
service of optometrists authorized under Chapter 4725. of the 3,466
Revised Code, chiropractors authorized under Chapter 4734. of the 3,468
Revised Code, psychologists authorized under Chapter 4732. of the 3,470
Revised Code, registered or licensed practical nurses authorized 3,471
under Chapter 4723. of the Revised Code, pharmacists authorized 3,474
under Chapter 4729. of the Revised Code, physical therapists 3,476
authorized under sections 4755.40 to 4755.53 of the Revised Code, 3,479
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 OF THE
REVISED CODE, or doctors of medicine and surgery, osteopathic 3,481
medicine and surgery, or podiatric medicine and surgery 3,482
authorized under Chapter 4731. of the Revised Code may organize 3,484
and become a shareholder or shareholders of a professional 3,485
association. Any group of individuals described in this section
74
who may be rendering one of the professional services as an 3,486
organization created otherwise than pursuant to this chapter may 3,487
incorporate under and pursuant to this chapter by amending the 3,488
agreement establishing the organization in a manner that the 3,489
agreement as amended constitutes articles of incorporation 3,490
prepared and filed in the manner prescribed in section 1785.08 of 3,491
the Revised Code and by otherwise complying with the applicable 3,492
requirements of this chapter.
Sec. 1785.03. A professional association may render a 3,501
particular professional service only through officers, employees, 3,502
and agents who are themselves duly licensed, certificated, or 3,503
otherwise legally authorized to render the professional service 3,504
within this state. As used in this section, "employee" does not 3,506
include clerks, bookkeepers, technicians, or other individuals 3,507
who are not usually and ordinarily considered by custom and 3,508
practice to be rendering a particular professional service for 3,509
which a license, certificate, or other legal authorization is 3,510
required and does not include any other person who performs all 3,512
of that person's employment under the direct supervision and 3,513
control of an officer, agent, or employee who renders a 3,514
particular professional service to the public on behalf of the 3,516
professional association.
No professional association formed for the purpose of 3,520
providing a combination of the professional services, as defined
in section 1785.01 of the Revised Code, of optometrists 3,521
authorized under Chapter 4725. of the Revised Code, chiropractors 3,522
authorized under Chapter 4734. of the Revised Code, psychologists 3,524
authorized under Chapter 4732. of the Revised Code, registered or 3,526
licensed practical nurses authorized under Chapter 4723. of the
Revised Code, pharmacists authorized under Chapter 4729. of the 3,527
Revised Code, physical therapists authorized under sections 3,528
4755.40 to 4755.53 of the Revised Code, MECHANOTHERAPISTS 3,529
AUTHORIZED UNDER SECTION 4731.151 OF THE REVISED CODE, and 3,530
doctors OF medicine and surgery, osteopathic medicine and
75
surgery, or podiatric medicine and surgery authorized under 3,531
Chapter 4731. of the Revised Code shall control the professional 3,532
clinical judgment exercised within accepted and prevailing 3,533
standards of practice of a licensed, certificated, or otherwise 3,534
legally authorized optometrist, chiropractor, psychologist, 3,535
nurse, pharmacist, physical therapist, MECHANOTHERAPIST, or 3,536
doctor of medicine and surgery, osteopathic medicine and surgery, 3,538
or podiatric medicine and surgery in rendering care, treatment, 3,539
or professional advice to an individual patient.
This division does not prevent a hospital, as defined in 3,541
section 3727.01 of the Revised Code, insurer, as defined in 3,542
section 3999.36 of the Revised Code, or intermediary 3,543
organization, as defined in section 1751.01 of the Revised Code, 3,545
from entering into a contract with a professional association 3,546
described in this division that includes a provision requiring 3,547
utilization review, quality assurance, peer review, or other
performance or quality standards. Those activities shall not be 3,548
construed as controlling the professional clinical judgment of an 3,549
individual practitioner listed in this division. 3,550
Sec. 1785.08. Chapter 1701. of the Revised Code applies to 3,559
professional associations, including their organization and the 3,560
manner of filing articles of incorporation, except that the 3,561
requirements of division (A) of section 1701.06 of the Revised 3,562
Code do not apply to professional associations. If any provision 3,563
of this chapter conflicts with any provision of Chapter 1701. of
the Revised Code, the provisions of this chapter shall take 3,564
precedence. A professional association for the practice of 3,565
medicine and surgery, osteopathic medicine and surgery, or 3,567
podiatric medicine and surgery or for the combined practice of
optometry, chiropractic, psychology, nursing, pharmacy, physical 3,568
therapy, MECHANOTHERAPY, medicine and surgery, osteopathic 3,570
medicine and surgery, or podiatric medicine and surgery may 3,571
provide in its articles of incorporation or bylaws that its 3,572
directors may have terms of office not exceeding six years. 3,573
76
Sec. 1907.161. (A) As used in this section, "health care 3,583
coverage" means sickness and accident insurance or other coverage 3,584
of hospitalization, surgical care, major medical care,
disability, dental care, eye care, medical care, hearing aids, 3,585
and prescription drugs or any combination of those benefits or 3,586
services.
(B) The board of county commissioners, after consultation 3,589
with the judges of the county court, shall negotiate and contract 3,590
for, purchase, or otherwise procure group health care coverage
for the judges and their spouses and dependents from insurance 3,591
companies authorized to engage in the business of insurance in 3,592
this state under Title XXXIA XXXIX of the Revised Code, medical 3,594
care corporations organized under Chapter 1737. of the Revised
Code, health care corporations organized under Chapter 1738. of 3,596
the Revised Code, or health maintenance organizations INSURING 3,597
CORPORATIONS organized under Chapter 1742. 1751. of the Revised 3,599
Code, except that, if the county provides group health care 3,601
coverage for its employees, the group health care coverage 3,602
required by this section shall be provided, if possible, through 3,603
the policy or plan under which the group health care coverage is 3,604
provided for the county employees.
(C) The portion of the costs, premiums, or charges for the 3,607
group health care coverage procured pursuant to division (B) of 3,608
this section that is not paid by the judges of the county court, 3,609
or all of the costs, premiums, or charges for the group health 3,610
care coverage if the judges will not be paying any portion of 3,611
those costs, premiums, or charges, shall be paid out of the
county treasury. 3,612
Sec. 2305.252. (A) As used in this section: 3,621
(1) "Review board, committee, risk management personnel, 3,623
or corporation" means any of the following: 3,624
(a) A peer review committee of a hospital, a nonprofit 3,626
health care corporation that is a member of the hospital or of 3,627
which the hospital is a member, or a community mental health 3,628
77
center;
(b) A board or committee of a hospital or of a nonprofit 3,630
health care corporation that is a member of the hospital or of 3,631
which the hospital is a member reviewing professional 3,632
qualifications or activities of the hospital medical staff or 3,633
applicants for admission to the medical staff;
(c) A utilization committee of a state or local society 3,635
composed of doctors of medicine or doctors of osteopathic 3,636
medicine and surgery or doctors of podiatric medicine; 3,637
(d) A peer review committee of nursing home providers or 3,639
administrators, including a corporation engaged in performing the 3,640
functions of a peer review committee of nursing home providers or 3,641
administrators, or a corporation engaged in performing the 3,642
functions of another type of peer review or professional 3,644
standards review committee;
(e) A peer review committee, professional standards review 3,646
committee, or arbitration committee of a state or local society 3,647
composed of doctors of medicine, doctors of osteopathic medicine 3,648
and surgery, doctors of dentistry, doctors of optometry, doctors 3,649
of podiatric medicine, psychologists, or registered pharmacists; 3,650
(f) A peer review committee of a health maintenance 3,652
organization INSURING CORPORATION that has at least a two-thirds 3,654
majority of member physicians in active practice and that 3,655
conducts professional credentialing and quality review activities 3,656
involving the competence or professional conduct of health care
providers, which conduct adversely affects, or could adversely 3,657
affect, the health or welfare of any patient. For purposes of 3,658
this division, "health maintenance organization INSURING 3,659
CORPORATION" includes wholly-owned WHOLLY OWNED subsidiaries of a 3,660
health maintenance organization INSURING CORPORATION. 3,661
(g) A peer review committee of any insurer authorized 3,663
under Title XXXIX of the Revised Code to do the business of 3,664
sickness and accident insurance in this state that has at least a 3,665
two-thirds majority of physicians in active practice and that 3,666
78
conducts professional credentialing and quality review activities 3,667
involving the competence or professional conduct of health care 3,668
providers, which conduct adversely affects, or could adversely
affect, the health or welfare of any patient; 3,669
(h) A peer review committee of any insurer authorized 3,671
under Title XXXIX of the Revised Code to do the business of 3,672
sickness and accident insurance in this state that has at least a 3,673
two-thirds majority of physicians in active practice and that 3,674
conducts professional credentialing and quality review activities 3,675
involving the competence or professional conduct of a health care 3,676
facility that has contracted with the insurer to provide health
care services to insureds, which conduct adversely affects, or 3,677
could adversely affect, the health or welfare of any patient; 3,678
(i) A peer review committee of an insurer authorized under 3,680
Title XXXIX of the Revised Code to do the business of medical 3,681
professional liability insurance in this state and that conducts 3,682
professional quality review activities involving the competence 3,683
or professional conduct of health care providers, which conduct 3,684
adversely affects, or could affect, the health or welfare of any 3,685
patient;
(j) A peer review committee of a health care entity. 3,687
(2) "Peer review committee" means a utilization review 3,689
committee, quality assurance committee, quality improvement 3,690
committee, tissue committee, credentialing committee, and any 3,691
other committee that conducts professional credentialing and 3,692
quality review activities involving the competence or
professional conduct of health care practitioners. 3,693
(3) "Health care entity" means a government entity, a 3,695
for-profit or nonprofit corporation, a limited liability company, 3,696
a partnership, a professional corporation, a state or local 3,697
society as described in division (A)(1)(c) of this section, or 3,698
other health care organization, including, but not limited to, 3,699
health care entities described in division (A)(1) of this 3,700
section, whether acting on its own behalf or on behalf of or in 3,701
79
affiliation with other health care entities, that conducts, as 3,702
part of its purpose, professional credentialing and quality
review activities involving the competence or professional 3,703
conduct of health care practitioners. 3,704
(4) "Incident report or risk management report" means a 3,707
report of an incident involving injury or potential injury to a
patient as a result of patient care by a health care entity that 3,708
is prepared by or for the use of a review board, committee, risk 3,709
management personnel, or corporation and is within the scope of 3,710
the functions of that review board, committee, risk management 3,711
personnel, or corporation.
(5) "Tort action" means a civil action for damages for 3,714
injury, death, or loss to a patient of a health care entity. 3,715
"Tort action" includes a product liability claim but does not 3,716
include a civil action for a breach of contract or another 3,717
agreement between persons.
(B) Notwithstanding any contrary provision of section 3,720
149.43, 1742.141 1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 3,721
of the Revised Code, an incident report or risk management report 3,723
and the contents of an incident report or risk management report 3,724
are not subject to discovery in, and are not admissible in 3,725
evidence in the trial of, a tort action. An individual who
prepares or has knowledge of the contents of an incident report 3,726
or risk management report shall not testify and shall not be 3,727
required to testify in a tort action as to the contents of the 3,728
report. This division does not prohibit or limit the discovery 3,729
or admissibility of testimony or evidence relating to patient 3,730
care that is within a person's personal knowledge. 3,731
(C) Except as specified in division (B) of this section, 3,734
this section does not affect any provision of section 1742.141 3,735
1751.21, 2305.24, 2305.25, 2305.251, or 2305.28 of the Revised 3,737
Code that describes, imposes, or confers an immunity from tort or 3,738
other civil liability, a forfeiture of an immunity from tort or 3,739
other civil liability, a requirement of confidentiality, a 3,740
80
limitation upon the use of information, data, reports, or 3,741
records, tort or other civil liability, or a limitation upon 3,742
discovery of matter, introduction into evidence of matter, or 3,743
testimony pertaining to matter in a tort or other civil action. 3,744
This section does not affect a privileged communication between 3,745
an attorney and the attorney's client under section 2317.02 of 3,746
the Revised Code.
(D) This section shall be considered to be purely remedial 3,748
in operation and shall be applied in a remedial manner in any 3,749
civil action in which this section is relevant, whether the civil 3,750
action is pending in court or commenced on or after the effective 3,751
date of this section JANUARY 27, 1997, regardless of when the 3,752
cause of action accrued and notwithstanding any other section of 3,753
the Revised Code or prior rule of law of this state. 3,754
Sec. 3701.18. (A) AS USED IN THIS SECTION: 3,757
(1) "AMBLYOPIA" MEANS REDUCED VISION IN AN EYE THAT HAS 3,759
NOT RECEIVED ADEQUATE USE DURING EARLY CHILDHOOD. 3,760
(2) "501(c) ORGANIZATION" MEANS AN ORGANIZATION EXEMPT 3,762
FROM FEDERAL INCOME TAXATION PURSUANT TO 26 U.S.C.A. 501(a) AND 3,765
(c).
(B) THERE IS HEREBY CREATED IN THE STATE TREASURY THE SAVE 3,768
OUR SIGHT FUND. THE FUND SHALL CONSIST OF VOLUNTARY
CONTRIBUTIONS DEPOSITED AS PROVIDED IN SECTION 4503.104 OF THE 3,770
REVISED CODE. ALL INVESTMENT EARNINGS FROM THE FUND SHALL BE 3,772
CREDITED TO THE FUND.
(C) THE DIRECTOR OF HEALTH SHALL USE THE MONEY IN THE SAVE 3,775
OUR SIGHT FUND AS FOLLOWS:
(1) TO PROVIDE SUPPORT TO 501(c) ORGANIZATIONS THAT OFFER 3,777
VISION SERVICES IN ALL COUNTIES OF THE STATE AND HAVE 3,779
DEMONSTRATED EXPERIENCE IN THE DELIVERY OF VISION SERVICES TO DO 3,780
ONE OR MORE OF THE FOLLOWING:
(a) IMPLEMENT A VOLUNTARY CHILDREN'S VISION SCREENING 3,782
TRAINING AND CERTIFICATION PROGRAM FOR VOLUNTEERS, CHILD DAY-CARE 3,784
PROVIDERS, NURSES, TEACHERS, HEALTH CARE PROFESSIONALS PRACTICING 3,785
81
IN PRIMARY CARE SETTINGS, AND OTHERS SERVING CHILDREN; 3,786
(b) PROVIDE MATERIALS FOR THE PROGRAM IMPLEMENTED UNDER 3,788
DIVISION (C)(1)(a) OF THIS SECTION; 3,789
(c) DEVELOP AND IMPLEMENT A REGISTRY AND TARGETED 3,792
VOLUNTARY CASE MANAGEMENT SYSTEM TO DETERMINE WHETHER CHILDREN 3,793
WITH AMBLYOPIA ARE RECEIVING PROFESSIONAL EYE CARE AND TO PROVIDE 3,794
THEIR PARENTS WITH INFORMATION AND SUPPORT REGARDING THEIR 3,795
CHILD'S VISION CARE;
(d) ESTABLISH A MATCHING GRANT PROGRAM FOR THE PURCHASE 3,798
AND DISTRIBUTION OF PROTECTIVE EYEWEAR TO CHILDREN; 3,799
(e) PROVIDE VISION HEALTH AND SAFETY PROGRAMS AND 3,801
MATERIALS FOR CLASSROOMS. 3,802
(2) FOR THE PURPOSE OF SECTION 4503.104 OF THE REVISED 3,804
CODE, TO DEVELOP AND DISTRIBUTE INFORMATIONAL MATERIALS ON THE 3,805
IMPORTANCE OF EYE CARE AND SAFETY TO THE REGISTRAR OF MOTOR 3,806
VEHICLES AND EACH DEPUTY REGISTRAR;
(3) TO PAY COSTS INCURRED BY THE DIRECTOR IN ADMINISTERING 3,808
THE FUND;
(4) TO REIMBURSE THE BUREAU OF MOTOR VEHICLES FOR THE 3,810
ADMINISTRATIVE COSTS INCURRED IN PERFORMING ITS DUTIES UNDER 3,811
SECTION 4503.104 OF THE REVISED CODE.
(D) A 501(c) ORGANIZATION SEEKING FUNDING FROM THE SAVE 3,814
OUR SIGHT FUND FOR ANY OF THE PROJECTS SPECIFIED IN DIVISION (C) 3,815
OF THIS SECTION SHALL SUBMIT A REQUEST FOR THE FUNDING TO THE 3,817
DIRECTOR IN ACCORDANCE WITH RULES ADOPTED UNDER DIVISION (E) OF 3,819
THIS SECTION. THE DIRECTOR SHALL DETERMINE THE APPROPRIATENESS 3,820
OF AND APPROVE OR DISAPPROVE PROJECTS FOR FUNDING AND APPROVE OR 3,821
DISAPPROVE THE DISBURSEMENT OF MONEY FROM THE SAVE OUR SIGHT 3,822
FUND.
(E) THE PUBLIC HEALTH COUNCIL SHALL ADOPT RULES IN 3,824
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE TO IMPLEMENT 3,825
THIS SECTION. THE RULES SHALL INCLUDE THE PARAMETERS OF THE 3,826
PROJECTS SPECIFIED IN DIVISION (C)(1) OF THIS SECTION THAT MAY BE 3,827
FUNDED WITH MONEY IN THE SAVE OUR SIGHT FUND AND PROCEDURES FOR 3,828
82
501(c) ORGANIZATIONS TO REQUEST FUNDING FROM THE FUND. 3,830
Sec. 3701.75. (A) As used in this section: 3,839
(1) "Electronic record" means a record communicated, 3,842
received, or stored by electronic, magnetic, optical, or similar 3,843
means for storage in an information system or transmission from 3,844
one information system to another. "Electronic record" includes 3,845
a record that is communicated, received, or stored by electronic
data interchange, electronic mail, facsimile, telex, or similar 3,847
methods of communication.
(2) "Electronic signature" means any of the following 3,849
attached to or associated with an electronic record by an 3,851
individual to authenticate the record:
(a) A code consisting of a combination of letters, 3,854
numbers, characters, or symbols that is adopted or executed by an 3,855
individual as that individual's electronic signature; 3,856
(b) A computer-generated signature code created for an 3,859
individual;
(c) An electronic image of an individual's handwritten 3,862
signature created by using a pen computer.
(3) "Health care record" means any document or combination 3,865
of documents pertaining to a patient's medical history,
diagnosis, prognosis, or medical condition that is generated and 3,866
maintained in the process of the patient's treatment. 3,867
(B) Any ALL NOTES, ORDERS, AND OBSERVATIONS ENTERED INTO A 3,870
HEALTH CARE RECORD, INCLUDING ANY INTERPRETIVE REPORTS OF 3,873
DIAGNOSTIC TESTS OR SPECIFIC TREATMENTS, SUCH AS RADIOLOGIC OR
ELECTROCARDIOGRAPHIC REPORTS, OPERATIVE REPORTS, REPORTS OF 3,874
PATHOLOGIC EXAMINATION OF TISSUE, AND SIMILAR REPORTS, SHALL BE 3,875
AUTHENTICATED BY THE INDIVIDUAL WHO MADE OR AUTHORIZED THE ENTRY. 3,876
AN entry into a health care record may be authenticated by 3,879
executing handwritten signatures or handwritten initials directly 3,880
on the entry or by executing an electronic signature. An ENTRY 3,882
THAT IS AN electronic signature executed in accordance with an 3,883
electronic signature system that is certified by the department 3,886
83
of health under division (C) of this section shall be considered 3,887
for all legal purposes to be the same as having executed a 3,888
handwritten signature or handwritten initials, except when any
federal law governing state participation in a federal program 3,889
requires that entries into health care records RECORD MAY be 3,890
authenticated only by handwritten signatures or handwritten 3,892
initials. The AN electronic signature generated by a certified 3,894
system shall be presumed to be the signature of the individual to 3,896
whom it is assigned and to be affixed for the purpose of 3,898
authenticating an entry into a health care record. 3,899
(C)(1) The department of health shall administer a program 3,901
under which entities that create and maintain health care records 3,902
may receive certification from the department of their electronic 3,903
signature systems. The department shall determine the types of 3,904
entities that are eligible to have their electronic signature 3,905
systems certified under this section.
The department shall certify an eligible entity's 3,907
electronic signature system if all of the following apply: 3,908
(a)(1) The entity RESPONSIBLE FOR CREATING AND MAINTAINING 3,911
THE HEALTH CARE RECORD adopts a policy that permits the use of 3,913
electronic signatures on electronic records. 3,914
(b)(2) The entity's electronic signature system utilizes 3,917
either a two-level access control mechanism that assigns a unique 3,918
identifier to each user or a biometric access control device. 3,919
(c)(3) The entity takes steps to safeguard against 3,922
unauthorized access to the system and forgery of electronic 3,924
signatures.
(d)(4) The system includes a process to verify that the 3,927
individual affixing the electronic signature has reviewed the 3,928
contents of the entry and determined that the entry contains what 3,929
that individual intended.
(e)(5) The policy adopted by the entity pursuant to 3,932
division (C)(B)(1)(a) of this section prescribes all of the 3,933
following:
84
(i)(a) A procedure by which each user of the system must 3,935
certify in writing that the user will follow the confidentiality 3,939
and security policies maintained by the entity for the system; 3,940
(ii)(b) Penalties for misusing the system; 3,942
(iii)(c) Training for all users of the system that 3,946
includes an explanation of the appropriate use of the system and
the consequences for not complying with the entity's 3,948
confidentiality and security policies.
(2) In lieu of making a direct determination of compliance 3,951
under division (C)(1) of this section, the department may accept 3,953
the approval of any private or public organization that has
reviewed the entity's system, if the department determines that 3,954
the organization has standards at least as stringent as those 3,955
specified in division (C)(1) of this section. Organizations with 3,957
standards for approval of electronic signature systems that the
department may accept include the joint commission on 3,960
accreditation of healthcare organizations, the American 3,961
osteopathic association, the United States food and drug 3,963
administration, and the United States health care financing 3,965
administration. If an entity receives approval of its electronic 3,966
signature system in this manner, and is subsequently cited by the 3,968
private or public organization for a violation that involves the 3,969
entity's system, the entity shall immediately notify the 3,971
department of the citation and the department shall withdraw its
certification. 3,972
(3) The public health council shall adopt rules in 3,974
accordance with Chapter 119. of the Revised Code as necessary for 3,976
the department's administration of the program for certifying the 3,977
electronic signature systems of entities that create and maintain 3,978
health care records.
Sec. 3702.141. (A) AS USED IN THIS SECTION, "EXISTING 3,981
HEALTH CARE FACILITY" HAS THE SAME MEANING AS IN SECTION 3702.51 3,982
OF THE REVISED CODE. 3,984
(B) SECTION 3702.14 OF THE REVISED CODE SHALL NOT BE 3,988
85
CONSTRUED TO REQUIRE ANY EXISTING HEALTH CARE FACILITY THAT IS 3,989
CONDUCTING AN ACTIVITY SPECIFIED IN SECTION 3702.11 OF THE 3,991
REVISED CODE, WHICH ACTIVITY WAS INITIATED ON OR BEFORE MARCH 20, 3,993
1997, TO ALTER, UPGRADE, OR OTHERWISE IMPROVE THE STRUCTURE OR 3,995
FIXTURES OF THE FACILITY IN ORDER TO COMPLY WITH ANY RULE ADOPTED 3,996
UNDER SECTION 3702.11 OF THE REVISED CODE RELATING TO THAT 3,998
ACTIVITY, UNLESS ONE OF THE FOLLOWING APPLIES: 3,999
(1) THE FACILITY INITIATES A CONSTRUCTION, RENOVATION, OR 4,001
RECONSTRUCTION PROJECT THAT INVOLVES A CAPITAL EXPENDITURE OF AT 4,002
LEAST FIFTY THOUSAND DOLLARS, NOT INCLUDING EXPENDITURES FOR 4,004
EQUIPMENT OR STAFFING OR OPERATIONAL COSTS, AND THAT DIRECTLY 4,005
INVOLVES THE AREA IN WHICH THE EXISTING SERVICE IS CONDUCTED. 4,006
(2) THE FACILITY INITIATES ANOTHER ACTIVITY SPECIFIED IN 4,008
SECTION 3702.11 OF THE REVISED CODE. 4,010
(3) THE FACILITY INITIATES A SERVICE LEVEL DESIGNATION 4,012
CHANGE FOR OBSTETRIC AND NEWBORN CARE. 4,013
(4) THE FACILITY PROPOSES TO ADD A CARDIAC CATHETERIZATION 4,016
LABORATORY TO AN EXISTING CARDIAC CATHETERIZATION SERVICE. 4,017
(5) THE FACILITY PROPOSES TO ADD AN OPEN-HEART OPERATING 4,019
ROOM TO AN EXISTING OPEN-HEART SURGERY SERVICE. 4,020
(6) THE DIRECTOR OF HEALTH DETERMINES, BY CLEAR AND 4,022
CONVINCING EVIDENCE, THAT FAILURE TO COMPLY WITH THE RULE WOULD 4,023
CREATE AN IMMINENT RISK TO THE HEALTH AND WELFARE OF ANY PATIENT. 4,025
(C) IF DIVISION (B)(4) OR (5) OF THIS SECTION APPLIES, ANY 4,029
ALTERATION, UPGRADE, OR OTHER IMPROVEMENT REQUIRED SHALL APPLY 4,030
ONLY TO THE PROPOSED ADDITION TO THE EXISTING SERVICE IF THE COST 4,031
OF THE ADDITION IS LESS THAN THE CAPITAL EXPENDITURE THRESHOLD 4,032
SET FORTH IN DIVISION (B)(1) OF THIS SECTION. 4,033
(D) NO PERSON OR GOVERNMENT ENTITY SHALL DIVIDE OR 4,037
OTHERWISE SEGMENT A CONSTRUCTION, RENOVATION, OR RECONSTRUCTION 4,038
PROJECT IN ORDER TO EVADE APPLICATION OF THE CAPITAL EXPENDITURE 4,039
THRESHOLD SET FORTH IN DIVISION (B)(1) OF THIS SECTION. 4,041
Sec. 3901.21. The following are hereby defined as unfair 4,050
and deceptive acts or practices in the business of insurance: 4,051
86
(A) Making, issuing, circulating, or causing or permitting 4,053
to be made, issued, or circulated, or preparing with intent to so 4,054
use, any estimate, illustration, circular, or statement 4,055
misrepresenting the terms of any policy issued or to be issued or 4,056
the benefits or advantages promised thereby or the dividends or 4,057
share of the surplus to be received thereon, or making any false 4,058
or misleading statements as to the dividends or share of surplus 4,059
previously paid on similar policies, or making any misleading 4,060
representation or any misrepresentation as to the financial 4,061
condition of any insurer as shown by the last preceding verified 4,062
statement made by it to the insurance department of this state, 4,063
or as to the legal reserve system upon which any life insurer 4,064
operates, or using any name or title of any policy or class of 4,065
policies misrepresenting the true nature thereof, or making any 4,066
misrepresentation or incomplete comparison to any person for the 4,067
purpose of inducing or tending to induce such person to purchase, 4,068
amend, lapse, forfeit, change, or surrender insurance. 4,069
Any written statement concerning the premiums for a policy 4,071
which refers to the net cost after credit for an assumed 4,072
dividend, without an accurate written statement of the gross 4,073
premiums, cash values, and dividends based on the insurer's 4,074
current dividend scale, which are used to compute the net cost 4,075
for such policy, and a prominent warning that the rate of 4,076
dividend is not guaranteed, is a misrepresentation for the 4,077
purposes of this division. 4,078
(B) Making, publishing, disseminating, circulating, or 4,080
placing before the public or causing, directly or indirectly, to 4,081
be made, published, disseminated, circulated, or placed before 4,082
the public, in a newspaper, magazine, or other publication, or in 4,083
the form of a notice, circular, pamphlet, letter, or poster, or 4,084
over any radio station, or in any other way, or preparing with 4,085
intent to so use, an advertisement, announcement, or statement 4,086
containing any assertion, representation, or statement, with 4,087
respect to the business of insurance or with respect to any 4,088
87
person in the conduct of the person's insurance business, which 4,090
is untrue, deceptive, or misleading. 4,091
(C) Making, publishing, disseminating, or circulating, 4,093
directly or indirectly, or aiding, abetting, or encouraging the 4,094
making, publishing, disseminating, or circulating, or preparing 4,095
with intent to so use, any statement, pamphlet, circular, 4,096
article, or literature, which is false as to the financial 4,097
condition of an insurer and which is calculated to injure any 4,098
person engaged in the business of insurance. 4,099
(D) Filing with any supervisory or other public official, 4,101
or making, publishing, disseminating, circulating, or delivering 4,102
to any person, or placing before the public, or causing directly 4,103
or indirectly to be made, published, disseminated, circulated, 4,104
delivered to any person, or placed before the public, any false 4,105
statement of financial condition of an insurer. 4,106
Making any false entry in any book, report, or statement of 4,108
any insurer with intent to deceive any agent or examiner lawfully 4,109
appointed to examine into its condition or into any of its 4,110
affairs, or any public official to whom such insurer is required 4,111
by law to report, or who has authority by law to examine into its 4,112
condition or into any of its affairs, or, with like intent, 4,113
willfully omitting to make a true entry of any material fact 4,114
pertaining to the business of such insurer in any book, report, 4,115
or statement of such insurer, or mutilating, destroying, 4,116
suppressing, withholding, or concealing any of its records. 4,117
(E) Issuing or delivering or permitting agents, officers, 4,119
or employees to issue or deliver agency company stock or other 4,120
capital stock or benefit certificates or shares in any common-law 4,121
corporation or securities or any special or advisory board 4,122
contracts or other contracts of any kind promising returns and 4,123
profits as an inducement to insurance. 4,124
(F) Making or permitting any unfair discrimination among 4,126
individuals of the same class and equal expectation of life in 4,127
the rates charged for any contract of life insurance or of life 4,128
88
annuity or in the dividends or other benefits payable thereon, or 4,129
in any other of the terms and conditions of such contract. 4,130
(G)(1) Except as otherwise expressly provided by law, 4,132
knowingly permitting or offering to make or making any contract 4,133
of life insurance, life annuity or accident and health insurance, 4,134
or agreement as to such contract other than as plainly expressed 4,135
in the contract issued thereon, or paying or allowing, or giving 4,136
or offering to pay, allow, or give, directly or indirectly, as 4,137
inducement to such insurance, or annuity, any rebate of premiums 4,138
payable on the contract, or any special favor or advantage in the 4,139
dividends or other benefits thereon, or any valuable 4,140
consideration or inducement whatever not specified in the 4,141
contract; or giving, or selling, or purchasing, or offering to 4,142
give, sell, or purchase, as inducement to such insurance or 4,143
annuity or in connection therewith, any stocks, bonds, or other 4,144
securities, or other obligations of any insurance company or 4,145
other corporation, association, or partnership, or any dividends 4,146
or profits accrued thereon, or anything of value whatsoever not 4,147
specified in the contract. 4,148
(2) Nothing in division (F) or division (G)(1) of this 4,150
section shall be construed as prohibiting any of the following 4,151
practices: (a) in the case of any contract of life insurance or 4,152
life annuity, paying bonuses to policyholders or otherwise 4,153
abating their premiums in whole or in part out of surplus 4,154
accumulated from nonparticipating insurance, provided that any 4,155
such bonuses or abatement of premiums shall be fair and equitable 4,156
to policyholders and for the best interests of the company and 4,157
its policyholders; (b) in the case of life insurance policies 4,158
issued on the industrial debit plan, making allowance to 4,159
policyholders who have continuously for a specified period made 4,160
premium payments directly to an office of the insurer in an 4,161
amount which fairly represents the saving in collection expenses; 4,162
(c) readjustment of the rate of premium for a group insurance 4,163
policy based on the loss or expense experience thereunder, at the 4,164
89
end of the first or any subsequent policy year of insurance 4,165
thereunder, which may be made retroactive only for such policy 4,166
year. 4,167
(H) Making, issuing, circulating, or causing or permitting 4,169
to be made, issued, or circulated, or preparing with intent to so 4,170
use, any statement to the effect that a policy of life insurance 4,171
is, is the equivalent of, or represents shares of capital stock 4,172
or any rights or options to subscribe for or otherwise acquire 4,173
any such shares in the life insurance company issuing that policy 4,174
or any other company. 4,175
(I) Making, issuing, circulating, or causing or permitting 4,177
to be made, issued or circulated, or preparing with intent to so 4,178
issue, any statement to the effect that payments to a 4,179
policyholder of the principal amounts of a pure endowment are 4,180
other than payments of a specific benefit for which specific 4,181
premiums have been paid. 4,182
(J) Making, issuing, circulating, or causing or permitting 4,184
to be made, issued, or circulated, or preparing with intent to so 4,185
use, any statement to the effect that any insurance company was 4,186
required to change a policy form or related material to comply 4,187
with Title XXXIX of the Revised Code or any regulation of the 4,188
superintendent of insurance, for the purpose of inducing or 4,189
intending to induce any policyholder or prospective policyholder 4,190
to purchase, amend, lapse, forfeit, change, or surrender 4,191
insurance. 4,192
(K) Aiding or abetting another to violate this section. 4,194
(L) Refusing to issue any policy of insurance, or 4,196
canceling or declining to renew such policy because of the sex or 4,197
marital status of the applicant, prospective insured, insured, or 4,198
policyholder. 4,199
(M) Making or permitting any unfair discrimination between 4,201
individuals of the same class and of essentially the same hazard 4,202
in the amount of premium, policy fees, or rates charged for any 4,203
policy or contract of insurance, other than life insurance, or in 4,204
90
the benefits payable thereunder, or in underwriting standards and 4,205
practices or eligibility requirements, or in any of the terms or 4,206
conditions of such contract, or in any other manner whatever. 4,207
(N) Refusing to make available disability income insurance 4,209
solely because the applicant's principal occupation is that of 4,210
managing a household. 4,211
(O) Refusing, when offering maternity benefits under any 4,213
individual or group sickness and accident insurance policy, to 4,214
make maternity benefits available to the policyholder for the 4,215
individual or individuals to be covered under any comparable 4,216
policy to be issued for delivery in this state, including family 4,217
members if the policy otherwise provides coverage for family 4,218
members. Nothing in this division shall be construed to prohibit 4,219
an insurer from imposing a reasonable waiting period for such 4,220
benefits under an individual sickness and accident insurance 4,222
policy ISSUED TO AN INDIVIDUAL WHO IS NOT A FEDERALLY ELIGIBLE 4,223
INDIVIDUAL OR A NONEMPLOYER-RELATED GROUP SICKNESS AND ACCIDENT 4,224
INSURANCE POLICY, but in no event shall such waiting period 4,226
exceed two hundred seventy days.
FOR PURPOSES OF DIVISION (O) OF THIS SECTION, "FEDERALLY 4,229
ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN 4,230
45 C.F.R. 148.103. 4,233
(P) Using, or permitting to be used, a pattern settlement 4,235
as the basis of any offer of settlement. As used in this 4,236
division, "pattern settlement" means a method by which liability 4,237
is routinely imputed to a claimant without an investigation of 4,238
the particular occurrence upon which the claim is based and by 4,239
using a predetermined formula for the assignment of liability 4,240
arising out of occurrences of a similar nature. Nothing in this 4,241
division shall be construed to prohibit an insurer from 4,242
determining a claimant's liability by applying formulas or 4,243
guidelines to the facts and circumstances disclosed by the 4,244
insurer's investigation of the particular occurrence upon which a 4,245
claim is based. 4,246
91
(Q) Refusing to insure, or refusing to continue to insure, 4,248
or limiting the amount, extent, or kind of life or sickness and 4,249
accident insurance or annuity coverage available to an 4,250
individual, or charging an individual a different rate for the 4,251
same coverage solely because of blindness or partial blindness. 4,252
With respect to all other conditions, including the underlying 4,253
cause of blindness or partial blindness, persons who are blind or 4,254
partially blind shall be subject to the same standards of sound 4,255
actuarial principles or actual or reasonably anticipated 4,256
actuarial experience as are sighted persons. Refusal to insure 4,257
includes, but is not limited to, denial by an insurer of 4,258
disability insurance coverage on the grounds that the policy 4,259
defines "disability" as being presumed in the event that the 4,260
eyesight of the insured is lost. However, an insurer may exclude 4,261
from coverage disabilities consisting solely of blindness or 4,262
partial blindness when such conditions existed at the time the 4,263
policy was issued. To the extent that the provisions of this 4,264
division may appear to conflict with any provision of section 4,265
3999.16 of the Revised Code, this division applies. 4,266
(R)(1) Directly or indirectly offering to sell, selling, 4,268
or delivering, issuing for delivery, renewing, or using or 4,269
otherwise marketing any policy of insurance or insurance product 4,270
in connection with or in any way related to the grant of a 4,271
student loan guaranteed in whole or in part by an agency or 4,272
commission of this state or the United States, except insurance 4,273
that is required under federal or state law as a condition for 4,274
obtaining such a loan and the premium for which is included in 4,275
the fees and charges applicable to the loan; or, in the case of 4,276
an insurer or insurance agent, knowingly permitting any lender 4,277
making such loans to engage in such acts or practices in 4,278
connection with the insurer's or agent's insurance business. 4,279
(2) Except in the case of a violation of division (G) of 4,281
this section, division (R)(1) of this section does not apply to 4,282
either of the following: 4,283
92
(a) Acts or practices of an insurer, its agents, 4,285
representatives, or employees in connection with the grant of a 4,286
guaranteed student loan to its insured or the insured's spouse or 4,287
dependent children where such acts or practices take place more 4,288
than ninety days after the effective date of the insurance; 4,289
(b) Acts or practices of an insurer, its agents, 4,291
representatives, or employees in connection with the 4,292
solicitation, processing, or issuance of an insurance policy or 4,293
product covering the student loan borrower or the borrower's 4,294
spouse or dependent children, where such acts or practices take 4,296
place more than one hundred eighty days after the date on which 4,297
the borrower is notified that the student loan was approved. 4,298
(S) Denying coverage, under any health insurance or health 4,300
care policy, contract, or plan providing family coverage, to any 4,301
natural or adopted child of the named insured or subscriber 4,302
solely on the basis that the child does not reside in the 4,303
household of the named insured or subscriber. 4,304
(T)(1) Using any underwriting standard or engaging in any 4,306
other act or practice that, directly or indirectly, due solely to 4,307
any health status-related factor in relation to one or more 4,308
individuals, does either of the following:
(a) Terminates or fails to renew an existing individual 4,310
policy, contract, or plan of health benefits, or a health benefit 4,311
plan issued to an employer, for which an individual would 4,312
otherwise be eligible;
(b) With respect to a health benefit plan issued to an 4,314
employer, excludes or causes the exclusion of an individual from 4,315
coverage under an existing employer-provided policy, contract, or 4,316
plan of health benefits.
(2) The superintendent of insurance may adopt rules in 4,318
accordance with Chapter 119. of the Revised Code for purposes of 4,319
implementing division (T)(1) of this section. 4,320
(3) For purposes of division (T)(1) of this section, 4,323
"health status-related factor" means any of the following: 4,324
93
(a) Health status; 4,326
(b) Medical condition, including both physical and mental 4,329
illnesses;
(c) Claims experience; 4,331
(d) Receipt of health care; 4,333
(e) Medical history; 4,335
(f) Genetic information; 4,337
(g) Evidence of insurability, including conditions arising 4,340
out of acts of domestic violence;
(h) Disability. 4,342
(U) With respect to a health benefit plan issued to a 4,344
small employer, as those terms are defined in section 3924.01 of 4,345
the Revised Code, negligently or willfully placing coverage for 4,346
adverse risks with a certain carrier, as defined in section 4,347
3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act 4,349
or practice that, directly or indirectly, causes or results in 4,350
the placing of coverage for adverse risks with another carrier, 4,351
as defined in section 3924.01 of the Revised Code. 4,352
(W) Failing to comply with section 3923.23, 3923.231, 4,354
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging 4,355
in any unfair, discriminatory reimbursement practice. 4,356
(X) Intentionally establishing an unfair premium for, or 4,358
misrepresenting the cost of, any insurance policy financed under 4,359
a premium finance agreement of an insurance premium finance 4,360
company. 4,361
(Y)(1)(a) Limiting coverage under, refusing to issue, 4,363
canceling, or refusing to renew, any individual policy or 4,364
contract of life insurance, or limiting coverage under or 4,365
refusing to issue any individual policy or contract of health 4,366
insurance, for the reason that the insured or applicant for 4,367
insurance is or has been a victim of domestic violence; 4,368
(b) Adding a surcharge or rating factor to a premium of 4,370
any individual policy or contract of life or health insurance for 4,371
94
the reason that the insured or applicant for insurance is or has 4,372
been a victim of domestic violence; 4,373
(c) Denying coverage under, or limiting coverage under, 4,375
any policy or contract of life or health insurance, for the 4,376
reason that a claim under the policy or contract arises from an 4,377
incident of domestic violence;
(d) Inquiring, directly or indirectly, of an insured 4,379
under, or of an applicant for, a policy or contract of life or 4,380
health insurance, as to whether the insured or applicant is or 4,381
has been a victim of domestic violence, or inquiring as to 4,382
whether the insured or applicant has sought shelter or protection 4,383
from domestic violence or has sought medical or psychological
treatment as a victim of domestic violence. 4,384
(2) Nothing in division (Y)(1) of this section shall be 4,386
construed to prohibit an insurer from inquiring as to, or from 4,387
underwriting or rating a risk on the basis of, a person's 4,388
physical or mental condition, even if the condition has been 4,389
caused by domestic violence, provided that all of the following 4,390
apply:
(a) The insurer routinely considers the condition in 4,392
underwriting or in rating risks, and does so in the same manner 4,393
for a victim of domestic violence as for an insured or applicant 4,394
who is not a victim of domestic violence; 4,395
(b) The insurer does not refuse to issue any policy or 4,397
contract of life or health insurance or cancel or refuse to renew 4,399
any policy or contract of life insurance, solely on the basis of
the condition, except where such refusal to issue, cancellation, 4,400
or refusal to renew is based on sound actuarial principles or is 4,401
related to actual or reasonably anticipated experience; 4,402
(c) The insurer does not consider a person's status as 4,404
being or as having been a victim of domestic violence, in itself, 4,405
to be a physical or mental condition; 4,406
(d) The underwriting or rating of a risk on the basis of 4,408
the condition is not used to evade the intent of division (Y)(1) 4,410
95
of this section, or of any other provision of the Revised Code. 4,412
(3)(a) Nothing in division (Y)(1) of this section shall be 4,415
construed to prohibit an insurer from refusing to issue a policy 4,416
or contract of life insurance insuring the life of a person who 4,417
is or has been a victim of domestic violence if the person who 4,418
committed the act of domestic violence is the applicant for the 4,419
insurance or would be the owner of the insurance policy or 4,420
contract.
(b) Nothing in division (Y)(2) of this section shall be 4,423
construed to permit an insurer to cancel or refuse to renew any 4,424
policy or contract of health insurance in violation of the 4,425
"Health Insurance Portability and Accountability Act of 1996," 4,426
110 Stat. 1955, 42 U.S.C.A. 300gg-41(b), as amended, or in a 4,428
manner that violates or is inconsistent with any provision of the 4,429
Revised Code that implements the "Health Insurance Portability 4,431
and Accountability Act of 1996." 4,432
(4) An insurer is immune from any civil or criminal 4,435
liability that otherwise might be incurred or imposed as a result
of any action taken by the insurer to comply with division (Y) of 4,437
this section.
(5) As used in division (Y) of this section, "domestic 4,440
violence" means any of the following acts: 4,441
(a) Knowingly causing or attempting to cause physical harm 4,443
to a family or household member; 4,445
(b) Recklessly causing serious physical harm to a family 4,447
or household member; 4,449
(c) Knowingly causing, by threat of force, a family or 4,451
household member to believe that the person will cause imminent 4,452
physical harm to the family or household member. 4,453
For the purpose of division (Y)(5) of this section, "family 4,457
or household member" has the same meaning as in section 2919.25
of the Revised Code. 4,458
Nothing in division (Y)(5) of this section shall be 4,461
construed to require, as a condition to the application of 4,462
96
division (Y) of this section, that the act described in division 4,464
(Y)(5) of this section be the basis of a criminal prosecution. 4,466
With respect to private passenger automobile insurance, no 4,468
insurer shall charge different premium rates to persons residing 4,469
within the limits of any municipal corporation based solely on 4,470
the location of the residence of the insured within those limits. 4,471
The enumeration in sections 3901.19 to 3901.26 of the 4,473
Revised Code of specific unfair or deceptive acts or practices in 4,474
the business of insurance is not exclusive or restrictive or 4,475
intended to limit the powers of the superintendent of insurance 4,476
to adopt rules to implement this section, or to take action under 4,477
other sections of the Revised Code. 4,478
This section does not prohibit the sale of shares of any 4,480
investment company registered under the "Investment Company Act 4,481
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any 4,482
policies, annuities, or other contracts described in section 4,483
3907.15 of the Revised Code. 4,484
As used in this section, "estimate," "statement," 4,486
"representation," "misrepresentation," "advertisement," or 4,487
"announcement" includes oral or written occurrences. 4,488
Sec. 3901.38. (A) As used in this section and section 4,497
3901.381 of the Revised Code: 4,498
(1) "Beneficiary" means any policyholder, subscriber, 4,500
member, employee, or other person who is eligible for benefits 4,501
under a benefits contract. 4,502
(2) "Benefits contract" means a sickness and accident 4,504
insurance policy providing hospital, surgical, or medical expense 4,505
coverage, or a health insuring corporation contract or other 4,508
policy or agreement under which a third-party payer agrees to 4,509
reimburse for covered health care or dental services rendered to 4,510
beneficiaries, up to the limits and exclusions contained in the 4,511
benefits contract.
(3) "Completed claim" means a proof of loss or a claim for 4,513
payment for health care services which has been submitted to the 4,514
97
appropriate claims processing office of the third-party payer 4,515
accompanied by sufficient documentation for the third-party payer 4,516
to determine proof of loss and reasonably required by the 4,517
third-party payer to accept or reject the claim. 4,518
(4) "Hospital" has the same meaning set forth in section 4,520
3727.01 of the Revised Code. 4,521
(5) "Proof of loss" means a claim for payment for health 4,523
care services which has been submitted to the appropriate claims 4,524
processing office of the third-party payer accompanied by 4,525
sufficient documentation for the third-party payer to determine 4,526
benefits payable under the benefits contract and reasonably 4,527
required by the third-party payer to accept or reject the claim. 4,528
(6) "Provider" means a hospital, nursing home, physician, 4,530
podiatrist, dentist, pharmacist, chiropractor, or other licensed 4,531
health care provider entitled to reimbursement by a third-party 4,532
payer for services rendered to a beneficiary under a benefits 4,533
contract. 4,534
(7) "Reimburse" means indemnify, make payment, or 4,536
otherwise accept responsibility for payment for health care 4,537
services rendered to a beneficiary, or arrange for the provision 4,538
of health care services to a beneficiary. 4,539
(8) "Third-party payer" means any of the following: 4,541
(a) An insurance company; 4,543
(b) A health insuring corporation; 4,545
(c) A preferred provider organization; 4,547
(d) A labor organization; 4,549
(e)(d) An employer; 4,551
(f)(e) An intermediary organization, as defined in section 4,554
1751.01 of the Revised Code, that is not a health delivery 4,556
network contracting solely with self-insured employers;
(g)(f) An administrator subject to sections 3959.01 to 4,558
3959.16 of the Revised Code; 4,559
(h)(g) A health delivery network, as defined in section 4,561
1751.01 of the Revised Code; 4,563
98
(i)(h) Any other person that is obligated pursuant to a 4,565
benefits contract to reimburse for covered health care services 4,566
rendered to beneficiaries under such contract. 4,567
(B)(1) Except as provided in division (B)(2) of this 4,569
section and in section 3901.381 of the Revised Code, within 4,571
twenty-four days of the receipt of a completed claim from a 4,572
provider or a beneficiary for reimbursement for health care 4,573
services rendered by the provider to a beneficiary, a third-party 4,574
payer shall, in accordance with division (D) of this section, 4,575
make payment of any amount due on such claim.
(2) A third-party payer and a provider may, in negotiating 4,577
a reimbursement contract, agree to any time period by which a 4,578
third-party payer shall, subject to division (D) of this section, 4,579
make payment of any amount due on a completed claim. Nothing in 4,580
this division shall be construed as limiting in any manner the 4,581
application of the requirements of this section to any benefits 4,582
or reimbursement contract. 4,583
(3) Any provider or beneficiary aggrieved with respect to 4,585
any act of a third-party payer that such provider or beneficiary 4,586
believes to be a violation of division (B)(1) or (2) of this 4,587
section may file a written complaint with the superintendent of 4,588
insurance. If a series of such complaints is received by the 4,589
superintendent with respect to a particular third-party payer and 4,590
if, after investigation, the superintendent finds that such 4,591
third-party payer has engaged in a series of such violations 4,592
which, taken together, constitute a consistent pattern or a 4,593
practice of such third-party payer to violate division (B)(1) or 4,594
(2) of this section, the superintendent shall issue an order 4,595
requiring such third-party payer to cease and desist from 4,596
engaging in such violations and to pay a late payment penalty as 4,597
specified in divisions (B)(4) and (5) of this section with 4,598
respect to the claims the superintendent finds were not timely 4,599
paid. In the order, the superintendent shall specify the reasons 4,600
for the superintendent's finding and order and state that a 4,601
99
hearing conducted pursuant to Chapter 119. of the Revised Code 4,603
shall be held within fifteen days after requested in writing by 4,604
the third-party payer. The provisions of this division (B)(3) of 4,605
this section are in addition to, and not in lieu of, such other 4,606
remedies as providers and beneficiaries may otherwise have by 4,607
law.
(4)(a) The late payment penalty shall be computed based 4,609
upon the number of days that have elapsed between the date 4,610
payment is due in accordance with division (B)(1) or (2) of this 4,611
section and the date payment is actually sent. 4,612
(b) The interest rate for determining the amount of the 4,614
late payment penalty shall be the rate agreed to by the provider 4,615
and the third-party payer or the rate specified by and determined 4,616
in accordance with division (A) of section 1343.01 of the Revised 4,617
Code. 4,618
(5) A provider and a third-party payer may enter into a 4,620
contractual agreement in which the timing of payments by the 4,621
third-party payer is not directly related to the receipt of a 4,622
completed claim. Such contractual arrangement may include 4,623
periodic interim payment arrangements, capitation payment 4,624
arrangements, or other payment arrangements acceptable to the 4,625
provider and the third-party payer. Except as agreed to under 4,626
such contract, this section does not apply to such payment 4,627
arrangements. 4,628
(6) Any late payment penalty due and payable by a 4,630
third-party payer in accordance with this section shall not be 4,631
used to reduce benefits or payments otherwise payable under a 4,632
benefits contract. 4,633
(C) No third-party payer shall refuse to process or pay 4,635
within the time period required under division (B)(1) or (2) of 4,636
this section a completed claim submitted by a provider on the 4,637
ground the beneficiary has not been discharged from the hospital 4,638
or the treatment has not been completed, if the submitted claim 4,639
covers services actually rendered and charges actually incurred 4,640
100
over at least a thirty-day period. 4,641
(D)(1) Notwithstanding section 1742.10 1751.13 or division 4,644
(I)(2) of section 3923.04 of the Revised Code, a reimbursement 4,645
contract entered into or renewed on or after June 29, 1988, 4,646
between a third-party payer and a hospital shall provide that 4,647
reimbursement for any service provided by a hospital pursuant to 4,648
a reimbursement contract and covered under a benefits contract 4,649
shall be made directly to the hospital. 4,650
(2) If the third-party payer and the hospital have not 4,652
entered into a contract regarding the provision and reimbursement 4,653
for covered services, the third-party payer shall accept and 4,654
honor a completed and validly executed assignment of benefits 4,655
with a hospital by a beneficiary, except when the third-party 4,656
payer has notified the hospital in writing of the conditions 4,657
under which the third-party payer will not accept and honor an 4,658
assignment of benefits. Such notice shall be made annually. 4,659
(3) A third-party payer may not refuse to accept and honor 4,661
a validly executed assignment of benefits with a hospital 4,662
pursuant to division (D)(2) of this section for medically 4,663
necessary hospital services provided on an emergency basis. 4,664
(E) A series of violations which taken together, 4,666
constitute a consistent pattern or a practice of violation of any 4,667
of the provisions of this section is an unfair and deceptive act 4,668
pursuant to sections 3901.19 to 3901.23 of the Revised Code and 4,669
is subject to proceedings pursuant to those sections. 4,670
Sec. 3917.01. (A) Group life insurance is that form of 4,679
life insurance covering not less than ten employees with or 4,680
without medical examination, written under a policy issued to the 4,681
employer, or to a trustee of a trust created by such employer, 4,682
the premium on which is to be paid by the employer, by the 4,683
employer and employees jointly, or by such trustee out of funds 4,684
contributed by the employer or by the employer and employees 4,685
jointly, and insuring only all of the employer's employees or all 4,687
of any classes thereof, determined by sex, age, or conditions 4,688
101
pertaining to the employment, for amounts of insurance based upon 4,689
some plan which will preclude individual selection, for the 4,690
benefit of persons other than the employer; but when the premium 4,691
is to be paid by the employer and employee jointly and the 4,692
benefits of the policy are offered to all eligible employees, not 4,693
less than seventy-five per cent of such employees may be so 4,694
insured. Such group policy may provide that "employees" includes 4,695
retired employees of the employer and the officers, managers, 4,696
employees, and retired employees of subsidiary or affiliated 4,697
corporations and the individual proprietors, partners, employees, 4,698
and retired employees of affiliated individuals and firms, when 4,699
the business of such subsidiary or affiliated corporations, 4,700
firms, or individuals is controlled by the common employer 4,701
through stock ownership, contract, or otherwise. This section 4,702
does not define as a group the lives covered by a policy issued 4,703
on more than one life which provides for payments upon the death 4,704
of any one or more or upon the death of each of the lives so 4,705
insured, and upon which the premium rates charged are computed on 4,706
the same basis as used by the issuing company on single life 4,707
policies and upon its regular forms of insurance. 4,708
(B) As used in sections 3917.01 to 3917.06 of the Revised 4,710
Code, the following forms of life insurance are group life 4,711
insurance: 4,712
(1) Life insurance covering the members of one or more 4,714
companies, batteries, troops, battalions, divisions, or other 4,715
units of the national guard or naval militia of any state, 4,716
written under a policy issued to the commanding general of the 4,717
national guard or commanding officer of the naval militia, who is 4,718
the employer for the purposes of such sections, the premium on 4,719
which is to be paid by the members of such units for the benefit 4,720
of persons other than the employer; provided that when the 4,721
benefits of the policy are offered to all eligible members of a 4,722
unit of the national guard or naval militia, not less than 4,723
seventy-five per cent of the members of such a unit may be 4,724
102
insured; 4,725
(2) Life insurance covering the members of one or more 4,727
troops or other units of the state troopers or state police of 4,728
any state, written under a policy issued to the commanding 4,729
officer of the state troopers or state police who is the employer 4,730
for the purposes of such sections, the premium on which is to be 4,731
paid by the members of such units for the benefit of persons 4,732
other than the employer; provided that when the benefits of the 4,733
policy are offered to all eligible members of a unit of the state 4,734
troopers or state police, not less than seventy-five per cent of 4,735
the members of such a unit may be insured; 4,736
(3) Life insurance covering the members of any labor 4,738
union, written under a policy issued to such union which is the 4,739
employer for the purposes of such sections, the premium on which 4,740
is to be paid by the union or by the union and its members 4,741
jointly, and insuring only all of its members, who are actively 4,742
engaged in the same occupation, for amounts of insurance based 4,743
upon some plan which will preclude individual selection, for the 4,744
benefit of persons other than the union or its officials; 4,745
provided that in case the insurance policy is cancellable at the 4,746
end of any policy year at the option of the insurance company and 4,747
that the basis of premium rates may be changed by the insurance 4,748
company at the beginning of any policy year, all members of a 4,749
labor union may be insured; and provided that when the premium is 4,750
to be paid by the union and its members jointly and the benefits 4,751
are offered to all eligible members, not less than seventy-five 4,752
per cent of such members may be insured; and provided that when 4,753
members apply and pay for additional amounts of insurance, a 4,754
smaller percentage of members may be insured for such additional 4,755
amounts if they pass satisfactory medical examinations or submit 4,756
satisfactory evidence of insurability; 4,757
(4) Life insurance written under a policy issued to a 4,759
creditor, who shall be deemed the policyholder, to insure debtors 4,760
of the creditor, subject to the following requirements: 4,761
103
(a) The debtors eligible for insurance under the policy 4,763
shall be all of the debtors of the creditor, excepting that no 4,764
debtor is eligible unless the indebtedness constitutes an 4,767
obligation to repay that is binding upon the debtor during the 4,768
debtor's lifetime at and from the date the insurance becomes 4,769
effective upon the debtor's life. The policy may provide that 4,770
"debtors" includes the debtors of one or more subsidiary 4,771
corporations and the debtors of one or more affiliated 4,772
corporations, proprietors, or partnerships if the business of the 4,773
policyholder and of such affiliated corporations, proprietors, or 4,774
partnerships is under common control through stock ownership, 4,775
contract, or otherwise. 4,776
(b) The premium for the policy shall be paid by the 4,778
policyholder, either from the creditor's funds, or from charges 4,779
collected from the insured debtors, or from both. A policy on 4,780
which part or all of the premium is to be derived from the 4,781
collection from the insured debtors of identifiable charges not 4,782
required of uninsured debtors shall not include debtors under 4,783
obligations outstanding at its date of issue without evidence of 4,784
individual insurability unless at least seventy-five per cent of 4,785
the then eligible debtors elect to pay the required charges. A 4,786
policy on which no part of the premium is to be derived from the 4,787
collection of such identifiable charges must insure all eligible 4,788
debtors, or all except any as to whom evidence of individual 4,789
insurability is not satisfactory to the insurer. 4,790
(c) The policy may be issued only if the group of eligible 4,792
debtors is then receiving new entrants at the rate of at least 4,793
one hundred persons yearly, or may reasonably be expected to 4,794
receive at least one hundred new entrants during the first policy 4,795
year, and continues to receive not less than one hundred new 4,796
entrants to the group yearly, and only if the policy reserves to 4,797
the insurer the right to require evidence of individual 4,798
insurability if less than seventy-five per cent of the new 4,799
entrants become insured. The policy may exclude from the classes 4,800
104
eligible for insurance classes of debtors determined by age. 4,801
(d) The amount of insurance on the life of any debtor may 4,803
be determined by the age of the debtor based upon a plan which 4,804
will preclude individual selection and shall at no time exceed 4,805
the amount owed by the debtor that is repayable in installments 4,807
to the creditor.
(e) The insurance shall be payable to the policyholder. 4,809
Such payment shall reduce or extinguish the unpaid indebtedness 4,810
of the debtor to the extent of such payment. 4,811
(5) Life insurance covering the members of any duly 4,813
organized corporation or association of veterans or veteran 4,814
society or association of the World War veterans, written under a 4,815
policy issued to such corporation, association, or society which 4,816
is the employer for the purpose of such sections, the premium on 4,817
which is to be paid by the corporation, association, society, and 4,818
its members jointly, and insuring all of its members who are 4,819
actively engaged in any occupation for amounts of insurance based 4,820
upon some plan which will preclude individual selection for the 4,821
benefit of persons other than the corporation, association, or 4,822
society or its officials; provided that when the premium is to be 4,823
paid by the corporation, association, or society and its members 4,824
jointly and the benefits are offered to all eligible members, not 4,825
less than seventy-five per cent of such members may be insured; 4,826
and provided that when members apply and pay for additional 4,827
amounts of insurance, a smaller percentage of members may be 4,828
insured for such additional amounts if they pass satisfactory 4,829
medical examinations or submit satisfactory evidence of 4,830
insurability; 4,831
(6) Life insurance covering the members of any 4,833
organization of agriculturists or horticulturists organized under 4,834
the co-operative laws of this state, written under a policy 4,835
issued to such co-operative association which is the employer for 4,836
the purpose of such sections, the premium on which is to be paid 4,837
by the association or by the association and its members jointly, 4,838
105
and insuring all of its members who are actively engaged in 4,839
agricultural or horticultural pursuits, for an amount of 4,840
insurance based upon some plan which will preclude individual 4,841
selection, and for the benefit of persons other than the 4,842
association or its officials; provided that when the premium is 4,843
to be paid by the corporation, association, or society and its 4,844
members jointly and the benefits are offered to all eligible 4,845
members, not less than seventy-five per cent of such members may 4,846
be insured; provided that when members apply and pay for 4,847
additional amounts of insurance, a smaller percentage of members 4,848
may be insured for such additional amounts if they pass 4,849
satisfactory medical examinations or submit satisfactory evidence 4,850
of insurability; 4,851
(7) Life insurance covering employees of a political 4,853
subdivision or district of this state, or of an educational or 4,854
other institution supported in whole or in part by public funds, 4,855
or of any classes thereof, determined by conditions pertaining to 4,856
employment, or of this state or any department or division 4,857
thereof, written under a policy issued to such political 4,858
subdivision, district, or institution, or the proper official or 4,859
board of this state or of such state department or division 4,860
thereof, which is the employer for the purpose of such sections, 4,861
the premium on which is to be paid by such employees, unless 4,862
otherwise provided by law, charter, or ordinance, for the benefit 4,863
of persons other than the employer; provided that when the 4,864
benefits of the policy are offered to all eligible employees of a 4,865
political subdivision or district of the state or of an 4,866
educational or other institution supported in whole, or in part 4,867
by public funds, or of this state or a state department or 4,868
division thereof, not less than seventy-five per cent of such 4,869
employees may be insured; and provided that when employees apply 4,870
and pay for additional amounts of insurance, a smaller percentage 4,871
of employees may be insured for such additional amounts if they 4,872
pass satisfactory medical examinations or submit satisfactory 4,873
106
evidence of insurability; and provided that upon acquisition by a 4,874
political subdivision of any privately owned property or 4,875
enterprise, the employees of which have been covered by a group 4,876
policy of life or other insurance as employees of such private 4,877
employer, such political subdivision and insurance company may 4,878
continue such contract in force upon similar conditions as the 4,879
last preceding private employer; 4,880
(8) Life insurance covering the members, or the members 4,882
and the employees of members of any duly organized association, 4,883
other than an association subject to any other provision of this 4,884
division, written under a policy issued to such association, 4,885
which association is the employer for the purpose of such 4,886
sections, the premium on which is to be paid by the insured 4,887
members or their employees, insuring members and their employees 4,888
for amounts of insurance based upon some plan which will preclude 4,889
individual selection except as provided in this section, for the 4,890
benefit of persons other than the association; provided the 4,891
association has been in existence for at least two years 4,892
immediately preceding the purchase of the insurance; provided 4,893
that there must be at least fifty insured members in any group; 4,894
and provided that the association has been organized and is 4,895
maintained in good faith for purposes other than that of 4,896
obtaining insurance; 4,897
(9) Life insurance issued to trustees of a trust fund 4,899
established jointly by one or more employers in the same 4,900
industry, on the one hand, and one or more labor unions 4,901
representing as bargaining agents employees of such employers, on 4,902
the other hand, or by two or more employers in the same industry, 4,903
or by two or more labor unions, which trustees shall be deemed 4,904
the policyholder to insure employees of the employers or members 4,905
of unions for the benefit of persons other than the employers or 4,906
the unions or the trustees, subject to the following 4,907
requirements: 4,908
(a) The persons eligible for such insurance shall be all 4,910
107
of the employees of the employers, or all of the members of the 4,911
unions, or all of any class of such employees determined by sex, 4,912
age, or conditions pertaining to their employment, or to 4,913
membership in the unions, or to any or all of them. The policy 4,914
may provide that "employees" includes the retired employees of 4,915
the employer and the officers, managers, employees, and retired 4,916
employees of subsidiary or affiliated corporations and the 4,917
individual proprietors, partners, employees, and retired 4,918
employees of affiliated individuals and firms, when the business 4,919
of such subsidiary or affiliated corporations, firms, or 4,920
individuals is controlled by the common employer through stock 4,921
ownership, contract, or otherwise. The policy may provide that 4,922
"employees" includes the individual proprietor or partners if the 4,923
employer is an individual proprietor or a partnership. The policy 4,924
may provide that "employees" includes the trustees or their 4,925
employees, or both, if their duties are principally connected 4,926
with such trusteeship. 4,927
(b) The premium for the policy shall be paid by the 4,929
trustees, either wholly from funds contributed by the employers 4,930
of the insured persons, or partly from such funds and partly from 4,931
funds contributed by the insured employees. If part of the 4,932
premium is to be derived from funds contributed by the insured 4,933
employees, then such policy may be placed in force only if it 4,934
covers at least seventy-five per cent of the then eligible 4,935
employees. A policy on which no part of the premium is derived 4,936
from funds contributed by the insured employees must insure all 4,937
eligible employees. 4,938
(c) Any policy must insure at least ten persons at date of 4,940
issue. 4,941
(d) The amounts of insurance under the policy must be 4,943
based upon some plan precluding individual selection by the 4,944
insured persons or the policyholder or the employers or the 4,945
unions or the trustees. 4,946
(10) Life insurance covering the members of a credit 4,948
108
union, which shall be deemed to be the employer for the purposes 4,949
of this section, the premium on which is to be paid by the credit 4,950
union or by the credit union and its members jointly, and 4,951
insuring all of its eligible members for amounts of insurance not 4,952
in excess of the share balance as to each member, and for the 4,953
benefit of persons other than the credit union or its officers; 4,954
provided that in the determination of the eligibility of members 4,955
there may be classifications and limitations based upon age; 4,956
provided also that when the premium is to be paid by the credit 4,957
union and its members jointly and the benefits are offered to all 4,958
eligible members, not less than seventy-five per cent of such 4,959
members may be so insured; provided also that in obtaining such 4,960
insurance, the officers of the credit union shall consider 4,961
proposals from any licensed insurer; provided also that members 4,962
may be required to provide evidence of insurability satisfactory 4,963
to the insurer. 4,964
(11) Life insurance covering the members of any duly 4,966
organized corporation or association of members of the Ohio 4,967
national guard, the Ohio naval militia, and the Ohio military 4,968
reserve, which shall have been in existence for at least two 4,969
years immediately preceding the purchase of such insurance, 4,970
written under a policy issued to such corporation or association, 4,971
which corporation or association is the employer for the purpose 4,972
of such sections, the premium on which is to be paid by the 4,973
insured members, insuring members for amounts of insurance based 4,974
upon some plan which will preclude individual selection, except 4,975
as provided in this section, for the benefit of persons other 4,976
than the corporation or association, provided that there must be 4,977
at least fifty insured members in any group, and provided further 4,978
that unless seventy-five per cent of all members or one thousand 4,979
members, whichever is the lesser number, are insured, each member 4,980
must pass a satisfactory medical examination in order to be 4,981
insured; and provided that, when members apply and pay for 4,982
additional amounts of insurance, they may be insured for such 4,983
109
additional amounts if they pass satisfactory medical examinations 4,984
or submit satisfactory evidence of insurability. 4,985
(12) LIFE INSURANCE THAT IS WRITTEN UNDER A POLICY ISSUED 4,988
TO A TRUSTEE UNDER A TRUST ESTABLISHED BY AN INSURER FOR THE 4,989
PURPOSE OF PROVIDING CONTINUED GROUP LIFE INSURANCE COVERAGE TO 4,990
THOSE FORMER EMPLOYEES, FORMER MEMBERS, OR FORMER MEMBERS AND THE 4,991
EMPLOYEES OF SUCH MEMBERS, AND THEIR SPOUSES AND DEPENDENT 4,992
CHILDREN, PREVIOUSLY COVERED UNDER POLICIES OF GROUP LIFE 4,993
INSURANCE ISSUED BY THE INSURER TO EMPLOYERS OR TRUSTEES PURSUANT 4,994
TO DIVISION (A) OF THIS SECTION, TO ASSOCIATIONS PURSUANT TO 4,995
DIVISION (B)(8) OF THIS SECTION, OR TO TRUSTEES PURSUANT TO 4,996
DIVISION (B)(9) OF THIS SECTION, AND THAT IS EVIDENCED BY THE 4,998
ISSUANCE OF A CERTIFICATE OF INSURANCE TO SUCH FORMER EMPLOYEES 4,999
OR MEMBERS; PROVIDED THAT THE AMOUNT OF THE CONTINUED LIFE 5,000
INSURANCE COVERAGE MADE AVAILABLE TO A FORMER EMPLOYEE OR MEMBER 5,001
AND TO THE EMPLOYEE'S OR MEMBER'S SPOUSE AND DEPENDENTS SHALL NOT 5,002
EXCEED THE AMOUNT OF THE GROUP LIFE INSURANCE COVERAGE PREVIOUSLY 5,003
PROVIDED TO THE EMPLOYEE OR MEMBER AND THE EMPLOYEE'S OR MEMBER'S 5,004
ELIGIBLE DEPENDENTS AT THE TIME OF THE EMPLOYEE'S SEPARATION FROM 5,007
EMPLOYMENT OR THE MEMBER'S TERMINATION OF MEMBERSHIP. 5,008
(C) Any policy issued pursuant to this section, except a 5,010
policy issued to a creditor pursuant to division (B) (4) of this 5,011
section, may be extended, in the form of group term life 5,012
insurance only, to insure the spouse and dependent children of an 5,013
insured employee or member, or any class or classes thereof, 5,014
subject to the following requirements: 5,015
(1) The premiums for the group term life insurance shall 5,017
be paid by the policyholder, either from the employer, union or 5,018
association funds, or from funds contributed by the employer, 5,019
union, or association, or from funds contributed by the insured 5,020
employee or member, or from both. 5,021
(2) The amounts of insurance under the policy must be 5,023
based upon some plan precluding individual selection either by 5,024
the insured employee or member or by the policyholder, provided 5,025
110
that group term life insurance upon the life of a spouse or 5,026
dependent child shall not exceed the lesser of (a) ten thousand 5,027
dollars, or (b) one-half of the amount of insurance on the life 5,028
of the insured employee or member under the group policy. 5,029
(3) Upon termination of the group term life insurance with 5,031
respect to the spouse of any insured employee or member by reason 5,032
of such person's termination of employment or membership or 5,033
death, the spouse insured pursuant to this section shall have the 5,034
same conversion rights as to the group term life insurance on the 5,035
spouse's life as is provided for the insured employee or member. 5,037
(4) Only one certificate need be issued for delivery to an 5,039
insured employee or member if a statement concerning any 5,040
dependent's coverage is included in such certificate. 5,041
Sec. 3917.06. No policy of group life insurance shall be 5,050
issued or delivered in this state until a copy of its form has 5,051
been filed with the superintendent of insurance and formally 5,052
approved by him THE SUPERINTENDENT; nor shall such policy be so 5,053
issued or delivered unless it contains in substance the following 5,054
provisions:
(A) A provision that the policyholder is entitled to a 5,056
grace period of thirty-one days for the payment of any premiums 5,057
due except the first during which grace period the death benefit 5,058
coverage shall continue in force, unless the policyholder has 5,059
given the insurer written notice of discontinuance in advance of 5,060
the date of discontinuance and in accordance with the terms of 5,061
the policy; the policy may provide that the policyholder is 5,062
liable to the insurer for the payment of a pro rata premium for 5,063
the time the policy was in force during such grace period; 5,064
(B) A provision that the policy is incontestable after two 5,066
years from its date of issue, except for nonpayment of premiums 5,067
and except for violation of the conditions of the policy relating 5,068
to military or naval service in time of war; 5,069
(C) A provision that the policy and the application 5,071
submitted in connection therewith constitute the entire contract 5,072
111
between the parties, and that all statements contained in such 5,073
application are deemed, in the absence of fraud, representations 5,074
and not warranties, and that no such statement shall be used in 5,075
defense to a claim under the policy, unless it is contained in a 5,076
written application; 5,077
(D) A provision for the equitable adjustment of the 5,079
premium or the amount of insurance payable in the event of a 5,080
misstatement of the age of an employee or other person whose life 5,081
is insured under a group life policy; 5,082
(E) Except in the case of a policy described in division 5,084
(B)(4) of section 3917.01 of the Revised Code, a provision that 5,085
the company will issue to the policyholder for delivery to each 5,086
person whose life is insured under such policy, an individual 5,087
certificate setting forth a statement as to the insurance 5,088
protection to which he THE PERSON is entitled, to whom payable, 5,089
together with provision to the effect that in case of the 5,090
termination of the employment for any reason or of membership in 5,091
the classes eligible for insurance under the policy, such person 5,092
is entitled to have issued to him THE PERSON by the company, 5,093
without evidence of insurability, and upon application made to 5,094
the company within thirty-one days after such termination, and 5,095
upon the payment of the premium applicable to the class of risk 5,096
to which he THE PERSON belongs and to the form and amount of the 5,097
policy at his THE PERSON'S then attained age, EITHER a policy of 5,098
life insurance in any one of the forms customarily issued by the 5,101
company, except term insurance, in any amount not in excess of 5,102
the amount of his THE PERSON'S protection under such THE group 5,103
insurance policy at the time of such THE termination, as he THE 5,105
PERSON elects OR, IF APPLICABLE, THE COVERAGE DESCRIBED IN 5,106
DIVISION (B)(12) OF SECTION 3917.01 OF THE REVISED CODE;
(F) A provision that if the group policy terminates or is 5,108
amended so as to terminate the insurance of any class of insured 5,109
persons, every person insured thereunder at the date of such 5,110
termination whose insurance terminates and who has been so 5,111
112
insured for at least five years prior to such termination date is 5,112
entitled to have issued to him THE PERSON by the insurer an 5,113
individual policy of life insurance, subject to the same 5,114
conditions as are provided by division (E) of this section, 5,115
except that the group policy may provide that the amount of such 5,116
individual policy shall not exceed the smaller of (1) the amount 5,117
of the person's life insurance protection ceasing because of the 5,118
termination of OR amendment of the group policy, less the amount 5,119
of any life insurance for which he THE PERSON is or becomes 5,120
eligible under any group policy issued or reinstated by the same 5,122
or another insurer within thirty-one days after such termination, 5,123
and (2) two thousand dollars; 5,124
(G) A provision that if a person insured under the group 5,126
policy dies during the period within which he THE PERSON would 5,127
have been entitled to have an individual policy issued to him THE 5,128
PERSON in accordance with division (E) or (F) of this section, 5,129
and before such an individual policy has become effective, the 5,131
amount of life insurance which he THE PERSON would have been 5,132
entitled to have issued to him THE PERSON under such individual 5,133
policy shall be payable as a claim under the group policy, 5,134
whether or not application for the individual policy or the 5,135
payment of the first premium therefor has been made; 5,136
(H) A provision that to the group or class of persons 5,138
originally insured there shall be added from time to time all new 5,139
employees of the employer or other persons eligible to insurance 5,140
in such group or class; 5,141
(I) In the case of a policy issued to a labor union 5,143
covering all members of the union, a notice that the annual 5,144
renewable term premium depends upon the attained ages of the 5,145
members in the group and increases with advancing ages. 5,146
Policies of group life insurance, when issued in this state 5,148
by any company not organized under the laws of this state, may 5,149
contain, when issued, any provision required by the law of the 5,150
state, territory, or district of the United States under which 5,151
113
the company is organized; and policies issued in other states or 5,152
countries by companies organized in this state, may contain any 5,153
provision required or permitted by the laws of the state, 5,154
territory, district, or country in which the same are issued. Any 5,156
such policy may be issued or delivered in this state which in the 5,157
opinion of the superintendent contains provisions on any one or 5,158
more of the requirements of this section more favorable to the
policyholder or to the person whose life is insured under such 5,159
policy than such requirements. 5,160
The group life insurance policy together with any 5,162
application in connection therewith shall be available for 5,163
inspection during regular business hours at the office of the 5,164
policyholder where such policy is on file, by any beneficiary 5,165
thereunder or by an authorized representative of such 5,166
beneficiary. 5,167
Except as provided in sections 3917.01 to 3917.06, 5,169
inclusive, of the Revised Code, no contract of life insurance 5,170
shall be made covering a group in this state. 5,171
Sec. 3923.021. (A) As used in this section, "benefits 5,180
provided are not unreasonable in relation to the premium charged" 5,181
means the rates were calculated in accordance with sound 5,182
actuarial principles. 5,183
(B) With respect to any filing, made pursuant to section 5,185
3923.02 of the Revised Code, of any premium rates for any 5,186
individual policy of sickness and accident insurance or for any 5,187
indorsement or rider pertaining thereto, the superintendent of 5,188
insurance may, within thirty days after filing: 5,189
(1) Disapprove such filing after finding that the benefits 5,192
provided are unreasonable in relation to the premium charged. 5,193
Such disapproval shall be effected by written order of the 5,194
superintendent, a copy of which shall be mailed to the insurer 5,195
that has made the filing. In the order, the superintendent shall 5,196
specify the reasons for the disapproval and state that a hearing 5,198
will be held within fifteen days after requested in writing by 5,199
114
the insurer. If a hearing is so requested, the superintendent 5,200
shall also give such public notice as the superintendent 5,201
considers appropriate. The superintendent, within fifteen days 5,203
after the commencement of any hearing, shall issue a written 5,204
order, a copy of which shall be mailed to the insurer that has 5,205
made the filing, either affirming the prior disapproval or 5,206
approving such filing after finding that the benefits provided 5,207
are not unreasonable in relation to the premium charged. 5,209
(2) Set a date for a public hearing to commence no later 5,211
than forty days after the filing. The superintendent shall give 5,212
the insurer making the filing twenty days' written notice of the 5,213
hearing and shall give such public notice as the superintendent 5,215
considers appropriate. The superintendent, within twenty days 5,216
after the commencement of a hearing, shall issue a written order, 5,217
a copy of which shall be mailed to the insurer that has made the 5,218
filing, either approving such filing if the superintendent finds 5,219
that the benefits provided are not unreasonable in relation to 5,221
the premium charged, or disapproving such filing if the 5,222
superintendent finds that the benefits provided are unreasonable 5,224
in relation to the premium charged. This division does not apply 5,225
to any insurer organized or transacting the business of insurance 5,226
under Chapter 3907. or 3909. of the Revised Code. 5,227
(3) Take no action, in which case such filing shall be 5,229
deemed to be approved and shall become effective upon the 5,230
thirty-first day after such filing, unless the superintendent has 5,231
previously given to the insurer a written approval. 5,232
(C) At any time after any filing has been approved 5,234
pursuant to this section, the superintendent may, after a hearing 5,235
of which at least twenty days' written notice has been given to 5,236
the insurer that has made such filing and for which such public 5,237
notice as the superintendent considers appropriate has been 5,238
given, withdraw approval of such filing after finding that the 5,240
benefits provided are unreasonable in relation to the premium 5,242
charged. Such withdrawal of approval shall be effected by 5,243
115
written order of the superintendent, a copy of which shall be 5,244
mailed to the insurer that has made the filing, which shall state 5,245
the ground for such withdrawal and the date, not less than forty 5,246
days after the date of such order, when the withdrawal or 5,247
approval shall become effective. 5,248
(D) The superintendent may retain at the insurer's expense 5,250
such attorneys, actuaries, accountants, and other experts not 5,251
otherwise a part of the superintendent's staff as shall be 5,252
reasonably necessary to assist in the preparation for and conduct 5,253
of any public hearing under this section. The expense for 5,254
retaining such experts and the expenses of the department of 5,255
insurance incurred in connection with such public hearing shall 5,256
be assessed against the insurer in an amount not to exceed one 5,257
one-hundredth of one per cent of the sum of premiums earned plus 5,258
net realized investment gain or loss of such insurer as reflected 5,259
in the most current annual statement on file with the 5,260
superintendent. Any person retained shall be under the direction 5,261
and control of the superintendent and shall act in a purely 5,262
advisory capacity. 5,263
(E) This section does not apply to any filing of any 5,265
premium rate or rating formula for individual sickness and 5,266
accident insurance policies offered in accordance with division 5,267
(L) of section 3923.58 of the Revised Code, or for any amendment 5,269
thereto.
Sec. 3923.122. (A) Every policy of group sickness and 5,278
accident insurance providing hospital, surgical, or medical 5,279
expense coverage for other than specific diseases or accidents 5,280
only, and delivered, issued for delivery, or renewed in this 5,281
state on or after January 1, 1976, shall include a provision 5,282
giving each insured the option to convert to the following: 5,283
(1) In the case of an individual who is not a federally 5,286
eligible individual, any of the individual policies of hospital, 5,287
surgical, or medical expense insurance then being issued by the 5,288
insurer with benefit limits not to exceed those in effect under 5,289
116
the group policy;
(2) In the case of a federally eligible individual, a 5,291
basic or standard plan established by the board of directors of 5,292
the Ohio health reinsurance program or plans substantially 5,293
similar to the basic and standard plan in benefit design and 5,294
scope of covered services. For purposes of division (A)(2) of 5,295
this section, the superintendent of insurance shall determine 5,296
whether a plan is substantially similar to the basic or standard 5,297
plan in benefit design and scope of covered services. 5,298
(B) An option for conversion to an individual policy shall 5,300
be available without evidence of insurability to every insured, 5,301
including any person eligible under division (D) of this section, 5,302
who terminates employment or membership in the group holding the 5,304
policy after having been continuously insured thereunder for at 5,305
least one year.
Upon receipt of the insured's written application and upon 5,307
payment of at least the first quarterly premium not later than 5,308
thirty-one days after the termination of coverage under the group 5,309
policy, the insurer shall issue a converted policy on a form then 5,310
available for conversion. The premium shall be in accordance 5,311
with the insurer's table of premium rates in effect on the later 5,312
of the following dates: 5,313
(1) The effective date of the converted policy; 5,315
(2) The date of application therefor; and shall be 5,317
applicable to the class of risk to which each person covered 5,319
belongs and to the form and amount of the policy at the person's 5,320
then attained age. However, premiums charged federally eligible 5,321
individuals may not exceed an amount that is two times the 5,323
midpoint of the standard rate charged any other individual of a 5,324
group to which the insurer is currently accepting new business 5,325
and for which similar copayments and deductibles are applied. 5,326
At the election of the insurer, a separate converted policy 5,328
may be issued to cover any dependent of an employee or member of 5,329
the group. 5,330
117
Except as provided in division (H) of this section, any 5,332
converted policy shall become effective as of the day following 5,333
the date of termination of insurance under the group policy. 5,334
Any probationary or waiting period set forth in the 5,336
converted policy is deemed to commence on the effective date of 5,337
the insured's coverage under the group policy. 5,338
(C) No insurer shall be required to issue a converted 5,340
policy to any person who is, or is eligible to be, covered for 5,341
benefits at least comparable to the group policy under: 5,342
(1) Title XVIII of the Social Security Act, as amended or 5,344
superseded; 5,345
(2) Any act of congress or law under this or any other 5,347
state of the United States that duplicates coverage offered under 5,348
division (C)(1) of this section; 5,349
(3) Any policy that duplicates coverage offered under 5,351
division (C)(1) of this section; 5,352
(4) Any other group sickness and accident insurance 5,354
providing hospital, surgical, or medical expense coverage for 5,355
other than specific diseases or accidents only. 5,356
(D) The option for conversion shall be available: 5,358
(1) Upon the death of the employee or member, to the 5,360
surviving spouse with respect to such of the spouse and 5,361
dependents as are then covered by the group policy; 5,362
(2) To a child solely with respect to the child upon 5,364
attaining the limiting age of coverage under the group policy 5,365
while covered as a dependent thereunder; 5,366
(3) Upon the divorce, dissolution, or annulment of the 5,368
marriage of the employee or member, to the divorced spouse, or 5,369
former spouse in the event of annulment, of such employee or 5,370
member, or upon the legal separation of the spouse from such 5,371
employee or member, to the spouse. 5,372
Persons possessing the option for conversion pursuant to 5,374
this division shall be considered members for the purposes of 5,375
division (H) of this section. 5,376
118
(E) If coverage is continued under a group policy on an 5,378
employee following retirement prior to the time the employee is, 5,380
or is eligible to be, covered by Title XVIII of the Social 5,381
Security Act, the employee may elect, in lieu of the continuance 5,382
of group insurance, to have the same conversion rights as would 5,384
apply had the employee's insurance terminated at retirement by 5,386
reason of termination of employment. 5,387
(F) If the insurer and the group policyholder agree upon 5,389
one or more additional plans of benefits to be available for 5,390
converted policies, the applicant for the converted policy may 5,391
elect such a plan in lieu of a converted policy. 5,392
(G) The converted policy may contain provisions for 5,394
avoiding duplication of benefits provided pursuant to divisions 5,395
(C)(1), (2), (3), and (4) of this section or provided under any 5,396
other insured or noninsured plan or program. 5,397
(H) If an employee or member becomes entitled to obtain a 5,399
converted policy pursuant to this section, and if the employee or 5,400
member has not received notice of the conversion privilege at 5,401
least fifteen days prior to the expiration of the thirty-one-day 5,402
conversion period provided in division (B) of this section, then 5,403
the employee or member has an additional period within which to 5,404
exercise the privilege. This additional period shall expire 5,405
fifteen days after the employee or member receives notice, but in 5,406
no event shall the period extend beyond sixty days after the 5,407
expiration of the thirty-one-day conversion period. 5,408
Written notice presented to the employee or member, or 5,410
mailed by the policyholder to the last known address of the 5,411
employee or member as indicated on its records, constitutes 5,412
notice for the purpose of this division. In the case of a person 5,413
who is eligible for a converted policy under division (D)(2) or 5,414
(D)(3) of this section, a policyholder shall not be responsible 5,415
for presenting or mailing such notice, unless such policyholder 5,416
has actual knowledge of the person's eligibility for a converted 5,417
policy. 5,418
119
If an additional period is allowed by an employee or member 5,420
for the exercise of a conversion privilege, and if written 5,421
application for the converted policy, accompanied by at least the 5,422
first quarterly premium, is made after the expiration of the 5,423
thirty-one-day conversion period, but within the additional 5,424
period allowed an employee or member in accordance with this 5,425
division, the effective date of the converted policy shall be the 5,426
date of application. 5,427
(I) The converted policy may provide: 5,429
(1) That THAT any hospital, surgical, or medical expense 5,431
benefits otherwise payable with respect to any person may be 5,432
reduced by the amount of any such benefits payable under the 5,433
group policy for the same loss after termination of coverage; 5,434
(2) For termination of coverage on any person who is, or 5,436
is eligible to be, covered pursuant to division (C) of this 5,437
section; 5,438
(3) That the insurer may request information in advance of 5,440
any premium due date of the policy as to whether the insured is, 5,441
or is eligible to be, covered pursuant to division (C) of this 5,442
section. If the insured is, or is eligible to be, covered, and 5,443
the insured fails to furnish the details of the insured's 5,445
coverage or eligibility to the insurer within thirty-one days 5,446
after the date of the request, the benefits payable under the 5,447
converted policy may be based on the hospital, surgical, or 5,448
medical expenses actually incurred after excluding expenses to 5,449
the extent of the amount of benefits for which the insured is, or 5,450
is eligible to be, covered pursuant to division (C) of this 5,451
section.
(J) The converted policy may contain: 5,453
(1) Any exclusion, reduction, or limitation contained in 5,455
the group policy or customarily used in individual policies 5,456
issued by the insurer; 5,457
(2) Any provision permitted in this section; 5,459
(3) Any other provision not prohibited by law. 5,461
120
Any provision required or permitted in this section may be 5,463
made a part of any converted policy by means of an endorsement or 5,464
rider. 5,465
(K) The time limit specified in a converted policy for 5,467
certain defenses with respect to any person who was covered by a 5,468
group policy shall commence on the effective date of such 5,469
person's coverage under the group policy. 5,470
(L) No insurer shall use deterioration of health as the 5,472
basis for refusing to renew a converted policy. 5,473
(M) No insurer shall use age as the basis for refusing to 5,475
renew a converted policy. 5,476
(N) A converted policy made available pursuant to this 5,478
section shall, if delivery of the policy is to be made in this 5,479
state, comply with this section. If delivery of a converted 5,480
policy is to be made in another state, it may be on a form 5,481
offered by the insurer in the jurisdiction where the delivery is 5,482
to be made and which provides benefits substantially in 5,483
compliance with those required in a policy delivered in this 5,484
state. 5,485
(O) As used in this section, "federally eligible 5,488
individual" means an eligible individual as defined in 45 C.F.R. 5,490
148.103. 5,491
Sec. 3923.57. Notwithstanding any provision of this 5,500
chapter, every individual policy of sickness and accident 5,501
insurance that is delivered, issued for delivery, or renewed in 5,502
this state is subject to the following conditions, as applicable: 5,503
(A) Pre-existing conditions provisions shall not exclude 5,505
or limit coverage for a period beyond twelve months following the 5,506
policyholder's effective date of coverage and may only relate to 5,507
conditions during the six months immediately preceding the 5,508
effective date of coverage. 5,509
(B) In determining whether a pre-existing conditions 5,511
provision applies to a policyholder or dependent, each policy 5,512
shall credit the time the policyholder or dependent was covered 5,513
121
under a previous policy, contract, or plan if the previous 5,515
coverage was continuous to a date not more than thirty days prior 5,517
to the effective date of the new coverage, exclusive of any 5,518
applicable service waiting period under the policy. 5,519
(C)(1) Except as otherwise provided in division (C) of 5,522
this section, an insurer that provides an individual sickness and 5,523
accident insurance policy to an individual shall renew or 5,524
continue in force such coverage at the option of the individual. 5,525
(2) An insurer may nonrenew or discontinue coverage of an 5,528
individual in the individual market based only on one or more of 5,529
the following reasons:
(a) The individual failed to pay premiums or contributions 5,532
in accordance with the terms of the policy or the insurer has not 5,533
received timely premium payments.
(b) The individual performed an act or practice that 5,536
constitutes fraud or made an intentional misrepresentation of 5,537
material fact under the terms of the policy.
(c) The insurer is ceasing to offer coverage in the 5,540
individual market in accordance with division (D) of this section 5,541
and the applicable laws of this state. 5,542
(d) If the insurer offers coverage in the market through a 5,545
network plan, the individual no longer resides, lives, or works 5,546
in the service area, or in an area for which the insurer is 5,547
authorized to do business; provided, however, that such coverage 5,548
is terminated uniformly without regard to any health 5,549
status-related factor of covered individuals.
(e) If the coverage is made available in the individual 5,552
market only through one or more bona fide associations, the 5,553
membership of the individual in the association, on the basis of 5,554
which the coverage is provided, ceases; provided, however, that 5,555
such coverage is terminated under division (C)(2)(e) of this 5,558
section uniformly without regard to any health status-related 5,559
factor of covered individuals.
AN INSURER OFFERING COVERAGE TO INDIVIDUALS SOLELY THROUGH 5,561
122
MEMBERSHIP IN A BONA FIDE ASSOCIATION SHALL NOT BE DEEMED, BY 5,562
VIRTUE OF THAT OFFERING, TO BE IN THE INDIVIDUAL MARKET FOR 5,563
PURPOSES OF SECTIONS 3923.58 AND 3923.581 OF THE REVISED CODE. 5,564
SUCH AN INSURER SHALL NOT BE REQUIRED TO ACCEPT APPLICANTS FOR 5,566
COVERAGE IN THE INDIVIDUAL MARKET PURSUANT TO SECTIONS 3923.58
AND 3923.581 OF THE REVISED CODE UNLESS THE INSURER ALSO OFFERS 5,568
COVERAGE TO INDIVIDUALS OTHER THAN THROUGH BONA FIDE
ASSOCIATIONS.
(3) An insurer may cancel or decide not to renew the 5,570
coverage of a dependent of an individual if the dependent has 5,571
performed an act or practice that constitutes fraud or made an 5,572
intentional misrepresentation of material fact under the terms of 5,573
the coverage and if the cancellation or nonrenewal is not based, 5,574
either directly or indirectly, on any health status-related 5,575
factor in relation to the dependent.
(D)(1) If an insurer decides to discontinue offering a 5,578
particular type of health insurance coverage offered in the 5,579
individual market, coverage of such type may be discontinued by 5,580
the insurer if the insurer does all of the following: 5,581
(a) Provides notice to each individual provided coverage 5,584
of this type in such market of the discontinuation at least 5,585
ninety days prior to the date of the discontinuation of the 5,586
coverage;
(b) Offers to each individual provided coverage of this 5,589
type in such market, the option to purchase any other individual 5,590
health insurance coverage currently being offered by the insurer 5,591
for individuals in that market;
(c) In exercising the option to discontinue coverage of 5,594
this type and in offering the option of coverage under division 5,595
(D)(1)(b) of this section, acts uniformly without regard to any 5,597
health status-related factor of covered individuals or of 5,598
individuals who may become eligible for such coverage. 5,599
(2) If an insurer elects to discontinue offering all 5,601
health insurance coverage in the individual market in this state, 5,603
123
health insurance coverage may be discontinued by the insurer only 5,604
if both of the following apply:
(a) The insurer provides notice to the department of 5,607
insurance and to each individual of the discontinuation at least 5,608
one hundred eighty days prior to the date of the expiration of 5,609
the coverage.
(b) All health insurance delivered or issued for delivery 5,612
in this state in such market is discontinued and coverage under 5,613
that health insurance in that market is not renewed. 5,614
(3) In the event of a discontinuation under division 5,616
(D)(2) of this section in the individual market, the insurer 5,618
shall not provide for the issuance of any health insurance 5,619
coverage in the market and this state during the five-year period 5,620
beginning on the date of the discontinuation of the last health 5,621
insurance coverage not so renewed. 5,622
(E) Nothwithstanding NOTWITHSTANDING divisions (C) and (D) 5,625
of this section, an insurer may, at the time of coverage renewal,
modify the health insurance coverage for a policy form offered to 5,627
individuals in the individual market if the modification is 5,628
consistent with the law of this state and effective on a uniform 5,629
basis among all individuals with that policy form. 5,630
(F) Such policies are subject to sections 2743 and 2747 of 5,633
the "Health Insurance Portability and Accountability Act of 5,637
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 5,643
and 300gg-47, as amended. 5,644
(G) Sections 3924.031 and 3924.032 of the Revised Code 5,648
shall apply to sickness and accident insurance policies offered 5,649
in the individual market in the same manner as they apply to 5,650
health benefit plans offered in the small employer market. 5,651
In accordance with 45 C.F.R. 148.102, divisions (C) to (G) 5,656
of this section also apply to all group sickness and accident 5,657
insurance policies that are not sold in connection with an 5,658
employment-related group health plan and that provide more than 5,659
short-term, limited duration coverage. 5,660
124
In applying divisions (C) to (G) of this section with 5,664
respect to health insurance coverage that is made available by an 5,666
insurer in the individual market to individuals only through one 5,667
or more associations, the term "individual" includes the
association of which the individual is a member. 5,668
For purposes of this section, any policy issued pursuant to 5,670
division (C) of section 3923.13 of the Revised Code in connection 5,673
with a public or private college or university student health
insurance program is considered to be issued to a bona fide 5,674
association and is not subject to divisions (C) to (G) of this 5,677
section.
As used in this section, "bona fide association" has the 5,680
same meaning as in section 3924.03 of the Revised Code, and 5,682
"health status-related factor" and "network plan" have the same 5,683
meanings as in section 3924.031 of the Revised Code. 5,685
This section does not apply to any policy that provides 5,687
coverage for specific diseases or accidents only, or to any 5,688
hospital indemnity, medicare supplement, long-term care, 5,689
disability income, one-time-limited-duration policy of no longer 5,690
than six months, or other policy that offers only supplemental 5,691
benefits. 5,692
Sec. 3923.571. Except as otherwise provided in section 5,702
2721 of the "Health Insurance Portability and Accountability Act 5,707
of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 5,712
300gg-21, as amended, the following conditions apply to all group 5,714
policies of sickness and accident insurance that are sold in
connection with an employment-related group health plan and that 5,715
are not subject to section 3924.03 of the Revised Code: 5,716
(A) Any such policy shall comply with the requirements of 5,718
division (A) of section 3924.03 and section 3924.033 of the 5,719
Revised Code. 5,720
(B)(1) Except as provided in section 2712(b) to (e) of the 5,724
"Health Insurance Portability and Accountability Act of 1996," if 5,728
an insurer offers coverage in the small or large group market in 5,729
125
connection with a group policy, the insurer shall renew or 5,730
continue in force such coverage at the option of the 5,731
policyholder.
(2) An insurer may cancel or decide not to renew the 5,733
coverage of an employee or of a dependent of an employee if the 5,734
employee or dependent, as applicable, has performed an act or 5,735
practice that constitutes fraud or made an intentional 5,736
misrepresentation of material fact under the terms of the
coverage and if the cancellation or nonrenewal is not based, 5,737
either directly or indirectly, on any health status-related 5,738
factor in relation to the employee or dependent. 5,739
As used in division (B)(2) of this section, "health 5,742
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 5,744
(C)(1) No such policy, or insurer offering health 5,746
insurance coverage in connection with such a policy, shall 5,748
require any individual, as a condition of coverage or continued 5,749
coverage under the policy, to pay a premium or contribution that 5,750
is greater than the premium or contribution for a similarly 5,751
situated individual covered under the policy on the basis of any 5,752
health status-related factor in relation to the individual or to 5,753
an individual covered under the policy as a dependent of the 5,754
individual. 5,755
(2) Nothing in division (C)(1) of this section shall be 5,758
construed to restrict the amount that an employer may be charged 5,759
for coverage under a group policy, or to prevent a group policy, 5,760
and an insurer offering group health insurance coverage, from 5,761
establishing premium discounts or rebates or modifying otherwise 5,762
applicable copayments or deductibles in return for adherence to 5,763
programs of health promotion and disease prevention. 5,764
(D) Such policies shall provide for the special enrollment 5,767
periods described in section 2701(f) of the "Health Insurance 5,770
Portability and Accountability Act of 1996." 5,773
(E) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, AN INSURER 5,776
126
SHALL PROVIDE TO ALL LATE ENROLLEES, AS DEFINED IN SECTION 5,777
3924.01 OF THE REVISED CODE, WHO ARE IDENTIFIED BY THE 5,779
POLICYHOLDER, THE OPTION TO ENROLL IN THE GROUP POLICY. THE 5,780
ENROLLMENT OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF 5,781
THIRTY CONSECUTIVE DAYS. ALL DELAYS OF COVERAGE IMPOSED UNDER 5,782
THE GROUP POLICY, INCLUDING ANY PRE-EXISTING CONDITION EXCLUSION 5,783
PERIOD OR SERVICE WAITING PERIOD, SHALL BEGIN ON THE DATE THE 5,784
INSURER RECEIVES NOTICE OF THE LATE ENROLLEE'S APPLICATION OR 5,785
REQUEST FOR COVERAGE, AND SHALL RUN CONCURRENTLY WITH EACH OTHER. 5,786
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 5,795
of the Revised Code: 5,796
(1) "Health benefit plan" and "MEWA" have the same 5,799
meanings as in section 3924.01 of the Revised Code. 5,800
(2) "Insurer" means any sickness and accident insurance 5,802
company authorized to do business in this state, or MEWA 5,805
authorized to issue insured health benefit plans in this state. 5,806
"Insurer" does not include any health insuring corporation that
is owned or operated by an insurer. 5,808
(3) "Pre-existing conditions provision" means a policy 5,811
provision that excludes or limits coverage for charges or 5,812
expenses incurred during a specified period following the 5,813
insured's effective date of coverage as to a condition which, 5,814
during a specified period immediately preceding the effective 5,815
date of coverage, had manifested itself in such a manner as would 5,817
cause an ordinarily prudent person to seek medical advice,
diagnosis, care, or treatment or for which medical advice, 5,818
diagnosis, care, or treatment was recommended or received, or a 5,819
pregnancy existing on the effective date of coverage. 5,820
(B) Beginning in January of each year, insurers in the 5,823
business of issuing individual policies of sickness and accident 5,824
insurance as contemplated by section 3923.021 of the Revised 5,825
Code, except individual policies issued pursuant to section 5,827
3923.122 of the Revised Code, shall accept applicants for open 5,831
enrollment coverage, as set forth in this division, in the order 5,833
127
in which they apply for coverage and subject to the limitation 5,834
set forth in division (G) of this section. Insurers shall accept 5,835
for coverage pursuant to this section individuals to whom both of 5,838
the following conditions apply:
(1) The individual is not applying for coverage as an 5,840
employee of an employer, as a member of an association, or as a 5,841
member of any other group. 5,842
(2) The individual is not covered, and is not eligible for 5,844
coverage, under any other private or public health benefits 5,845
arrangement, including the medicare program established under 5,846
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 5,847
U.S.C.A. 301, as amended, or any other act of congress or law of 5,848
this or any other state of the United States that provides 5,849
benefits comparable to the benefits provided under this section, 5,850
any medicare supplement policy, or any continuation of coverage 5,852
policy under state or federal law.
(C) An insurer shall offer to any individual accepted 5,855
under this section the small employer OHIO health care plan BASIC 5,857
AND STANDARD PLANS established by the board of directors of the 5,859
Ohio health reinsurance program under division (A) of section 5,861
3924.10 of the Revised Code or a health benefit plan PLANS that 5,863
is ARE substantially similar to the small employer OHIO health 5,864
care plan BASIC AND STANDARD PLANS in benefit plan design and 5,866
scope of covered services.
An insurer may offer other health benefit plans in addition 5,868
to, but not in lieu of, the plan PLANS required to be offered 5,869
under this division. These additional A BASIC health benefit 5,871
plans PLAN shall provide, at a minimum, the coverage provided by 5,873
the small employer OHIO health care BASIC plan or any health 5,874
benefit plan that is substantially similar to the small employer 5,875
OHIO health care BASIC plan in benefit plan design and scope of 5,877
covered services. A STANDARD HEALTH BENEFIT PLAN SHALL PROVIDE, 5,878
AT A MINIMUM, THE COVERAGE PROVIDED BY THE OHIO HEALTH CARE 5,879
STANDARD PLAN OR ANY HEALTH BENEFIT PLAN THAT IS SUBSTANTIALLY 5,880
128
SIMILAR TO THE OHIO HEALTH CARE STANDARD PLAN IN BENEFIT PLAN 5,881
DESIGN AND SCOPE OF COVERED SERVICES.
For purposes of this division, the superintendent of 5,883
insurance shall determine whether a health benefit plan is 5,884
substantially similar to the small employer OHIO health care plan 5,886
BASIC AND STANDARD PLANS in benefit plan design and scope of 5,888
covered services. 5,889
(D) Health benefit plans issued under this section may 5,891
establish pre-existing conditions provisions that exclude or 5,892
limit coverage for a period of up to twelve months following the 5,893
individual's effective date of coverage and that may relate only 5,894
to conditions during the six months immediately preceding the 5,895
effective date of coverage. 5,896
(E) Premiums charged to individuals under this section may 5,899
not exceed an amount that is two and one-half times the highest 5,900
rate charged any other individual to which the insurer is
currently accepting new business, and for which similar 5,901
copayments and deductibles are applied. 5,902
(F) In offering health benefit plans under this section, 5,904
an insurer may require the purchase of health benefit plans that 5,905
condition the reimbursement of health services upon the use of a 5,906
specific network of providers. 5,907
(G)(1) In no event shall an insurer be required to accept 5,909
annually under this section individuals who, in the aggregate, 5,910
would cause the insurer to have a total number of new insureds 5,913
that is more than one-half per cent of its total number of 5,914
insured individuals in this state per year, as contemplated by 5,915
section 3923.021 of the Revised Code, calculated as of the 5,916
immediately preceding thirty-first day of December and excluding 5,917
the insurer's medicare supplement policies and conversion or 5,918
continuation of coverage policies under state or federal law and 5,919
any policies described in division (M)(L) of this section. 5,920
(2) An officer of the insurer shall certify to the 5,922
department of insurance when it has met the enrollment limit set 5,923
129
forth in division (G)(1) of this section. Upon providing such 5,924
certification, the insurer shall be relieved of its open 5,925
enrollment requirement under this section for the remainder of 5,926
the calendar year. 5,927
(H) An insurer shall not be required to accept under this 5,929
section applicants who, at the time of enrollment, are confined 5,930
to a health care facility because of chronic illness, permanent 5,931
injury, or other infirmity that would cause economic impairment 5,932
to the insurer if the applicants were accepted, or to make the 5,933
effective date of benefits for individuals accepted under this 5,935
section earlier than ninety days after the date of acceptance. 5,936
(I) The requirements of this section do not apply to any 5,938
insurer that is currently in a state of supervision, insolvency, 5,939
or liquidation. If an insurer demonstrates to the satisfaction 5,940
of the superintendent that the requirements of this section would 5,942
place the insurer in a state of supervision, insolvency, or 5,943
liquidation, the superintendent may waive or modify the 5,944
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 5,946
a period of not more than one year. At the expiration of such 5,947
time, a new showing of need for a waiver or modification by the 5,948
insurer shall be made before a new waiver or modification is 5,949
issued or imposed.
(J) No hospital, health care facility, or health care 5,951
practitioner, and no person who employs any health care 5,952
practitioner, shall balance bill any individual or dependent of 5,953
an individual for any health care supplies or services provided 5,954
to the individual or dependent who is insured under a policy 5,956
issued under this section. The hospital, health care facility, 5,958
or health care practitioner, or any person that employs the 5,959
health care practitioner, shall accept payments made to it by the 5,960
insurer under the terms of the policy or contract insuring or 5,961
covering such individual as payment in full for such health care 5,962
supplies or services. 5,963
130
As used in this division, "hospital" has the same meaning 5,965
as in section 3727.01 of the Revised Code; "health care 5,966
practitioner" has the same meaning as in section 4769.01 of the 5,967
Revised Code; and "balance bill" means charging or collecting an 5,968
amount in excess of the amount reimbursable or payable under the 5,969
policy or health care service contract issued to an individual 5,970
under this section for such health care supply or service. 5,971
"Balance bill" does not include charging for or collecting 5,972
copayments or deductibles required by the policy or contract. 5,973
(K) An insurer shall pay an agent a commission in the 5,975
amount of five per cent of the premium charged for initial 5,976
placement or for otherwise securing the issuance of a policy or 5,977
contract issued to an individual under this section, and four per 5,979
cent of the premium charged for the renewal of such a policy or 5,980
contract. The superintendent may adopt, in accordance with 5,981
Chapter 119. of the Revised Code, such rules as are necessary to 5,982
enforce this division.
(L) Individuals accepted for coverage under this section 5,984
may be issued contracts and certificates subject to the 5,985
requirements of section 3923.12 of the Revised Code. The 5,986
coverage issued to such individuals is not subject to the 5,987
requirements of section 3923.021 of the Revised Code. 5,988
(M) This section does not apply to any policy that 5,990
provides coverage for specific diseases or accidents only, or to 5,992
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 5,994
than six months, or other policy that offers only supplemental 5,995
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 6,004
the Revised Code: 6,005
(A) "Actuarial certification" means a written statement 6,007
prepared by a member of the American academy of actuaries, or by 6,008
any other person acceptable to the superintendent of insurance, 6,009
that states that, based upon the person's examination, a carrier 6,010
131
offering health benefit plans to small employers is in compliance 6,011
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 6,012
certification" shall include a review of the appropriate records 6,013
of, and the actuarial assumptions and methods used by, the 6,014
carrier relative to establishing premium rates for the health 6,015
benefit plans. 6,016
(B) "Adjusted average market premium price" means the 6,018
average market premium price as determined by the board of 6,020
directors of the Ohio health reinsurance program either on the 6,021
basis of the arithmetic mean of all carriers' premium rates for 6,023
an SEHC OHC plan sold to groups with similar case characteristics 6,025
by all carriers selling SEHC OHC plans in the state, or on any 6,027
other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 6,029
plan that is issued by a carrier and that covers at least two but 6,030
no more than fifty employees of a small employer, the lowest 6,032
premium rate for a new or existing business prescribed by the 6,033
carrier for the same or similar coverage under a plan or 6,034
arrangement covering any small employer with similar case 6,035
characteristics.
(D) "Carrier" means any sickness and accident insurance 6,037
company or health insuring corporation authorized to issue health 6,040
benefit plans in this state or a MEWA. A sickness and accident 6,042
insurance company that owns or operates a health insuring 6,043
corporation, either as a separate corporation or as a line of 6,045
business, shall be considered as a separate carrier from that 6,046
health insuring corporation for purposes of sections 3924.01 to 6,048
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 6,050
employer, the geographic area in which the employees work; the 6,051
age and sex of the individual employees and their dependents; the 6,052
appropriate industry classification as determined by the carrier; 6,053
the number of employees and dependents; and such other objective 6,054
criteria as may be established by the carrier. "Case 6,055
132
characteristics" does not include claims experience, health 6,056
status, or duration of coverage from the date of issue. 6,057
(F) "Dependent" means the spouse or child of an eligible 6,059
employee, subject to applicable terms of the health benefits plan 6,060
covering the employee. 6,061
(G) "Eligible employee" means an employee who works a 6,063
normal work week of twenty-five or more hours. "Eligible 6,064
employee" does not include a temporary or substitute employee, or 6,066
a seasonal employee who works only part of the calendar year on 6,067
the basis of natural or suitable times or circumstances. 6,068
(H) "Health benefit plan" means any hospital or medical 6,070
expense policy or certificate or any health plan provided by a 6,072
carrier, that is delivered, issued for delivery, renewed, or used 6,074
in this state on or after the date occurring six months after 6,075
November 24, 1995. "Health benefit plan" does not include 6,077
policies covering only accident, credit, dental, disability 6,078
income, long-term care, hospital indemnity, medicare supplement, 6,079
specified disease, or vision care; coverage under a 6,080
one-time-limited-duration policy of no longer than six months; 6,082
coverage issued as a supplement to liability insurance; insurance 6,083
arising out of a workers' compensation or similar law; automobile 6,084
medical-payment insurance; or insurance under which benefits are 6,085
payable with or without regard to fault and which is statutorily 6,086
required to be contained in any liability insurance policy or 6,087
equivalent self-insurance.
(I) "Late enrollee" means an eligible employee or 6,089
dependent who enrolls in a small employer's health benefit plan 6,092
other than during the first period in which the employee or 6,093
dependent is eligible to enroll under the plan or during a 6,095
special enrollment period described in section 2701(f) of the 6,096
"Health Insurance Portability and Accountability Act of 1996," 6,101
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg, as 6,107
amended.
(J) "MEWA" means any "multiple employer welfare 6,109
133
arrangement" as defined in section 3 of the "Federal Employee 6,110
Retirement Income Security Act of 1974," 88 Stat. 832, 29 6,111
U.S.C.A. 1001, as amended, except for any arrangement which is 6,112
fully insured as defined in division (b)(6)(D) of section 514 of 6,113
that act. 6,114
(K) "Midpoint rate" means, for small employers with 6,116
similar case characteristics and plan designs and as determined 6,117
by the applicable carrier for a rating period, the arithmetic 6,118
average of the applicable base premium rate and the corresponding 6,119
highest premium rate. 6,120
(L) "Pre-existing conditions provision" means a policy 6,122
provision that excludes or limits coverage for charges or 6,124
expenses incurred during a specified period following the 6,125
insured's enrollment date as to a condition for which medical 6,127
advice, diagnosis, care, or treatment was recommended or received 6,128
during a specified period immediately preceding the enrollment 6,131
date. Genetic information shall not be treated as such a 6,132
condition in the absence of a diagnosis of the condition related 6,133
to such information. 6,134
For purposes of this division, "enrollment date" means, 6,136
with respect to an individual covered under a group health 6,137
benefit plan, the date of enrollment of the individual in the 6,138
plan or, if earlier, the first day of the waiting period for such 6,140
enrollment.
(M) "Service waiting period" means the period of time 6,142
after employment begins before an employee is eligible to be 6,143
covered for benefits under the terms of any applicable health 6,145
benefit plan offered by the small employer.
(N)(1) "Small employer" means, in connection with a group 6,149
health benefit plan and with respect to a calendar year and a
plan year, an employer who employed an average of at least two 6,150
but no more than fifty eligible employees on business days during 6,152
the preceding calendar year and who employs at least two 6,154
employees on the first day of the plan year.
134
(2) For purposes of division (N)(1) of this section, all 6,157
persons treated as a single employer under subsection (b), (c), 6,158
(m), or (o) of section 414 of the "Internal Revenue Code of 6,162
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be 6,166
considered one employer. In the case of an employer that was not 6,167
in existence throughout the preceding calendar year, the 6,168
determination of whether the employer is a small or large 6,169
employer shall be based on the average number of eligible 6,170
employees that it is reasonably expected the employer will employ 6,171
on business days in the current calendar year. Any reference in 6,172
division (N) of this section to an "employer" includes any 6,174
predecessor of the employer. Except as otherwise specifically 6,175
provided, provisions of sections 3924.01 to 3924.14 of the 6,176
Revised Code that apply to a small employer that has a health 6,177
benefit plan shall continue to apply until the plan anniversary 6,178
following the date the employer no longer meets the requirements 6,179
of this division.
(O) "SEHC OHC plan" means an Ohio small employer health 6,183
care plan, which is a health benefit THE BASIC, STANDARD, OR 6,184
CARRIER REIMBURSEMENT plan for small individuals and employers 6,186
AND INDIVIDUALS established by the board in accordance with 6,187
section 3924.10 of the Revised Code. 6,188
Sec. 3924.03. Except as otherwise provided in section 2721 6,197
of the "Health Insurance Portability and Accountability Act of 6,203
1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, 6,209
as amended, health benefit plans covering small employers are 6,210
subject to the following conditions, as applicable:
(A)(1) Pre-existing conditions provisions shall not 6,212
exclude or limit coverage for a period beyond twelve months, or 6,213
eighteen months in the case of a late enrollee, following the 6,214
individual's enrollment date and may only relate to a physical or 6,217
mental condition, regardless of the cause of the condition, for 6,219
which medical advice, diagnosis, care, or treatment was 6,220
recommended or received within the six months immediately
135
preceding the enrollment date. 6,222
Division (A)(1) of this section is subject to the 6,225
exceptions set forth in section 2701(d) of the "Health Insurance 6,228
Portability and Accountability Act of 1996." 6,231
(2) The period of any such pre-existing condition 6,233
exclusion shall be reduced by the aggregate of the periods of 6,234
creditable coverage, if any, applicable to the employee or 6,235
dependent as of the enrollment date. 6,236
(3) A period of creditable coverage shall not be counted, 6,239
with respect to enrollment of an individual under a group health 6,240
benefit plan, if, after that period and before the enrollment 6,241
date, there was a sixty-three-day period during all of which the 6,242
individual was not covered under any creditable coverage. 6,243
Subsections (c)(2) to (4) and (e) of section 2701 of the "Health 6,245
Insurance Portability and Accountability Act of 1996" apply with 6,249
respect to crediting previous coverage. 6,250
(4) As used in division (A) of this section: 6,253
(a) "Creditable coverage" has the same meaning as in 6,256
section 2701(c)(1) of the "Health Insurance Portability and 6,259
Accountability Act of 1996." 6,261
(b) "Enrollment date" means, with respect to an individual 6,264
covered under a group health benefit plan, the date of enrollment 6,265
of the individual in the plan or, if earlier, the first day of 6,266
the waiting period for such enrollment.
(B)(1) Except as provided in section 2712(b) to (e) of the 6,269
"Health Insurance Portability and Accountability Act of 1996," if 6,270
a carrier offers coverage in the small employer market in 6,271
connection with a group health benefit plan, the carrier shall 6,272
renew or continue in force such coverage at the option of the 6,273
plan sponsor of the plan. 6,274
(2) A carrier may cancel or decide not to renew the 6,276
coverage of any eligible employee or of a dependent of an 6,277
eligible employee if the employee or dependent, as applicable, 6,279
has performed an act or practice that constitutes fraud or made 6,280
136
an intentional misrepresentation of material fact under the terms 6,281
of the coverage and if the cancellation or nonrenewal is not
based, either directly or indirectly, on any health 6,282
status-related factor in relation to the employee or dependent. 6,283
As used in division (B)(2) of this section, "health 6,286
status-related factor" has the same meaning as in section
3924.031 of the Revised Code. 6,287
(C) A carrier shall not exclude any eligible employee or 6,289
dependent, who would otherwise be covered under a health benefit 6,290
plan, on the basis of any actual or expected health condition of 6,292
the employee or dependent.
If, prior to November 24, 1995, a carrier excluded an 6,296
eligible employee or dependent, other than a late enrollee, on 6,297
the basis of an actual or expected health condition, the carrier 6,298
shall, upon the initial renewal of the coverage on or after that 6,299
date, extend coverage to the employee or dependent if all other 6,300
eligibility requirements are met.
(D) No health benefit plan issued by a carrier shall limit 6,303
or exclude, by use of a rider or amendment applicable to a
specific individual, coverage by type of illness, treatment, 6,305
medical condition, or accident, except for pre-existing 6,306
conditions as permitted under division (A) of this section. If a 6,307
health benefit plan that is delivered or issued for delivery 6,309
prior to April 14, 1993, contains such limitations or exclusions, 6,311
by use of a rider or amendment applicable to a specific 6,312
individual, the plan shall eliminate the use of such riders or 6,313
amendments within eighteen months after April 14, 1993. 6,314
(E)(1) Except as provided in sections 3924.031 and 6,317
3924.032 of the Revised Code, and subject to such rules as may be 6,320
adopted by the superintendent of insurance in accordance with
Chapter 119. of the Revised Code, a carrier shall offer and make 6,322
available every health benefit plan that it is actively marketing 6,323
to every small employer that applies to the carrier for such 6,324
coverage.
137
Division (E)(1) of this section does not apply to a health 6,327
benefit plan that a carrier makes available in the small employer 6,328
market only through one or more bona fide associations. 6,329
Division (E)(1) of this section shall not be construed to 6,332
preclude a carrier from establishing employer contribution rules 6,333
or group participation rules for the offering of coverage in 6,334
connection with a group health benefit plan in the small employer 6,335
market, as allowed under the law of this state. As used in 6,336
division (E)(1) of this section, "employer contribution rule" 6,338
means a requirement relating to the minimum level or amount of 6,339
employer contribution toward the premium for enrollment of 6,340
employees and dependents and "group participation rule" means a 6,341
requirement relating to the minimum number of employees or 6,342
dependents that must be enrolled in relation to a specified 6,343
percentage or number of eligible individuals or employees of an 6,344
employer.
(2) Each health benefit plan, at the time of initial group 6,346
enrollment, shall make coverage available to all the eligible 6,347
employees of a small employer without a service waiting period. 6,348
The decision of whether to impose a service waiting period shall 6,350
be made by the small employer. Such waiting periods shall not be 6,351
greater than ninety days. 6,352
(3) Each health benefit plan shall provide for the special 6,355
enrollment periods described in section 2701(f) of the "Health 6,357
Insurance Portability and Accountability Act of 1996." 6,361
(4) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, A CARRIER 6,364
SHALL PROVIDE TO ALL LATE ENROLLEES WHO ARE IDENTIFIED BY THE
SMALL EMPLOYER, THE OPTION TO ENROLL IN THE HEALTH BENEFIT PLAN. 6,366
THE ENROLLMENT OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF 6,367
THIRTY CONSECUTIVE DAYS. ALL DELAYS OF COVERAGE IMPOSED UNDER 6,368
THE HEALTH BENEFIT PLAN, INCLUDING ANY PRE-EXISTING CONDITION 6,369
EXCLUSION PERIOD, AFFILIATION PERIOD, OR SERVICE WAITING PERIOD, 6,370
SHALL BEGIN ON THE DATE THE CARRIER RECEIVES NOTICE OF THE LATE 6,371
ENROLLEE'S APPLICATION OR REQUEST FOR COVERAGE, AND SHALL RUN 6,372
138
CONCURRENTLY WITH EACH OTHER. 6,373
(F) The benefit structure of any health benefit plan may, 6,376
at the time of coverage renewal, be changed by the carrier to 6,378
make it consistent with the benefit structure contained in health 6,379
benefit plans being marketed to new small employer groups. If 6,380
the health benefit plan is available in the small employer market 6,382
other than only through one or more bona fide associations, the 6,383
modification must be consistent with the law of this state and 6,384
effective on a uniform basis among small employer group plans. 6,385
(G) A carrier may obtain any facts and information 6,387
necessary to apply this section, or supply those facts and 6,388
information to any other third-party payer, without the consent 6,389
of the beneficiary. Each person claiming benefits under a health 6,390
benefit plan shall provide any facts and information necessary to 6,391
apply this section. 6,392
For purposes of this section, "bona fide association" means 6,395
an association that has been actively in existence for at least 6,396
five years; has been formed and maintained in good faith for 6,397
purposes other than obtaining insurance; does not condition 6,398
membership in the association on any health status-related 6,399
factor, as defined in section 3924.031 of the Revised Code, 6,401
relating to an individual, including an employee or dependent; 6,402
makes health insurance coverage offered through the association 6,403
available to all members regardless of any health status-related 6,404
factor, as defined in section 3924.031 of the Revised Code, 6,407
relating to such members or to individuals eligible for coverage 6,408
through a member; does not make health insurance coverage offered 6,409
through the association available other than in connection with a 6,410
member of the association; and meets any other requirement 6,411
imposed by the superintendent. To maintain its status as a "bona 6,412
fide association," each association shall annually certify to the 6,413
superintendent that it meets the requirements of this paragraph. 6,414
Sec. 3924.033. (A) Each carrier, in connection with the 6,424
offering of a health benefit plan to a small employer, shall 6,425
139
disclose to the employer, as part of its solicitation and sales 6,426
materials, that the information described in division (B) of this 6,427
section is available upon request. 6,428
(B) A carrier shall provide the following information to a 6,431
small employer upon request: 6,432
(1) The provisions of the plan concerning the carrier's 6,435
right to change premium rates and the factors that may affect 6,436
changes in premium rates;
(2) The provisions of the plan relating to renewability of 6,439
coverage;
(3) The provisions of the plan relating to any 6,441
pre-existing condition exclusion; 6,442
(4) The benefits and premiums available under all health 6,445
benefit plans for which the employer is qualified.
(C)(B) The information described in division (B)(A) of 6,448
this section shall be provided in a manner determined to be 6,449
understandable by the average small employer, and in a manner 6,450
sufficient to reasonably inform a small employer regarding the 6,451
employer's rights and obligations under the health benefit plan. 6,453
(D)(C) Nothing in this section requires a carrier to 6,456
disclose any information that is by law proprietary and trade 6,457
secret information.
Sec. 3924.08. (A) The board of directors of the Ohio 6,467
health reinsurance program shall consist of nine appointed 6,469
members who shall serve staggered terms as determined by the 6,470
initial board for its members and by the plan of operation of the 6,471
program for members of subsequent boards. Within thirty days 6,472
after April 14, 1993, the members of the board shall be
appointed, as follows: 6,473
(1) The chairperson of the senate committee having 6,475
jurisdiction over insurance shall appoint the following members: 6,476
(a) Two member carriers that are small employer carriers; 6,478
(b) One member carrier that is a health insuring 6,480
corporation predominantly in the small employer market; 6,481
140
(c) One representative of providers of health care. 6,483
(2) The chairperson of the committee in the house of 6,485
representatives having jurisdiction over insurance shall appoint 6,486
the following members: 6,487
(a) One member carrier that is a small employer carrier; 6,489
(b) One member carrier whose principal health insurance 6,491
business is in the large employer market; 6,492
(c) One representative of an employer with fifty or fewer 6,494
employees; 6,495
(d) One representative of consumers in this state. 6,497
(3) The superintendent of insurance shall appoint a 6,499
representative of a member carrier operating in the small 6,501
employer market who is a fellow of the society of actuaries. 6,502
The superintendent, a member of the house of 6,504
representatives appointed by the speaker of the house of 6,505
representatives, and a member of the senate appointed by the 6,506
president of the senate, shall be ex-officio members of the 6,507
board. The membership of all boards subsequent to the initial 6,508
board shall reflect the distribution described in division (A) of 6,510
this section.
The chairperson of the initial board and each subsequent 6,512
board shall represent a small employer member carrier and shall 6,513
be elected by a majority of the voting members of the board. 6,514
Each chairperson shall serve for the maximum duration established 6,515
in the plan of operation. 6,516
(B) Within one hundred eighty days after the appointment 6,518
of the initial board, the board shall establish a plan of 6,519
operation and, thereafter, any amendments to the plan that are 6,520
necessary or suitable, to assure the fair, reasonable, and 6,521
equitable administration of the program. The board shall, 6,522
immediately upon adoption, provide to the superintendent copies 6,523
of the plan of operation and all subsequent amendments to it. 6,524
(C) The plan of operation shall establish rules, 6,526
conditions, and procedures for all of the following: 6,527
141
(1) The handling and accounting of assets and moneys of 6,529
the program and for an annual fiscal reporting to the 6,530
superintendent; 6,531
(2) Filling vacancies on the board; 6,533
(3) Selecting an administering insurer, which shall be a 6,535
carrier as defined in section 3924.01 of the Revised Code 6,536
ADMINISTRATOR OF THE PROGRAM, and setting forth the powers and 6,538
duties of the administering insurer; ADMINISTRATOR. THE 6,539
ADMINISTRATOR MAY BE A CARRIER AS DEFINED IN SECTION 3924.01 OF 6,540
THE REVISED CODE OR A PERSON LICENSED AS AN ADMINISTRATOR UNDER 6,543
CHAPTER 3959. OF THE REVISED CODE, OR THE BOARD MAY, IN ITS SOLE 6,546
DISCRETION, CHOOSE TO SERVE AS ADMINISTRATOR OF THE PROGRAM. 6,547
(4) Reinsuring risks in accordance with sections 3924.07 6,549
to 3924.14 of the Revised Code; 6,550
(5) Collecting assessments subject to section 3924.13 of 6,552
the Revised Code from all members to provide for claims reinsured 6,553
by the program and for administrative expenses incurred or 6,554
estimated to be incurred during the period for which the 6,555
assessment is made; 6,556
(6) Providing protection for carriers from the financial 6,558
risk associated with small employers that present poor credit 6,559
risks; 6,560
(7) Establishing standards for the coverage of small 6,562
employers that have a high turnover of employees; 6,563
(8) Establishing an appeals process for carriers to seek 6,565
relief when a carrier has experienced an unfair share of 6,566
administrative and credit risks; 6,567
(9) Establishing the adjusted average market premium 6,569
prices for use by the SEHC plan OHC PLANS for individuals, for 6,572
groups of two to twenty-five employees, and for groups of 6,574
twenty-six to fifty employees that are offered in the state; 6,575
(10) Establishing participation standards at issue and 6,577
renewal for reinsured cases; 6,578
(11) Reinsuring risks and collecting assessments in 6,580
142
accordance with division (G) of section 3924.11 of the Revised 6,581
Code; 6,582
(12) Any additional matters as determined by the board. 6,584
Sec. 3924.09. The Ohio health reinsurance program shall 6,594
have the general powers and authority granted under the laws of 6,595
the state to insurance companies licensed to transact sickness 6,596
and accident insurance, except the power to issue insurance. The 6,597
board of directors of the program also shall have the specific 6,598
authority to do all of the following:
(A) Enter into contracts as are necessary or proper to 6,600
carry out the provisions and purposes of sections 3924.07 to 6,601
3924.14 of the Revised Code, including the authority to enter 6,602
into contracts with similar programs of other states for the 6,603
joint performance of common functions, or with persons or other 6,604
organizations for the performance of administrative functions; 6,605
(B) Sue or be sued, including taking any legal actions 6,607
necessary or proper for recovery of any assessments for, on 6,608
behalf of, or against any program or board member; 6,609
(C) Take such legal action as is necessary to avoid the 6,611
payment of improper claims against the program; 6,612
(D) Design the SEHC plan OHC PLANS which, when offered by 6,616
a carrier, is ARE eligible for reinsurance and issue reinsurance 6,617
policies in accordance with the requirements of sections 3924.07 6,619
to 3924.14 of the Revised Code; 6,620
(E) Establish rules, conditions, and procedures pertaining 6,622
to the reinsurance of members' risks by the program; 6,623
(F) Establish appropriate rates, rate schedules, rate 6,625
adjustments, rate classifications, and any other actuarial 6,626
functions appropriate to the operation of the program; 6,627
(G) Assess members in accordance with division (G) of 6,630
section 3924.11 and the provisions of section 3924.13 of the 6,631
Revised Code, and make such advance interim assessments as may be 6,632
reasonable and necessary for organizational and interim operating 6,633
expenses. Any interim assessments shall be credited as offsets 6,634
143
against any regular assessments due following the close of the 6,635
calendar year.
(H) Appoint members to appropriate legal, actuarial, and 6,637
other committees if necessary to provide technical assistance 6,638
with respect to the operation of the program, policy and other 6,639
contract design, and any other function within the authority of 6,640
the program; 6,641
(I) Borrow money to effect the purposes of the program. 6,643
Any notes or other evidence of indebtedness of the program not in 6,644
default shall be legal investments for carriers and may be 6,645
carried as admitted assets. 6,646
(J) Reinsure risks, collect assessments, and otherwise 6,648
carry out its duties under division (G) of section 3924.11 of the 6,649
Revised Code; 6,650
(K) Study the operation of the Ohio health reinsurance 6,652
program and the open enrollment reinsurance program and, based on 6,654
its findings, make legislative recommendations to the general 6,655
assembly for improvements in the effectiveness, operation, and 6,656
integrity of the programs;
(L) Design a basic and standard plan for purposes of 6,658
sections 1751.16, 3923.122, and 3923.581 of the Revised Code. 6,659
Sec. 3924.10. (A) The board of directors of the Ohio 6,668
health reinsurance program shall design the SEHC plan OHC BASIC, 6,670
STANDARD, AND CARRIER REIMBURSEMENT PLANS which, when offered by 6,671
a carrier, is ARE eligible for reinsurance under the program. 6,673
The board shall establish the form and level of coverage to be 6,674
made available by carriers in their SEHC plan OHC PLANS. In 6,675
designing the plan PLANS the board shall also establish benefit 6,677
levels, deductibles, coinsurance factors, exclusions, and 6,678
limitations for the plan PLANS. The forms and levels of coverage 6,680
established by the board shall specify which components of a 6,681
health benefit plan PLANS offered by a carrier may be reinsured. 6,682
The SEHC plan is OHC PLANS ARE subject to division (C) of section 6,684
3924.02 of the Revised Code and to the provisions in Chapters 6,685
144
1751., 1753., 3923., and any other chapter of the Revised Code 6,687
that require coverage or the offer of coverage of a health care 6,688
service or benefit.
(B) The board shall adopt the SEHC plan OHC PLANS within 6,691
one hundred eighty days after its appointment THE EFFECTIVE DATE 6,692
OF THIS AMENDMENT. The plan PLANS may include cost containment 6,694
features including any of the following:
(1) Utilization review of health care services, including 6,696
review of the medical necessity of hospital and physician 6,697
services; 6,698
(2) Case management benefit alternatives; 6,700
(3) Selective contracting with hospitals, physicians, and 6,702
other health care providers; 6,703
(4) Reasonable benefit differentials applicable to 6,705
participating and nonparticipating providers; 6,706
(5) Employee assistance program options that provide 6,708
preventive and early intervention mental health and substance 6,709
abuse services; 6,710
(6) Other provisions for the cost-effective management of 6,712
the plan PLANS. 6,713
(C) An SEHC plan OHC PLANS established for use by health 6,717
insuring corporations shall be consistent with the basic method 6,720
of operation of such corporations.
(D) Each carrier shall certify to the superintendent of 6,722
insurance, in the form and manner prescribed by the 6,723
superintendent, that the SEHC plan OHC PLANS filed by the carrier 6,725
is ARE in substantial compliance with the provisions of the board 6,727
SEHC plan OHC PLANS. Upon receipt by the superintendent of the 6,729
certification, the carrier may use the certified plan PLANS. 6,730
(E) Each carrier shall, on and after sixty days after the 6,732
date that the program becomes operational and as a condition of 6,733
transacting business in this state, renew coverage provided to 6,734
any individual or group under its SEHC plan OHC PLANS. 6,736
Sec. 3924.11. Any member of the Ohio health reinsurance 6,746
145
program may reinsure small employer groups or individuals in 6,747
accordance with the following conditions and limitations: 6,748
(A) With respect to eligible employees and their 6,750
dependents who are hired subsequent to the commencement of the 6,751
employer's coverage by a carrier and who are not late enrollees, 6,752
and with respect to employees of an employer who are otherwise 6,753
eligible for insurance but were excluded by the carrier's 6,754
underwriting and who are not late enrollees, coverage may be 6,755
reinsured in any of the following ways: 6,756
(1) Except in the case of late enrollees, within sixty 6,758
days after the commencement of their coverage under the plan; 6,759
(2) In the case of late enrollees who were not eligible to 6,762
enroll during a special enrollment period described in section 6,763
2701(f) of the "Health Insurance Portability and Accountability 6,765
Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 6,768
300gg-42, as amended, eighteen months after the date the late 6,770
enrollee becomes a member of the small employer's plan; 6,771
(3) In the case of late enrollees who were eligible to 6,773
enroll during a special enrollment period described in section 6,774
2701(f) of the "Health Insurance Portability and Accountability 6,776
Act of 1996," as amended, within sixty days after the 6,778
commencement of their coverage under the plan A SMALL EMPLOYER 6,780
GROUP OR INDIVIDUAL MAY BE REINSURED WITHIN SIXTY DAYS AFTER THE 6,781
COMMENCEMENT OF THE GROUP'S OR INDIVIDUAL'S COVERAGE UNDER THE 6,782
PLAN.
(B)(1) The carrier may reinsure either the entire eligible 6,785
group or any eligible individual, in accordance with the premium 6,787
rates established in section 3924.12 of the Revised Code, upon 6,789
commencement of the coverage.
(2) The carrier may reinsure an eligible employee, or the 6,792
dependents of an eligible employee, who were previously excluded 6,793
from group coverage for medical reasons, and shall reinsure such 6,794
employees or dependents within sixty days after the carrier is 6,795
required to include them in the group coverage.
146
(C) With respect to an SEHC OHC plan, the program shall 6,798
reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, 6,800
the program shall reinsure the level of coverage provided up to, 6,801
but not exceeding, the level of coverage provided in an SEHC OHC 6,803
CARRIER REIMBURSEMENT plan. In the coverage provided to small 6,804
employers, carriers shall be required to use high-cost care 6,805
management, hospital precertification techniques, and other cost 6,806
containment mechanisms established by the program. 6,807
(E) A carrier may not reinsure existing business, except 6,809
pursuant to division (A) of this section. 6,810
(F) If an employer group is covered under a plan other 6,812
than an SEHC OHC CARRIER REIMBURSEMENT plan and the carrier 6,814
chooses to reinsure the group subsequent to the initial coverage 6,815
period, or if a new individual joins the group and the carrier 6,816
wants to reinsure that individual, the carrier shall not force 6,817
the employer to change to an SEHC OHC CARRIER REIMBURSEMENT plan. 6,818
The carrier shall allow the employer to maintain the same benefit 6,820
plan and reinsure only that portion of the plan that is 6,821
consistent with an SEHC OHC CARRIER REIMBURSEMENT plan. 6,822
(G) With respect to coverage provided to an individual 6,824
acquired under section 3923.58 or a federally eligible individual 6,826
acquired under section 3923.581 of the Revised Code, the 6,827
following conditions and limitations apply: 6,828
(1) Within sixty days after the commencement of the 6,831
initial coverage, any carrier may reinsure coverage of such an 6,832
individual with the open enrollment reinsurance program in 6,834
accordance with division (G) of this section. Premium rates 6,835
charged for coverage reinsured by the program shall be 6,837
established in accordance with section 3924.12 of the Revised 6,838
Code.
(2) The board of directors of the Ohio health reinsurance 6,841
program shall establish the open enrollment reinsurance fund for 6,842
coverage provided under section 3923.58 of the Revised Code and, 6,843
147
with respect to federally eligible individuals, coverage provided 6,845
under section 3923.581 of the Revised Code. The fund shall be 6,846
maintained separately from any reinsurance fund established for 6,847
small employer OHIO health care plans issued pursuant to sections 6,848
3924.07 to 3924.14 of the Revised Code. The board shall 6,849
calculate, on a retrospective basis, the amount needed for 6,850
maintenance of the open enrollment reinsurance fund and, on the 6,851
basis of that calculation, shall determine the amount to be 6,852
assessed each carrier that is required to provide open enrollment 6,853
coverage. 6,854
Assessments shall be apportioned by the board among all 6,856
carriers participating in the open enrollment reinsurance program 6,857
in proportion to their respective shares of the total premiums, 6,858
net of reinsurance premiums paid by a carrier for open enrollment 6,859
coverage and net of reinsurance premiums paid by the carrier for 6,860
all other individual health benefit plans, earned in this state 6,862
from all health benefit plans covering individuals that are
issued by all such carriers during the calendar year coinciding 6,865
with or ending during the fiscal year of the open enrollment 6,866
program, or on any other equitable basis reflecting coverage of 6,867
individuals in this state as may be provided in the plan of 6,868
operation adopted by the board. In no event shall the assessment 6,869
of any carrier under this section exceed, on an annual basis, 6,871
three per cent of its Ohio premiums for health benefit plans 6,872
covering individuals as reported on its most recent annual 6,873
statement filed with the superintendent of insurance. 6,874
The board shall submit its determination of the amount of 6,876
the assessment to the superintendent for review of the accuracy 6,878
of the calculation of the assessment. Upon approval by the 6,879
superintendent, each carrier shall, within thirty days after 6,880
receipt of the notice of assessment, submit the assessment to the 6,881
board for purposes of the open enrollment reinsurance fund. 6,882
(3) If the assessments made and collected pursuant to 6,884
division (G)(2) of this section are not sufficient to pay the 6,885
148
claims reinsured under division (G) of this section and the 6,886
allocated administrative expenses, incurred or estimated to be 6,887
incurred during the period for which the assessment was made, the 6,888
secretary of the board shall immediately notify the 6,889
superintendent, and the superintendent shall suspend the 6,890
operation of open enrollment under section 3923.58 of the Revised 6,891
Code and, with respect to federally eligible individuals, under 6,892
section 3923.581 of the Revised Code until the board has 6,893
collected in subsequent years through assessments made pursuant 6,894
to division (G)(2) of this section an amount sufficient to pay 6,895
such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment 6,897
under section 3923.58 of the Revised Code may elect not to 6,899
participate in the open enrollment reinsurance program under 6,900
division (G) of this section by filing an application with the 6,901
superintendent and obtaining the superintendent's approval. In 6,902
determining whether to approve an application, the superintendent 6,903
shall consider whether the carrier meets all of the following 6,904
standards: 6,905
(i) Demonstration by the carrier of a substantial and 6,907
established market presence; 6,908
(ii) Demonstrated experience in the individual market and 6,911
history of rating and underwriting individual plans; 6,912
(iii) Commitment to comply with the requirements of 6,914
section 3923.58 of the Revised Code; 6,915
(iv) Financial ability to assume and manage the risk of 6,917
enrolling open enrollment individuals without the need for, or 6,919
protection of, reinsurance.
(b) A carrier whose application for nonparticipation has 6,921
been rejected by the superintendent may appeal the decision in 6,922
accordance with Chapter 119. of the Revised Code. A carrier that 6,923
has received approval of the superintendent not to participate in 6,924
the open enrollment reinsurance program shall, on or before the 6,925
first day of December, annually certify to the superintendent 6,926
149
that it continues to meet the standards described in division 6,927
(G)(4)(a) of this section. 6,928
(c) In any year subsequent to the year in which its 6,930
application not to participate has been approved, a carrier may 6,931
elect to participate in the open enrollment reinsurance program 6,932
by giving notice to the superintendent and board on or before the 6,933
thirty-first day of December. If, after a period of 6,934
nonparticipation, a carrier elects to participate in the open 6,935
enrollment reinsurance program, the carrier retains the risks it 6,936
assumed during the period when it was not participating. 6,937
(d) The superintendent may, at any time, authorize a 6,939
carrier to modify an election not to participate if the risk from 6,940
the carrier's open enrollment business jeopardizes the financial 6,941
condition of the carrier. If the superintendent authorizes the 6,942
carrier to again participate in the open enrollment reinsurance 6,943
program, the carrier shall retain the risks it assumed during the 6,944
period of nonparticipation. 6,945
(5)(a) The open enrollment reinsurance program shall be 6,948
operated separately from the Ohio health reinsurance program. 6,949
(b) A carrier's election to participate in the open 6,951
enrollment reinsurance program under division (G) of this section 6,953
shall not be construed as an election to participate in the Ohio 6,954
health reinsurance program under section 3924.07 of the Revised 6,955
Code.
Sec. 3924.13. (A) Following the close of each calendar 6,964
year, the administering insurer ADMINISTRATOR of the Ohio health 6,965
reinsurance program shall determine the net premiums, the program 6,966
expenses for administration, and the incurred losses, if any, for 6,967
the year, taking into account investment income and other 6,968
appropriate gains and losses. For purposes of this section, 6,969
health benefit plan premiums earned by MEWAs shall be established 6,970
by adding paid claim losses and administrative expenses of the 6,971
MEWA. Health benefit plan premiums and benefits paid by a 6,973
carrier that are less than an amount determined by the board of 6,974
150
directors of the program to justify the cost of collection shall 6,975
not be considered for purposes of determining assessments. For 6,976
purposes of this division, "net premiums" means health benefit 6,977
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 6,979
assessments of carriers in accordance with this division. 6,980
Assessments shall be apportioned by the board among all carriers 6,981
participating in the program in proportion to their respective 6,982
shares of the total premiums, net of reinsurance premiums paid 6,983
for coverage under this program earned in the state from health 6,984
benefit plans covering small employers that are issued by 6,985
participating members during the calendar year coinciding with or 6,986
ending during the fiscal year of the program, or on any other 6,987
equitable basis reflecting coverage of small employers as may be 6,988
provided in the plan of operation. An assessment shall be made 6,989
pursuant to this division against a health insuring corporation 6,990
that is approved by the secretary of health and human services as 6,993
a federally qualified health maintenance organization pursuant to 6,994
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 6,995
as amended, subject to an assessment adjustment formula adopted 6,996
by the board for such health insuring corporations that 6,997
recognizes the restrictions imposed on the entities by federal 6,999
law. The adjustment formula shall be adopted by the board prior 7,001
to the first anniversary of the program's operation. In no event 7,002
shall the assessment made pursuant to this division exceed, on an 7,003
annual basis, one per cent of the carrier's Ohio small employer 7,005
group premium as reported on its most recent annual statement 7,006
filed with the superintendent of insurance. If an excess is 7,007
actuarially projected, the superintendent may take any action 7,008
necessary to lower the assessment to the maximum level of one per 7,009
cent.
(C) If assessments exceed actual losses and administrative 7,011
expenses of the program, the excess shall be held at interest and 7,012
used by the board to offset future losses or to reduce program 7,013
151
premiums. As used in this division, "future losses" includes 7,014
reserves for incurred but not reported claims. 7,015
(D) Each carrier's proportion of participation in the 7,017
program shall be determined annually by the board based on annual 7,019
statements and other reports deemed necessary by the board and 7,020
filed by the carrier with the board. MEWAs shall report to the 7,021
board claims payments made and administrative expenses incurred 7,022
in this state on an annual basis on a form prescribed by the 7,023
superintendent.
(E) Provision shall be made in the plan of operation for 7,025
the imposition of an interest penalty for late payment of 7,026
assessments. 7,027
(F) A carrier may seek from the superintendent a 7,029
deferment, in whole or in part, from any assessment issued by the 7,030
board. The superintendent may defer, in whole or in part, the 7,031
assessment of a carrier if, in the opinion of the superintendent, 7,032
payment of the assessment would endanger the carrier's ability to 7,033
fulfill its contractual obligations. 7,034
(G) In the event an assessment against a carrier is 7,036
deferred in whole or in part, the amount by which the assessment 7,037
is deferred may be assessed against the other carriers in a 7,038
manner consistent with the basis for assessments set forth in 7,039
this section. In such event, the other carriers assessed shall 7,040
have a claim in the amount of the assessment against the carrier 7,041
receiving the deferment. The carrier receiving the deferment 7,042
shall remain liable to the program for the amount deferred. The 7,043
superintendent may attach appropriate conditions to any 7,044
deferment. 7,045
Sec. 3999.22. (A) As used in this section: 7,054
(1) "Claim" means any attempt to cause a health care 7,056
insurer to make payment of a health care benefit. 7,057
(2) "Health care benefit" means the right under a contract 7,059
or a certificate or policy of insurance to have a payment made by 7,060
a health care insurer for a specified health care service. 7,061
152
(3) "Health care insurer" means any person that is 7,063
authorized to do the business of sickness and accident 7,065
insurance;, any prepaid dental plan, medical care corporation, 7,066
health care corporation, dental care corporation, or health 7,067
maintenance organization; INSURING CORPORATION, and any legal 7,068
entity that is self-insured and provides health care benefits to 7,070
its employees or members.
(B) No person shall knowingly solicit, offer, pay, or 7,072
receive any kickback, bribe, or rebate, directly or indirectly, 7,073
overtly or covertly, in cash or in kind, in return for referring 7,074
an individual for the furnishing of health care services or goods 7,075
for which whole or partial reimbursement is or may be made by a 7,076
health care insurer, except as authorized by the health care or 7,077
health insurance contract, policy, or plan. This division does 7,078
not apply to any of the following: 7,079
(1) Deductibles, copayments, or similar amounts owed by 7,081
the person covered by the health care or health insurance 7,082
contract, policy, or plan; 7,083
(2) Discounts or similar reductions in prices; 7,085
(3) Any amount paid within a bona fide legal entity, or 7,087
within legal entities under common ownership or control, 7,088
including any amount paid to an employee in a bona fide 7,089
employment relationship; 7,090
(4) Any amount paid as part of a bona fide lease, 7,092
management, or other business contract. 7,093
(C) Nothing in this section shall be construed to apply to 7,095
any of the following: 7,096
(1) A provider who provides goods or services requested by 7,098
an individual that are not covered by the individual's health 7,099
care or health insurance contract, policy, or plan; 7,100
(2) A provider who, in good faith, provides goods or 7,102
services ordered by another health care provider; 7,103
(3) A provider who, in good faith, resubmits a claim 7,105
previously submitted that has not been paid or denied within 7,106
153
thirty days of the original submission, if the provider notifies 7,107
the payor or returns any duplicate payment within sixty days 7,108
after receipt of the duplicate payment; 7,109
(4) A provider who, in good faith, makes a diagnosis that 7,111
differs from the interpretation of a diagnosis reached by a 7,112
health care insurer in the payment of claims. 7,113
(D) Whoever violates this section is guilty of a felony of 7,115
the fifth degree on a first offense and a felony of the fourth 7,116
degree on each subsequent offense. 7,117
Sec. 4503.104. IN ADDITION TO THE FEES COLLECTED UNDER 7,120
SECTIONS 4503.10 AND 4503.102 OF THE REVISED CODE, THE REGISTRAR 7,123
OF MOTOR VEHICLES OR DEPUTY REGISTRAR SHALL ASK EACH PERSON 7,124
APPLYING FOR OR RENEWING A MOTOR VEHICLE REGISTRATION WHETHER THE 7,125
PERSON WISHES TO MAKE A ONE-DOLLAR VOLUNTARY CONTRIBUTION TO THE 7,127
SAVE OUR SIGHT FUND ESTABLISHED UNDER SECTION 3701.18 OF THE 7,128
REVISED CODE. EVERY APPLICATION FOR REGISTRATION OR RENEWAL 7,130
NOTICE SHALL STATE WHETHER THE OWNER OF THE MOTOR VEHICLE WISHES 7,131
TO MAKE A ONE-DOLLAR VOLUNTARY CONTRIBUTION TO THE SAVE OUR SIGHT 7,132
FUND ESTABLISHED UNDER SECTION 3701.18 OF THE REVISED CODE. THE 7,135
REGISTRAR OR DEPUTY REGISTRAR SHALL ALSO MAKE AVAILABLE TO EACH 7,136
PERSON APPLYING FOR OR RENEWING A MOTOR VEHICLE REGISTRATION 7,137
INFORMATIONAL MATERIALS ON THE IMPORTANCE OF EYE CARE AND SAFETY 7,138
PROVIDED BY THE DIRECTOR OF HEALTH UNDER DIVISION (C)(2) OF 7,139
SECTION 3701.18 OF THE REVISED CODE. 7,140
ALL DONATIONS COLLECTED UNDER THIS SECTION DURING EACH 7,142
CALENDAR QUARTER SHALL BE FORWARDED BY THE REGISTRAR TO THE 7,143
TREASURER OF STATE, WHO SHALL DEPOSIT THEM INTO THE SAVE OUR 7,145
SIGHT FUND.
Sec. 4715.22. (A) AS USED IN THIS SECTION, "HEALTH CARE 7,155
FACILITY" MEANS EITHER OF THE FOLLOWING:
(1) A HOSPITAL REGISTERED UNDER SECTION 3701.07 OF THE 7,157
REVISED CODE; 7,158
(2) A "HOME" AS DEFINED IN SECTION 3721.01 OF THE REVISED 7,160
CODE. 7,161
154
(B) A licensed dental hygienist may SHALL practice UNDER 7,164
THE SUPERVISION, ORDER, CONTROL, AND FULL RESPONSIBILITY OF A 7,165
DENTIST LICENSED UNDER THIS CHAPTER. A DENTAL HYGIENIST MAY
PRACTICE in a dental office, public or private school, hospital 7,166
HEALTH CARE FACILITY, dispensary, or public institution, provided 7,167
the service is rendered under the supervision of a licensed 7,168
dentist of this state. EXCEPT AS PROVIDED IN DIVISION (C) OR (D) 7,170
OF THIS SECTION, A DENTAL HYGIENIST MAY NOT PROVIDE DENTAL 7,171
HYGIENE SERVICES TO A PATIENT WHEN THE SUPERVISING DENTIST IS NOT 7,172
PHYSICALLY PRESENT AT THE LOCATION WHERE THE DENTAL HYGIENIST IS 7,173
PRACTICING.
(C) A DENTAL HYGIENIST MAY PROVIDE, FOR NOT MORE THAN 7,176
FIFTEEN CONSECUTIVE BUSINESS DAYS, DENTAL HYGIENE SERVICES TO A 7,177
PATIENT WHEN THE SUPERVISING DENTIST IS NOT PHYSICALLY PRESENT AT 7,178
THE LOCATION AT WHICH THE SERVICES ARE PROVIDED IF ALL OF THE 7,179
FOLLOWING REQUIREMENTS ARE MET: 7,180
(1) THE DENTAL HYGIENIST HAS AT LEAST TWO YEARS AND A 7,182
MINIMUM OF THREE THOUSAND HOURS OF EXPERIENCE IN THE PRACTICE OF 7,183
DENTAL HYGIENE. 7,184
(2) THE DENTAL HYGIENIST HAS SUCCESSFULLY COMPLETED A 7,186
COURSE APPROVED BY THE STATE DENTAL BOARD IN THE IDENTIFICATION 7,189
AND PREVENTION OF POTENTIAL MEDICAL EMERGENCIES. 7,190
(3) THE DENTAL HYGIENIST COMPLIES WITH WRITTEN PROTOCOLS 7,192
FOR EMERGENCIES THE SUPERVISING DENTIST ESTABLISHES. 7,193
(4) THE DENTAL HYGIENIST DOES NOT PERFORM, WHILE THE 7,195
SUPERVISING DENTIST IS ABSENT FROM THE LOCATION, PROCEDURES WHILE 7,196
THE PATIENT IS ANESTHETIZED, DEFINITIVE ROOT PLANING, DEFINITIVE 7,197
SUBGINGIVAL CURETTAGE, OR OTHER PROCEDURES IDENTIFIED IN RULES 7,198
THE STATE DENTAL BOARD ADOPTS. 7,199
(5) THE SUPERVISING DENTIST HAS EVALUATED THE DENTAL 7,201
HYGIENIST'S SKILLS. 7,202
(6) THE SUPERVISING DENTIST EXAMINED THE PATIENT NOT MORE 7,204
THAN SEVEN MONTHS PRIOR TO THE DATE THE DENTAL HYGIENIST PROVIDES 7,206
THE DENTAL HYGIENE SERVICES TO THE PATIENT.
155
(7) THE DENTAL HYGIENIST COMPLIES WITH WRITTEN PROTOCOLS 7,208
OR WRITTEN STANDING ORDERS THAT THE SUPERVISING DENTIST 7,209
ESTABLISHES.
(8) THE SUPERVISING DENTIST COMPLETED AND EVALUATED A 7,211
MEDICAL AND DENTAL HISTORY OF THE PATIENT NOT MORE THAN ONE YEAR 7,212
PRIOR TO THE DATE THE DENTAL HYGIENIST PROVIDES DENTAL HYGIENE 7,213
SERVICES TO THE PATIENT AND, EXCEPT WHEN THE DENTAL HYGIENE 7,214
SERVICES ARE PROVIDED IN A HEALTH CARE FACILITY, THE SUPERVISING 7,215
DENTIST DETERMINES THAT THE PATIENT IS IN A MEDICALLY STABLE 7,216
CONDITION. 7,217
(9) IF THE DENTAL HYGIENE SERVICES ARE PROVIDED IN A 7,219
HEALTH CARE FACILITY, A DOCTOR OF MEDICINE AND SURGERY OR 7,221
OSTEOPATHIC MEDICINE AND SURGERY WHO HOLDS A CURRENT CERTIFICATE 7,222
ISSUED UNDER CHAPTER 4731. OF THE REVISED CODE OR A REGISTERED 7,225
NURSE LICENSED UNDER CHAPTER 4723. OF THE REVISED CODE IS PRESENT 7,228
IN THE HEALTH CARE FACILITY WHEN THE SERVICES ARE PROVIDED. 7,229
(10) IN ADVANCE OF THE APPOINTMENT FOR DENTAL HYGIENE 7,232
SERVICES, THE PATIENT IS NOTIFIED THAT THE SUPERVISING DENTIST 7,233
WILL BE ABSENT FROM THE LOCATION AND THAT THE DENTAL HYGIENIST 7,234
CANNOT DIAGNOSE THE PATIENT'S DENTAL HEALTH CARE STATUS. 7,235
(11) THE DENTAL HYGIENIST IS EMPLOYED BY, OR UNDER 7,237
CONTRACT WITH, ONE OF THE FOLLOWING: 7,238
(a) THE SUPERVISING DENTIST; 7,240
(b) A DENTIST LICENSED UNDER THIS CHAPTER WHO IS ONE OF 7,243
THE FOLLOWING:
(i) THE EMPLOYER OF THE SUPERVISING DENTIST; 7,246
(ii) A SHAREHOLDER IN A PROFESSIONAL ASSOCIATION FORMED 7,249
UNDER CHAPTER 1785. OF THE REVISED CODE OF WHICH THE SUPERVISING 7,251
DENTIST IS A SHAREHOLDER; 7,252
(iii) A MEMBER OR MANAGER OF A LIMITED LIABILITY COMPANY 7,255
FORMED UNDER CHAPTER 1705. OF THE REVISED CODE OF WHICH THE 7,258
SUPERVISING DENTIST IS A MEMBER OR MANAGER; 7,259
(iv) A SHAREHOLDER IN A CORPORATION FORMED UNDER DIVISION 7,262
(B) OF SECTION 1701.03 OF THE REVISED CODE OF WHICH THE 7,264
156
SUPERVISING DENTIST IS A SHAREHOLDER; 7,265
(v) A PARTNER OR EMPLOYEE OF A PARTNERSHIP OR A LIMITED 7,268
LIABILITY PARTNERSHIP FORMED UNDER CHAPTER 1775. OF THE REVISED 7,271
CODE OF WHICH THE SUPERVISING DENTIST IS A PARTNER OR EMPLOYEE. 7,272
(c) A GOVERNMENT ENTITY THAT EMPLOYS THE DENTAL HYGIENIST 7,274
TO PROVIDE DENTAL HYGIENE SERVICES IN A PUBLIC SCHOOL OR IN 7,275
CONNECTION WITH OTHER PROGRAMS THE GOVERNMENT ENTITY ADMINISTERS. 7,277
(D) A DENTAL HYGIENIST MAY PROVIDE DENTAL HYGIENE SERVICES 7,279
TO A PATIENT WHEN THE SUPERVISING DENTIST IS NOT PHYSICALLY 7,281
PRESENT AT THE LOCATION AT WHICH THE SERVICES ARE PROVIDED IF THE 7,284
SERVICES ARE PROVIDED AS PART OF A DENTAL HYGIENE PROGRAM THAT IS
APPROVED BY THE STATE DENTAL BOARD AND ALL OF THE FOLLOWING 7,285
REQUIREMENTS ARE MET: 7,286
(1) THE PROGRAM IS OPERATED THROUGH A SCHOOL DISTRICT 7,288
BOARD OF EDUCATION OR THE GOVERNING BOARD OF AN EDUCATIONAL 7,290
SERVICE CENTER; THE BOARD OF HEALTH OF A CITY OR GENERAL HEALTH 7,292
DISTRICT OR THE AUTHORITY HAVING THE DUTIES OF A BOARD OF HEALTH 7,293
UNDER SECTION 3709.05 OF THE REVISED CODE; A NATIONAL, STATE, 7,294
DISTRICT, OR LOCAL DENTAL ASSOCIATION; OR ANY OTHER PUBLIC OR 7,296
PRIVATE ENTITY RECOGNIZED BY THE STATE DENTAL BOARD.
(2) THE SUPERVISING DENTIST IS EMPLOYED BY OR A VOLUNTEER 7,298
FOR, AND THE PATIENTS ARE REFERRED BY, THE ENTITY THROUGH WHICH 7,300
THE PROGRAM IS OPERATED.
(3) THE SERVICES ARE PERFORMED AFTER EXAMINATION AND 7,302
DIAGNOSIS BY THE DENTIST AND IN ACCORDANCE WITH THE DENTIST'S 7,303
WRITTEN TREATMENT PLAN.
(E) NO PERSON SHALL DO EITHER OF THE FOLLOWING: 7,306
(1) PRACTICE DENTAL HYGIENE IN A MANNER THAT IS SEPARATE 7,308
OR OTHERWISE INDEPENDENT FROM THE DENTAL PRACTICE OF A 7,309
SUPERVISING DENTIST; 7,310
(2) ESTABLISH OR MAINTAIN AN OFFICE OR PRACTICE THAT IS 7,312
PRIMARILY DEVOTED TO THE PROVISION OF DENTAL HYGIENE SERVICES. 7,313
(F) THE STATE DENTAL BOARD SHALL ADOPT RULES UNDER 7,317
DIVISION (C) OF SECTION 4715.03 OF THE REVISED CODE IDENTIFYING 7,320
157
PROCEDURES A DENTAL HYGIENIST MAY NOT PERFORM WHEN PRACTICING IN 7,321
THE ABSENCE OF THE SUPERVISING DENTIST PURSUANT TO DIVISION (C) 7,323
OR (D) OF THIS SECTION.
Sec. 4715.39. (A) The state dental board may adopt rules, 7,332
in accordance with Chapter 119. of the Revised Code, defining 7,333
DEFINE THE duties which THAT may be performed by DENTAL 7,335
ASSISTANTS AND OTHER INDIVIDUALS DESIGNATED BY THE BOARD AS 7,336
qualified personnel, and may adopt rules establishing. IF 7,338
DEFINED, THE DUTIES SHALL BE DEFINED IN RULES ADOPTED IN 7,339
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. THE RULES MAY 7,340
INCLUDE training and practice standards for DENTAL ASSISTANTS AND 7,341
OTHER qualified personnel; such. THE standards may include 7,342
examination and issuance of a certificate. IF THE BOARD ISSUES A 7,344
CERTIFICATE, THE RECIPIENT SHALL DISPLAY THE CERTIFICATE IN A 7,345
CONSPICUOUS LOCATION IN ANY OFFICE IN WHICH THE RECIPIENT IS 7,346
EMPLOYED TO PERFORM THE DUTIES AUTHORIZED BY THE CERTIFICATE.
THE BOARD'S RULES MAY ALLOW A DENTAL ASSISTANT TO POLISH 7,348
THE CLINICAL CROWNS OF TEETH IF ALL OF THE FOLLOWING REQUIREMENTS 7,349
ARE MET:
(1) THE DENTAL ASSISTANT'S POLISHING ACTIVITIES ARE 7,351
LIMITED TO THE USE OF A RUBBER CUP ATTACHED TO A SLOW-SPEED 7,352
ROTARY DENTAL HAND PIECE.
(2) THE DENTIST SUPERVISING THE ASSISTANT SUPERVISES NOT 7,354
MORE THAN TWO DENTAL ASSISTANTS ENGAGING IN POLISHING ACTIVITIES 7,355
AT ANY GIVEN TIME.
(3) THE DENTAL ASSISTANT IS CERTIFIED BY THE DENTAL 7,357
ASSISTING NATIONAL BOARD OR THE OHIO COMMISSION ON DENTAL 7,358
ASSISTANT CERTIFICATION.
(4) THE DENTAL ASSISTANT RECEIVES A CERTIFICATE FROM THE 7,360
BOARD AUTHORIZING THE ASSISTANT TO ENGAGE IN THE POLISHING 7,361
ACTIVITIES. THE BOARD MAY ISSUE THE CERTIFICATE ONLY IF THE 7,362
INDIVIDUAL HAS SUCCESSFULLY COMPLETED TRAINING IN THE POLISHING 7,363
OF CLINICAL CROWNS THROUGH A PROGRAM ACCREDITED BY THE COMMISSION 7,364
ON DENTAL ACCREDITATION OR EQUIVALENT TRAINING APPROVED BY THE 7,365
158
BOARD. THE TRAINING SHALL INCLUDE COURSES IN BASIC DENTAL 7,366
ANATOMY AND INFECTION CONTROL, FOLLOWED BY A COURSE IN CORONAL 7,367
POLISHING THAT INCLUDES DIDACTIC, PRECLINICAL, AND CLINICAL 7,368
TRAINING; ANY OTHER TRAINING REQUIRED BY THE BOARD; AND A SKILLS 7,370
ASSESSMENT THAT INCLUDES SUCCESSFUL COMPLETION OF STANDARDIZED 7,371
TESTING.
(B) Subject to the rules of the board, licensed dentists 7,373
may assign to DENTAL ASSISTANTS AND OTHER qualified personnel 7,374
dental procedures that do not require the professional competence 7,376
or skill of the licensed dentist or dental hygienist as the board 7,377
by rule authorizes such DENTAL ASSISTANTS AND OTHER QUALIFIED 7,378
personnel to perform. The performance of dental procedures by 7,379
DENTAL ASSISTANTS AND OTHER qualified personnel shall be under 7,381
direct supervision and full responsibility of the licensed 7,382
dentist.
(C) Nothing in this section shall be construed by rule of 7,384
the state dental board or otherwise to authorize " DO THE 7,385
FOLLOWING:
(1) AUTHORIZE DENTAL ASSISTANTS OR OTHER qualified 7,387
personnel" as that term is used in this section to engage in the 7,388
practice of dental hygiene as defined by sections 4715.22 and 7,389
4715.23 of the Revised Code or to perform the duties of a dental 7,390
hygienist, including the removal of calcarious deposits or 7,391
accretions on the crowns and roots of teeth, or as authorizing; 7,393
(2) AUTHORIZE the assignment of diagnosis, treatment ANY 7,396
OF THE FOLLOWING:
(a) DIAGNOSIS; 7,398
(b) TREATMENT planning and prescription (, including 7,401
prescription for drugs and medicaments or authorization for 7,402
restorative, prosthodontic, or orthodontic appliances), or 7,403
surgical;
(c) SURGICAL procedures on hard or soft tissue of the oral 7,406
cavity, or any other intraoral procedure that contributes to or 7,407
results in an irremediable alteration of the oral anatomy or the; 7,408
159
(d) THE making of final impressions from which casts are 7,410
made to construct any dental restoration. 7,412
(D) No dentist shall assign any DENTAL ASSISTANT OR OTHER 7,414
INDIVIDUAL ACTING IN THE CAPACITY OF qualified personnel to 7,415
perform any dental procedure such personnel are THAT THE 7,416
ASSISTANT OR OTHER INDIVIDUAL IS not authorized by board rule to 7,418
perform. No DENTAL ASSISTANT OR OTHER INDIVIDUAL ACTING IN THE
CAPACITY OF qualified personnel shall perform any dental 7,419
procedure other than in accordance with board rule or ANY DENTAL 7,420
PROCEDURE that such personnel are THE ASSISTANT OR OTHER 7,422
INDIVIDUAL IS not authorized by board rule to perform. 7,423
Sec. 4723.16. (A) An individual whom the board of nursing 7,433
licenses, certificates, or otherwise legally authorizes to engage
in the practice of nursing as a registered nurse or as a licensed 7,434
practical nurse may render the professional services of a 7,435
registered or licensed practical nurse within this state through 7,437
a corporation formed under division (B) of section 1701.03 of the 7,438
Revised Code, a limited liability company formed under Chapter 7,439
1705. of the Revised Code, a partnership, or a professional 7,440
association formed under Chapter 1785. of the Revised Code. This 7,442
division does not preclude an individual of that nature from 7,443
rendering professional services as a registered or licensed 7,444
practical nurse through another form of business entity, 7,445
including, but not limited to, a nonprofit corporation or 7,446
foundation, or in another manner that is authorized by or in 7,447
accordance with this chapter, another chapter of the Revised 7,448
Code, or rules of the board of nursing adopted pursuant to this 7,449
chapter.
(B) A corporation, limited liability company, partnership, 7,452
or professional association described in division (A) of this 7,453
section may be formed for the purpose of providing a combination 7,454
of the professional services of the following individuals who are 7,455
licensed, certificated, or otherwise legally authorized to 7,456
practice their respective professions: 7,457
160
(1) Optometrists who are authorized to practice optometry 7,459
under Chapter 4725. of the Revised Code; 7,460
(2) Chiropractors who are authorized to practice 7,462
chiropractic under Chapter 4734. of the Revised Code; 7,463
(3) Psychologists who are authorized to practice 7,465
psychology under Chapter 4732. of the Revised Code; 7,467
(4) Registered or licensed practical nurses who are 7,469
authorized to practice nursing as registered nurses or as 7,470
licensed practical nurses under this chapter; 7,471
(5) Pharmacists who are authorized to practice pharmacy 7,474
under Chapter 4729. of the Revised Code; 7,477
(6) Physical therapists who are authorized to practice 7,479
physical therapy under sections 4755.40 to 4755.53 of the Revised 7,481
Code; 7,482
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 7,484
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 7,487
(8) Doctors of medicine and surgery, osteopathic medicine 7,490
and surgery, or podiatric medicine and surgery who are licensed, 7,491
certificated, or otherwise legally authorized for their
respective practices under Chapter 4731. of the Revised Code. 7,494
This division shall apply notwithstanding a provision of a 7,497
code of ethics applicable to a nurse that prohibits a registered 7,499
or licensed practical nurse from engaging in the practice of 7,500
nursing as a registered nurse or as a licensed practical nurse in 7,501
combination with a person who is licensed, certificated, or 7,502
otherwise legally authorized to practice optometry, chiropractic, 7,503
psychology, pharmacy, physical therapy, MECHANOTHERAPY, medicine 7,504
and surgery, osteopathic medicine and surgery, or podiatric 7,506
medicine and surgery, but who is not also licensed, certificated, 7,507
or otherwise legally authorized to engage in the practice of 7,508
nursing as a registered nurse or as a licensed practical nurse.
Sec. 4725.114. (A) An individual whom the state board of 7,517
optometry licenses, certificates, or otherwise legally authorizes 7,518
to engage in the practice of optometry may render the 7,519
161
professional services of an optometrist within this state through 7,521
a corporation formed under division (B) of section 1701.03 of the 7,522
Revised Code, a limited liability company formed under Chapter 7,523
1705. of the Revised Code, a partnership, or a professional 7,524
association formed under Chapter 1785. of the Revised Code. This 7,526
division does not preclude an individual of that nature from 7,527
rendering professional services as an optometrist through another 7,528
form of business entity, including, but not limited to, a 7,529
nonprofit corporation or foundation, or in another manner that is 7,530
authorized by or in accordance with this chapter, another chapter 7,532
of the Revised Code, or rules of the state board of optometry 7,533
adopted pursuant to this chapter.
(B) A corporation, limited liability company, partnership, 7,536
or professional association described in division (A) of this 7,537
section may be formed for the purpose of providing a combination 7,538
of the professional services of the following individuals who are 7,539
licensed, certificated, or otherwise legally authorized to 7,540
practice their respective professions: 7,541
(1) Optometrists who are authorized to practice optometry 7,543
under Chapter 4725. of the Revised Code; 7,544
(2) Chiropractors who are authorized to practice 7,546
chiropractic under Chapter 4734. of the Revised Code; 7,547
(3) Psychologists who are authorized to practice 7,549
psychology under Chapter 4732. of the Revised Code; 7,550
(4) Registered or licensed practical nurses who are 7,552
authorized to practice nursing as registered nurses or as 7,553
licensed practical nurses under Chapter 4723. of the Revised 7,554
Code;
(5) Pharmacists who are authorized to practice pharmacy 7,557
under Chapter 4729. of the Revised Code; 7,560
(6) Physical therapists who are authorized to practice 7,562
physical therapy under sections 4755.40 to 4755.53 of the Revised 7,564
Code; 7,565
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 7,567
162
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 7,570
(8) Doctors of medicine and surgery, osteopathic medicine 7,573
and surgery, or podiatric medicine and surgery who are authorized 7,574
for their respective practices under Chapter 4731. of the Revised 7,575
Code. 7,576
This division shall apply notwithstanding a provision of a 7,579
code of ethics applicable to an optometrist that prohibits an 7,581
optometrist from engaging in the practice of optometry in 7,582
combination with a person who is licensed, certificated, or 7,583
otherwise legally authorized to practice chiropractic, 7,584
psychology, nursing, pharmacy, physical therapy, MECHANOTHERAPY, 7,585
medicine and surgery, osteopathic medicine and surgery, or 7,587
podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the 7,588
practice of optometry. 7,589
Sec. 4729.161. (A) An individual registered with the 7,598
state board of pharmacy to engage in the practice of pharmacy may 7,601
render the professional services of a pharmacist within this 7,602
state through a corporation formed under division (B) of section 7,604
1701.03 of the Revised Code, a limited liability company formed 7,605
under Chapter 1705. of the Revised Code, a partnership, or a 7,606
professional association formed under Chapter 1785. of the 7,607
Revised Code. This division does not preclude an individual of 7,609
that nature from rendering professional services as a pharmacist 7,610
through another form of business entity, including, but not 7,611
limited to, a nonprofit corporation or foundation, or in another 7,612
manner that is authorized by or in accordance with this chapter, 7,613
another chapter of the Revised Code, or rules of the state board 7,615
of pharmacy adopted pursuant to this chapter.
(B) A corporation, limited liability company, partnership, 7,618
or professional association described in division (A) of this 7,619
section may be formed for the purpose of providing a combination 7,620
of the professional services of the following individuals who are 7,621
licensed, certificated, or otherwise legally authorized to 7,622
163
practice their respective professions: 7,623
(1) Optometrists who are authorized to practice optometry 7,625
under Chapter 4725. of the Revised Code; 7,626
(2) Chiropractors who are authorized to practice 7,628
chiropractic under Chapter 4734. of the Revised Code; 7,629
(3) Psychologists who are authorized to practice 7,631
psychology under Chapter 4732. of the Revised Code; 7,632
(4) Registered or licensed practical nurses who are 7,634
authorized to practice nursing as registered nurses or as 7,635
licensed practical nurses under Chapter 4723. of the Revised 7,636
Code;
(5) Pharmacists who are authorized to practice pharmacy 7,638
under Chapter 4729. of the Revised Code; 7,639
(6) Physical therapists who are authorized to practice 7,641
physical therapy under sections 4755.40 to 4755.53 of the Revised 7,642
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 7,644
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 7,647
(8) Doctors of medicine and surgery, osteopathic medicine 7,650
and surgery, or podiatric medicine and surgery who are authorized 7,651
for their respective practices under Chapter 4731. of the Revised 7,652
Code. 7,653
This division shall apply notwithstanding a provision of a 7,656
code of ethics applicable to a pharmacist that prohibits a 7,658
pharmacist from engaging in the practice of pharmacy in 7,659
combination with a person who is licensed, certificated, or 7,660
otherwise legally authorized to practice optometry, chiropractic, 7,661
psychology, nursing, physical therapy, MECHANOTHERAPY, medicine 7,662
and surgery, osteopathic medicine and surgery, or podiatric 7,664
medicine and surgery, but who is not also licensed, certificated, 7,665
or otherwise legally authorized to engage in the practice of 7,666
pharmacy.
Sec. 4731.226. (A)(1) An individual whom the state 7,675
medical board licenses, certificates, or otherwise legally 7,676
164
authorizes to engage in the practice of medicine and surgery, 7,677
osteopathic medicine and surgery, or podiatric medicine and 7,678
surgery may render the professional services of a doctor of 7,679
medicine and surgery, osteopathic medicine and surgery, or 7,680
podiatric medicine and surgery within this state through a 7,681
corporation formed under division (B) of section 1701.03 of the 7,682
Revised Code, a limited liability company formed under Chapter 7,684
1705. of the Revised Code, a partnership, or a professional 7,685
association formed under Chapter 1785. of the Revised Code. This 7,686
division DIVISION (A)(1) OF THIS SECTION does not preclude an 7,688
individual of that nature from rendering professional services as 7,689
a doctor of medicine and surgery, osteopathic medicine and 7,690
surgery, or podiatric medicine and surgery through another form 7,691
of business entity, including, but not limited to, a nonprofit 7,692
corporation or foundation, or in another manner that is 7,693
authorized by or in accordance with this chapter, another chapter 7,694
of the Revised Code, or rules of the state medical board adopted 7,695
pursuant to this chapter.
(2) AN INDIVIDUAL WHOM THE STATE MEDICAL BOARD AUTHORIZES 7,698
TO ENGAGE IN THE PRACTICE OF MECHANOTHERAPY MAY RENDER THE 7,699
PROFESSIONAL SERVICES OF A MECHANOTHERAPIST WITHIN THIS STATE 7,700
THROUGH A CORPORATION FORMED UNDER DIVISION (B) OF SECTION 7,701
1701.03 OF THE REVISED CODE, A LIMITED LIABILITY COMPANY FORMED 7,704
UNDER CHAPTER 1705. OF THE REVISED CODE, A PARTNERSHIP, OR A 7,706
PROFESSIONAL ASSOCIATION FORMED UNDER CHAPTER 1785. OF THE 7,709
REVISED CODE. DIVISION (A)(2) OF THIS SECTION DOES NOT PRECLUDE 7,712
AN INDIVIDUAL OF THAT NATURE FROM RENDERING PROFESSIONAL SERVICES 7,713
AS A MECHANOTHERAPIST THROUGH ANOTHER FORM OF BUSINESS ENTITY, 7,714
INCLUDING, BUT NOT LIMITED TO, A NONPROFIT CORPORATION OR 7,715
FOUNDATION, OR IN ANOTHER MANNER THAT IS AUTHORIZED BY OR IN 7,716
ACCORDANCE WITH THIS CHAPTER, ANOTHER CHAPTER OF THE REVISED 7,718
CODE, OR RULES OF THE STATE MEDICAL BOARD ADOPTED PURSUANT TO 7,719
THIS CHAPTER.
(B) A corporation, limited liability company, partnership, 7,722
165
or professional association described in division (A) of this 7,723
section may be formed for the purpose of providing a combination 7,724
of the professional services of the following individuals who are 7,725
licensed, certificated, or otherwise legally authorized to 7,726
practice their respective professions: 7,727
(1) Optometrists who are authorized to practice optometry 7,729
under Chapter 4725. of the Revised Code; 7,730
(2) Chiropractors who are authorized to practice 7,732
chiropractic under Chapter 4734. of the Revised Code; 7,733
(3) Psychologists who are authorized to practice 7,735
psychology under Chapter 4732. of the Revised Code; 7,737
(4) Registered or licensed practical nurses who are 7,739
authorized to practice nursing as registered nurses or as 7,740
licensed practical nurses under Chapter 4723. of the Revised 7,742
Code;
(5) Pharmacists who are authorized to practice pharmacy 7,745
under Chapter 4729. of the Revised Code; 7,748
(6) Physical therapists who are authorized to practice 7,750
physical therapy under sections 4755.40 to 4755.53 of the Revised 7,752
Code; 7,753
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 7,755
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 7,758
(8) Doctors of medicine and surgery, osteopathic medicine 7,761
and surgery, or podiatric medicine and surgery who are authorized 7,762
for their respective practices under this chapter.
This division (C) DIVISION (B) OF THIS SECTION shall apply 7,765
notwithstanding a provision of a code of ethics described in 7,766
division (B)(18) of section 4731.22 of the Revised Code that 7,769
prohibits a EITHER OF THE FOLLOWING:
(1) A doctor of medicine and surgery, osteopathic medicine 7,772
and surgery, or podiatric medicine and surgery from engaging in 7,773
the doctor's authorized practice in combination with a person who 7,774
is licensed, certificated, or otherwise legally authorized to 7,775
engage in the practice of optometry, chiropractic, psychology, 7,776
166
nursing, pharmacy, or physical therapy, OR MECHANOTHERAPY, but 7,777
who is not also licensed, certificated, or otherwise legally 7,778
authorized to practice medicine and surgery, osteopathic medicine 7,779
and surgery, or podiatric medicine and surgery. 7,780
(2) A MECHANOTHERAPIST FROM ENGAGING IN THE PRACTICE OF 7,783
MECHANOTHERAPY IN COMBINATION WITH A PERSON WHO IS LICENSED, 7,784
CERTIFICATED, OR OTHERWISE LEGALLY AUTHORIZED TO ENGAGE IN THE 7,785
PRACTICE OF OPTOMETRY, CHIROPRACTIC, PSYCHOLOGY, NURSING, 7,786
PHARMACY, PHYSICAL THERAPY, MEDICINE AND SURGERY, OSTEOPATHIC 7,787
MEDICINE AND SURGERY, OR PODIATRIC MEDICINE AND SURGERY, BUT WHO 7,788
IS NOT ALSO LICENSED, CERTIFICATED, OR OTHERWISE LEGALLY 7,789
AUTHORIZED TO ENGAGE IN THE PRACTICE OF MECHANOTHERAPY. 7,790
Sec. 4731.65. As used in sections 4731.65 to 4731.71 of 7,799
the Revised Code: 7,800
(A)(1) "Clinical laboratory services" means either of the 7,802
following:
(a) Any examination of materials derived from the human 7,804
body for the purpose of providing information for the diagnosis, 7,805
prevention, or treatment of any disease or impairment or for the 7,806
assessment of health; 7,807
(b) Procedures to determine, measure, or otherwise 7,809
describe the presence or absence of various substances or 7,810
organisms in the body. 7,811
(2) "Clinical laboratory services" does not include the 7,813
mere collection or preparation of specimens. 7,814
(B) "Designated health services" means any of the 7,816
following: 7,817
(1) Clinical laboratory services; 7,819
(2) Home health care services; 7,821
(3) Outpatient prescription drugs. 7,823
(C) "Fair market value" means the value in arms-length 7,825
transactions, consistent with general market value and: 7,826
(1) With respect to rentals or leases, the value of rental 7,828
property for general commercial purposes, not taking into account 7,829
167
its intended use; 7,830
(2) With respect to a lease of space, not adjusted to 7,832
reflect the additional value the prospective lessee or lessor 7,833
would attribute to the proximity or convenience to the lessor if 7,834
the lessor is a potential source of referrals to the lessee. 7,835
(D) "Governmental health care program" means any program 7,838
providing health care benefits that is administered by the 7,839
federal government, this state, or a political subdivision of 7,840
this state, including the medicare program established under 7,841
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 7,842
U.S.C.A. 301, as amended, health care coverage for public 7,843
employees, health care benefits administered by the bureau of 7,844
workers' compensation, the medical assistance program established 7,845
under Chapter 5111. of the Revised Code, and disability 7,846
assistance medical assistance established under Chapter 5115. of 7,848
the Revised Code.
(E)(1) "Group practice" means a group of two or more 7,851
holders of certificates under this chapter legally organized as a 7,852
partnership, professional corporation or association, limited 7,853
liability company, foundation, nonprofit corporation, faculty 7,854
practice plan, or similar group practice entity, including an 7,855
organization comprised of a nonprofit medical clinic that 7,856
contracts with a professional corporation or association of 7,857
physicians to provide medical services exclusively to patients of 7,858
the clinic in order to comply with section 1701.03 of the Revised 7,859
Code and including a corporation, limited liability company, 7,860
partnership, or professional association described in division 7,861
(B) of section 4731.226 of the Revised Code formed for the 7,863
purpose of providing a combination of the professional services
of optometrists who are licensed, certificated, or otherwise 7,864
legally authorized to practice optometry under Chapter 4725. of 7,865
the Revised Code, chiropractors who are licensed, certificated, 7,867
or otherwise legally authorized to practice chiropractic under 7,868
Chapter 4734. of the Revised Code, psychologists who are 7,869
168
licensed, certificated, or otherwise legally authorized to 7,870
practice psychology under Chapter 4732. of the Revised Code, 7,871
registered or licensed practical nurses who are licensed, 7,872
certificated, or otherwise legally authorized to practice nursing 7,873
under Chapter 4723. of the Revised Code, pharmacists who are 7,875
licensed, certificated, or otherwise legally authorized to 7,876
practice pharmacy under Chapter 4729. of the Revised Code, 7,878
physical therapists who are licensed, certificated, or otherwise 7,879
legally authorized to practice physical therapy under sections 7,880
4755.40 to 4755.53 of the Revised Code, MECHANOTHERAPISTS WHO ARE 7,883
LICENSED, CERTIFICATED, OR OTHERWISE LEGALLY AUTHORIZED TO 7,884
PRACTICE MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED 7,886
CODE, and of doctors of medicine and surgery, osteopathic 7,888
medicine and surgery, or podiatric medicine and surgery who are 7,889
licensed, certificated, or otherwise legally authorized for their 7,890
respective practices under this chapter, to which all of the
following apply: 7,891
(a) Each physician who is a member of the group practice 7,893
provides substantially the full range of services that the 7,894
physician routinely provides, including medical care, 7,895
consultation, diagnosis, or treatment, through the joint use of 7,896
shared office space, facilities, equipment, and personnel. 7,897
(b) Substantially all of the services of the members of 7,899
the group are provided through the group and are billed in the 7,902
name of the group and amounts so received are treated as receipts 7,903
of the group.
(c) The overhead expenses of and the income from the 7,905
practice are distributed in accordance with methods previously 7,906
determined by members of the group. 7,907
(d) The group practice meets any other requirements that 7,909
the state medical board applies in rules adopted under section 7,910
4731.70 of the Revised Code. 7,911
(2) In the case of a faculty practice plan associated with 7,913
a hospital with a medical residency training program in which 7,914
169
physician members may provide a variety of specialty services and 7,915
provide professional services both within and outside the group, 7,916
as well as perform other tasks such as research, the criteria in 7,917
division (E)(1) of this section apply only with respect to 7,919
services rendered within the faculty practice plan. 7,920
(F) "Home health care services" and "immediate family" 7,923
have the same meanings as in the rules adopted under section 7,924
4731.70 of the Revised Code.
(G) "Hospital" has the same meaning as in section 3727.01 7,927
of the Revised Code.
(H) A "referral" includes both of the following: 7,929
(1) A request by a holder of a certificate under this 7,931
chapter for an item or service, including a request for a 7,932
consultation with another physician and any test or procedure 7,933
ordered by or to be performed by or under the supervision of the 7,934
other physician; 7,935
(2) A request for or establishment of a plan of care by a 7,937
certificate holder that includes the provision of designated 7,938
health services.
(I) "Third-party payer" has the same meaning as in section 7,941
3901.38 of the Revised Code.
Sec. 4732.28. (A) An individual whom the state board of 7,950
psychology licenses, certificates, or otherwise legally 7,951
authorizes to engage in the practice of psychology may render the 7,952
professional services of a psychologist within this state through 7,954
a corporation formed under division (B) of section 1701.03 of the 7,955
Revised Code, a limited liability company formed under Chapter 7,956
1705. of the Revised Code, a partnership, or a professional 7,957
association formed under Chapter 1785. of the Revised Code. This 7,959
division does not preclude an individual of that nature from 7,960
rendering professional services as a psychologist through another 7,961
form of business entity, including, but not limited to, a 7,962
nonprofit corporation or foundation, or in another manner that is 7,963
authorized by or in accordance with this chapter, another chapter 7,965
170
of the Revised Code, or rules of the state board of psychology 7,966
adopted pursuant to this chapter.
(B) A corporation, limited liability company, partnership, 7,969
or professional association described in division (A) of this 7,970
section may be formed for the purpose of providing a combination 7,971
of the professional services of the following individuals who are 7,972
licensed, certificated, or otherwise legally authorized to 7,973
practice their respective professions: 7,974
(1) Optometrists who are authorized to practice optometry 7,976
under Chapter 4725. of the Revised Code; 7,977
(2) Chiropractors who are authorized to practice 7,979
chiropractic under Chapter 4734. of the Revised Code; 7,980
(3) Psychologists who are authorized to practice 7,982
psychology under this chapter; 7,983
(4) Registered or licensed practical nurses who are 7,985
authorized to practice nursing as registered nurses or as 7,986
licensed practical nurses under Chapter 4723. of the Revised 7,988
Code;
(5) Pharmacists who are authorized to practice pharmacy 7,991
under Chapter 4729. of the Revised Code; 7,994
(6) Physical therapists who are authorized to practice 7,996
physical therapy under sections 4755.40 to 4755.53 of the Revised 7,998
Code; 7,999
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 8,001
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 8,004
(8) Doctors of medicine and surgery, osteopathic medicine 8,007
and surgery, or podiatric medicine and surgery who are authorized 8,008
for their respective practices under Chapter 4731. of the Revised 8,009
Code. 8,010
This division shall apply notwithstanding a provision of a 8,013
code of ethics applicable to a psychologist that prohibits a 8,015
psychologist from engaging in the practice of psychology in 8,016
combination with a person who is licensed, certificated, or 8,017
otherwise legally authorized to practice optometry, chiropractic, 8,018
171
nursing, pharmacy, physical therapy, MECHANOTHERAPY, medicine and 8,019
surgery, osteopathic medicine and surgery, or podiatric medicine 8,021
and surgery, but who is not also licensed, certificated, or 8,022
otherwise legally authorized to engage in the practice of 8,023
psychology.
Sec. 4734.091. (A) An individual whom the chiropractic 8,032
examining board licenses, certificates, or otherwise legally 8,033
authorizes to engage in the practice of chiropractic may render 8,034
the professional services of a chiropractor within this state 8,035
through a corporation formed under division (B) of section 8,036
1701.03 of the Revised Code, a limited liability company formed
under Chapter 1705. of the Revised Code, a partnership, or a 8,038
professional association formed under Chapter 1785. of the 8,040
Revised Code. This division does not preclude an individual of 8,042
that nature from rendering professional services as a
chiropractor through another form of business entity, including, 8,044
but not limited to, a nonprofit corporation or foundation, or in 8,045
another manner that is authorized by or in accordance with this 8,046
chapter, another chapter of the Revised Code, or rules of the
chiropractic examining board adopted pursuant to this chapter. 8,047
(B) A corporation, limited liability company, partnership, 8,049
or professional association described in division (A) of this 8,050
section may be formed for the purpose of providing a combination 8,051
of the professional services of the following individuals who are 8,052
licensed, certificated, or otherwise legally authorized to 8,054
practice their respective professions:
(1) Optometrists who are authorized to practice optometry, 8,056
under Chapter 4725. of the Revised Code; 8,057
(2) Chiropractors who are authorized to practice 8,059
chiropractic under this chapter; 8,060
(3) Psychologists who are authorized to practice 8,062
psychology under Chapter 4732. of the Revised Code; 8,063
(4) Registered or licensed practical nurses who are 8,065
authorized to practice nursing as registered nurses or as 8,066
172
licensed practical nurses under Chapter 4723. of the Revised 8,068
Code;
(5) Pharmacists who are authorized to practice pharmacy 8,071
under Chapter 4729. of the Revised Code; 8,074
(6) Physical therapists who are authorized to practice 8,076
physical therapy under sections 4755.40 to 4755.53 of the Revised 8,078
Code; 8,079
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 8,081
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 8,084
(8) Doctors of medicine and surgery, osteopathic medicine 8,087
and surgery, or podiatric medicine and surgery who are authorized 8,088
for their respective practices under Chapter 4731. of the Revised 8,089
Code.
This division shall apply notwithstanding a provision of a 8,092
code of ethics described in division (A)(9) of section 4734.10 of 8,093
the Revised Code that prohibits an individual from engaging in 8,094
the practice of chiropractic in combination with a person who is 8,095
licensed, certificated, or otherwise authorized for the practice 8,096
of optometry, psychology, nursing, pharmacy, physical therapy, 8,097
MECHANOTHERAPY, medicine and surgery, osteopathic medicine and 8,098
surgery, or podiatric medicine and surgery, but who is not also 8,100
licensed, certificated, or otherwise legally authorized to engage 8,102
in the practice of chiropractic.
Sec. 4755.471. (A) An individual whom the physical 8,111
therapy section of the Ohio occupational therapy, physical 8,112
therapy, and athletic trainers board licenses, certificates, or 8,113
otherwise legally authorizes to engage in the practice of 8,115
physical therapy may render the professional services of a
physical therapist within this state through a corporation formed 8,117
under division (B) of section 1701.03 of the Revised Code, a 8,118
limited liability company formed under Chapter 1705. of the 8,119
Revised Code, a partnership, or a professional association formed 8,121
under Chapter 1785. of the Revised Code. This division does not 8,122
preclude an individual of that nature from rendering professional 8,124
173
services as a physical therapist through another form of business 8,125
entity, including, but not limited to, a nonprofit corporation or 8,126
foundation, or in another manner that is authorized by or in 8,127
accordance with sections 4755.40 to 4755.53 of the Revised Code,
another chapter of the Revised Code, or rules of the Ohio 8,128
occupational therapy, physical therapy, and athletic trainers 8,129
board adopted pursuant to sections 4755.40 to 4755.53 of the 8,130
Revised Code.
(B) A corporation, limited liability company, partnership, 8,133
or professional association described in division (A) of this 8,134
section may be formed for the purpose of providing a combination 8,135
of the professional services of the following individuals who are 8,136
licensed, certificated, or otherwise legally authorized to 8,137
practice their respective professions: 8,138
(1) Optometrists who are authorized to practice optometry 8,140
under Chapter 4725. of the Revised Code; 8,141
(2) Chiropractors who are authorized to practice 8,143
chiropractic under Chapter 4734. of the Revised Code; 8,144
(3) Psychologists who are authorized to practice 8,146
psychology under Chapter 4732. of the Revised Code; 8,147
(4) Registered or licensed practical nurses who are 8,149
authorized to practice nursing as registered nurses or as 8,150
licensed practical nurses under Chapter 4723. of the Revised 8,152
Code;
(5) Pharmacists who are authorized to practice pharmacy 8,154
under Chapter 4729. of the Revised Code; 8,155
(6) Physical therapists who are authorized to practice 8,157
physical therapy under sections 4755.40 to 4755.53 of the Revised 8,158
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE 8,160
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE REVISED CODE; 8,163
(8) Doctors of medicine and surgery, osteopathic medicine 8,166
and surgery, or podiatric medicine and surgery who are authorized 8,167
for their respective practices under Chapter 4731. of the Revised 8,168
174
Code. 8,169
This division shall apply notwithstanding a provision of a 8,172
code of ethics applicable to a physical therapist that prohibits 8,174
a physical therapist from engaging in the practice of physical 8,175
therapy in combination with a person who is licensed, 8,176
certificated, or otherwise legally authorized to practice 8,177
optometry, chiropractic, psychology, nursing, pharmacy,
MECHANOTHERAPY, medicine and surgery, osteopathic medicine and 8,181
surgery, or podiatric medicine and surgery, but who is not also 8,182
licensed, certificated, or otherwise legally authorized to engage 8,183
in the practice of physical therapy. 8,184
Sec. 5111.25. (A) The department of human services shall 8,193
pay each eligible nursing facility a per resident per day rate 8,194
for its reasonable capital costs established prospectively each 8,195
fiscal year for each facility. Except as otherwise provided in 8,196
sections 5111.20 to 5111.32 of the Revised Code, the rate shall 8,197
be based on the facility's capital costs for the calendar year
preceding the fiscal year in which the rate will be paid. The 8,198
rate shall equal the sum of divisions (A)(1) to (3) of this 8,199
section:
(1) The lesser of the following: 8,201
(a) Eighty-eight and sixty-five one-hundredths per cent of 8,203
the facility's desk-reviewed, actual, allowable, per diem cost of 8,204
ownership and eighty-five per cent of the facility's actual, 8,205
allowable, per diem cost of nonextensive renovation determined 8,206
under division (F) of this section; 8,207
(b) Eighty-eight and sixty-five one-hundredths per cent of 8,209
the following limitation: 8,210
(i) For the fiscal year beginning July 1, 1993, sixteen 8,212
dollars per resident day; 8,213
(ii) For the fiscal year beginning July 1, 1994, sixteen 8,215
dollars per resident day, adjusted to reflect the rate of 8,216
inflation for the twelve-month period beginning July 1, 1992, and 8,217
ending June 30, 1993, using the consumer price index for shelter 8,218
175
costs for all urban consumers for the north central region, 8,219
published by the United States bureau of labor statistics; 8,220
(iii) For subsequent fiscal years, the limitation in 8,222
effect during the previous fiscal year, adjusted to reflect the 8,223
rate of inflation for the twelve-month period beginning on the 8,224
first day of July for the calendar year preceding the calendar 8,225
year that precedes the fiscal year and ending on the following 8,226
thirtieth day of June, using the consumer price index for shelter 8,227
costs for all urban consumers for the north central region, 8,228
published by the United States bureau of labor statistics. 8,229
(2) Any efficiency incentive determined under division (D) 8,231
of this section; 8,232
(3) Any amounts for return on equity determined under 8,234
division (H) of this section. 8,235
Buildings shall be depreciated using the straight line 8,237
method over forty years or over a different period approved by 8,238
the department. Components and equipment shall be depreciated 8,239
using the straight-line method over a period designated in rules 8,240
adopted by the department in accordance with Chapter 119. of the 8,241
Revised Code, consistent with the guidelines of the American 8,242
hospital association, or over a different period approved by the 8,243
department. Any rules adopted under this division that specify 8,244
useful lives of buildings, components, or equipment apply only to 8,245
assets acquired on or after July 1, 1993. Depreciation for costs 8,246
paid or reimbursed by any government agency shall not be included 8,247
in cost of ownership or renovation unless that part of the 8,248
payment under sections 5111.20 to 5111.32 of the Revised Code is 8,249
used to reimburse the government agency. 8,250
(B) The capital cost basis of nursing facility assets 8,252
shall be determined in the following manner: 8,253
(1) For purposes of calculating the rate to be paid for 8,255
the fiscal year beginning July 1, 1993, for facilities with dates 8,257
of licensure on or before June 30, 1993, the capital cost basis 8,258
shall be equal to the following: 8,259
176
(a) For facilities that have not had a change of ownership 8,261
during the period beginning January 1, 1993 and ending June 30, 8,262
1993, the desk-reviewed, actual, allowable capital cost basis 8,263
that is listed on the facility's cost report for the cost 8,264
reporting period ending December 31, 1992, plus the actual, 8,265
allowable capital cost basis of any assets constructed or 8,266
acquired after December 31, 1992, but before July 1, 1993, if the 8,267
aggregate capital costs of those assets would increase the 8,268
facility's rate for capital costs by twenty or more cents per 8,269
resident per day. 8,270
(b) For facilities that have a date of licensure or had a 8,272
change of ownership during the period beginning January 1, 1993, 8,273
and ending June 30, 1993, the actual, allowable capital cost 8,274
basis of the person or government entity that owns the facility 8,275
on June 30, 1993. 8,276
Capital cost basis shall be calculated as provided in 8,278
division (B)(1) of this section subject to approval by the United 8,279
States health care financing administration of any necessary 8,280
amendment to the state plan for providing medical assistance. 8,281
The department shall include the actual, allowable capital 8,283
cost basis of assets constructed or acquired during the period 8,284
beginning January 1, 1993, and ending June 30, 1993, in the 8,285
calculation for the facility's rate effective July 1, 1993, if 8,286
the aggregate capital costs of the assets would increase the 8,287
facility's rate by twenty or more cents per resident per day and 8,288
the facility provides the department with sufficient 8,289
documentation of the costs before June 1, 1993. If the facility 8,290
provides the documentation after that date, the department shall 8,291
adjust the facility's rate to reflect the costs of the assets one 8,292
month after the first day of the month after the department 8,293
receives the documentation. 8,294
(2) Except as provided in division (B)(4) of this section, 8,297
for purposes of calculating the rates to be paid for fiscal years 8,298
beginning after June 30, 1994, for facilities with dates of 8,299
177
licensure on or before June 30, 1993, the capital cost basis of 8,300
each asset shall be equal to the desk-reviewed, actual, 8,301
allowable, capital cost basis that is listed on the facility's 8,302
cost report for the calendar year preceding the fiscal year 8,303
during which the rate will be paid.
(3) For facilities with dates of licensure after June 30, 8,306
1993, the capital cost basis shall be determined in accordance 8,307
with the principles of the medicare program established under 8,308
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 8,309
U.S.C.A. 301, as amended, except as otherwise provided in 8,310
sections 5111.20 to 5111.32 of the Revised Code. 8,311
(4) If EXCEPT AS PROVIDED IN DIVISION (B)(5) OF THIS 8,313
SECTION, IF a provider transfers AN INTEREST IN a facility to 8,314
another provider after June 30, 1993, there shall be no increase 8,316
in the capital cost basis of the asset if the providers are 8,317
related parties. If the providers are not related parties OR IF 8,318
THEY ARE RELATED PARTIES AND DIVISION (B)(5) OF THIS SECTION 8,319
REQUIRES THE ADJUSTMENT OF THE CAPITAL COST BASIS UNDER THIS 8,320
DIVISION, the basis of the asset shall be adjusted by the lesser 8,321
of the following:
(a) One-half of the change in construction costs during 8,323
the time that the transferor held the asset, as calculated by the 8,324
department of human services using the "Dodge building cost 8,325
indexes, northeastern and north central states," published by 8,326
Marshall and Swift; 8,327
(b) One-half of the change in the consumer price index for 8,329
all items for all urban consumers, as published by the United 8,330
States bureau of labor statistics, during the time that the 8,331
transferor held the asset. 8,332
(5) IF A PROVIDER TRANSFERS AN INTEREST IN A FACILITY TO 8,335
ANOTHER PROVIDER WHO IS A RELATED PARTY, THE CAPITAL COST BASIS
OF THE ASSET SHALL BE ADJUSTED AS SPECIFIED IN DIVISION (B)(4) OF 8,338
THIS SECTION FOR A TRANSFER TO A PROVIDER THAT IS NOT A RELATED 8,339
PARTY IF ALL OF THE FOLLOWING CONDITIONS ARE MET:
178
(a) THE RELATED PARTY IS A RELATIVE OF OWNER; 8,342
(b) THE PROVIDER MAKING THE TRANSFER RETAINS NO OWNERSHIP 8,345
INTEREST IN THE FACILITY;
(c) THE UNITED STATES INTERNAL REVENUE SERVICE HAS ISSUED 8,348
A RULING THAT THE TRANSFER IS AN ARM'S LENGTH TRANSACTION FOR 8,349
PURPOSES OF FEDERAL INCOME TAXATION;
(d) EXCEPT IN THE CASE OF HARDSHIP CAUSED BY A 8,352
CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT, OR IN THE 8,353
CASE OF A PROVIDER MAKING THE TRANSFER WHO IS AT LEAST SIXTY-FIVE
YEARS OF AGE, NOT LESS THAN TWENTY YEARS HAVE ELAPSED SINCE, FOR 8,355
THE SAME FACILITY, THE CAPITAL COST BASIS WAS ADJUSTED MOST 8,356
RECENTLY UNDER DIVISION (B)(5) OF THIS SECTION OR ACTUAL, 8,358
ALLOWABLE COST OF OWNERSHIP WAS DETERMINED MOST RECENTLY UNDER
DIVISION (C)(9) OF THIS SECTION. 8,360
(C) As used in this division, "lease expense" means lease 8,362
payments in the case of an operating lease and depreciation 8,363
expense and interest expense in the case of a capital lease. As 8,364
used in this division, "new lease" means a lease, to a different 8,365
lessee, of a nursing facility that previously was operated under 8,366
a lease. 8,367
(1) Subject to the limitation specified in division (A)(1) 8,369
of this section, for a lease of a facility that was effective on 8,370
May 27, 1992, the entire lease expense is an actual, allowable 8,371
cost of ownership during the term of the existing lease. The 8,372
entire lease expense also is an actual, allowable cost of 8,373
ownership if a lease in existence on May 27, 1992, is renewed 8,374
under either of the following circumstances: 8,375
(a) The renewal is pursuant to a renewal option that was 8,377
in existence on May 27, 1992; 8,378
(b) The renewal is for the same lease payment amount and 8,380
between the same parties as the lease in existence on May 27, 8,381
1992. 8,382
(2) Subject to the limitation specified in division (A)(1) 8,384
of this section, for a lease of a facility that was in existence 8,385
179
but not operated under a lease on May 27, 1992, actual, allowable 8,386
cost of ownership shall include the lesser of the annual lease 8,387
expense or the annual depreciation expense and imputed interest 8,388
expense that would be calculated at the inception of the lease 8,389
using the lessor's entire historical capital asset cost basis, 8,390
adjusted by the lesser of the following amounts: 8,391
(a) One-half of the change in construction costs during 8,393
the time the lessor held each asset until the beginning of the 8,394
lease, as calculated by the department using the "Dodge building 8,395
cost indexes, northeastern and north central states," published 8,396
by Marshall and Swift; 8,397
(b) One-half of the change in the consumer price index for 8,399
all items for all urban consumers, as published by the United 8,400
States bureau of labor statistics, during the time the lessor 8,401
held each asset until the beginning of the lease. 8,402
(3) Subject to the limitation specified in division (A)(1) 8,404
of this section, for a lease of a facility with a date of 8,405
licensure on or after May 27, 1992, that is initially operated 8,406
under a lease, actual, allowable cost of ownership shall include 8,407
the annual lease expense if there was a substantial commitment of 8,408
money for construction of the facility after December 22, 1992, 8,409
and before July 1, 1993. If there was not a substantial 8,410
commitment of money after December 22, 1992, and before July 1, 8,411
1993, actual, allowable cost of ownership shall include the 8,412
lesser of the annual lease expense or the sum of the following: 8,413
(a) The annual depreciation expense that would be 8,415
calculated at the inception of the lease using the lessor's 8,416
entire historical capital asset cost basis; 8,417
(b) The greater of the lessor's actual annual amortization 8,419
of financing costs and interest expense at the inception of the 8,420
lease or the imputed interest expense calculated at the inception 8,421
of the lease using seventy per cent of the lessor's historical 8,422
capital asset cost basis. 8,423
(4) Subject to the limitation specified in division (A)(1) 8,425
180
of this section, for a lease of a facility with a date of 8,426
licensure on or after May 27, 1992, that was not initially 8,427
operated under a lease and has been in existence for ten years, 8,428
actual, allowable cost of ownership shall include the lesser of 8,429
the annual lease expense or the annual depreciation expense and 8,430
imputed interest expense that would be calculated at the 8,431
inception of the lease using the entire historical capital asset 8,432
cost basis of the lessor, adjusted by the lesser of the 8,433
following: 8,434
(a) One-half of the change in construction costs during 8,436
the time the lessor held each asset until the beginning of the 8,437
lease, as calculated by the department using the "Dodge building 8,438
cost indexes, northeastern and north central states," published 8,439
by Marshall and Swift; 8,440
(b) One-half of the change in the consumer price index for 8,442
all items for all urban consumers, as published by the United 8,443
States bureau of labor statistics, during the time the lessor 8,444
held each asset until the beginning of the lease. 8,445
(5) Subject to the limitation specified in division (A)(1) 8,447
of this section, for a new lease of a facility that was operated 8,448
under a lease on May 27, 1992, actual, allowable cost of 8,449
ownership shall include the lesser of the annual new lease 8,450
expense or the annual old lease payment. If the old lease was in 8,451
effect for ten years or longer, the old lease payment from the 8,452
beginning of the old lease shall be adjusted by the lesser of the 8,453
following: 8,454
(a) One-half of the change in construction costs from the 8,456
beginning of the old lease to the beginning of the new lease, as 8,457
calculated by the department using the "Dodge building cost 8,458
indexes, northeastern and north central states," published by 8,459
Marshall and Swift; 8,460
(b) One-half of the change in the consumer price index for 8,462
all items for all urban consumers, as published by the United 8,463
States bureau of labor statistics, from the beginning of the old 8,464
181
lease to the beginning of the new lease. 8,465
(6) Subject to the limitation specified in division (A)(1) 8,467
of this section, for a new lease of a facility that was not in 8,468
existence or that was in existence but not operated under a lease 8,469
on May 27, 1992, actual, allowable cost of ownership shall 8,470
include the lesser of annual new lease expense or the annual 8,471
amount calculated for the old lease under division (C)(2), (3), 8,472
(4), or (6) of this section, as applicable. If the old lease was 8,473
in effect for ten years or longer, the lessor's historical 8,474
capital asset cost basis shall be adjusted by the lesser of the 8,475
following for purposes of calculating the annual amount under 8,476
division (C)(2), (3), (4), or (6) of this section: 8,477
(a) One-half of the change in construction costs from the 8,479
beginning of the old lease to the beginning of the new lease, as 8,480
calculated by the department using the "Dodge building cost 8,481
indexes, northeastern and north central states," published by 8,482
Marshall and Swift; 8,483
(b) One-half of the change in the consumer price index for 8,485
all items for all urban consumers, as published by the United 8,486
States bureau of labor statistics, from the beginning of the old 8,487
lease to the beginning of the new lease. 8,488
In the case of a lease under division (C)(3) of this 8,490
section of a facility for which a substantial commitment of money 8,491
was made after December 22, 1992, and before July 1, 1993, the 8,492
old lease payment shall be adjusted for the purpose of 8,493
determining the annual amount. 8,494
(7) For any revision of a lease described in division 8,496
(C)(1), (2), (3), (4), (5), or (6) of this section, or for any 8,497
subsequent lease of a facility operated under such a lease, other 8,498
than execution of a new lease, the portion of actual, allowable 8,499
cost of ownership attributable to the lease shall be the same as 8,500
before the revision or subsequent lease. 8,501
(8) EXCEPT AS PROVIDED IN DIVISION (C)(9) OF THIS SECTION, 8,504
IF A PROVIDER LEASES AN INTEREST IN A FACILITY TO ANOTHER 8,505
182
PROVIDER WHO IS A RELATED PARTY, THE RELATED PARTY'S ACTUAL, 8,507
ALLOWABLE COST OF OWNERSHIP SHALL INCLUDE THE LESSER OF THE 8,508
ANNUAL LEASE EXPENSE OR THE REASONABLE COST TO THE LESSOR. 8,509
(9) IF A PROVIDER LEASES AN INTEREST IN A FACILITY TO 8,511
ANOTHER PROVIDER WHO IS A RELATED PARTY, REGARDLESS OF THE DATE 8,513
OF THE LEASE, THE RELATED PARTY'S ACTUAL, ALLOWABLE COST OF 8,514
OWNERSHIP SHALL INCLUDE THE ANNUAL LEASE EXPENSE, SUBJECT TO THE 8,515
LIMITATIONS SPECIFIED IN DIVISIONS (C)(1) TO (7) OF THIS SECTION, 8,516
IF ALL OF THE FOLLOWING CONDITIONS ARE MET: 8,517
(a) THE RELATED PARTY IS A RELATIVE OF OWNER; 8,519
(b) IF THE LESSOR RETAINS AN OWNERSHIP INTEREST, IT IS IN 8,522
ONLY THE REAL PROPERTY AND ANY IMPROVEMENTS ON THE REAL PROPERTY; 8,523
(c) THE UNITED STATES INTERNAL REVENUE SERVICE HAS ISSUED 8,526
A RULING THAT THE LEASE IS AN ARM'S LENGTH TRANSACTION FOR 8,527
PURPOSES OF FEDERAL INCOME TAXATION;
(d) EXCEPT IN THE CASE OF HARDSHIP CAUSED BY A 8,530
CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT, OR IN THE 8,531
CASE OF A LESSOR WHO IS AT LEAST SIXTY-FIVE YEARS OF AGE, NOT
LESS THAN TWENTY YEARS HAVE ELAPSED SINCE, FOR THE SAME FACILITY, 8,533
THE CAPITAL COST BASIS WAS ADJUSTED MOST RECENTLY UNDER DIVISION 8,534
(B)(5) OF THIS SECTION OR ACTUAL, ALLOWABLE COST OF OWNERSHIP WAS 8,536
DETERMINED MOST RECENTLY UNDER DIVISION (C)(9) OF THIS SECTION. 8,538
(10) This division does not apply to leases of specific 8,540
items of equipment. 8,541
(D)(1) Subject to division (D)(2) of this section, the 8,543
department shall pay each nursing facility an efficiency 8,544
incentive that is equal to fifty per cent of the difference 8,545
between the following:
(a) Eighty-eight and sixty-five one-hundredths per cent of 8,547
the facility's desk-reviewed, actual, allowable, per diem cost of 8,548
ownership;
(b) The applicable amount specified in division (E) of 8,550
this section. 8,551
(2) The efficiency incentive paid to a nursing facility 8,554
183
shall not exceed the greater of the following:
(a) The efficiency incentive the facility was paid during 8,557
the fiscal year ending June 30, 1994;
(b) Three dollars per resident per day, adjusted annually 8,560
for rates paid beginning July 1, 1994, for the inflation rate for 8,561
the twelve-month period beginning on the first day of July of the 8,562
calendar year preceding the calendar year that precedes the 8,563
fiscal year for which the efficiency incentive is determined and 8,564
ending on the thirtieth day of the following June, using the 8,565
consumer price index for shelter costs for all urban consumers 8,566
for the north central region, as published by the United States 8,567
bureau of labor statistics. 8,568
(3) For purposes of calculating the efficiency incentive, 8,571
depreciation for costs that are paid or reimbursed by any 8,572
government agency shall be considered as costs of ownership, and 8,573
renovation costs that are paid under division (F) of this section 8,574
shall not be considered costs of ownership. 8,575
(E) The following amounts shall be used to calculate 8,577
efficiency incentives for nursing facilities under this section: 8,578
(1) For facilities with dates of licensure prior to 8,580
January 1, 1958, four dollars and twenty-four cents per patient 8,581
day; 8,582
(2) For facilities with dates of licensure after December 8,584
31, 1957, but prior to January 1, 1968: 8,585
(a) Five dollars and twenty-four cents per patient day if 8,587
the cost of construction was three thousand five hundred dollars 8,588
or more per bed; 8,589
(b) Four dollars and twenty-four cents per patient day if 8,591
the cost of construction was less than three thousand five 8,592
hundred dollars per bed. 8,593
(3) For facilities with dates of licensure after December 8,595
31, 1967, but prior to January 1, 1976: 8,596
(a) Six dollars and twenty-four cents per patient day if 8,598
the cost of construction was five thousand one hundred fifty 8,599
184
dollars or more per bed; 8,600
(b) Five dollars and twenty-four cents per patient day if 8,602
the cost of construction was less than five thousand one hundred 8,603
fifty dollars per bed, but exceeded three thousand five hundred 8,604
dollars per bed; 8,605
(c) Four dollars and twenty-four cents per patient day if 8,607
the cost of construction was three thousand five hundred dollars 8,608
or less per bed. 8,609
(4) For facilities with dates of licensure after December 8,611
31, 1975, but prior to January 1, 1979: 8,612
(a) Seven dollars and twenty-four cents per patient day if 8,614
the cost of construction was six thousand eight hundred dollars 8,615
or more per bed; 8,616
(b) Six dollars and twenty-four cents per patient day if 8,618
the cost of construction was less than six thousand eight hundred 8,619
dollars per bed but exceeded five thousand one hundred fifty 8,620
dollars per bed; 8,621
(c) Five dollars and twenty-four cents per patient day if 8,623
the cost of construction was five thousand one hundred fifty 8,624
dollars or less per bed, but exceeded three thousand five hundred 8,625
dollars per bed; 8,626
(d) Four dollars and twenty-four cents per patient day if 8,628
the cost of construction was three thousand five hundred dollars 8,629
or less per bed. 8,630
(5) For facilities with dates of licensure after December 8,632
31, 1978, but prior to January 1, 1981: 8,633
(a) Seven dollars and seventy-four cents per patient day 8,635
if the cost of construction was seven thousand six hundred 8,636
twenty-five dollars or more per bed; 8,637
(b) Seven dollars and twenty-four cents per patient day if 8,639
the cost of construction was less than seven thousand six hundred 8,640
twenty-five dollars per bed but exceeded six thousand eight 8,641
hundred dollars per bed; 8,642
(c) Six dollars and twenty-four cents per patient day if 8,644
185
the cost of construction was six thousand eight hundred dollars 8,645
or less per bed but exceeded five thousand one hundred fifty 8,646
dollars per bed; 8,647
(d) Five dollars and twenty-four cents per patient day if 8,649
the cost of construction was five thousand one hundred fifty 8,650
dollars or less but exceeded three thousand five hundred dollars 8,651
per bed; 8,652
(e) Four dollars and twenty-four cents per patient day if 8,654
the cost of construction was three thousand five hundred dollars 8,655
or less per bed. 8,656
(6) For facilities with dates of licensure in 1981 or any 8,658
year thereafter prior to December 22, 1992, the following amount: 8,659
(a) For facilities with construction costs less than seven 8,661
thousand six hundred twenty-five dollars per bed, the applicable 8,662
amounts for the construction costs specified in divisions 8,663
(E)(5)(b) to (e) of this section; 8,664
(b) For facilities with construction costs of seven 8,666
thousand six hundred twenty-five dollars or more per bed, six 8,667
dollars per patient day, provided that for 1981 and annually 8,668
thereafter prior to December 22, 1992, department shall do both 8,669
of the following to the six-dollar amount: 8,670
(i) Adjust the amount for fluctuations in construction 8,672
costs calculated by the department using the "Dodge building cost 8,673
indexes, northeastern and north central states," published by 8,674
Marshall and Swift, using 1980 as the base year; 8,675
(ii) Increase the amount, as adjusted for inflation under 8,677
division (E)(6)(b)(i) of this section, by one dollar and 8,678
seventy-four cents. 8,679
(7) For facilities with dates of licensure on or after 8,681
January 1, 1992, seven dollars and ninety-seven cents, adjusted 8,682
for fluctuations in construction costs between 1991 and 1993 as 8,683
calculated by the department using the "Dodge building cost 8,684
indexes, northeastern and north central states," published by 8,685
Marshall and Swift, and then increased by one dollar and 8,686
186
seventy-four cents. 8,687
For the fiscal year that begins July 1, 1994, each of the 8,689
amounts listed in divisions (E)(1) to (7) of this section shall 8,690
be increased by twenty-five cents. For the fiscal year that 8,691
begins July 1, 1995, each of those amounts shall be increased by 8,692
an additional twenty-five cents. For subsequent fiscal years, 8,693
each of those amounts, as increased for the prior fiscal year, 8,694
shall be adjusted to reflect the rate of inflation for the 8,695
twelve-month period beginning on the first day of July of the 8,696
calendar year preceding the calendar year that precedes the 8,697
fiscal year and ending on the following thirtieth day of June, 8,698
using the consumer price index for shelter costs for all urban 8,699
consumers for the north central region, as published by the 8,700
United States bureau of labor statistics. 8,701
If the amount established for a nursing facility under this 8,703
division is less than the amount that applied to the facility 8,704
under division (B) of former section 5111.25 of the Revised Code, 8,705
as the former section existed immediately prior to December 22, 8,706
1992, the amount used to calculate the efficiency incentive for 8,707
the facility under division (D)(2) of this section shall be the 8,708
amount that was calculated under division (B) of the former 8,709
section. 8,710
(F) Beginning July 1, 1993, regardless of the facility's 8,712
date of licensure or the date of the nonextensive renovations, 8,713
the rate for the costs of nonextensive renovations for nursing 8,714
facilities shall be eighty-five per cent of the desk-reviewed, 8,715
actual, allowable, per diem, nonextensive renovation costs. This 8,716
division applies to nonextensive renovations regardless of 8,717
whether they are made by an owner or a lessee. If the tenancy of 8,718
a lessee that has made nonextensive renovations ends before the 8,719
depreciation expense for the renovation costs has been fully 8,720
reported, the former lessee shall not report the undepreciated 8,721
balance as an expense. 8,722
(1) For a nonextensive renovation made after July 1, 1993, 8,724
187
to qualify for payment under this division, both of the following 8,725
conditions must be met: 8,726
(a) At least five years have elapsed since the date of 8,728
licensure of the portion of the facility that is proposed to be 8,729
renovated, except that this condition does not apply if the 8,730
renovation is necessary to meet the requirements of federal, 8,731
state, or local statutes, ordinances, rules, or policies. 8,732
(b) The provider has obtained prior approval from the 8,734
department of human services, and if required the director of 8,735
health has granted a certificate of need for the renovation under 8,736
section 3702.52 of the Revised Code. The provider shall submit a 8,737
plan that describes in detail the changes in capital assets to be 8,738
accomplished by means of the renovation and the timetable for 8,739
completing the project. The time for completion of the project 8,740
shall be no more than eighteen months after the renovation 8,741
begins. The department of human services shall adopt rules in 8,742
accordance with Chapter 119. of the Revised Code that specify 8,743
criteria and procedures for prior approval of renovation 8,744
projects. No provider shall separate a project with the intent 8,745
to evade the characterization of the project as a renovation or 8,746
as an extensive renovation. No provider shall increase the scope 8,747
of a project after it is approved by the department of human 8,748
services unless the increase in scope is approved by the 8,749
department. 8,750
(2) The payment provided for in this division is the only 8,752
payment that shall be made for the costs of a nonextensive 8,753
renovation. Nonextensive renovation costs shall not be included 8,754
in costs of ownership, and a nonextensive renovation shall not 8,755
affect the date of licensure for purposes of calculating the 8,756
efficiency incentive under divisions (D) and (E) of this section. 8,757
(G) The owner of a nursing facility operating under a 8,759
provider agreement shall provide written notice to the department 8,760
of human services at least forty-five days prior to entering into 8,761
any contract of sale for the facility or voluntarily terminating 8,762
188
participation in the medical assistance program. After the date 8,763
on which a transaction of sale is closed, the owner shall refund 8,764
to the department the amount of excess depreciation paid to the 8,765
facility by the department for each year the owner has operated 8,766
the facility under a provider agreement and prorated according to 8,767
the number of medicaid patient days for which the facility has 8,768
received payment. If a nursing facility is sold after five or 8,769
fewer years of operation under a provider agreement, the refund 8,770
to the department shall be equal to the excess depreciation paid 8,771
to the facility. If a nursing facility is sold after more than 8,772
five years but less than ten years of operation under a provider 8,773
agreement, the refund to the department shall equal the excess 8,774
depreciation paid to the facility multiplied by twenty per cent, 8,775
multiplied by the difference between ten and the number of years 8,776
that the facility was operated under a provider agreement. If a 8,777
nursing facility is sold after ten or more years of operation 8,778
under a provider agreement, the owner shall not refund any excess 8,779
depreciation to the department. The owner of a facility that is 8,780
sold or that voluntarily terminates participation in the medical 8,781
assistance program also shall refund any other amount that the 8,782
department properly finds to be due after the audit conducted 8,783
under this division. For the purposes of this division, 8,784
"depreciation paid to the facility" means the amount paid to the 8,785
nursing facility for cost of ownership pursuant to this section 8,786
less any amount paid for interest costs, amortization of 8,787
financing costs, and lease expenses. For the purposes of this 8,788
division, "excess depreciation" is the nursing facility's 8,789
depreciated basis, which is the owner's cost less accumulated 8,790
depreciation, subtracted from the purchase price net of selling 8,791
costs but not exceeding the amount of depreciation paid to the 8,793
facility.
A cost report shall be filed with the department within 8,795
ninety days after the date on which the transaction of sale is 8,796
closed or participation is voluntarily terminated. The report 8,797
189
shall show the accumulated depreciation, the sales price, and 8,798
other information required by the department. The amount of the 8,799
last two monthly payments to a nursing facility made pursuant to 8,800
division (A)(1) of section 5111.22 of the Revised Code before a 8,801
sale or termination of participation shall be held in escrow by a 8,802
bank, trust company, or savings and loan association, except that 8,803
if the amount the owner will be required to refund under this 8,804
section is likely to be less than the amount of the last two 8,805
monthly payments, the department shall take one of the following 8,806
actions instead of withholding the amount of the last two monthly 8,807
payments: 8,808
(1) In the case of an owner that owns other facilities 8,810
that participate in the medical assistance program, obtain a 8,811
promissory note in an amount sufficient to cover the amount 8,812
likely to be refunded; 8,813
(2) In the case of all other owners, withhold the amount 8,815
of the last monthly payment to the nursing facility. 8,816
The department shall, within ninety days following the 8,818
filing of the cost report, audit the cost report and issue an 8,819
audit report to the owner. The department also may audit any 8,820
other cost report that the facility has filed during the previous 8,821
three years. In the audit report, the department shall state its 8,822
findings and the amount of any money owed to the department by 8,823
the nursing facility. The findings shall be subject to 8,824
adjudication conducted in accordance with Chapter 119. of the 8,825
Revised Code. No later than fifteen days after the owner agrees 8,826
to a settlement, any funds held in escrow less any amounts due to 8,827
the department shall be released to the owner and amounts due to 8,828
the department shall be paid to the department. If the amounts 8,829
in escrow are less than the amounts due to the department, the 8,830
balance shall be paid to the department within fifteen days after 8,831
the owner agrees to a settlement. If the department does not 8,832
issue its audit report within the ninety-day period, the 8,833
department shall release any money held in escrow to the owner. 8,834
190
For the purposes of this section, a transfer of corporate stock, 8,835
the merger of one corporation into another, or a consolidation 8,836
does not constitute a sale. 8,837
If a nursing facility is not sold or its participation is 8,839
not terminated after notice is provided to the department under 8,840
this division, the department shall order any payments held in 8,841
escrow released to the facility upon receiving written notice 8,842
from the owner that there will be no sale or termination. After 8,843
written notice is received from a nursing facility that a sale or 8,844
termination will not take place, the facility shall provide 8,845
notice to the department at least forty-five days prior to 8,846
entering into any contract of sale or terminating participation 8,847
at any future time. 8,848
(H) The department shall pay each eligible proprietary 8,850
nursing facility a return on the facility's net equity computed 8,851
at the rate of one and one-half times the average interest rate 8,852
on special issues of public debt obligations issued to the 8,853
federal hospital insurance trust fund for the cost reporting 8,854
period, except that no facility's return on net equity shall 8,855
exceed one dollar per patient day. 8,856
When calculating the rate for return on net equity, the 8,858
department shall use the greater of the facility's inpatient days 8,859
during the applicable cost reporting period or the number of 8,860
inpatient days the facility would have had during that period if 8,861
its occupancy rate had been ninety-five per cent. 8,862
(I) If a nursing facility would receive a lower rate for 8,864
capital costs for assets in the facility's possession on July 1, 8,865
1993, under this section than it would receive under former 8,866
section 5111.25 of the Revised Code, as the former section 8,867
existed immediately prior to December 22, 1992, the facility 8,868
shall receive for those assets the rate it would have received 8,869
under the former section for each fiscal year beginning on or 8,870
after July 1, 1993, until the rate it would receive under this 8,871
section exceeds the rate it would have received under the former 8,872
191
section. Any facility that receives a rate calculated under the 8,873
former section 5111.25 of the Revised Code for assets in the 8,874
facility's possession on July 1, 1993, also shall receive a rate 8,875
calculated under this section for costs of any assets it 8,876
constructs or acquires after July 1, 1993. 8,877
Sec. 5111.251. (A) The department of human services shall 8,886
pay each eligible intermediate care facility for the mentally 8,887
retarded for its reasonable capital costs, a per resident per day 8,888
rate established prospectively each fiscal year for each 8,889
intermediate care facility for the mentally retarded. Except as 8,890
otherwise provided in sections 5111.20 to 5111.32 of the Revised 8,891
Code, the rate shall be based on the facility's capital costs for 8,892
the calendar year preceding the fiscal year in which the rate 8,893
will be paid. The rate shall equal the sum of the following: 8,894
(1) The facility's desk-reviewed, actual, allowable, per 8,896
diem cost of ownership for the preceding cost reporting period, 8,897
limited as provided in divisions (C) and (F) of this section; 8,898
(2) Any efficiency incentive determined under division (B) 8,900
of this section; 8,901
(3) Any amounts for renovations determined under division 8,903
(D) of this section; 8,904
(4) Any amounts for return on equity determined under 8,906
division (I) of this section. 8,907
Buildings shall be depreciated using the straight line 8,909
method over forty years or over a different period approved by 8,910
the department. Components and equipment shall be depreciated 8,911
using the straight line method over a period designated by the 8,912
department in rules adopted in accordance with Chapter 119. of 8,913
the Revised Code, consistent with the guidelines of the American 8,914
hospital association, or over a different period approved by the 8,915
department of human services. Any rules adopted under this 8,916
division that specify useful lives of buildings, components, or 8,918
equipment apply only to assets acquired on or after July 1, 1993. 8,919
Depreciation for costs paid or reimbursed by any government 8,920
192
agency shall not be included in costs of ownership or renovation 8,921
unless that part of the payment under sections 5111.20 to 5111.32 8,922
of the Revised Code is used to reimburse the government agency. 8,923
(B) The department of human services shall pay to each 8,925
intermediate care facility for the mentally retarded an 8,927
efficiency incentive equal to fifty per cent of the difference 8,928
between any desk-reviewed, actual, allowable cost of ownership 8,929
and the applicable limit on cost of ownership payments under 8,930
division (C) of this section. For purposes of computing the 8,931
efficiency incentive, depreciation for costs paid or reimbursed 8,932
by any government agency shall be considered as a cost of
ownership, and the applicable limit under division (C) of this 8,933
section shall apply both to facilities with more than eight beds 8,934
and facilities with eight or fewer beds. The efficiency 8,935
incentive paid to a facility with eight or fewer beds shall not 8,936
exceed three dollars per patient day, adjusted annually for the 8,937
inflation rate for the twelve-month period beginning on the first 8,938
day of July of the calendar year preceding the calendar year that 8,939
precedes the fiscal year for which the efficiency incentive is 8,940
determined and ending on the thirtieth day of the following June, 8,941
using the consumer price index for shelter costs for all urban 8,942
consumers for the north central region, as published by the 8,943
United States bureau of labor statistics. 8,944
(C) Cost of ownership payments to intermediate care 8,946
facilities for the mentally retarded with more than eight beds 8,947
shall not exceed the following limits: 8,948
(1) For facilities with dates of licensure prior to 8,950
January 1, l958, not exceeding two dollars and fifty cents per 8,951
patient day; 8,952
(2) For facilities with dates of licensure after December 8,954
31, l957, but prior to January 1, l968, not exceeding: 8,955
(a) Three dollars and fifty cents per patient day if the 8,957
cost of construction was three thousand five hundred dollars or 8,958
more per bed; 8,959
193
(b) Two dollars and fifty cents per patient day if the 8,961
cost of construction was less than three thousand five hundred 8,962
dollars per bed. 8,963
(3) For facilities with dates of licensure after December 8,965
31, l967, but prior to January 1, l976, not exceeding: 8,966
(a) Four dollars and fifty cents per patient day if the 8,968
cost of construction was five thousand one hundred fifty dollars 8,969
or more per bed; 8,970
(b) Three dollars and fifty cents per patient day if the 8,972
cost of construction was less than five thousand one hundred 8,973
fifty dollars per bed, but exceeds three thousand five hundred 8,974
dollars per bed; 8,975
(c) Two dollars and fifty cents per patient day if the 8,977
cost of construction was three thousand five hundred dollars or 8,978
less per bed. 8,979
(4) For facilities with dates of licensure after December 8,981
31, l975, but prior to January 1, l979, not exceeding: 8,982
(a) Five dollars and fifty cents per patient day if the 8,984
cost of construction was six thousand eight hundred dollars or 8,985
more per bed; 8,986
(b) Four dollars and fifty cents per patient day if the 8,988
cost of construction was less than six thousand eight hundred 8,989
dollars per bed but exceeds five thousand one hundred fifty 8,990
dollars per bed; 8,991
(c) Three dollars and fifty cents per patient day if the 8,993
cost of construction was five thousand one hundred fifty dollars 8,994
or less per bed, but exceeds three thousand five hundred dollars 8,995
per bed; 8,996
(d) Two dollars and fifty cents per patient day if the 8,998
cost of construction was three thousand five hundred dollars or 8,999
less per bed. 9,000
(5) For facilities with dates of licensure after December 9,002
31, l978, but prior to January 1, l980, not exceeding: 9,003
(a) Six dollars per patient day if the cost of 9,005
194
construction was seven thousand six hundred twenty-five dollars 9,006
or more per bed; 9,007
(b) Five dollars and fifty cents per patient day if the 9,009
cost of construction was less than seven thousand six hundred 9,010
twenty-five dollars per bed but exceeds six thousand eight 9,011
hundred dollars per bed; 9,012
(c) Four dollars and fifty cents per patient day if the 9,014
cost of construction was six thousand eight hundred dollars or 9,015
less per bed but exceeds five thousand one hundred fifty dollars 9,016
per bed; 9,017
(d) Three dollars and fifty cents per patient day if the 9,019
cost of construction was five thousand one hundred fifty dollars 9,020
or less but exceeds three thousand five hundred dollars per bed; 9,021
(e) Two dollars and fifty cents per patient day if the 9,023
cost of construction was three thousand five hundred dollars or 9,024
less per bed. 9,025
(6) For facilities with dates of licensure after December 9,028
31, 1979, but prior to January 1, 1981, not exceeding: 9,029
(a) Twelve dollars per patient day if the beds were 9,031
originally licensed as residential facility beds by the 9,032
department of mental retardation and developmental disabilities; 9,033
(b) Six dollars per patient day if the beds were 9,035
originally licensed as nursing home beds by the department of 9,036
health.
(7) For facilities with dates of licensure after December 9,038
31, 1980, but prior to January 1, 1982, not exceeding: 9,039
(a) Twelve dollars per patient day if the beds were 9,041
originally licensed as residential facility beds by the 9,042
department of mental retardation and developmental disabilities; 9,043
(b) Six dollars and forty-five cents per patient day if 9,045
the beds were originally licensed as nursing home beds by the 9,046
department of health.
(8) For facilities with dates of licensure after December 9,048
31, 1981, but prior to January 1, 1983, not exceeding: 9,049
195
(a) Twelve dollars per patient day if the beds were 9,051
originally licensed as residential facility beds by the 9,052
department of mental retardation and developmental disabilities; 9,053
(b) Six dollars and seventy-nine cents per patient day if 9,055
the beds were originally licensed as nursing home beds by the 9,056
department of health.
(9) For facilities with dates of licensure after December 9,058
31, 1982, but prior to January 1, 1984, not exceeding: 9,059
(a) Twelve dollars per patient day if the beds were 9,061
originally licensed as residential facility beds by the 9,062
department of mental retardation and developmental disabilities; 9,063
(b) Seven dollars and nine cents per patient day if the 9,065
beds were originally licensed as nursing home beds by the 9,066
department of health.
(10) For facilities with dates of licensure after December 9,068
31, 1983, but prior to January 1, 1985, not exceeding: 9,069
(a) Twelve dollars and twenty-four cents per patient day 9,071
if the beds were originally licensed as residential facility beds 9,073
by the department of mental retardation and developmental 9,074
disabilities;
(b) Seven dollars and twenty-three cents per patient day 9,076
if the beds were originally licensed as nursing home beds by the 9,078
department of health.
(11) For facilities with dates of licensure after December 9,080
31, 1984, but prior to January 1, 1986, not exceeding: 9,081
(a) Twelve dollars and fifty-three cents per patient day 9,083
if the beds were originally licensed as residential facility beds 9,085
by the department of mental retardation and developmental 9,086
disabilities;
(b) Seven dollars and forty cents per patient day if the 9,088
beds were originally licensed as nursing home beds by the 9,090
department of health.
(12) For facilities with dates of licensure after December 9,092
31, 1985, but prior to January 1, 1987, not exceeding: 9,093
196
(a) Twelve dollars and seventy cents per patient day if 9,095
the beds were originally licensed as residential facility beds by 9,097
the department of mental retardation and developmental 9,098
disabilities;
(b) Seven dollars and fifty cents per patient day if the 9,100
beds were originally licensed as nursing home beds by the 9,102
department of health.
(13) For facilities with dates of licensure after December 9,104
31, 1986, but prior to January 1, 1988, not exceeding: 9,105
(a) Twelve dollars and ninety-nine cents per patient day 9,107
if the beds were originally licensed as residential facility beds 9,109
by the department of mental retardation and developmental 9,110
disabilities;
(b) Seven dollars and sixty-seven cents per patient day if 9,112
the beds were originally licensed as nursing home beds by the 9,114
department of health.
(14) For facilities with dates of licensure after December 9,116
31, 1987, but prior to January 1, 1989, not exceeding thirteen 9,117
dollars and twenty-six cents per patient day; 9,118
(15) For facilities with dates of licensure after December 9,120
31, 1988, but prior to January 1, 1990, not exceeding thirteen 9,121
dollars and forty-six cents per patient day; 9,122
(16) For facilities with dates of licensure after December 9,124
31, 1989, but prior to January 1, 1991, not exceeding thirteen 9,125
dollars and sixty cents per patient day; 9,126
(17) For facilities with dates of licensure after December 9,128
31, 1990, but prior to January 1, 1992, not exceeding thirteen 9,129
dollars and forty-nine cents per patient day; 9,130
(18) For facilities with dates of licensure after December 9,132
31, 1991, but prior to January 1, 1993, not exceeding thirteen 9,133
dollars and sixty-seven cents per patient day; 9,134
(19) For facilities with dates of licensure after December 9,136
31, 1992, not exceeding fourteen dollars and twenty-eight cents 9,137
per patient day.
197
(D) Beginning January 1, 1981, regardless of the original 9,139
date of licensure, the department of human services shall pay a 9,140
rate for the per diem capitalized costs of renovations to 9,142
intermediate care facilities for the mentally retarded made after 9,143
January 1, l981, not exceeding six dollars per patient day using 9,144
1980 as the base year and adjusting the amount annually until 9,145
June 30, 1993, for fluctuations in construction costs calculated 9,146
by the department using the "Dodge building cost indexes, 9,147
northeastern and north central states," published by Marshall and 9,148
Swift. The payment provided for in this division is the only 9,149
payment that shall be made for the capitalized costs of a 9,150
nonextensive renovation of an intermediate care facility for the 9,151
mentally retarded. Nonextensive renovation costs shall not be 9,152
included in cost of ownership, and a nonextensive renovation 9,153
shall not affect the date of licensure for purposes of division 9,154
(C) of this section. This division applies to nonextensive 9,155
renovations regardless of whether they are made by an owner or a 9,156
lessee. If the tenancy of a lessee that has made renovations 9,157
ends before the depreciation expense for the renovation costs has 9,158
been fully reported, the former lessee shall not report the 9,159
undepreciated balance as an expense. 9,160
For a nonextensive renovation to qualify for payment under 9,162
this division, both of the following conditions must be met: 9,163
(1) At least five years have elapsed since the date of 9,165
licensure or date of an extensive renovation of the portion of 9,166
the facility that is proposed to be renovated, except that this 9,167
condition does not apply if the renovation is necessary to meet 9,168
the requirements of federal, state, or local statutes, 9,169
ordinances, rules, or policies. 9,170
(2) The provider has obtained prior approval from the 9,172
department of human services. The provider shall submit a plan 9,173
that describes in detail the changes in capital assets to be 9,175
accomplished by means of the renovation and the timetable for 9,176
completing the project. The time for completion of the project 9,177
198
shall be no more than eighteen months after the renovation 9,178
begins. The department of human services shall adopt rules in 9,180
accordance with Chapter 119. of the Revised Code that specify 9,181
criteria and procedures for prior approval of renovation 9,182
projects. No provider shall separate a project with the intent 9,183
to evade the characterization of the project as a renovation or 9,184
as an extensive renovation. No provider shall increase the scope 9,185
of a project after it is approved by the department of human 9,186
services unless the increase in scope is approved by the 9,187
department.
(E) The amounts specified in divisions (C) and (D) of this 9,189
section shall be adjusted beginning July 1, 1993, for the 9,190
estimated inflation for the twelve-month period beginning on the 9,191
first day of July of the calendar year preceding the calendar 9,192
year that precedes the fiscal year for which rate will be paid 9,193
and ending on the thirtieth day of the following June, using the 9,194
consumer price index for shelter costs for all urban consumers 9,195
for the north central region, as published by the United States 9,196
bureau of labor statistics. 9,197
(F)(1) For facilities of eight or fewer beds that have 9,199
dates of licensure or have been granted project authorization by 9,200
the department of mental retardation and developmental 9,201
disabilities before July 1, 1993, and for facilities of eight or 9,202
fewer beds that have dates of licensure or have been granted 9,203
project authorization after that date if the facilities 9,204
demonstrate that they made substantial commitments of funds on or 9,205
before that date, cost of ownership shall not exceed eighteen 9,206
dollars and thirty cents per resident per day. The 9,207
eighteen-dollar and thirty-cent amount shall be increased by the 9,208
change in the "Dodge building cost indexes, northeastern and 9,209
north central states," published by Marshall and Swift, during 9,210
the period beginning June 30, 1990, and ending July 1, 1993, and 9,211
by the change in the consumer price index for shelter costs for 9,212
all urban consumers for the north central region, as published by 9,213
199
the United States bureau of labor statistics, annually 9,214
thereafter. 9,215
(2) For facilities with eight or fewer beds that have 9,217
dates of licensure or have been granted project authorization by 9,218
the department of mental retardation and developmental 9,219
disabilities on or after July 1, 1993, for which substantial 9,220
commitments of funds were not made before that date, cost of 9,221
ownership payments shall not exceed the applicable amount 9,222
calculated under division (F)(1) of this section, if the 9,223
department of human services gives prior approval for 9,224
construction of the facility. If the department does not give 9,225
prior approval, cost of ownership payments shall not exceed the 9,226
amount specified in division (C) of this section. 9,227
(3) Notwithstanding divisions (D) and (F)(1) and (2) of 9,229
this section, the total payment for cost of ownership, cost of 9,230
ownership efficiency incentive, and capitalized costs of 9,231
renovations for an intermediate care facility for the mentally 9,232
retarded with eight or fewer beds shall not exceed the sum of the 9,233
limitations specified in divisions (C) and (D) of this section. 9,235
(G) Notwithstanding any provision of this section or 9,237
section 5111.24 of the Revised Code, the department of human 9,238
services may adopt rules in accordance with Chapter 119. of the 9,240
Revised Code that provide for a calculation of a combined maximum 9,241
payment limit for indirect care costs and cost of ownership for 9,242
intermediate care facilities for the mentally retarded with eight 9,243
or fewer beds.
(H) After June 30, 1980, the owner of an intermediate care 9,245
facility for the mentally retarded operating under a provider 9,246
agreement shall provide written notice to the department of human 9,247
services at least forty-five days prior to entering into any 9,248
contract of sale for the facility or voluntarily terminating 9,249
participation in the medical assistance program. After the date 9,250
on which a transaction of sale is closed, the owner shall refund 9,251
to the department the amount of excess depreciation paid to the 9,252
200
facility by the department for each year the owner has operated 9,253
the facility under a provider agreement and prorated according to 9,254
the number of medicaid patient days for which the facility has 9,255
received payment. If an intermediate care facility for the 9,256
mentally retarded is sold after five or fewer years of operation 9,257
under a provider agreement, the refund to the department shall be 9,258
equal to the excess depreciation paid to the facility. If an 9,259
intermediate care facility for the mentally retarded is sold 9,260
after more than five years but less than ten years of operation 9,261
under a provider agreement, the refund to the department shall 9,262
equal the excess depreciation paid to the facility multiplied by 9,263
twenty per cent, multiplied by the number of years less than ten 9,264
that a facility was operated under a provider agreement. If an 9,265
intermediate care facility for the mentally retarded is sold 9,266
after ten or more years of operation under a provider agreement, 9,267
the owner shall not refund any excess depreciation to the 9,268
department. For the purposes of this division, "depreciation 9,269
paid to the facility" means the amount paid to the intermediate 9,270
care facility for the mentally retarded for cost of ownership 9,271
pursuant to this section less any amount paid for interest costs. 9,272
For the purposes of this division, "excess depreciation" is the 9,273
intermediate care facility for the mentally retarded's 9,274
depreciated basis, which is the owner's cost less accumulated 9,275
depreciation, subtracted from the purchase price but not 9,276
exceeding the amount of depreciation paid to the facility. 9,277
A cost report shall be filed with the department within 9,279
ninety days after the date on which the transaction of sale is 9,280
closed or participation is voluntarily terminated for an 9,281
intermediate care facility for the mentally retarded subject to 9,282
this division. The report shall show the accumulated 9,283
depreciation, the sales price, and other information required by 9,284
the department. The amount of the last two monthly payments to 9,285
an intermediate care facility for the mentally retarded made 9,286
pursuant to division (A)(1) of section 5111.22 of the Revised 9,287
201
Code before a sale or voluntary termination of participation 9,288
shall be held in escrow by a bank, trust company, or savings and 9,289
loan association, except that if the amount the owner will be 9,290
required to refund under this section is likely to be less than 9,291
the amount of the last two monthly payments, the department shall 9,292
take one of the following actions instead of withholding the 9,293
amount of the last two monthly payments: 9,294
(1) In the case of an owner that owns other facilities 9,296
that participate in the medical assistance program, obtain a 9,297
promissory note in an amount sufficient to cover the amount 9,298
likely to be refunded; 9,299
(2) In the case of all other owners, withhold the amount 9,301
of the last monthly payment to the intermediate care facility for 9,302
the mentally retarded. 9,303
The department shall, within ninety days following the 9,305
filing of the cost report, audit the report and issue an audit 9,306
report to the owner. The department also may audit any other 9,307
cost reports for the facility that have been filed during the 9,308
previous three years. In the audit report, the department shall 9,309
state its findings and the amount of any money owed to the 9,310
department by the intermediate care facility for the mentally 9,311
retarded. The findings shall be subject to an adjudication 9,312
conducted in accordance with Chapter 119. of the Revised Code. 9,313
No later than fifteen days after the owner agrees to a 9,314
settlement, any funds held in escrow less any amounts due to the 9,315
department shall be released to the owner and amounts due to the 9,316
department shall be paid to the department. If the amounts in 9,317
escrow are less than the amounts due to the department, the 9,318
balance shall be paid to the department within fifteen days after 9,319
the owner agrees to a settlement. If the department does not 9,320
issue its audit report within the ninety-day period, the 9,321
department shall release any money held in escrow to the owner. 9,322
For the purposes of this section, a transfer of corporate stock, 9,323
the merger of one corporation into another, or a consolidation 9,324
202
does not constitute a sale. 9,325
If an intermediate care facility for the mentally retarded 9,327
is not sold or its participation is not terminated after notice 9,328
is provided to the department under this division, the department 9,329
shall order any payments held in escrow released to the facility 9,330
upon receiving written notice from the owner that there will be 9,331
no sale or termination of participation. After written notice is 9,332
received from an intermediate care facility for the mentally 9,333
retarded that a sale or termination of participation will not 9,334
take place, the facility shall provide notice to the department 9,335
at least forty-five days prior to entering into any contract of 9,336
sale or terminating participation at any future time. 9,337
(I) The department of human services shall pay each 9,339
eligible proprietary intermediate care facility for the mentally 9,340
retarded a return on the facility's net equity computed at the 9,341
rate of one and one-half times the average of interest rates on 9,342
special issues of public debt obligations issued to the federal 9,343
hospital insurance trust fund for the cost reporting period. No 9,344
facility's return on net equity paid under this division shall 9,345
exceed one dollar per patient day. 9,346
In calculating the rate for return on net equity, the 9,348
department shall use the greater of the facility's inpatient days 9,349
during the applicable cost reporting period or the number of 9,350
inpatient days the facility would have had during that period if 9,351
its occupancy rate had been ninety-five per cent. 9,352
(J)(1) EXCEPT AS PROVIDED IN DIVISION (J)(2) OF THIS 9,355
SECTION, IF A PROVIDER LEASES OR TRANSFERS AN INTEREST IN A 9,356
FACILITY TO ANOTHER PROVIDER WHO IS A RELATED PARTY, THE RELATED 9,358
PARTY'S ALLOWABLE COST OF OWNERSHIP SHALL INCLUDE THE LESSER OF 9,359
THE FOLLOWING:
(a) THE ANNUAL LEASE EXPENSE OR ACTUAL COST OF OWNERSHIP, 9,362
WHICHEVER IS APPLICABLE;
(b) THE REASONABLE COST TO THE LESSOR OR PROVIDER MAKING 9,365
THE TRANSFER.
203
(2) IF A PROVIDER LEASES OR TRANSFERS AN INTEREST IN A 9,367
FACILITY TO ANOTHER PROVIDER WHO IS A RELATED PARTY, REGARDLESS 9,368
OF THE DATE OF THE LEASE OR TRANSFER, THE RELATED PARTY'S 9,370
ALLOWABLE COST OF OWNERSHIP SHALL INCLUDE THE ANNUAL LEASE 9,371
EXPENSE OR ACTUAL COST OF OWNERSHIP, WHICHEVER IS APPLICABLE, 9,372
SUBJECT TO THE LIMITATIONS SPECIFIED IN DIVISIONS (B) TO (I) OF 9,374
THIS SECTION, IF ALL OF THE FOLLOWING CONDITIONS ARE MET: 9,375
(a) THE RELATED PARTY IS A RELATIVE OF OWNER; 9,378
(b) IN THE CASE OF A LEASE, IF THE LESSOR RETAINS ANY 9,380
OWNERSHIP INTEREST, IT IS IN ONLY THE REAL PROPERTY AND ANY 9,381
IMPROVEMENTS ON THE REAL PROPERTY; 9,382
(c) IN THE CASE OF A TRANSFER, THE PROVIDER MAKING THE 9,385
TRANSFER RETAINS NO OWNERSHIP INTEREST IN THE FACILITY; 9,386
(d) THE UNITED STATES INTERNAL REVENUE SERVICE HAS ISSUED 9,389
A RULING THAT THE LEASE OR TRANSFER IS AN ARM'S LENGTH
TRANSACTION FOR PURPOSES OF FEDERAL INCOME TAXATION; 9,390
(e) EXCEPT IN THE CASE OF HARDSHIP CAUSED BY A 9,393
CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT, OR IN THE 9,394
CASE OF A LESSOR OR PROVIDER MAKING THE TRANSFER WHO IS AT LEAST
SIXTY-FIVE YEARS OF AGE, NOT LESS THAN TWENTY YEARS HAVE ELAPSED 9,395
SINCE, FOR THE SAME FACILITY, ALLOWABLE COST OF OWNERSHIP WAS 9,396
DETERMINED MOST RECENTLY UNDER THIS DIVISION. 9,398
Sec. 5111.264. The EXCEPT AS PROVIDED IN SECTION 5111.25 9,407
OR 5111.251 OF THE REVISED CODE, THE costs of goods, services, 9,409
and facilities, furnished to a provider by a related party are 9,410
includable in the allowable costs of the provider at the 9,411
reasonable cost to the related party.
Sec. 5111.81. (A) There is hereby established the 9,420
pharmacy and therapeutics committee of the department of human 9,421
services. The committee shall consist of eight members and shall 9,422
be appointed by the director of human services. The membership 9,423
of the committee shall include: two pharmacists licensed under 9,424
Chapter 4729. of the Revised Code; two doctors of medicine and 9,425
two doctors of osteopathy licensed under Chapter 4731. of the
204
Revised Code; a registered nurse licensed under Chapter 4723. of 9,426
the Revised Code; and a pharmacologist who has a doctoral degree. 9,427
The committee shall elect one of its members as chairperson. 9,428
(B) In the absence of fraud or bad faith, neither the 9,430
pharmacy and therapeutics committee nor a current or former 9,431
member, agent, representative, employee, or independent 9,432
contractor of the committee shall be held liable in damages to a 9,433
person as the result of an act, omission, proceeding, conduct, or 9,434
decision relating to the official duties undertaken or performed 9,435
pursuant to this section, section 5111.811 of the Revised Code, 9,436
or rules promulgated pursuant to section 111.15 or Chapter 119. 9,437
of the Revised Code. If a current or former member, agent, 9,438
representative, employee, or independent contractor of the 9,440
committee requests the state to defend the current or former 9,441
member, agent, representative, employee, or independent
contractor against a claim or in an action arising out of an act, 9,442
omission, proceeding, conduct, or decision relating to official 9,444
duties undertaken or performed, if the request is made in writing 9,445
at a reasonable time before the trial of the claim or in the 9,446
action, and if the person requesting the defense cooperates in
good faith in the defense of the claim or action, the state shall 9,447
provide and pay for the defense of the claim or action and shall 9,448
pay any resulting judgment, compromise, or settlement. The state 9,449
shall not pay that part of a claim or judgment that is for 9,450
punitive or exemplary damages.
Sec. 5112.01. As used in sections 5112.02 to 5112.21 of 9,459
the Revised Code:
(A)(1) "Hospital" means a nonfederal hospital to which 9,461
either of the following applies: 9,462
(a) The hospital is registered under section 3701.07 of 9,464
the Revised Code as a general medical and surgical hospital or a 9,465
pediatric general hospital, and provides inpatient hospital 9,466
services, as defined in 42 C.F.R. 440.10; 9,467
(b) The hospital is recognized under the medicare program 9,469
205
established by Title XVIII of the "Social Security Act," 49 Stat. 9,471
620 (1935), 42 U.S.C.A. 301, as amended, as a cancer hospital and 9,473
is exempt from the medicare prospective payment system. 9,474
"Hospital" does not include a hospital operated by a health 9,476
maintenance organization INSURING CORPORATION that has been 9,477
issued a certificate of authority under section 1742.05 1751.05 9,479
of the Revised Code or a hospital that does not charge patients 9,481
for services.
(2) "Disproportionate share hospital" means a hospital 9,483
that meets the definition of a disproportionate share hospital in 9,484
rules adopted under section 5112.03 of the Revised Code. 9,485
(B) "Bad debt," "charity care," "courtesy care," and 9,487
"contractual allowances" have the same meanings given these terms 9,488
in regulations adopted under Title XVIII of the "Social Security 9,490
Act." 9,491
(C) "Cost reporting period" means the twelve-month period 9,493
used by a hospital in reporting costs for purposes of Title XVIII 9,495
of the "Social Security Act." 9,496
(D) "Governmental hospital" means a county hospital with 9,498
more than five hundred registered beds or a state-owned and 9,500
-operated hospital with more than five hundred registered beds. 9,501
(E) "Indigent care pool" means the sum of the following: 9,503
(1) The total of assessments to be paid in a program year 9,505
by all hospitals under section 5112.06 of the Revised Code, less 9,506
the assessments deposited into the legislative budget services 9,507
fund under section 5112.19 of the Revised Code; 9,509
(2) The total amount of intergovernmental transfers 9,511
required to be made in the same program year by governmental 9,512
hospitals under section 5112.07 of the Revised Code, less the 9,513
amount of transfers deposited into the legislative budget 9,515
services fund under section 5112.19 of the Revised Code; 9,516
(3) The total amount of federal matching funds that will 9,518
be made available in the same program year as a result of 9,519
payments the department of human services makes to hospitals 9,520
206
under section 5112.08 of the Revised Code. 9,521
(F) "Intergovernmental transfer" means any transfer of 9,523
money by a governmental hospital under section 5112.07 of the 9,524
Revised Code.
(G) "Medical assistance program" means the program of 9,526
medical assistance established under section 5111.01 of the 9,527
Revised Code and Title XIX of the "Social Security Act." 9,528
(H) "Program year" means a period beginning the first day 9,530
of October, or a later date designated in rules adopted under 9,531
section 5112.03 of the Revised Code, and ending the thirtieth day 9,532
of September, or an earlier date designated in rules adopted 9,533
under that section. 9,534
(I) "Registered beds" means the total number of hospital 9,536
beds registered with the department of health, as reported in the 9,537
most recent "directory of registered hospitals" published by the 9,538
department of health. 9,539
(J) "Total facility costs" means the total costs for all 9,541
services rendered to all patients, including the direct, 9,542
indirect, and overhead cost to the hospital of all services, 9,543
supplies, equipment, and capital related to the care of patients, 9,544
regardless of whether patients are enrolled in a health 9,545
maintenance organization INSURING CORPORATION, excluding costs 9,546
associated with providing skilled nursing services in 9,548
distinct-part nursing facility units, as shown on the hospital's 9,549
cost report filed under section 5112.04 of the Revised Code. 9,550
Effective October 1, 1993, if rules adopted under section 5112.03 9,551
of the Revised Code so provide, "total facility costs" may 9,552
exclude costs associated with providing care to recipients of any 9,553
of the governmental programs listed in division (B) of that 9,554
section.
(K) "Uncompensated care" means bad debt and charity care. 9,556
Sec. 5112.08. The director of human services shall adopt 9,565
rules under section 5112.03 of the Revised Code establishing a 9,566
methodology to pay hospitals that is sufficient to expend all 9,567
207
money in the indigent care pool. Under the rules: 9,568
(A) The department of human services shall classify 9,570
similar hospitals into groups and allocate funds for distribution 9,571
within each group. 9,572
(B) The department shall establish a method of allocating 9,574
funds to each group of hospitals, taking into consideration the 9,575
relative amount of indigent care provided by each group. The 9,576
amount to be allocated to each group shall be based on any 9,577
combination of the following indicators of indigent care that the 9,578
director considers appropriate: 9,579
(1) Total costs, volume, or proportion of services to 9,581
recipients of the medical assistance program, including 9,582
recipients enrolled in health maintenance organizations INSURING 9,583
CORPORATIONS; 9,584
(2) Total costs, volume, or proportion of services to 9,586
low-income patients in addition to recipients of the medical 9,587
assistance program, which may include recipients of Title V of 9,589
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 9,591
as amended, general assistance established under Chapter 5113. of 9,592
the Revised Code, and disability assistance established under 9,593
Chapter 5115. of the Revised Code; 9,594
(3) The amount of uncompensated care provided by the 9,596
hospitals; 9,597
(4) Other factors that the director considers to be 9,599
appropriate indicators of indigent care. 9,600
(C) The department shall distribute funds to hospitals in 9,602
each group in a manner that first may provide for an additional 9,603
payment to individual hospitals that provide a high proportion of 9,604
indigent care in relation to the total care provided by the 9,605
hospital or in relation to other hospitals. The department shall 9,606
establish a formula to distribute the remainder of the funds 9,607
allocated to the group to all hospitals in the group. The 9,608
formula shall be consistent with section 1923 of the "Social 9,609
Security Act," 42 U.S.C.A. 1396r-4, as amended, and shall be 9,612
208
based on any combination of the indicators of indigent care 9,613
listed in division (B) of this section that the director 9,615
considers appropriate.
(D) The department shall make payments to each hospital in 9,617
installments not later than ten working days after the deadline 9,618
established in rules for each hospital to pay an installment on 9,619
its assessment under section 5112.06 of the Revised Code. In the 9,620
case of a governmental hospital that makes intergovernmental 9,621
transfers, the department shall pay an installment under this 9,622
section not later than ten working days after the earlier of that 9,623
deadline or the deadline established in rules for the 9,624
governmental hospital to pay an installment on its 9,625
intergovernmental transfer. If the amount in the hospital care 9,626
assurance program fund and the hospital care assurance match fund 9,627
created under section 5112.18 of the Revised Code is insufficient 9,628
to make the total payments for which hospitals are eligible to 9,629
receive in any period, the department shall reduce the amount of 9,630
each payment by the percentage by which the amount is 9,631
insufficient. The department shall pay hospitals any amounts not 9,632
paid in the period in which they are due as soon as moneys are 9,633
available in the funds. 9,634
Sec. 5725.18. (A) An annual franchise tax on the 9,643
privilege of being an insurance company is hereby levied on each 9,644
domestic insurance company. In the month of May, annually, the 9,645
treasurer of state shall charge for collection from each domestic 9,646
insurance company a franchise tax in the amount computed in 9,647
accordance with the following, as applicable: 9,648
(1) With respect to a domestic insurance company that is a 9,651
health insuring corporation, one per cent of all premium rate 9,654
payments received, exclusive of payments received under the 9,655
medicare program established under Title XVIII of the "Social 9,658
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, 9,663
or pursuant to the medical assistance program established under 9,664
Chapter 5111. of the Revised Code, as reflected in its annual 9,667
209
report for the preceding calendar year;
(2) With respect to a domestic insurance company that is 9,670
not a health insuring corporation, one and four-tenths per cent 9,671
of the gross amount of premiums received from policies covering 9,673
risks within this state, EXCLUSIVE OF PREMIUMS RECEIVED UNDER THE 9,674
MEDICARE PROGRAM ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL 9,679
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, 9,683
OR PURSUANT TO THE MEDICAL ASSISTANCE PROGRAM ESTABLISHED UNDER 9,685
CHAPTER 5111. OF THE REVISED CODE, as reflected in its annual 9,688
statement for the preceding calendar year, AND, IF THE COMPANY 9,689
OPERATES A HEALTH INSURING CORPORATION AS A LINE OF BUSINESS, ONE 9,691
PER CENT OF ALL PREMIUM RATE PAYMENTS RECEIVED FROM THAT LINE OF 9,692
BUSINESS, EXCLUSIVE OF PAYMENTS RECEIVED UNDER THE MEDICARE 9,694
PROGRAM ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY 9,696
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, OR 9,698
PURSUANT TO THE MEDICAL ASSISTANCE PROGRAM ESTABLISHED UNDER 9,699
CHAPTER 5111. OF THE REVISED CODE, AS REFLECTED IN ITS ANNUAL 9,701
STATEMENT FOR THE PRECEDING CALENDAR YEAR.
(B) The gross amount of premium rate payments or premiums 9,704
used to compute the applicable tax in accordance with division 9,705
(A) of this section is subject to the deductions prescribed by 9,707
section 5729.03 of the Revised Code for foreign insurance 9,708
companies. The objects of such tax are those declared in section 9,709
5725.24 of the Revised Code, to which only such tax shall be 9,710
applied.
(C) In no case shall such tax be less than two hundred 9,713
fifty dollars.
Sec. 5729.03. (A) If the superintendent of insurance 9,722
finds the annual statement required by section 5729.02 of the 9,723
Revised Code to be correct, the superintendent shall compute the 9,725
following amount, as applicable, of the balance of such gross 9,726
amount, after deducting such return premiums and considerations 9,728
received for reinsurance, and charge such amount to such company 9,729
as a tax upon the business done by it in this state for the 9,730
210
period covered by such annual statement: 9,731
(1) If the company is a health insuring corporation, one 9,733
per cent of the balance of premium rate payments received, 9,734
exclusive of payments received under the medicare program 9,735
established under Title XVIII of the "Social Security Act," 49 9,736
Stat. 620 (1935), 42 U.S.C.A. 301, as amended, or pursuant to the 9,737
medical assistance program established under Chapter 5111. of the 9,738
Revised Code, as reflected in its annual report; 9,739
(2) If the company is not a health insuring corporation, 9,741
one and four-tenths per cent of the balance of premiums received, 9,742
EXCLUSIVE OF PREMIUMS RECEIVED UNDER THE MEDICARE PROGRAM 9,744
ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 9,750
STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, OR PURSUANT TO THE 9,752
MEDICAL ASSISTANCE PROGRAM ESTABLISHED UNDER CHAPTER 5111. OF THE 9,754
REVISED CODE, as reflected in its annual statement, AND, IF THE 9,757
COMPANY OPERATES A HEALTH INSURING CORPORATION AS A LINE OF 9,758
BUSINESS, ONE PER CENT OF THE BALANCE OF PREMIUM RATE PAYMENTS 9,759
RECEIVED FROM THAT LINE OF BUSINESS, EXCLUSIVE OF PAYMENTS 9,761
RECEIVED UNDER THE MEDICARE PROGRAM ESTABLISHED UNDER TITLE XVIII 9,762
OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 9,764
301, AS AMENDED, OR PURSUANT TO THE MEDICAL ASSISTANCE PROGRAM 9,765
ESTABLISHED UNDER CHAPTER 5111. OF THE REVISED CODE, AS REFLECTED 9,767
IN ITS ANNUAL STATEMENT. 9,768
(B) Any insurance policies that were not issued in 9,771
violation of Title XXXIX of the Revised Code and that were issued 9,772
prior to April 15, 1967, by a life insurance company organized 9,773
and operated without profit to any private shareholder or 9,774
individual, exclusively for the purpose of aiding educational or 9,775
scientific institutions organized and operated without profit to 9,776
any private shareholder or individual, are not subject to the tax 9,777
imposed by this section. All taxes collected pursuant to this 9,778
section shall be credited to the general revenue fund.
(C) In no case shall the tax imposed under this section be 9,780
less than two hundred fifty dollars. 9,781
211
Section 2. That existing sections 1701.03, 1705.03, 9,783
1705.04, 1705.53, 1739.01, 1751.01, 1751.02, 1751.03, 1751.05, 9,785
1751.06, 1751.11, 1751.12, 1751.13, 1751.14, 1751.15, 1751.16,
1751.20, 1751.31, 1751.32, 1751.46, 1751.55, 1751.58, 1751.59, 9,786
1751.60, 1751.62, 1751.81, 1785.01, 1785.02, 1785.03, 1785.08, 9,787
1907.161, 2305.252, 3701.75, 3901.21, 3901.38, 3917.01, 3917.06, 9,788
3923.021, 3923.122, 3923.57, 3923.571, 3923.58, 3924.01, 3924.03, 9,792
3924.033, 3924.08, 3924.09, 3924.10, 3924.11, 3924.13, 3999.22, 9,793
4715.22, 4715.39, 4723.16, 4725.114, 4729.161, 4731.226, 4731.65, 9,795
4732.28, 4734.091, 4755.471, 5111.25, 5111.251, 5111.264, 9,796
5111.81, 5112.01, 5112.08, 5725.18, and 5729.03 and sections 9,798
3924.05, 5111.75, 5111.77, 5111.771, and 5111.811 of the Revised 9,800
Code are hereby repealed. 9,801
Section 3. That Section 3 of Am. Sub. S.B. 67 of the 122nd 9,803
General Assembly be amended to read as follows: 9,804
"Sec. 3. (A) The certificate of authority of every 9,806
prepaid dental plan organization, health care corporation, dental 9,807
care corporation, and health maintenance organization licensed to 9,809
operate under Chapter 1736., 1738., 1740., or 1742. of the 9,811
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 9,814
Chapter 1751. of the Revised Code. All assets and liabilities of 9,815
the prepaid dental plan organization, health care corporation, 9,816
dental care corporation, or health maintenance organization, 9,817
including all obligations under subscriber contracts delivered, 9,818
issued for delivery, or renewed prior to the effective date of 9,819
this section JUNE 4, 1997, shall be assumed by the successor 9,821
entity. Except as otherwise provided in division (B) of this 9,822
section, such entity shall, no later than January 1, 1998, comply 9,823
with Chapter 1751. of the Revised Code. 9,824
(B)(1) Each entity described in division (A) of this 9,826
section shall do both of the following: 9,827
(a) Comply with sections 1751.19 and 1751.26 of the 9,830
Revised Code no later than six months after the effective date of
212
this section JUNE 4, 1997. 9,832
(b) Comply with section 1751.28 of the Revised Code by 9,835
making annual deposits with the Superintendent of Insurance, no 9,836
later than the first day of January of each year, for up to three 9,837
years, beginning the first day of January immediately following 9,838
the effective date of this section INCREASING THE ENTITY'S NET 9,840
WORTH, ON THE FIRST DAY OF JANUARY IN EACH OF THE YEARS 1998, 9,841
1999, AND 2000, BY AN AMOUNT EQUAL TO AT LEAST ONE-THIRD OF ANY 9,843
DIFFERENCE BETWEEN THE ENTITY'S NET WORTH AS OF JUNE 4, 1997, AND 9,845
THE NET WORTH REQUIRED BY SECTION 1751.28 OF THE REVISED CODE. 9,846
EACH ENTITY SHALL ATTAIN THE NET WORTH REQUIRED BY SECTION 9,847
1751.28 OF THE REVISED CODE NO LATER THAN JANUARY 1, 2000. 9,849
(2) Every contract delivered, issued for delivery, or 9,851
renewed by an entity described in division (A) of this section 9,852
prior to the effective date of this section JUNE 4, 1997, shall 9,854
comply with section 1751.13 of the Revised Code no later than the 9,856
contract's first renewal date after the first day of January 9,857
immediately following the effective date of this section JUNE 4, 9,859
1997.
(3) Every contract delivered, issued for delivery, or 9,862
renewed by an entity described in division (A) of this section 9,863
prior to the effective date of this section JUNE 4, 1997, shall 9,864
comply with section 1751.31 of the Revised Code no later than 9,866
three months after the effective date of this section JUNE 4, 9,867
1997.
(4) An entity described in division (A) of this section 9,869
may comply with section 1751.27 of the Revised Code by making 9,870
annual deposits with the Superintendent of Insurance, not later 9,871
than the first day of January of each year, for up to three years 9,872
beginning the first day of January immediately following the 9,873
effective date of this section JUNE 4, 1997. An equal amount 9,875
shall be deposited each year until the total amount required 9,877
under section 1751.27 of the Revised Code has been deposited." 9,878
Section 4. That existing Section 3 of Am. Sub. S.B. 67 of 9,880
213
the 122nd General Assembly is hereby repealed. 9,881
Section 5. That Section 6 of Am. Sub. S.B. 154 of the 9,883
122nd General Assembly be amended to read as follows: 9,884
"Sec. 6. The Insurance Agent Education Advisory Council 9,888
operating pursuant to section 3905.483 of the Revised Code shall 9,889
create a temporary committee to conduct a special study of the 9,890
continuing education requirements for insurance agents as set 9,891
forth in the Revised Code and the Administrative Code. The 9,892
committee shall be composed of the eleven members of the 9,893
Insurance Agent Education Advisory Council appointed by the 9,894
Superintendent of Insurance pursuant to section 3905.483 of the 9,895
Revised Code; A REPRESENTATIVE, APPOINTED BY THE GOVERNOR, OF THE 9,896
ASSOCIATION OF FRATERNAL INSURANCE COUNSELORS; a representative, 9,897
appointed by the Governor, of private entities engaged in the 9,899
business of providing continuing education to agents; a 9,900
representative, appointed by the Governor, of financial 9,901
institutions; two members of the House of Representatives, one 9,902
from each party, appointed by the Speaker of the House of 9,903
Representatives; and two members of the Senate, one from each 9,904
party, appointed by the President of the Senate. The 9,905
Superintendent or the Superintendent's designee shall serve on 9,906
the committee as a nonvoting member. 9,907
The committee shall hold an organizational meeting within 9,909
thirty days after the effective date of this section JUNE 30, 9,911
1998. At the organizational meeting, the voting members of the
committee shall elect a chairperson and a vice-chairperson for 9,912
the committee. The committee shall meet at the call of the 9,913
chairperson. 9,914
The committee shall study all aspects of the continuing 9,916
education requirements for insurance agents as set forth in the 9,917
Revised Code and the Administrative Code, and shall be charged 9,918
with providing findings and recommendations on how any aspect of 9,919
these requirements may be improved. 9,920
The study shall include, but is not limited to, an 9,922
214
examination of issues related to the following questions: 9,923
(A) Will a reduction in the biennial continuing education 9,926
requirement satisfy the continuing education requirements imposed 9,927
by other states on nonresident agents? 9,928
(B) What are the best methods for assuring the quality of 9,931
continuing education courses and programs of study? 9,932
(C) Is the Superintendent of Insurance's annual approval 9,935
of a continuing education course or program of study necessary if 9,936
there is no change in the course's or program's curriculum, or 9,937
could a course or program of study be approved for a longer 9,938
period of time?
(D) Could the process of approval for continuing education 9,941
courses and programs of study be streamlined, to provide for a 9,942
more timely and efficient process of approval? 9,943
(E) Should an agent receive continuing education credit 9,946
for completing courses or programs of study that pertain to 9,947
subjects outside of the agent's area of practice or licensure? 9,948
(F) What is the optimal number of hours of instruction a 9,951
statutory continuing education requirement should require agents 9,952
to complete?
(G) Should continuing education requirements include a 9,955
minimum number of hours of courses or programs of study on 9,956
ethics?
(H) Should the completion of a correspondence course, 9,959
which course requires the successful completion of a test on the 9,960
course material, be an optional method for an agent's fulfillment 9,961
of continuing education requirements? 9,962
(I) Should minimum requirements be established for 9,965
instructors of continuing education courses, such as minimum 9,966
industry experience and a current agent's license? 9,967
(J) Should an agent be limited as to the number of hours 9,970
of continuing education credit that the agent may earn from 9,971
private providers and associations or from insurance companies, 9,972
as a percentage of the total number of hours of continuing 9,973
215
education credit that the agent earns, or is permitted to earn, 9,974
during a single compliance period?
(K) Should an agent receive continuing education credit 9,977
for completing sales-related courses or programs of study? 9,978
(L) Should an agent's receipt of any special designation 9,981
exempt the agent from the completion of further continuing 9,982
education requirements?
(M) Has the continuing education requirement improved the 9,985
quality of licensed insurance agents?
(N) Would a system in which agents certified their 9,987
compliance with continuing education requirements to the 9,988
Superintendent, which system included a program of random 9,989
verification of agent compliance by the Department of Insurance, 9,990
be a feasible alternative to the current system of continuing 9,991
education compliance verification? 9,992
The committee shall hold a sufficient number of public 9,994
hearings outside of Franklin County to provide interested parties 9,995
throughout the state a chance to voice their opinions and make 9,996
recommendations with regard to the continuing education 9,997
requirements for insurance agents. 9,998
The committee shall issue an interim report within nine 10,000
months after the effective date of this section JUNE 30, 1998. 10,002
The committee shall issue its final report within eighteen months 10,003
after the effective date of this section JUNE 30, 1998. Copies 10,004
of the interim and the final reports shall be submitted, at the 10,005
time of their issuance, to the Speaker of the House of
Representatives, to the President of the Senate, to the Governor, 10,007
to the chair of the House committee having primary jurisdiction 10,008
over insurance legislation, to the chair of the Senate committee 10,009
having primary jurisdiction over insurance legislation, to the 10,010
Superintendent of Insurance, and to the Insurance Agent Education 10,011
Advisory Council. The committee may request staff assistance 10,012
from the Legislative Service Commission as needed for the 10,013
completion of the reports. Upon the issuance of its final 10,014
216
report, the committee shall cease to exist." 10,015
Section 6. That existing Section 6 of Am. Sub. S.B. 154 of 10,017
the 122nd General Assembly is hereby repealed. 10,018
Section 7. That Section 194 of Am. Sub. H.B. 215 of the 10,021
122nd General Assembly be amended to read as follows: 10,022
"Sec. 194. Insurance Tax Phase-in Schedules 10,024
Sections 1731.07, 5725.18, 5725.181, 5729.03, and 5729.031 10,026
of the Revised Code, as amended or enacted by this act AM. SUB. 10,028
H.B. 215 OR SUB. H.B. 698 OF THE 122nd GENERAL ASSEMBLY, shall 10,030
first apply to tax year 1999 and shall be implemented according 10,031
to the following schedule: 10,032
(A) For tax years 1999 through 2002, the tax imposed under 10,034
section 5729.03 of the Revised Code on the gross premiums of 10,035
foreign insurance companies that are not health insuring 10,036
corporations shall be EQUAL THE SUM OF THE AMOUNTS computed UNDER 10,038
DIVISIONS (A)(1) AND (2) OF THIS SECTION. 10,039
(1) WITH RESPECT TO THE GROSS PREMIUMS OF THE COMPANY, 10,041
EXCLUSIVE OF PREMIUMS RECEIVED UNDER MEDICARE OR MEDICAID, THE 10,043
AMOUNT COMPUTED using the following rates: 10,044
The percentage of 10,047
For Tax Year premiums is 10,048
1999 2.3% 10,049
2000 2.09% 10,050
2001 1.84% 10,051
2002 1.62% 10,052
(2) WITH RESPECT TO PREMIUM RATE PAYMENTS RECEIVED BY THE 10,056
COMPANY, EXCLUSIVE OF PAYMENTS RECEIVED UNDER MEDICARE OR 10,058
MEDICAID, IF THE COMPANY OPERATES A HEALTH INSURING CORPORATION 10,059
AS A LINE OF BUSINESS, THE AMOUNT COMPUTED USING THE FOLLOWING 10,060
RATES:
THE PERCENTAGE OF PREMIUM 10,063
FOR TAX YEAR RATE PAYMENTS IS 10,066
1999 .21% 10,067
2000 .42% 10,068
217
2001 .60% 10,069
2002 .80% 10,070
(B) For tax years 1999 through 2002, the tax imposed under 10,073
section 5725.18 of the Revised Code on domestic insurance 10,074
companies that are not health insuring corportaions CORPORATIONS 10,075
shall equal the sum of the amounts computed under division 10,076
DIVISIONS (B)(1) and (2) of this section. 10,077
(1) The tax computed according to the method prescribed in 10,079
section 5725.181 of the Revised Code, as enacted by this act AM. 10,081
SUB. H.B. 215 OF THE 122nd GENERAL ASSEMBLY, multiplied by the 10,082
percentage prescribed as follows: 10,083
Multiply the tax under 10,085
section 5725.181 of 10,086
For Tax Year the Revised Code by 10,087
1999 79% 10,088
2000 58% 10,089
2001 40% 10,090
2002 20% 10,091
(2) The tax computed using ACCORDING TO the percentage of 10,094
gross premiums METHOD prescribed by IN section 5725.18 of the 10,096
Revised Code, as amended by this act SUB. H.B. 698 OF THE 122nd 10,098
GENERAL ASSEMBLY, multiplied by the percentage prescribed as 10,099
follows:
Multiply the tax 10,101
under amended section 10,102
5725.18 of the 10,103
For Tax Year Revised Code by 10,104
1999 21% 10,105
2000 42% 10,106
2001 60% 10,107
2002 80% 10,108
(C) For tax years 1999 through 2002, the tax imposed under 10,112
sections 5725.18 and 5729.03 of the Revised Code on domestic and
foreign insurance companies that are health insuring corporations 10,113
218
shall be computed using the following rates: 10,114
10,116
The percentage of premium
10,118
For Tax Year rate payments is
10,119
1999 .21%
10,120
2000 .42%
10,121
2001 .60%
10,122
2002 .80%
(D) For tax years 1999 through 2002, the minimum tax for 10,124
domestic insurance companies taxed under sections 5725.18 and 10,125
5725.181 of the Revised Code, the minimum tax for foreign 10,126
insurance companies taxed under section 5729.03 of the Revised 10,127
Code, and the minimum tax for COMPANIES THAT ARE health insuring 10,128
corporations taxed under those sections shall equal the amount 10,129
prescribed as follows:
For Tax Year The minimum tax is 10,131
1999 $50 10,132
2000 $100 10,133
2001 $150 10,134
2002 $200 10,135
(E) For tax years 1999 through 2002, the credit available 10,137
under section 5729.031 of the Revised Code may be claimed against 10,138
the tax imposed on foreign insurance companies as computed under 10,139
division (A) of this section, against the tax imposed on domestic 10,140
insurance companies as computed under division (B) of this 10,141
section, or against the tax imposed on COMPANIES THAT ARE health 10,142
insuring corporations as computed under division (C) of this
section. The credit shall equal a percentage of the amount 10,144
computed under division (C) of section 5729.031 of the Revised
219
Code according to the following schedule: 10,145
Percentage of 10,147
For Tax Year credit allowed 10,148
1999 20% 10,149
2000 40% 10,150
2001 60% 10,151
2002 80% 10,152
As used in this section, "health insuring corporation" has 10,155
the same meaning as in section 1751.01 of the Revised Code, and 10,156
"tax year" means the calendar year in which the tax imposed on 10,157
the insurance company or health insuring corporation is charged." 10,158
Section 8. That existing Section 194 of Am. Sub. H.B. 215 10,160
of the 122nd General Assembly is hereby repealed. 10,161
Section 9. Pursuant to the authority granted under section 10,163
3905.29 of the Revised Code, the Superintendent of Insurance 10,164
shall modify the forms on which annual financial statements are 10,165
submitted by domestic and foreign insurance companies to include, 10,167
as a separate item, the amount of premium rate payments received, 10,168
exclusive of payments received under Medicare or Medicaid, by any 10,169
such insurance company that operates a health insuring 10,170
corporation as a line of business.
Section 10. (A) Until November 1, 1999, the Director of 10,173
Health shall not adopt any rule, whether by adopting, amending, 10,174
or rescinding a rule or by submitting a rule for review under 10,175
section 119.032 of the Revised Code, that has the effect of 10,176
allowing cardiac catheterization to be performed without an 10,177
on-site open-heart surgery service.
(B) In 1999, the Director of Health shall appear three 10,180
times before the standing committee of the House of
Representatives that primarily deals with health matters and the 10,181
standing committee of the Senate that primarily deals with health 10,183
matters to report on the progress of the Department of Health in 10,184
collecting statewide and national data on the outcomes of cardiac 10,185
catheterization performed without an on-site open-heart surgery 10,186
220
service. The first appearance before each committee shall be 10,187
made not later than April 1, 1999. The second appearance shall 10,188
be made not sooner than 30 days after the first appearance, but 10,189
not later than June 1, 1999. The third appearance shall be made 10,190
not sooner than 30 days after the second appearance, but not 10,191
later than October 1, 1999. At the third appearance, the 10,192
Director shall make a final report on the Department's findings. 10,193
The Director shall submit a written copy of the report to the 10,194
Speaker of the House of Representatives and the President of the 10,195
Senate. 10,196
Section 11. For purposes of determining whether a dental 10,198
hygienist has met the experience requirements specified in 10,199
division (C)(1) of section 4715.22 of the Revised Code, as 10,200
amended by this act, all experience that the dental hygienist
obtained prior to the effective date of this act shall be 10,201
counted.
Section 12. Sections 3701.18 and 4503.104 of the Revised 10,203
Code, as enacted by this act, shall take effect on the first day 10,204
of the month that follows the month that includes the day that is 10,205
the ninetieth day after the effective of this act. 10,206
Section 13. The amendment of sections 5112.01 and 5112.08 10,208
of the Revised Code by this act is not intended to supersede the 10,209
repeal of those sections effective July 1, 1999. 10,210
Section 14. The repeal of sections 5111.75, 5111.77, 10,212
5111.771, and 5111.811 of the Revised Code is intended to confirm 10,213
that such repeal was the result intended by the General Assembly 10,214
in enacting Am. Sub. S.B. 62 and Am. Sub. S.B. 150 of the 121st 10,215
General Assembly. The earlier of the two acts, Am. Sub. S.B. 62, 10,216
repealed the sections in pursuance of its specific purpose of
abolishing the Legislative Committee on Medicaid Oversight. The 10,217
later of the two acts, Am. Sub. S.B. 150, purportedly amended the 10,218
sections as they related to its general purpose of revising the 10,219
health care and insurance laws. The later act, Am. Sub. S.B. 10,220
150, did not have a purpose sufficiently independent from that of 10,221
221
Am. Sub. S.B. 62 such as to revive the sections.
Section 15. Section 3901.21 of the Revised Code is 10,223
presented in this act as a composite of the section as amended by 10,224
both Sub. H.B. 374 and Am. Sub. S.B. 70 of the 122nd General 10,225
Assembly, with the language of neither of the acts shown in 10,226
capital letters. Section 3924.08 of the Revised Code is
presented in this act as a composite of the section as amended by 10,228
both Sub. H.B. 374 and Am. Sub. S.B. 67 of the 122nd General 10,229
Assembly, with the new language of neither of the acts shown in 10,232
capital letters. This is in recognition of the principle stated 10,233
in division (B) of section 1.52 of the Revised Code that such 10,234
amendments are to be harmonized where not substantively 10,235
irreconcilable and constitutes a legislative finding that such is 10,236
the resulting version in effect prior to the effective date of 10,237
this act.