As Introduced 1
122nd General Assembly 4
Regular Session S. B. No. 67 5
1997-1998 6
SENATOR GILLMOR 8
10
A B I L L
To amend sections 101.271, 124.81, 124.82, 124.822, 12
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 13
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 14
742.45, 742.53, 1319.12, 1337.16, 1545.071, 15
1731.01, 1731.06, 1739.05, 1901.111, 1901.312,
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 16
3113.217, 3307.74, 3307.741, 3309.69, 3309.691, 17
3313.202, 3375.40, 3381.14, 3501.141, 3701.24, 18
3701.76, 3702.51, 3702.62, 3709.16, 3729.12,
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 19
3901.19, 3901.31, 3901.32, 3901.38, 3901.40, 21
3901.41, 3901.48, 3901.72, 3902.01, 3902.02,
3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 22
3923.30, 3923.301, 3923.33, 3923.333, 3923.38, 24
3923.382, 3923.41, 3923.51, 3923.54, 3923.58,
3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 26
3924.13, 3924.41, 3924.61, 3924.62, 3924.64,
3924.73, 3929.77, 3956.01, 3959.01, 3999.32, 27
3999.36, 4582.041, 4582.29, 4715.02, 4719.01, 28
4729.381, 4731.67, 5111.02, 5111.17, 5111.171,
5111.19, 5111.74, 5115.10, 5119.01, 5119.202, 30
5505.28, 5505.33, and 5923.051; to enact sections 31
1751.01 to 1751.08, 1751.11 to 1751.21, 1751.25 32
to 1751.28, 1751.31 to 1751.36, 1751.38, 1751.40,
1751.42, 1751.44 to 1751.48, 1751.51 to 1751.56, 33
1751.59 to 1751.67, 1751.70, and 1751.71; and to 35
repeal sections 1736.01, 1736.02, 1736.03,
1736.04, 1736.05, 1736.06, 1736.07, 1736.08, 37
2
1736.09, 1736.10, 1736.11, 1736.12, 1736.13, 38
1736.14, 1736.15, 1736.16, 1736.17, 1736.18,
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 39
1736.24, 1736.25, 1736.26, 1736.27, 1736.28, 41
1737.01, 1737.02, 1737.03, 1737.04, 1737.05,
1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 42
1737.11, 1737.12, 1737.13, 1737.14, 1737.15, 44
1737.16, 1737.17, 1737.18, 1737.19, 1737.20, 45
1737.21, 1737.22, 1737.23, 1737.24, 1737.25,
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 46
1737.301, 1737.31, 1737.32, 1737.99, 1738.01, 48
1738.02, 1738.03, 1738.04, 1738.05, 1738.06,
1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 49
1738.12, 1738.13, 1738.14, 1738.15, 1738.16, 51
1738.17, 1738.18, 1738.19, 1738.20, 1738.21, 52
1738.22, 1738.23, 1738.24, 1738.25, 1738.26,
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 53
1738.99, 1740.01, 1740.02, 1740.03, 1740.04, 55
1740.05, 1740.06, 1740.07, 1740.08, 1740.09,
1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 56
1740.15, 1740.16, 1740.17, 1740.18, 1740.19, 58
1740.20, 1740.21, 1740.22, 1740.23, 1740.24, 59
1740.25, 1740.26, 1740.99, 1742.01, 1742.02,
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 60
1742.08, 1742.09, 1742.10, 1742.11, 1742.12, 61
1742.13, 1742.131, 1742.14, 1742.141, 1742.15,
1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 62
1742.19, 1742.20, 1742.21, 1742.22, 1742.23, 63
1742.24, 1742.25, 1742.26, 1742.27, 1742.28, 64
1742.29, 1742.30, 1742.301, 1742.31, 1742.32,
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 65
1742.37, 1742.38, 1742.39, 1742.40, 1742.41, 66
1742.42, 1742.43, 1742.44, and 1742.45 of the
Revised Code to provide for the establishment, 67
3
operation, and regulation of health insuring 68
corporations; to repeal the laws governing
prepaid dental plan organizations, medical care 69
corporations, health care corporations, dental 70
care corporations, and health maintenance 71
organizations; and to eliminate certain
provisions of this act on and after February 9, 73
2004, by repealing section 1751.64 of the Revised
Code on that date. 74
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 76
Section 1. That sections 101.271, 124.81, 124.82, 124.822, 78
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 305.171, 79
306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 1319.12, 80
1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 1901.312, 81
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 3307.74, 82
3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 83
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 84
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 85
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 86
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 87
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 88
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 89
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 91
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 92
4719.01, 4729.381, 4731.67, 5111.02, 5111.17, 5111.171, 5111.19,
5111.74, 5115.10, 5119.01, 5119.202, 5505.28, 5505.33, and 94
5923.051 be amended and sections 1751.01, 1751.02, 1751.03, 95
1751.04, 1751.05, 1751.06, 1751.07, 1751.08, 1751.11, 1751.12, 96
1751.13, 1751.14, 1751.15, 1751.16, 1751.17, 1751.18, 1751.19, 97
1751.20, 1751.21, 1751.25, 1751.26, 1751.27, 1751.28, 1751.31, 99
1751.32, 1751.33, 1751.34, 1751.35, 1751.36, 1751.38, 1751.40, 100
1751.42, 1751.44, 1751.45, 1751.46, 1751.47, 1751.48, 1751.51, 101
1751.52, 1751.53, 1751.54, 1751.55, 1751.56, 1751.59, 1751.60, 102
4
1751.61, 1751.62, 1751.63, 1751.64, 1751.65, 1751.66, 1751.67, 103
1751.70, and 1751.71 of the Revised Code be enacted to read as 105
follows:
Sec. 101.271. (A) As used in this section, "medical 114
insurance premium" means any premium payment made under a 115
contract with an insurance company, nonprofit health plan, health 116
care INSURING corporation, health maintenance organization, or 118
any combination of such organizations, pursuant to section 124.82 119
of the Revised Code. 120
(B) After the general election in each even-numbered year, 122
the clerk of the senate, with the assistance of the department of 123
administrative services, shall estimate the cost of the medical 124
insurance premiums that will be necessary to provide coverage, on 125
the same basis as for a similarly situated state employee, for 126
each person who is elected to a term as senator at such election, 127
or appointed to fill the unexpired portion of any such term, and 128
any of his THE SENATOR'S dependents qualified for coverage at the 130
time he THE SENATOR assumes office. Using this estimate, the 131
clerk shall determine a fixed amount to be paid by the state in 132
equal monthly installments on behalf of the senator each year of 133
his THE SENATOR'S term as a medical insurance premium, but in no 134
event in an amount to exceed the total premium required in any 136
month by the contract of the state by the carrier. Any amount 137
not paid in such a case shall be placed in reserve and applied 138
against any subsequent month's premium up to the full amount 139
thereof until the entire amount has been paid along with the 140
original estimate for each month. This fixed amount shall be 141
such that, as nearly as can be predicted, the sum of the monthly 142
premiums paid for the senator during his THE SENATOR'S term shall 144
equal the total amount of medical insurance premiums that will be 145
paid for such an employee, as required by section 124.82 of the 146
Revised Code, during that term. The senator shall pay the 147
difference between the amount so fixed and the total premium 148
required by the contract of the state with the carrier.
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(C) After the general election in each even-numbered year, 150
the executive secretary of the house of representatives, with the 151
assistance of the department of administrative services, shall 152
estimate the cost of the medical insurance premiums that will be 153
necessary to provide coverage, on the same basis as for a 154
similarly situated state employee, for each person who is elected 155
to a term as representative at such election, or appointed to 156
fill the unexpired portion of any such term, and any of his THE 157
REPRESENTATIVE'S dependents qualified for coverage at the time he 158
THE REPRESENTATIVE assumes office. Using this estimate, the 159
executive secretary shall determine a fixed amount to be paid by 160
the state in equal monthly installments on behalf of the 162
representative each year of his THE REPRESENTATIVE'S term as a 164
medical insurance premium, but in no event in an amount to exceed 165
the total premium required in any month by the contract of the 166
state with the carrier. Any amount not paid in such a case shall 167
be placed in reserve and applied against any subsequent month's 168
premium up to the full amount thereof until the entire reserve 169
has been paid along with the original estimate for each month. 170
This fixed amount shall be such that, as nearly as can be 171
predicted, the sum of the monthly premiums paid for the
representative during his THE REPRESENTATIVE'S term shall equal 172
the total amount of medical insurance premiums that will be paid 174
for such an employee, as required by section 124.82 of the 175
Revised Code, during that term. The representative shall pay the 176
difference between the amount so fixed and the total premium 177
required by the contract of the state with the carrier. 178
Sec. 124.81. (A) Except as provided in division (E) of 187
this section, the department of administrative services in 188
consultation with the superintendent of insurance shall negotiate 189
with and, in accordance with the competitive selection procedures 190
of Chapter 125. of the Revised Code, contract with one or more 191
insurance companies authorized to do business in this state, for 192
the issuance of one of the following: 193
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(1) A policy of group life insurance covering all state 195
employees who are paid directly by warrant of the state auditor, 196
including elected state officials; 197
(2) A combined policy, or coordinated policies of one or 199
more insurance companies, medical care corporations, health care 200
corporations, dental care corporations, or health maintenance 201
INSURING corporations in combination with one or more insurance 202
companies providing group life and health, medical, hospital, 204
dental, or surgical insurance, or any combination thereof, 205
covering all such employees; 206
(3) A policy that may include, but is not limited to, 208
hospitalization, surgical, major medical, dental, vision, and 209
medical care, disability, hearing aids, prescription drugs, group 210
life, life, sickness, and accident insurance, group legal 211
services, or a combination of the above benefits for some or all 212
of the employees paid in accordance with section 124.152 of the 213
Revised Code and for some or all of the employees listed in 214
divisions (B)(2) and (4) of section 124.14 of the Revised Code, 215
and their immediate dependents. 216
(B) If a state employee uses all accumulated sick leave 219
and then goes on an extended medical disability, the policyholder 220
shall continue at no cost to the employee the coverage of the 221
group life insurance for such employee for the period of such 222
extended leave, but not beyond three years.
(C) If a state employee insured under a group life 225
insurance policy as provided in division (A) of this section is 226
laid off pursuant to section 124.32 of the Revised Code, such
employee by request to the policyholder, made no later than the 227
effective date of the layoff, may elect to continue the 228
employee's group life insurance for the one-year period through 229
which the employee may be considered to be on laid-off status by 230
paying the policyholder through payroll deduction or otherwise 232
twelve times the monthly premium computed at the existing average 233
rate for the group life case for the amount of the employee's 234
7
insurance thereunder at the time of the employee's layoff. The 236
policyholder shall pay the premiums to the insurance company at 238
the time of the next regular monthly premium payment for the 239
actively insured employees and furnish the company appropriate 240
data as to such laid-off employees. At the time an employee 241
receives written notice of a layoff, the policyholder shall also 242
give such employee written notice of the opportunity to continue 243
group life insurance in accordance with this division. When such 245
laid-off employee is reinstated for active work before the end of 246
the one-year period, the employee shall be reclassified as 248
insured again as an active employee under the group and 249
appropriate refunds for the number of full months of unearned 250
premium payment shall be made by the policyholder.
(D) This section does not affect the conversion rights of 252
an insured employee when the employee's group insurance 253
terminates under the policy. 254
(E) Notwithstanding division (A) of this section, the 256
department may provide benefits equivalent to those that may be 257
paid under a policy issued by an insurance company, or the 258
department may, to comply with a collectively bargained contract, 259
enter into an agreement with a jointly administered trust fund 260
which receives contributions pursuant to a collective bargaining 261
agreement entered into between this state, or any of its 262
political subdivisions, and any collective bargaining 263
representative of the employees of this state or any political 264
subdivision for the purpose of providing for self-insurance of 265
all risk in the provision of fringe benefits similar to those 266
that may be paid pursuant to division (A) of this section, and 267
the jointly administered trust fund may provide through the 268
self-insurance method specific fringe benefits as authorized by 269
the rules of the board of trustees of the jointly administered 270
trust fund. Amounts from the fund may be used to pay direct and 271
indirect costs that are attributable to consultants or a 272
third-party administrator and that are necessary to administer 273
8
this section. Benefits provided under this section include, but 274
are not limited to, hospitalization, surgical care, major medical 275
care, disability, dental care, vision care, medical care, hearing 276
aids, prescription drugs, group life insurance, sickness and 277
accident insurance, group legal services, or a combination of the 278
above benefits, for the employees and their immediate dependents. 279
(F) Notwithstanding any other provision of the Revised 281
Code, any public employer, including the state, and any of its 282
political subdivisions, including, but not limited to, any 283
county, county hospital, municipal corporation, township, park 284
district, school district, state institution of higher education, 285
public or special district, state agency, authority, commission, 286
or board, or any other branch of public employment, and any 287
collective bargaining representative of employees of the state or 288
any political subdivision may agree in a collective bargaining 289
agreement that any mutually agreed fringe benefit including, but 290
not limited to, hospitalization, surgical care, major medical 291
care, disability, dental care, vision care, medical care, hearing 292
aids, prescription drugs, group life insurance, sickness and 293
accident insurance, group legal services, or a combination 294
thereof, for employees and their dependents be provided through a 295
mutually agreed upon contribution to a jointly administered trust 296
fund. Amounts from the fund may be used to pay direct and 297
indirect costs that are attributable to consultants or a 298
third-party administrator and that are necessary to administer 299
this section. The amount, type, and structure of fringe benefits 301
provided under this division is subject to the determination of 302
the board of trustees of the jointly administered trust fund. 303
Notwithstanding any other provision of the Revised Code, 304
competitive bidding does not apply to the purchase of fringe 305
benefits for employees under this division through a jointly 306
administered trust fund. 307
Sec. 124.82. (A) Except as provided in division (D) of 316
this section, the department of administrative services, in 317
9
consultation with the superintendent of insurance, shall, in 318
accordance with competitive selection procedures of Chapter 125. 319
of the Revised Code, contract with an insurance company or a 321
nonprofit health plan in combination with an insurance company, 322
authorized to do business in this state, for the issuance of a 323
policy or contract of health, medical, hospital, dental, or 324
surgical benefits, or any combination thereof, covering state 325
employees who are paid directly by warrant of the auditor of 326
state, including elected state officials. The department may 327
fulfill its obligation under this division by exercising its 328
authority under division (A)(2) of section 124.81 of the Revised 329
Code.
(B) The department may, in addition, in consultation with 331
the superintendent of insurance, negotiate and contract with 332
health care INSURING corporations organized HOLDING A CERTIFICATE 334
OF AUTHORITY under Chapter 1738. 1751. of the Revised Code, in 335
their APPROVED service areas only, for issuance of any policy or 336
policies or contract or contracts of health, medical, hospital, 337
dental, or surgical benefits, or any combination thereof, or with 338
health maintenance organizations organized under Chapter 1742. of 339
the Revised Code, in their service areas only, for issuance of a 340
contract or contracts of health care services, covering state 341
employees who are paid directly by warrant of the auditor of 342
state, including elected state officials. Except for health care 343
corporation and health maintenance organization plans INSURING 344
CORPORATIONS, no more than one insurance carrier or nonprofit 345
health plan, shall be contracted with to provide the same plan of 347
benefits, provided that:
(1) The amount of the premium or cost for such coverage 349
contributed by the state, for an individual or for an individual 350
and his THE INDIVIDUAL'S family, does not exceed that same amount 352
of the premium or cost contributed by the state under division 353
(A) of this section; 354
(2) The employee be permitted to exercise his THE option 356
10
as to which plan he THE EMPLOYEE will select under division (A) 357
or (B) of this section, at a set time each year, which time shall 359
be determined by the department; 360
(3) The health care INSURING corporations or the health 362
maintenance organizations do not refuse to accept the employee, 363
or the employee and his THE EMPLOYEE'S family, if he THE EMPLOYEE 365
exercises the option to select care provided by the corporations 366
or organizations;
(4) The employee may choose participation in only one of 368
the plans sponsored by the department; 369
(5) The director of health examines and certifies to the 371
department that the quality and adequacy of care rendered by the 372
health care INSURING corporations or the health maintenance 373
organizations meet at least the standards of care provided by 374
hospitals and physicians in that employee's community, who would 375
be providing such care as would be covered by a contract awarded 376
under division (A) of this section. 377
(C) All or any portion of the cost, premium, or charge for 379
the coverage in divisions (A) and (B) of this section may be paid 380
in such manner or combination of manners as the department 381
determines and may include the proration of health care costs, 382
premiums, or charges for part-time employees. 383
(D) Notwithstanding division (A) of this section, the 385
department may provide benefits equivalent to those that may be 386
paid under a policy or contract issued by an insurance company or 387
a nonprofit health plan pursuant to division (A) of this section. 388
(E) This section does not prohibit the state office of 390
collective bargaining from entering into an agreement with an 391
employee representative for the purposes of providing fringe 392
benefits including, but not limited to, hospitalization, surgical 393
care, major medical care, disability, dental care, vision care, 394
medical care, hearing aids, prescription drugs, group life 395
insurance, sickness and accident insurance, group legal services 396
or other benefits, or any combination thereof, to employees paid 397
11
directly by warrant of the auditor of state through a jointly 398
administered trust fund. The employer's contribution for the 399
cost of the benefit care shall be mutually agreed to in the 400
collectively bargained agreement. The amount, type, and 401
structure of fringe benefits provided under this division is 402
subject to the determination of the board of trustees of the 403
jointly administered trust fund. Notwithstanding any other 404
provision of the Revised Code, competitive bidding does not apply 405
to the purchase of fringe benefits for employees under this 406
division when such benefits are provided through a jointly 407
administered trust fund. 408
Sec. 124.822. (A) The department of administrative 418
services shall require, as a condition of entering into a 419
contract with a health maintenance organization INSURING 420
CORPORATION that desires to provide health care services to state 422
employees, including elected public officials, who are paid 423
directly by warrant of the auditor of state and who reside within 424
its APPROVED service area, that the health maintenance 425
organization INSURING CORPORATION enroll at least five hundred of 426
such eligible state employees, or at least five per cent of such 427
eligible state employees, whichever is less. 428
(B) Division (A) of this section applies only to contracts 430
that are entered into or renewed on or after the effective date 431
of this section JULY 16, 1991. 432
Sec. 124.84. (A) The department of administrative 441
services, in consultation with the superintendent of insurance 442
and subject to division (D) of this section, shall negotiate and 443
contract with, one or more insurance companies, medical or health 445
care INSURING corporations, or health maintenance organizations 447
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 449
state employees who are paid directly by warrant of the auditor 450
of state, including elected state officials. Any policy 451
purchased under this division shall be negotiated and entered 452
12
into in accordance with the competitive selection procedures 453
specified in Chapter 125. of the Revised Code. As used in this 454
section, "long-term care insurance" has the same meaning as in 455
section 3923.41 of the Revised Code. 456
(B) Any elected state official or state employee paid 458
directly by warrant of the auditor of state may elect to 459
participate in any long-term care insurance policy purchased 460
under division (A) of this section and any official or employee 461
who does so shall be responsible for paying the entire premium 462
charged, which shall be deducted from the official's or 463
employee's salary or wage and be remitted by the auditor of state 465
directly to the insurance company, medical or health care 466
INSURING corporation, or health maintenance organization. 467
Participation in the policy may include the dependents and family 468
members of the elected state official or state employee. 469
If a participant in a long-term care insurance policy 471
leaves employment, the participant and the participant's 473
dependents and family members may, at their election, continue to 474
participate in a policy established under this section in the 475
same manner as if the participant had not left employment. 476
(C) Any long-term care insurance policy purchased under 478
this section or section 124.841 or 145.581 of the Revised Code 479
shall provide for all of the following with respect to the 480
premiums charged for the policy: 481
(1) They shall be set at the entry age of the official or 483
employee when first covered by the policy and shall not increase 484
except as a class during coverage under the policy. 485
(2) They shall be based on the class of all officials or 487
employees covered by the policy. 488
(3) They shall continue, pursuant to section 145.581 of 490
the Revised Code, after the retirement of the official or 491
employee who is covered under the policy, at the rate in effect 492
on the date of the official's or employee's retirement. 493
(D) Prior to entering into a contract with an insurance 495
13
company, medical or health care INSURING corporation, or health 497
maintenance organization for the purchase of a long-term care
insurance policy under this section, the department shall request 498
the superintendent of insurance to certify the financial 499
condition of the company, OR corporation, or organization. The 501
department shall not enter into the contract if, according to 502
that certification, the company, OR corporation, or organization 504
is insolvent, is determined by the superintendent to be
potentially unable to fulfill its contractual obligations, or is 506
placed under an order of rehabilitation or conservation by a 507
court of competent jurisdiction or under an order of supervision 508
by the superintendent. 509
(E) The department shall adopt rules in accordance with 511
section 111.15 of the Revised Code governing long-term care 512
insurance purchased under this section. The rules shall 513
establish methods of payment for participation under this 514
section, which may include establishment of a payroll deduction 515
plan. 516
Sec. 124.841. (A) As used in this section: 525
(1) "Long-term care insurance" has the same meaning as in 527
section 3923.41 of the Revised Code. 528
(2) "Political subdivision" has the same meaning as in 530
section 9.833 of the Revised Code. 531
(B) Any political subdivision may negotiate with and may 533
contract with, one or more insurance companies, medical or health 535
care INSURING corporations, or health maintenance organizations 536
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 537
elected officials and employees of the political subdivision. 539
The contract may be entered into without competitive bidding. 540
Any elected official or employee of a political subdivision may 541
elect to participate in any long-term care insurance policy that 542
the political subdivision purchases under this division and any 543
official or employee who does so shall be responsible for paying 544
14
the entire premium charged, which shall be deducted from his THE 545
OFFICIAL'S OR EMPLOYEE'S salary or wage and be remitted directly 546
to the insurance company, medical or health care INSURING 547
corporation, or health maintenance organization. 548
(C) Any long-term care insurance policy entered into under 550
this section is subject to division (C) of section 124.84 of the 551
Revised Code. 552
Sec. 124.92. If the superintendent of insurance has 561
approved all or a portion of a service area expansion of a health 562
maintenance organization INSURING CORPORATION into an additional 563
county or counties, the department of administrative services 564
shall authorize the organization CORPORATION, at the next open 565
enrollment period conducted by the department, to participate in 566
the open enrollment for state employees who reside in the 567
expanded service area, if both of the following apply:
(A) The open enrollment is conducted in accordance with 569
section 1742.12 1751.15 of the Revised Code; 570
(B) Prior to the expansion of the service area, fewer than 572
two health maintenance organizations INSURING CORPORATIONS were 573
available to state employees in the county or counties into which 575
the organization CORPORATION expanded.
Sec. 124.93. (A) As used in this section, "physician" 584
means any person who holds a valid certificate to practice 585
medicine and surgery or osteopathic medicine and surgery issued 586
under Chapter 4731. of the Revised Code. 587
(B) No health maintenace organization INSURING CORPORATION 589
that, on or after the effective date of this section JULY 1, 592
1993, enters into or renews a contract with the department of 593
administrative services under section 124.82 of the Revised Code 594
shall, because of a physician's race, color, religion, sex, 595
national origin, handicap, age, or ancestry, refuse to contract 596
with that physician for the provision of health care services 597
under that section. 598
Any health maintenance organization INSURING CORPORATION 600
15
that violates this division is deemed to have engaged in an 601
unlawful discriminatory practice as defined in section 4112.02 of 602
the Revised Code and is subject to Chapter 4112. of the Revised 603
Code.
(C) Each health maintenance organization INSURING 605
CORPORATION that, on or after the efective date of this section 607
JULY 1, 1993, enters into or renews a contract with the 609
department of administrative services under section 124.82 of the 610
Revised Code and that refuses to contract with a physician for 611
the provision of health care services under that section shall 612
provide that physician with a written notice that clearly 613
explains the reason or reasons for the refusal. The notice shall 614
be sent to the physician by regular mail within thirty days after 615
the refusal.
Any health maintenance organization INSURING CORPORATION 617
that fails to provide notice in compliance with this division is 618
deemed to have engaged in an unfair and deceptive act or practice 619
in the business of insurance as defined in section 3901.21 of the 620
Revised Code and is subject to sections 3901.19 to 3901.26 of the 621
Revised Code.
Sec. 145.58. (A) As used in this section, "ineligible 630
individual" means all of the following: 631
(1) A former member receiving benefits pursuant to section 633
145.32, 145.33, 145.331, 145.34, or 145.46 of the Revised Code 634
for whom eligibility is established more than five years after 635
June 13, 1981, and who, at the time of establishing eligibility, 636
has accrued less than ten years' service credit, exclusive of 637
credit obtained pursuant to section 145.297 or 145.298 of the 638
Revised Code, credit obtained after January 29, 1981, pursuant to 639
section 145.293 or 145.301 of the Revised Code, and credit 640
obtained after May 4, 1992, pursuant to section 145.28 of the 641
Revised Code; 642
(2) The spouse of the former member; 644
(3) The beneficiary of the former member receiving 646
16
benefits pursuant to section 145.46 of the Revised Code. 647
(B) The public employees retirement board may enter into 649
agreements with insurance companies, medical or health care 650
INSURING corporations, health maintenance organizations, or 652
government agencies authorized to do business in the state for 653
issuance of a policy or contract of health, medical, hospital, or 654
surgical benefits, or any combination thereof, for those 655
individuals receiving age and service retirement or a disability 657
or survivor benefit subscribing to the plan, or for PERS 658
retirants employed under section 145.38 of the Revised Code, for 659
coverage of benefits in accordance with division (D)(4)(b) of 660
section 145.38 of the Revised Code. Notwithstanding any other 661
provision of this chapter, the policy or contract may also 662
include coverage for any eligible individual's spouse and 663
dependent children and for any of the individual's sponsored 664
dependents as the board determines appropriate. If all or any 666
portion of the policy or contract premium is to be paid by any 667
individual receiving age and service retirement or a disability 668
or survivor benefit, the individual shall, by written 669
authorization, instruct the board to deduct the premium agreed to 671
be paid by the individual to the company, corporation, or agency. 673
The board may contract for coverage on the basis of part or 676
all of the cost of the coverage to be paid from appropriate funds 677
of the public employees retirement system. The cost paid from 678
the funds of the system shall be included in the employer's 680
contribution rate provided by sections 145.48 and 145.51 of the 681
Revised Code. The board may by rule provide coverage to 682
ineligible individuals if the coverage is provided at no cost to 683
the retirement system. The board shall not pay or reimburse the 684
cost for coverage under this section or section 145.325 of the 685
Revised Code for any ineligible individual.
The board may provide for self-insurance of risk or level 687
of risk as set forth in the contract with the companies, 688
corporations, or agencies, and may provide through the 689
17
self-insurance method specific benefits as authorized by rules of 690
the board. 691
(C) If the board provides health, medical, hospital, or 693
surgical benefits through any means other than a health 694
maintenance organization INSURING CORPORATION, it shall offer to 695
each individual eligible for the benefits the alternative of 698
receiving benefits through enrollment in a health maintenance 700
organization INSURING CORPORATION, if all of the following apply: 702
(1) The health maintenance organization INSURING 704
CORPORATION provides services in the geographical area in which 706
the individual lives; 707
(2) The eligible individual was receiving health care 709
benefits through a health maintenance organization OR A HEALTH 711
INSURING CORPORATION before retirement; 712
(3) The rate and coverage provided by the health 714
maintenance organization INSURING CORPORATION to eligible 715
individuals is comparable to that currently provided by the board 718
under division (B) of this section. If the rate or coverage 719
provided by the health maintenance organization INSURING 720
CORPORATION is not comparable to that currently provided by the 722
board under division (B) of this section, the board may deduct 723
the additional cost from the eligible individual's monthly 724
benefit.
The health maintenance organization INSURING CORPORATION 726
shall accept as an enrollee any eligible individual who requests 728
enrollment.
The board shall permit each eligible individual to change 730
from one plan to another at least once a year at a time 732
determined by the board. 733
(D) The board shall, beginning the month following receipt 735
of satisfactory evidence of the payment for coverage, pay monthly 736
to each recipient of service retirement, or a disability or 737
survivor benefit under the public employees retirement system who 738
is eligible for medical insurance coverage under part B of Title 739
18
XVIII of "The Social Security Act," 79 Stat. 301 (1965), 42 740
U.S.C.A. 1395j, as amended, an amount equal to the basic premium 741
for such coverage, except that the board shall make no such 743
payment to any ineligible individual.
(E) The board shall establish by rule requirements for the 745
coordination of any coverage, payment, or benefit provided under 747
this section or section 145.325 of the Revised Code with any 748
similar coverage, payment, or benefit made available to the same 749
individual by the police and firemen's disability and pension
fund, state teachers retirement system, school employees 750
retirement system, or state highway patrol retirement system. 751
(F) The board shall make all other necessary rules 755
pursuant to the purpose and intent of this section. 756
Sec. 145.581. (A) As used in this section: 765
(1) "Long-term care insurance" has the same meaning as in 767
section 3923.41 of the Revised Code. 768
(2) "Retirement systems" means the public employees 770
retirement system, the police and firemen's disability and 772
pension fund, the state teachers retirement system, the school 773
employees retirement system, and the state highway patrol 774
retirement system. 775
(B) The public employees retirement board shall establish 777
a long-term care insurance program consisting of the programs 778
authorized by divisions (C) and (D) of this section. Such 779
program may be established independently or jointly with one or 780
more of the other retirement systems. If the program is 781
established jointly, the board shall adopt rules in accordance 782
with section 111.15 of the Revised Code to establish the terms 783
and conditions of such joint participation. 784
(C) The board shall establish a program under which it 786
makes long-term care insurance available to any person who 787
participated in a policy of long-term care insurance for which 788
the state or a political subdivision contracted under section 789
124.84 or 124.841 of the Revised Code and is the recipient of a 790
19
pension, benefit, or allowance from the system. To implement the 791
program under this division, the board, subject to division (E) 792
of this section, may enter into an agreement with the insurance 793
company, medical or health care INSURING corporation, health 795
maintenance organization, or government agency that provided the
insurance. The board shall, under any such agreement, deduct the 796
full premium charged from the person's benefit, pension, or 797
allowance notwithstanding any employer agreement to the contrary. 798
Any long-term care insurance policy entered into under this 800
division is subject to division (C) of section 124.84 of the 801
Revised Code. 802
(D)(1) The board, subject to division (E) of this section, 804
shall establish a program under which a recipient of a pension, 805
benefit, or allowance from the system who is not eligible for 806
such insurance under division (C) of this section may participate 807
in a contract for long-term care insurance. Participation may 808
include the recipient's dependents and family members. 809
(2) The board shall adopt rules in accordance with section 811
111.15 of the Revised Code governing the program. The rules 812
shall establish methods of payment for participation under this 813
section, which may include deduction of the full premium charged 814
from a recipient's pension, benefit, or allowance, or any other 815
method of payment considered appropriate by the board. 816
(E) Prior to entering into any agreement or contract with 818
an insurance company, medical or health care INSURING 820
corporation, or health maintenance organization for the purchase
of, or participation in, a long-term care insurance policy under 821
this section, the board shall request the superintendent of 822
insurance to certify the financial condition of the company, OR 823
corporation, or organization. The board shall not enter into the 824
agreement or contract if, according to that certification, the 826
company, OR corporation, or organization is insolvent, is 827
determined by the superintendent to be potentially unable to 828
fulfill its contractual obligations, or is placed under an order 829
20
of rehabilitation or conservation by a court of competent 830
jurisdiction or under an order of supervision by the 831
superintendent. 832
Sec. 305.171. (A) The board of county commissioners of 841
any county may contract for, purchase, or otherwise procure and 842
pay all or any part of the cost of group insurance policies that 843
may provide benefits including, but not limited to, 844
hospitalization, surgical care, major medical care, disability, 845
dental care, eye care, medical care, hearing aids, or 846
prescription drugs, and that may provide sickness and accident 847
insurance, group legal services, or group life insurance, or a 848
combination of any of the foregoing types of insurance or 849
coverage for county officers and employees and their immediate 850
dependents from the funds or budgets from which the officers or 851
employees are compensated for services, issued by an insurance 852
company, a medical care corporation organized under Chapter 1737. 853
of the Revised Code, or a dental care corporation organized under 854
Chapter 1740. of the Revised Code. 855
(B) The board also may negotiate and contract for any plan 857
or plans of group insurance or health care services with health 858
care INSURING corporations organized HOLDING A CERTIFICATE OF 860
AUTHORITY under Chapter 1738. 1751. of the Revised Code and 861
health maintenance organizations organized under Chapter 1742. of 862
the Revised Code, provided that each officer or employee shall be 863
permitted to do both of the following:
(1) Exercise an option between a plan offered by an 865
insurance company, medical care corporation, or dental care 866
corporation, and such plan or plans offered by health care 867
INSURING corporations or health maintenance organizations under 868
this division, on the condition that the officer or employee 869
shall pay any amount by which the cost of the plan chosen by such 870
officer or employee pursuant to this division exceeds the cost of 871
the plan offered under division (A) of this section; 872
(2) Change from one of the plans to another at a time each 874
21
year as determined by the board. 875
(C) Section 307.86 of the Revised Code does not apply to 877
the purchase of benefits for county officers or employees under 878
divisions (A) and (B) of this section when those benefits are 879
provided through a jointly administered health and welfare trust 880
fund in which the county or contracting authority and a 881
collective bargaining representative of the county employees or 882
contracting authority agree to participate. 883
(D) The board of trustees of a jointly administered trust 885
fund that receives contributions pursuant to collective 886
bargaining agreements entered into between the board of county 887
commissioners of any county and a collective bargaining 888
representative of the employees of the county may provide for 889
self-insurance of all risk in the provision of fringe benefits, 890
and may provide through the self-insurance method specific fringe 891
benefits as authorized by the rules of the board of trustees of 892
the jointly administered trust fund. The fringe benefits may 893
include, but are not limited to, hospitalization, surgical care, 894
major medical care, disability, dental care, vision care, medical 895
care, hearing aids, prescription drugs, group life insurance, 896
sickness and accident insurance, group legal services, or a 897
combination of any of the foregoing types of insurance or 898
coverage, for employees and their dependents. 899
(E) The board of county commissioners may provide the 901
benefits described in divisions (A) to (D) of this section 902
through an individual self-insurance program or a joint 903
self-insurance program as provided in section 9.833 of the 904
Revised Code. 905
(F) When a board of county commissioners offers health 907
benefits authorized under this section to an officer or employee 908
of the county, the board may offer the benefits through a 909
cafeteria plan meeting the requirements of section 125 of the 910
"Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 125, 911
as amended, and, as part of that plan, may offer the officer or
22
employee the option of receiving a cash payment in any form 912
permissible under such cafeteria plans. A cash payment made to 913
an officer or employee under this division shall not exceed 914
twenty-five per cent of the cost of premiums or payments that 915
otherwise would be paid by the board for benefits for the officer 916
or employee under a policy or plan.
(G) The board of county commissioners may establish a 918
policy authorizing any county appointing authority to make a cash 919
payment to any officer or employee in lieu of providing a benefit 920
authorized under this section if the officer or employee elects 921
to take the cash payment instead of the offered benefit. A cash 922
payment made to an officer or employee under this division shall
not exceed twenty-five per cent of the cost of premiums or 923
payments that otherwise would be paid by the board for benefits 924
for the officer or employee under an offered policy or plan. 925
(H) No cash payment in lieu of a health benefit shall be 927
made to a county officer or employee under division (F) or (G) of 928
this section unless the officer or employee signs a statement 929
affirming that he THE OFFICER OR EMPLOYEE is covered under 930
another health insurance or health care policy, contract, or 931
plan, and setting forth the name of the employer, if any, that 932
sponsors the coverage, the name of the carrier that provides the
coverage, and the identifying number of the policy, contract, or 933
plan.
(I)(1) As used in this division: 935
(a) "County-operated municipal court" and "legislative 937
authority" have the same meanings as in section 1901.03 of the 938
Revised Code. 939
(b) "Health care coverage" has the same meaning as in 941
section 1901.111 of the Revised Code. 942
(2) The legislative authority of a county-operated 944
municipal court, after consultation with the judges, or the clerk 945
and deputy clerks, of the municipal court, shall negotiate and 946
contract for, purchase, or otherwise procure, and pay the costs, 947
23
premiums, or charges for, group health care coverage for the 948
judges, and group health care coverage for the clerk and deputy 949
clerks, in accordance with section 1901.111 or 1901.312 of the 950
Revised Code. 951
Sec. 306.48. A regional transit authority may procure and 960
pay all or any part of the cost of group hospitalization, 961
surgical, major medical, or sickness and accident insurance or a 962
combination of any of the foregoing for the officers and 963
employees of the regional transit authority and their immediate
dependents, whether issued by an insurance company, or nonprofit 964
medical care A HEALTH INSURING corporation duly authorized to do 965
business in this state. 966
Sec. 307.86. Anything to be purchased, leased, leased with 975
an option or agreement to purchase, or constructed, including, 976
but not limited to, any product, structure, construction, 977
reconstruction, improvement, maintenance, repair, or service, 978
except the services of an accountant, architect, attorney at law, 979
physician, professional engineer, construction project manager, 980
consultant, surveyor, or appraiser by or on behalf of the county 981
or contracting authority, as defined in section 307.92 of the 982
Revised Code, at a cost in excess of fifteen thousand dollars, 983
except as otherwise provided in division (D) of section 713.23 984
and in sections 125.04, 307.022, 307.041, 307.861, 339.05, 985
340.03, 340.033, 4115.31 to 4115.35, 5119.16, 5513.01, 5543.19, 986
5713.01, and 6137.05 of the Revised Code, shall be obtained 987
through competitive bidding. However, competitive bidding is not 988
required when: 989
(A) The board of county commissioners, by a unanimous vote 991
of its members, makes a determination that a real and present 992
emergency exists and such determination and the reasons therefor 993
are entered in the minutes of the proceedings of the board, when: 994
(1) The estimated cost is less than fifty thousand 996
dollars; or 997
(2) There is actual physical disaster to structures, radio 999
24
communications equipment, or computers. 1,000
Whenever a contract of purchase, lease, or construction is 1,002
exempted from competitive bidding under division (A)(1) of this 1,003
section because the estimated cost is less than fifty thousand 1,004
dollars, but the estimated cost is fifteen thousand dollars or 1,005
more, the county or contracting authority shall solicit informal 1,006
estimates from no fewer than three persons who could perform the 1,007
contract, before awarding the contract. With regard to each such 1,008
contract, the county or contracting authority shall maintain a 1,009
record of such estimates, including the name of each person from 1,010
whom an estimate is solicited, for no less than one year after 1,011
the contract is awarded. 1,012
(B) The purchase consists of supplies or a replacement or 1,014
supplemental part or parts for a product or equipment owned or 1,015
leased by the county and the only source of supply for such 1,016
supplies, part, or parts is limited to a single supplier. 1,017
(C) The purchase is from the federal government, state, 1,019
another county or contracting authority thereof, a board of 1,020
education, township, or municipal corporation. 1,021
(D) Public social services are purchased for provision by 1,023
the county department of human services under section 329.04 of 1,024
the Revised Code or program services, such as direct and 1,025
ancillary client services, child day-care, case management 1,026
services, residential services, and family resource services, are 1,027
purchased for provision by a county board of mental retardation 1,028
and developmental disabilities under section 5126.05 of the 1,029
Revised Code. 1,030
(E) The purchase consists of human and social services by 1,032
the board of county commissioners from nonprofit corporations or 1,033
associations under programs which are funded entirely by the 1,034
federal government. 1,035
(F) The purchase consists of any form of an insurance 1,037
policy or contract authorized to be issued under Title XXXIX of 1,038
the Revised Code or any form of health care contract or plan 1,039
25
authorized to be issued under Chapter 1736., 1737., 1740., or 1,040
1742. 1751. of the Revised Code, or any combination of such 1,041
policies, contracts, or plans that the contracting authority is 1,042
authorized to purchase, and the contracting authority does all of 1,043
the following: 1,044
(1) Determines that compliance with the requirements of 1,046
this section would increase, rather than decrease, the cost of 1,047
such purchase; 1,048
(2) Employs a competent consultant to assist the 1,050
contracting authority in procuring appropriate coverages at the 1,051
best and lowest prices; 1,052
(3) Requests issuers of such policies, contracts, or plans 1,054
to submit proposals to the contracting authority, in a form 1,055
prescribed by the contracting authority, setting forth the 1,056
coverage and cost of such policies, contracts, or plans as the 1,057
contracting authority desires to purchase; 1,058
(4) Negotiates with such issuers for the purpose of 1,060
purchasing such policies, contracts, or plans at the best and 1,061
lowest price reasonably possible. 1,062
(G) The purchase consists of computer hardware, software, 1,064
or consulting services that are necessary to implement a 1,065
computerized case management automation project administered by 1,066
the Ohio prosecuting attorneys association and funded by a grant 1,067
from the federal government. 1,068
(H) Child day-care services are purchased for provision to 1,070
county employees. 1,071
(I)(1) Property, including land, buildings, and other real 1,073
property, is leased for offices, storage, parking, or other 1,074
purposes and all of the following apply: 1,075
(a) The contracting authority is authorized by the Revised 1,077
Code to lease the property; 1,078
(b) The contracting authority develops requests for 1,080
proposals for leasing the property, specifying the criteria that 1,081
will be considered prior to leasing the property, including the 1,082
26
desired size and geographic location of the property; 1,083
(c) The contracting authority receives responses from 1,085
prospective lessors with property meeting the criteria specified 1,086
in the requests for proposals by giving notice in a manner 1,087
substantially similar to the procedures established for giving 1,088
notice under section 307.87 of the Revised Code; 1,089
(d) The contracting authority negotiates with the 1,091
prospective lessors to obtain a lease at the best and lowest 1,092
price reasonably possible considering the fair market value of 1,093
the property and any relocation and operational costs that may be 1,094
incurred during the period the lease is in effect. 1,096
(2) The contracting authority may use the services of a 1,098
real estate appraiser to obtain advice, consultations, or other 1,099
recommendations regarding the lease of property under this 1,100
division. 1,101
Any issuer of policies, contracts, or plans listed in 1,103
division (F) of this section and any prospective lessor under 1,104
division (I) of this section may have his THE ISSUER'S OR 1,105
PROSPECTIVE LESSOR'S name and address, or the name and address of 1,107
an agent, placed on a special notification list to be kept by the 1,108
contracting authority, by sending the contracting authority such 1,109
name and address. The contracting authority shall send notice to 1,110
all persons listed on the special notification list. Notices 1,111
shall state the deadline and place for submitting proposals. The 1,112
contracting authority shall mail the notices at least six weeks 1,113
prior to the deadline set by the contracting authority for 1,114
submitting such proposals. Every five years the contracting 1,115
authority may review this list and remove any person from the 1,116
list after mailing the person notification of such action. 1,117
Any contracting authority that negotiates a contract under 1,119
division (F) of this section shall request proposals and 1,120
renegotiate with issuers in accordance with that division at 1,121
least every three years from the date of the signing of such a 1,122
contract. 1,123
27
Any consultant employed pursuant to division (F) of this 1,125
section and any real estate appraiser employed pursuant to 1,126
division (I) of this section shall disclose any fees or 1,127
compensation received from any source in connection with that 1,128
employment.
Sec. 339.16. A board of trustees of any county hospital, 1,137
or of any county or district tuberculosis hospital, may contract 1,138
for, purchase, or otherwise procure on behalf of any or all of 1,139
its employees or such employees and their immediate dependents 1,140
the following types of fringe benefits: 1,141
(A) Group or individual insurance contracts which may 1,143
include life, sickness, accident, disability, annuities, 1,144
endowment, health, medical expense, hospital, dental, surgical 1,145
and related coverage or any combination thereof; 1,146
(B) Group or individual contracts with medical care 1,148
corporations, health care INSURING corporations, dental care 1,150
corporations, or other providers of professional services, care, 1,151
or benefits duly authorized to do business in this state.
A board of trustees of any county hospital, or of any 1,153
county or district tuberculosis hospital, may contract for, 1,154
purchase, or otherwise procure insurance contracts which provide 1,155
protection for the trustees and employees against liability, 1,156
including professional liability, provided that this section or 1,157
any insurance contract issued pursuant to this section shall not 1,158
be construed as a waiver of or in any manner affect the immunity 1,159
of the hospital or county. 1,160
All or any portion of the cost, premium, fees, or charges 1,162
therefor may be paid in such manner or combination of manners as 1,163
the board of trustees may determine, including direct payment by 1,164
the employee, and, if authorized in writing by the employee, by 1,165
the board of trustees with moneys made available by deduction 1,166
from or reduction in salary or wages or by the foregoing of a 1,167
salary or wage increase. 1,168
Notwithstanding sections 3917.01 and 3917.06 of the Revised 1,170
28
Code, the board of trustees may purchase group life insurance 1,171
authorized by this section by reason of payment of premiums 1,172
therefor by the board of trustees from its funds, and such group 1,173
life insurance may be issued and purchased if otherwise 1,174
consistent with sections 3917.01 to 3917.06 of the Revised Code. 1,175
Sec. 351.08. (A) A convention facilities authority may 1,184
procure and pay any or all of the cost of group hospitalization, 1,185
surgical, major medical, sickness and accident insurance, or 1,186
group life insurance, or a combination of any of the foregoing 1,187
types of insurance or coverage for full-time employees and their 1,188
dependents, whether issued by an insurance company or a medical 1,189
care corporation, duly authorized to do business in this state. 1,190
(B) A convention facilities authority also may procure and 1,192
pay any or all of the cost of a plan of group hospitalization, 1,193
surgical, or major medical insurance with a health care INSURING 1,194
corporation with a certificate of authority or license issued 1,195
under Chapter 1738. 1751. of the Revised Code, provided that each 1,197
full-time employee shall be permitted to:
(1) Exercise an option between a plan offered by an 1,199
insurance company or medical care corporation as provided in 1,200
division (A) of this section and a plan offered by a health care 1,201
INSURING corporation under this division, on the condition that 1,202
the full-time employee shall pay the amount by which the cost of 1,203
the plan offered in this division exceeds the cost of the plan 1,204
offered under division (A) of this section; and 1,205
(2) Change from one of the two plans to the other at a 1,207
time each year as determined by the convention facilities 1,208
authority. 1,209
Sec. 505.60. (A) The board of township trustees of any 1,218
township may procure and pay all or any part of the cost of 1,219
insurance policies that may provide benefits for hospitalization, 1,220
surgical care, major medical care, disability, dental care, eye 1,221
care, medical care, hearing aids, prescription drugs, or sickness 1,222
and accident insurance, or a combination of any of the foregoing 1,223
29
types of insurance for township officers and employees. If the 1,224
board so procures any such insurance policies, the board shall 1,225
provide uniform coverage under these policies for township 1,226
officers and full-time township employees and their immediate 1,227
dependents and may provide coverage under these policies for 1,228
part-time township employees and their immediate dependents, from 1,229
the funds or budgets from which the officers or employees are 1,230
compensated for services, whether such policies are TO BE issued 1,232
by an insurance company, a medical care corporation organized
under Chapter 1737. of the Revised Code, or a dental care 1,233
corporation organized under Chapter 1740. of the Revised Code 1,234
duly authorized to do business in this state. Any township 1,235
officer or employee may refuse to accept the insurance coverage 1,236
without affecting the availability of such insurance coverage to 1,237
other township officers and employees. 1,238
The board may also contract for group insurance or health 1,240
care services with health care INSURING corporations organized 1,242
HOLDING CERTIFICATES OF AUTHORITY under Chapter 1738. 1751. of 1,243
the Revised Code and health maintenance organizations organized 1,244
under Chapter 1742. of the Revised Code for township officers and 1,245
employees. If the board so contracts, it shall provide uniform 1,246
coverage under any such contracts for township officers and 1,247
full-time township employees and their immediate dependents and 1,248
may provide coverage under such contracts for part-time township 1,249
employees and their immediate dependents, provided that each 1,250
officer and employee so covered is permitted to: 1,251
(1) Choose between a plan offered by an insurance company, 1,253
medical care corporation, or dental care corporation and a plan 1,254
offered by a health care INSURING corporation or health 1,255
maintenance organization, and provided further that the officer 1,256
or employee pays any amount by which the cost of the plan chosen 1,258
by him exceeds the cost of the plan offered by the board under 1,259
this section; 1,260
(2) Change his THE choice MADE under division (A) of this 1,263
30
section at a time each year as determined in advance by the 1,264
board.
An addition of a class or change of definition of coverage 1,266
to the plan offered by the board may be made at any time that it 1,267
is determined by the board to be in the best interest of the 1,268
township. If the total cost to the township of the revised plan 1,269
for any trustee's coverage does not exceed that cost under the 1,270
plan in effect during the prior policy year, the revision of the 1,271
plan does not cause an increase in that trustee's compensation. 1,272
The board may provide the benefits authorized under this 1,274
section, without competitive bidding, by contributing to a health 1,275
and welfare trust fund administered through or in conjunction 1,276
with a collective bargaining representative of the township 1,277
employees. 1,278
The board may also provide the benefits described in this 1,280
section through an individual self-insurance program or a joint 1,281
self-insurance program as provided in section 9.833 of the 1,282
Revised Code. 1,283
(B) A board of township trustees may procure and pay all 1,285
or any part of the cost of group life insurance to insure the 1,286
lives of officers and full-time employees of the township. The 1,287
amount of group life insurance coverage provided by the board to 1,288
insure the lives of officers of the township shall not exceed 1,289
fifty thousand dollars per officer. 1,290
(C) If a board of township trustees fails to pay one or 1,292
more premiums for a policy, contract, or plan of insurance or 1,293
health care services authorized by division (A) of this section 1,294
and the failure causes a lapse, cancellation, or other 1,295
termination of coverage under the policy, contract, or plan, it 1,296
may reimburse a township officer or employee for, or pay on 1,297
behalf of the officer or employee, any expenses incurred that 1,298
would have been covered under the policy, contract, or plan. 1,299
(D) As used in this section, "part-time township employee" 1,301
means a township employee who is hired with the expectation that 1,302
31
the employee will work not more than one thousand five hundred 1,303
hours in any year. 1,304
Sec. 742.45. (A) The board of trustees of the police and 1,313
firemen's disability and pension fund may enter into an agreement 1,315
with insurance companies, medical or health care INSURING 1,316
corporations, health maintenance organizations, or government 1,318
agencies authorized to do business in the state for issuance of a 1,319
policy or contract of health, medical, hospital, or surgical 1,320
benefits, or any combination thereof, for those individuals 1,321
receiving service or disability pensions or survivor benefits 1,323
subscribing to the plan. Notwithstanding any other provision of 1,324
this chapter, the policy or contract may also include coverage 1,325
for any eligible individual's spouse and dependent children and 1,326
for any of the eligible individual's sponsored dependents as the 1,328
board considers appropriate. 1,329
If all or any portion of the policy or contract premium is 1,331
to be paid by any individual receiving a service, disability, or 1,333
survivor pension or benefit, the individual shall, by written 1,335
authorization, instruct the board to deduct from the individual's 1,337
benefit the premium agreed to be paid by the individual to the 1,338
company, corporation, or agency. 1,340
The board may contract for coverage on the basis of part or 1,343
all of the cost of the coverage to be paid from appropriate funds 1,344
of the police and firemen's disability and pension fund. The 1,345
cost paid from the funds of the police and firemen's disability 1,346
and pension fund shall be included in the employer's contribution 1,347
rates provided by sections 742.33 and 742.34 of the Revised Code. 1,349
The board may provide for self-insurance of risk or level 1,351
of risk as set forth in the contract with the companies, 1,352
corporations, or agencies, and may provide through the 1,353
self-insurance method specific benefits as authorized by the 1,354
rules of the board. 1,355
(B) If the board provides health, medical, hospital, or 1,357
surgical benefits through any means other than a health 1,358
32
maintenance organization INSURING CORPORATION, it shall offer to 1,359
each individual eligible for the benefits the alternative of 1,362
receiving benefits through enrollment in a health maintenance 1,363
organization INSURING CORPORATION, if all of the following apply: 1,365
(1) The health maintenance organization INSURING 1,367
CORPORATION provides HEALTH CARE services in the geographical 1,369
area in which the individual lives; 1,370
(2) The eligible individual was receiving health care 1,372
benefits through a health maintenance organization OR A HEALTH 1,374
INSURING CORPORATION before retirement; 1,375
(3) The rate and coverage provided by the health 1,377
maintenance organization INSURING CORPORATION to eligible 1,378
individuals is comparable to that currently provided by the board 1,381
under division (A) of this section. If the rate or coverage 1,382
provided by the health maintenance organization INSURING 1,383
CORPORATION is not comparable to that currently provided by the 1,385
board under division (A) of this section, the board may deduct 1,386
the additional cost from the eligible individual's monthly 1,387
benefit.
The health maintenance organization INSURING CORPORATION 1,389
shall accept as an enrollee any eligible individual who requests 1,391
enrollment.
The board shall permit each eligible individual to change 1,393
from one plan to another at least once a year at a time 1,395
determined by the board. 1,396
(C) The board shall, beginning the month following receipt 1,398
of satisfactory evidence of the payment for coverage, pay monthly 1,399
to each recipient of service, disability, or survivor benefits 1,401
under the police and firemen's disability and pension fund who is 1,402
eligible for medical insurance coverage under part B of "The 1,403
Social Security Amendments of 1965," 79 Stat. 301, 42 U.S.C.A. 1,404
1395j, as amended, an amount equal to the basic premiums for such 1,405
coverage.
(D) The board shall establish by rule requirements for the 1,407
33
coordination of any coverage, payment, or benefit provided under 1,408
this section with any similar coverage, payment, or benefit made 1,409
available to the same individual by the public employees 1,411
retirement system, state teachers retirement system, school
employees retirement system, or state highway patrol retirement 1,412
system.
(E) The board shall make all other necessary rules 1,414
pursuant to the purpose and intent of this section. 1,415
Sec. 742.53. (A) As used in this section: 1,424
(1) "Long-term care insurance" has the same meaning as in 1,426
section 3923.41 of the Revised Code. 1,427
(2) "Retirement systems" has the same meaning as in 1,429
division (A) of section 145.581 of the Revised Code. 1,430
(B) The board of trustees of the police and firemen's 1,432
disability and pension fund shall establish a program under which 1,433
members of the fund, employers on behalf of members, and persons 1,434
receiving service or disability pensions or survivor benefits are 1,435
permitted to participate in contracts for long-term care 1,436
insurance. Participation may include dependents and family 1,437
members. If a participant in a contract for long-term care 1,438
insurance leaves his employment, he THE PARTICIPANT and his THE 1,440
PARTICIPANT'S dependents and family members may, at their 1,441
election, continue to participate in a program established under 1,442
this section in the same manner as if he THE PARTICIPANT had not 1,443
left his employment, except that no part of the cost of the 1,445
insurance shall be paid by his THE PARTICIPANT'S former employer. 1,446
Such program may be established independently or jointly 1,448
with one or more of the other retirement systems. 1,449
(C) The fund may enter into an agreement with insurance 1,451
companies, medical or health care INSURING corporations, health 1,453
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 1,454
insurance policy or contract. However, prior to entering into 1,455
such an agreement with an insurance company, medical or health 1,456
34
care INSURING corporation, or health maintenance organization, 1,458
the fund shall request the superintendent of insurance to certify 1,459
the financial condition of the company, OR corporation, or 1,460
organization. The fund shall not enter into the agreement if, 1,461
according to that certification, the company, OR corporation, or 1,462
organization is insolvent, is determined by the superintendent to 1,464
be potentially unable to fulfill its contractual obligations, or 1,465
is placed under an order of rehabilitation or conservation by a 1,466
court of competent jurisdiction or under an order of supervision 1,467
by the superintendent. 1,468
(D) The board shall adopt rules in accordance with section 1,470
111.15 of the Revised Code governing the program. The rules 1,471
shall establish methods of payment for participation under this 1,472
section, which may include establishment of a payroll deduction 1,473
plan under section 742.56 of the Revised Code, deduction of the 1,474
full premium charged from a person's service or disability 1,475
pension or survivor benefit, or any other method of payment 1,476
considered appropriate by the board. If the program is 1,477
established jointly with one or more of the other retirement 1,478
systems, the rules also shall establish the terms and conditions 1,479
of such joint participation. 1,480
Sec. 1319.12. (A)(1) As used in this section, "collection 1,490
agency" means any person who, for compensation, contingent or 1,491
otherwise, or for other valuable consideration, offers services 1,492
to collect an alleged debt asserted to be owed to another. 1,493
(2) "Collection agency" does not mean a person whose 1,495
collection activities are confined to and directly related to the 1,497
operation of another business, including, but not limited to, the 1,498
following:
(a) Any bank, including the trust department of a bank, 1,501
trust company, savings and loan association, savings bank, credit 1,502
union, or fiduciary as defined in section 1339.03 of the Revised 1,504
Code, except those that own or operate a collection agency; 1,506
(b) Any real estate broker, real estate salesperson, 1,509
35
limited real estate broker, or limited real estate salesperson, 1,510
as these persons are defined in section 4735.01 of the Revised 1,511
Code;
(c) Any retail seller collecting its own accounts; 1,514
(d) Any insurance company authorized to do business in 1,516
this state under Title XXXIX of the Revised Code or a health 1,517
maintenance organization INSURING CORPORATION authorized to 1,518
operate in this state under Chapter 1742. 1751. of the Revised 1,519
Code;
(e) Any public officer or judicial officer acting under 1,521
order of a court;
(f) Any licensee as defined either in section 1321.01 or 1,523
1321.71 of the Revised Code, or any registrant as defined in 1,524
section 1321.51 of the Revised Code; 1,525
(g) Any public utility. 1,527
(B) A collection agency with a place of business in this 1,530
state may take assignment of another person's accounts, bills, or 1,532
other evidences of indebtedness in its own name for the purpose 1,533
of billing, collecting, or filing suit in its own name as the 1,534
real party in interest.
(C) No collection agency shall commence litigation for the 1,537
collection of an assigned account, bill, or other evidence of 1,538
indebtedness unless it has taken the assignment in accordance 1,539
with all of the following requirements: 1,540
(1) The assignment was voluntary, properly executed, and 1,542
acknowledged by the person transferring title to the collection 1,543
agency. 1,544
(2) The collection agency did not require the assignment 1,546
as a condition to listing the account, bill, or other evidence of 1,548
indebtedness with the collection agency for collection.
(3) The assignment was manifested by a written agreement 1,550
separate from and in addition to any document intended for the 1,551
purpose of listing the account, bill, or other evidence of 1,552
indebtedness with the collection agency. The written agreement 1,553
36
must state the effective date of the assignment and the 1,554
consideration paid or given, if any, for the assignment, and must 1,556
expressly authorize the collection agency to refer the assigned 1,557
account, bill, or other evidence of indebtedness to an attorney 1,558
admitted to the practice of law in this state for the
commencement of litigation. The written agreement must also 1,559
disclose that the collection agency may, for purposes of filing 1,560
an action, consolidate the assigned account, bill, or other 1,561
evidence of indebtedness with those of other creditors against an 1,562
individual debtor or co-debtors.
(4) Upon the effective date of the assignment to the 1,564
collection agency, the creditor's account maintained by the 1,565
collection agency in connection with the assigned account, bill, 1,566
or other evidence of indebtedness was canceled. 1,567
(D) A collection agency shall commence litigation for the 1,570
collection of an assigned account, bill, or other evidence of 1,571
indebtedness in a court of competent jurisdiction located in the 1,572
county in which the debtor resides, or in the case of co-debtors, 1,573
a county in which at least one of the co-debtors resides. 1,574
(E) No collection agency shall commence any litigation 1,577
authorized by this section unless the agency appears by an 1,578
attorney admitted to the practice of law in this state. 1,579
(F) This section does not affect the powers and duties of 1,581
any person described in division (A)(2) of this section. 1,582
(G) Nothing in this section relieves a collection agency 1,584
from complying with the "Fair Debt Collection Practices Act," 91 1,585
Stat. 874 (1977), 15 U.S.C. 1692, as amended, or deprives any 1,586
debtor of the right to assert defenses as provided in section 1,587
1317.031 of the Revised Code and 16 C.F.R. 433, as amended. 1,588
(H) For purposes of filing an action, a collection agency 1,591
that has taken an assignment or assignments pursuant to this 1,592
section may consolidate the assigned accounts, bills, or other 1,593
evidences of indebtedness of one or more creditors against an 1,594
individual debtor or co-debtors. Each separate assigned account, 1,595
37
bill, or evidence of indebtedness must be separately identified 1,596
and pled in any consolidated action authorized by this section. 1,597
If a debtor or co-debtor raises a good faith dispute concerning 1,598
any account, bill, or other evidence of indebtedness, the court 1,599
shall separate each disputed account, bill, or other evidence of 1,600
indebtedness from the action and hear the disputed account, bill, 1,602
or other evidence of indebtedness on its own merits in a separate 1,603
action. The court shall charge the filing fee of the separate 1,604
action to the losing party.
Sec. 1337.16. (A) No physician, health care facility, 1,613
other health care provider, person authorized to engage in the 1,614
business of insurance in this state under Title XXXIX of the 1,615
Revised Code, medical care corporation, health care INSURING 1,617
corporation, health maintenance organization, other health care 1,618
plan, or legal entity that is self-insured and provides benefits 1,619
to its employees or members shall require an individual to create 1,620
or refrain from creating a durable power of attorney for health 1,621
care, or shall require an individual to revoke or refrain from 1,622
revoking a durable power of attorney for health care, as a 1,623
condition of being admitted to a health care facility, being 1,624
provided health care, being insured, or being the recipient of 1,625
benefits. 1,626
(B)(1) Subject to division (B)(2) of this section, an 1,628
attending physician of a principal or a health care facility in 1,629
which a principal is confined may refuse to comply or allow 1,630
compliance with the instructions of an attorney in fact under a 1,631
durable power of attorney for health care on the basis of a 1,632
matter of conscience or on another basis. An employee or agent 1,633
of an attending physician of a principal or of a health care 1,634
facility in which a principal is confined may refuse to comply 1,635
with the instructions of an attorney in fact under a durable 1,636
power of attorney for health care on the basis of a matter of 1,637
conscience. 1,638
(2)(a) An attending physician of a principal who, or 1,640
38
health care facility in which a principal is confined that, is 1,641
not willing or not able to comply or allow compliance with the 1,642
instructions of an attorney in fact under a durable power of 1,643
attorney for health care to use or continue, or to withhold or 1,644
withdraw, health care that were given under division (A) of 1,645
section 1337.13 of the Revised Code, or with any probate court 1,646
reevaluation order issued pursuant to division (D)(6) of this 1,647
section, shall not prevent or attempt to prevent, or unreasonably 1,648
delay or attempt to unreasonably delay, the transfer of the 1,649
principal to the care of a physician who, or a health care 1,650
facility that, is willing and able to so comply or allow 1,651
compliance. 1,652
(b) If the instruction of an attorney in fact under a 1,654
durable power of attorney for health care that is given under 1,655
division (A) of section 1337.13 of the Revised Code is to use or 1,656
continue life-sustaining treatment in connection with a principal 1,657
who is in a terminal condition or in a permanently unconscious 1,658
state, the attending physician of the principal who, or the 1,659
health care facility in which the principal is confined that, is 1,660
not willing or not able to comply or allow compliance with that 1,661
instruction shall use or continue the life-sustaining treatment 1,662
or cause it to be used or continued until a transfer as described 1,663
in division (B)(2)(a) of this section is made. 1,664
(C) Sections 1337.11 to 1337.17 of the Revised Code and a 1,666
durable power of attorney for health care created under section 1,667
1337.12 of the Revised Code do not affect or limit the authority 1,668
of a physician or a health care facility to provide or not to 1,669
provide health care to a person in accordance with reasonable 1,670
medical standards applicable in an emergency situation. 1,671
(D)(1) If the attending physician of a principal and one 1,673
other physician who examines the principal determine that he THE 1,674
PRINCIPAL is in a terminal condition or in a permanently 1,676
unconscious state, if the attending physician additionally 1,677
determines that the principal has lost the capacity to make 1,678
39
informed health care decisions for himself THE PRINCIPAL and that 1,679
there is no reasonable possibility that the principal will regain 1,681
the capacity to make informed health care decisions for himself 1,682
THE PRINCIPAL, and if the attorney in fact under the principal's 1,684
durable power of attorney for health care makes a health care 1,685
decision pertaining to the use or continuation, or the 1,686
withholding or withdrawal, of life-sustaining treatment, the 1,687
attending physician shall do all of the following: 1,688
(a) Record the determinations and health care decision in 1,690
the principal's medical record; 1,691
(b) Make a good faith effort, and use reasonable 1,693
diligence, to notify the appropriate individual or individuals, 1,694
in accordance with the following descending order of priority, of 1,695
the determinations and health care decision: 1,696
(i) If any, the guardian of the principal. This division 1,698
does not permit or require the appointment of a guardian for the 1,699
principal. 1,700
(ii) The principal's spouse; 1,702
(iii) The principal's adult children who are available 1,704
within a reasonable period of time for consultation with the 1,705
principal's attending physician; 1,706
(iv) The principal's parents; 1,708
(v) An adult sibling of the principal or, if there is more 1,710
than one adult sibling, a majority of the principal's adult 1,711
siblings who are available within a reasonable period of time for 1,712
such consultation. 1,713
(c) Record in the principal's medical record the names of 1,714
the individual or individuals notified pursuant to division 1,715
(D)(1)(b) of this section and the manner of notification; 1,716
(d) Afford time for the individual or individuals notified 1,718
pursuant to division (D)(1)(b) of this section to object in the 1,719
manner described in division (D)(3)(a) of this section. 1,720
(2)(a) If, despite making a good faith effort, and despite 1,722
using reasonable diligence, to notify the appropriate individual 1,723
40
or individuals described in division (D)(1)(b) of this section, 1,724
the attending physician cannot notify the individual or 1,725
individuals of the determinations and health care decision 1,726
because the individual or individuals are deceased, cannot be 1,727
located, or cannot be notified for some other reason, the 1,728
requirements of divisions (D)(1)(b), (c), and (d) of this section 1,729
and, except as provided in division (D)(3)(b) of this section, 1,730
the provisions of divisions (D)(3) to (6) of this section shall 1,731
not apply in connection with the principal. However, the 1,732
attending physician shall record in the principal's medical 1,733
record information pertaining to the reason for the failure to 1,734
provide the requisite notices and information pertaining to the 1,735
nature of the good faith effort and reasonable diligence used. 1,736
(b) The requirements of divisions (D)(1)(b), (c), and (d) 1,738
of this section and, except as provided in division (D)(3)(b) of 1,739
this section, the provisions of divisions (D)(3) to (6) of this 1,740
section shall not apply in connection with the principal if only 1,741
one individual would have to be notified pursuant to division 1,742
(D)(1)(b) of this section and that individual is the attorney in 1,743
fact under the durable power of attorney for health care. 1,744
However, the attending physician of the principal shall record in 1,745
the principal's medical record information indicating that no 1,746
notice was given pursuant to division (D)(1)(b) of this section 1,747
because of the provisions of division (D)(2)(b) of this section. 1,748
(3)(a) Within forty-eight hours after receipt of a notice 1,750
pursuant to division (D)(1) of this section, any individual so 1,751
notified shall advise the attending physician of the principal 1,752
whether he THE INDIVIDUAL objects on a basis specified in 1,753
division (D)(4)(c) of this section. If an objection as described 1,755
in that division is communicated to the attending physician, 1,756
then, within two business days after the communication, the 1,757
individual shall file a complaint as described in division (D)(4) 1,758
of this section in the probate court of the county in which the 1,759
principal is located. If the individual fails to so file a 1,760
41
complaint, his THE INDIVIDUAL'S objections as described in 1,762
division (D)(4)(c) of this section shall be considered to be 1,763
void.
(b) Within forty-eight hours after the priority individual 1,765
or any member of a priority class of individuals receives a 1,766
notice pursuant to division (D)(1) of this section or within 1,767
forty-eight hours after information pertaining to an unnotified 1,768
priority individual or unnotified priority class of individuals 1,769
is recorded in a principal's medical record pursuant to division 1,770
(D)(2)(a) or (b) of this section, the individual or a majority of 1,771
the individuals in the next class of individuals that pertains to 1,772
the principal in the descending order of priority set forth in 1,773
divisions (D)(1)(b)(i) to (v) of this section shall advise the 1,774
attending physician of the principal whether he THE INDIVIDUAL or 1,776
they MAJORITY object on a basis specified in division (D)(4)(c) 1,777
of this section. If an objection as described in that division 1,778
is communicated to the attending physician, then, within two 1,779
business days after the communication, the objecting individual 1,780
or majority shall file a complaint as described in division 1,781
(D)(4) of this section in the probate court of the county in 1,782
which the principal is located. If the objecting individual or 1,783
majority fails to file a complaint, his or their THE objections 1,784
as described in division (D)(4)(c) of this section shall be 1,785
considered to be void.
(4) A complaint of an individual that is filed in 1,787
accordance with division (D)(3)(a) of this section or of an 1,788
individual or majority of individuals that is filed in accordance 1,789
with division (D)(3)(b) of this section shall satisfy all of the 1,790
following: 1,791
(a) Name any health care facility in which the principal 1,793
is confined; 1,794
(b) Name the principal, his THE PRINCIPAL'S attending 1,796
physician, and the consulting physician associated with the 1,798
determination that the principal is in a terminal condition or in 1,799
42
a permanently unconscious state; 1,800
(c) Indicate whether the plaintiff or plaintiffs object on 1,802
one or more of the following bases: 1,803
(i) To the attending physician's determination that the 1,805
principal has lost the capacity to make informed health care 1,806
decisions for himself THE PRINCIPAL; 1,807
(ii) To the attending physician's determination that there 1,809
is no reasonable possibility that the principal will regain the 1,810
capacity to make informed health care decisions for himself THE 1,811
PRINCIPAL; 1,812
(iii) That, in exercising his THE ATTORNEY IN FACT'S 1,814
authority, the attorney in fact is not acting consistently with 1,816
the desires of the principal or, if the desires of the principal 1,817
are unknown, in the best interest of the principal; 1,818
(iv) That the durable power of attorney for health care 1,820
has expired or otherwise is no longer effective; 1,821
(v) To the attending physician's and consulting 1,823
physician's determinations that the principal is in a terminal 1,824
condition or in a permanently unconscious state; 1,825
(vi) That the attorney in fact's health care decision 1,827
pertaining to the use or continuation, or the withholding or 1,828
withdrawal, of life-sustaining treatment is not authorized by the 1,829
durable power of attorney for health care or is prohibited under 1,830
section 1337.13 of the Revised Code; 1,831
(vii) That the durable power of attorney for health care 1,833
was executed when the principal was not of sound mind or was 1,834
under or subject to duress, fraud, or undue influence; 1,835
(viii) That the durable power of attorney for health care 1,837
otherwise does not substantially comply with section 1337.12 of 1,838
the Revised Code. 1,839
(d) Request the probate court to issue one or more of the 1,841
following types of orders: 1,842
(i) An order to the attending physician to reevaluate, in 1,844
light of the court proceedings, the determination that the 1,845
43
principal has lost the capacity to make informed health care 1,846
decisions for himself THE PRINCIPAL, the determination that the 1,847
principal is in a terminal condition or in a permanently 1,849
unconscious state, or the determination that there is no 1,850
reasonable possibility that the principal will regain the 1,851
capacity to make informed health care decisions for himself THE 1,852
PRINCIPAL;
(ii) An order to the attorney in fact to act consistently 1,854
with the desires of the principal or, if the desires of the 1,855
principal are unknown, in the best interest of the principal in 1,856
exercising his THE ATTORNEY IN FACT'S authority, or to make only 1,857
health care decisions pertaining to life-sustaining treatment 1,859
that are authorized by the durable power of attorney for health 1,860
care and that are not prohibited under section 1337.13 of the 1,861
Revised Code;
(iii) An order invalidating the durable power of attorney 1,863
for health care because it has expired or otherwise is no longer 1,864
effective, it was executed when the principal was not of sound 1,865
mind or was under or subject to duress, fraud, or undue 1,866
influence, or it otherwise does not substantially comply with 1,867
section 1337.12 of the Revised Code. 1,868
(e) Be accompanied by an affidavit of the plaintiff or 1,869
plaintiffs that includes averments relative to whether he THE 1,870
PLAINTIFF is an individual or they THE PLAINTIFFS are individuals 1,872
as described in division (D)(1)(b)(i), (ii), (iii), (iv), or (v) 1,874
of this section and to the factual basis for his THE PLAINTIFF'S 1,875
or their THE PLAINTIFFS' objections; 1,876
(f) Name any individuals who were notified by the 1,878
attending physician in accordance with division (D)(1)(b) of this 1,879
section and who are not joining in the complaint as plaintiffs; 1,880
(g) Name, in the caption of the complaint, as defendants 1,882
the attending physician of the principal, the attorney in fact 1,883
under the durable power of attorney for health care, the 1,884
consulting physician associated with the determination that the 1,885
44
principal is in a terminal condition or in a permanently 1,886
unconscious state, any health care facility in which the 1,887
principal is confined, and any individuals who were notified by 1,888
the attending physician in accordance with division (D)(1)(b) of 1,889
this section and who are not joining in the complaint as 1,890
plaintiffs. 1,891
(5) Notwithstanding any contrary provision of the Revised 1,893
Code or of the Rules of Civil Procedure, the state and persons 1,894
other than an objecting individual as described in division 1,895
(D)(3)(a) of this section, other than an objecting individual or 1,896
majority of individuals as described in division (D)(3)(b) of 1,897
this section, and other than persons described in division 1,898
(D)(4)(g) of this section are prohibited from commencing a civil 1,899
action under division (D) of this section and from joining or 1,900
being joined as parties to an action commenced under division (D) 1,901
of this section, including joining by way of intervention. 1,902
(6)(a) A probate court in which a complaint as described 1,904
in division (D)(4) of this section is filed within the period 1,905
specified in division (D)(3)(a) or (b) of this section shall 1,906
conduct a hearing on the complaint after a copy of it and a 1,907
notice of the hearing have been served upon the defendants. The 1,908
clerk of the probate court in which the complaint is filed shall 1,909
cause the complaint and the notice of the hearing to be so served 1,910
in accordance with the Rules of Civil Procedure, which service 1,911
shall be made, if possible, within three days after the filing of 1,912
the complaint. The hearing shall be conducted at the earliest 1,913
possible time, but no later than the third business day after 1,914
such service has been completed. Immediately following the 1,915
hearing, the court shall enter on its journal its determination 1,916
whether a requested order will be issued. 1,917
(b) If the health care decision of the attorney in fact 1,919
authorized the use or continuation of life-sustaining treatment 1,920
and if the plaintiff or plaintiffs requested a reevaluation order 1,921
to the attending physician of the principal or an order to the 1,922
45
attorney in fact as described in division (D)(4)(d)(i) or (ii) of 1,923
this section, the court shall issue the requested order only if 1,924
it finds that the plaintiff or plaintiffs have established a 1,925
factual basis for the objection or objections involved by clear 1,926
and convincing evidence and, if applicable, to a reasonable 1,927
degree of medical certainty and in accordance with reasonable 1,928
medical standards. 1,929
(c) If the health care decision of the attorney in fact 1,931
authorized the withholding or withdrawal of life-sustaining 1,932
treatment and if the plaintiff or plaintiffs requested a 1,933
reevaluation order to the attending physician of the principal or 1,934
an order to the attorney in fact as described in division 1,935
(D)(4)(d)(i) or (ii) of this section, the court shall issue the 1,936
requested order only if it finds that the plaintiff or plaintiffs 1,937
have established a factual basis for the objection or objections 1,938
involved by a preponderance of the evidence and, if applicable, 1,939
to a reasonable degree of medical certainty and in accordance 1,940
with reasonable medical standards. 1,941
(d) If the plaintiff or plaintiffs requested an 1,943
invalidation order as described in division (D)(4)(d)(iii) of 1,944
this section, the court shall issue the order only if it finds 1,945
that the plaintiff or plaintiffs have established a factual basis 1,946
for the objection or objections involved by clear and convincing 1,947
evidence. 1,948
(e) If the court issues a reevaluation order to the 1,950
principal's attending physician pursuant to division (D)(6)(b) or 1,951
(c) of this section, the attending physician shall make the 1,952
requisite reevaluation. If, after doing so, the attending 1,953
physician again determines that the principal has lost the 1,954
capacity to make informed health care decisions for himself THE 1,955
PRINCIPAL, that the principal is in a terminal condition or in a 1,957
permanently unconscious state, or that there is no reasonable 1,958
possibility that the principal will regain the capacity to make 1,959
informed health care decisions for himself THE PRINCIPAL, the 1,960
46
attending physician shall notify the court in writing of the 1,963
determination and comply with division (B)(2) of this section. 1,964
(E)(1) In connection with the provision of comfort care in 1,966
a manner consistent with divisions (C) and (E) of section 1337.13 1,967
of the Revised Code to a principal who is in a terminal condition 1,968
or in a permanently unconscious state, nothing in sections 1,969
1337.11 to 1337.17 of the Revised Code precludes the attending 1,970
physician of the principal who carries out the responsibility to
provide comfort care to the principal in good faith and while 1,971
acting within the scope of his THE ATTENDING PHYSICIAN'S 1,972
authority from prescribing, dispensing, administering, or causing 1,974
to be administered any particular medical procedure, treatment,
intervention, or other measure to the principal, including, but 1,975
not limited to, prescribing, dispensing, administering, or 1,976
causing to be administered by judicious titration or in another 1,977
manner any form of medication, for the purpose of diminishing his 1,978
THE PRINCIPAL'S pain or discomfort and not for the purpose of 1,980
postponing or causing his THE PRINCIPAL'S death, even though the 1,981
medical procedure, treatment, intervention, or other measure may 1,983
appear to hasten or increase the risk of the principal's death. 1,984
In connection with the provision of comfort care in a manner 1,985
consistent with divisions (C) and (E) of section 1337.13 of the
Revised Code to a principal who is in a terminal condition or in 1,986
a permanently unconscious state, nothing in sections 1337.11 to 1,987
1337.17 of the Revised Code precludes health care personnel 1,988
acting under the direction of the principal's attending physician 1,989
who carry out the responsibility to provide comfort care to the 1,990
principal in good faith and while acting within the scope of
their authority from dispensing, administering, or causing to be 1,991
administered any particular medical procedure, treatment, 1,992
intervention, or other measure to the principal, including, but 1,993
not limited to, dispensing, administering, or causing to be 1,994
administered by judicious titration or in another manner any form 1,995
of medication, for the purpose of diminishing his THE PRINCIPAL'S 1,996
47
pain or discomfort and not for the purpose of postponing or 1,997
causing his THE PRINCIPAL'S death, even though the medical 1,999
procedure, treatment, intervention, or other measure may appear
to hasten or increase the risk of the principal's death. 2,000
(2) If, at any time, a priority individual or any member 2,002
of a priority class of individuals under division (D)(1)(b) of 2,003
this section or if, at any time, the individual or a majority of 2,005
the individuals in the next class of individuals that pertains to 2,006
the principal in the descending order of priority set forth in 2,007
that division, believes in good faith that both of the following 2,008
circumstances apply, the priority individual, the member of the 2,010
priority class of individuals, or the individual or majority of 2,011
individuals in the next class of individuals that pertains to the 2,012
principal may commence an action in the probate court of the
county in which a principal who is in a terminal condition or 2,013
permanently unconscious state is located for the issuance of an 2,014
order mandating the use or continuation of comfort care in 2,015
connection with the principal in a manner that is consistent with 2,016
sections 1337.11 to 1337.17 of the Revised Code: 2,017
(a) Comfort care is not being used or continued in 2,019
connection with the principal. 2,020
(b) The withholding or withdrawal of the comfort care is 2,022
contrary to sections 1337.11 to 1337.17 of the Revised Code. 2,023
(F) Except as provided in divisions (D) and (E) of this 2,025
section in connection with principals who are in a terminal 2,026
condition or in a permanently unconscious state, sections 1337.11 2,027
to 1337.17 of the Revised Code do not authorize the commencement 2,028
of any civil action in a probate court or court of common pleas 2,030
for the purpose of obtaining an order relative to a health care 2,031
decision made by an attorney in fact under a durable power of 2,032
attorney for health care. 2,033
(G) A durable power of attorney for health care, or other 2,035
document, that is similar to a durable power of attorney for 2,036
health care authorized by sections 1337.11 to 1337.17 of the 2,037
48
Revised Code, that is or has been executed under the law of 2,038
another state prior to, on, or after October 10, 1991, and that 2,039
substantially complies with that law or with sections 1337.11 to 2,041
1337.17 of the Revised Code shall be considered to be valid for 2,042
purposes of those sections.
Sec. 1545.071. The board of park commissioners of any park 2,051
district may procure and pay all or any part of the cost of group 2,052
insurance policies that may provide benefits for hospitalization, 2,053
surgical care, major medical care, disability, dental care, eye 2,054
care, medical care, hearing aids, or prescription drugs, or 2,055
sickness and accident insurance or a combination of any of the 2,056
foregoing types of insurance or coverage for park district 2,057
officers and employees and their immediate dependents issued by 2,058
an insurance company, a medical care corporation organized under 2,059
Chapter 1737. of the Revised Code, or a dental care corporation 2,060
organized under Chapter 1740. of the Revised Code duly authorized 2,061
to do business in this state. 2,062
The board may procure and pay all or any part of the cost 2,064
of group life insurance to insure the lives of park district 2,065
employees. 2,066
The board also may contract for group insurance or health 2,068
care services with health care INSURING corporations organized 2,070
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 2,071
the Revised Code and health maintenance organizations organized 2,072
under Chapter 1742. of the Revised Code provided that each 2,073
officer or employee is permitted to:
(A) Choose between a plan offered by an insurance company, 2,075
medical care corporation, or dental care corporation and a plan 2,076
offered by a health care INSURING corporation or health 2,077
maintenance organization and provided further that the officer or 2,079
employee pays any amount by which the cost of the plan chosen by 2,080
him THE OFFICER OR EMPLOYEE exceeds the cost of the plan offered 2,081
by the board under this section; 2,083
(B) Change his THE choice MADE under division (A) of this 2,086
49
section at a time each year as determined in advance by the
board.
Any appointed member of the board of park commissioners and 2,088
the spouse and dependent children of the member may be covered, 2,089
at the option and expense of the member, as a noncompensated 2,090
employee of the park district under any benefit plan described in 2,091
division (A) of this section. The member shall pay to the park 2,092
district the amount certified to it by the benefit provider as 2,093
the provider's charge for the coverage the member has chosen 2,094
under division (A) of this section. Payments for coverage shall 2,095
be made, in advance, in a manner prescribed by the board. The 2,096
member's exercise of an option to be covered under this section 2,097
shall be in writing, announced at a regular public meeting of the 2,098
board, and recorded as a public record in the minutes of the 2,099
board. 2,100
The board may provide the benefits authorized in this 2,102
section by contributing to a health and welfare trust fund 2,103
administered through or in conjunction with a collective 2,104
bargaining representative of the park district employees. 2,105
The board may provide the benefits described in this 2,107
section through an individual self-insurance program or a joint 2,108
self-insurance program as provided in section 9.833 of the 2,109
Revised Code. 2,110
Sec. 1731.01. As used in this chapter: 2,119
(A) "Alliance" or "small employer health care alliance" 2,121
means an existing or newly created organization that has been 2,122
granted a certificate of authority by the superintendent of 2,123
insurance under section 1731.021 of the Revised Code and that is 2,124
either of the following: 2,125
(1) A chamber of commerce, trade association, professional 2,127
organization, or any other organization that has all of the 2,128
following characteristics: 2,129
(a) Is a nonprofit corporation or association; 2,131
(b) Has members that include or are exclusively small 2,133
50
employers; 2,134
(c) Sponsors or is part of a program to assist such small 2,136
employer members to obtain coverage for their employees under one 2,137
or more health benefit plans; 2,138
(d) Is not directly or indirectly controlled, through 2,140
voting membership, representation on its governing board, or 2,141
otherwise, by any insurance company, person, firm, or corporation 2,142
that sells insurance, any provider, or by persons who are 2,143
officers, trustees, or directors of such enterprises, or by any 2,144
combination of such enterprises or persons. 2,145
(2) A nonprofit corporation controlled by one or more 2,147
organizations described in division (A)(1) of this section. 2,148
(B) "Alliance program" or "alliance health care program" 2,150
means a program sponsored by a small employer health care 2,151
alliance that assists small employer members of such small 2,152
employer health care alliance or any other small employer health 2,153
care alliance to obtain coverage for their employees under one or 2,154
more health benefit plans, and that includes at least one 2,155
agreement between a small employer health care alliance and an 2,156
insurer that contains the insurer's agreement to offer and sell 2,157
one or more health benefit plans to such small employers and 2,158
contains all of the other features required under section 1731.04 2,159
of the Revised Code. 2,160
(C) "Eligible employees, retirees, their dependents, and 2,162
members of their families," as used together or separately, means 2,163
the active employees of a small employer, or retired former 2,164
employees of a small employer or predecessor firm or 2,165
organization, their dependents or members of their families, who 2,166
are eligible for coverage under the terms of the applicable 2,167
alliance program. 2,168
(D) "Enrolled small employer" or "enrolled employer" means 2,170
a small employer that has obtained coverage for its eligible 2,171
employees from an insurer under an alliance program. 2,172
(E) "Health benefit plan" means any hospital or medical 2,174
51
expense policy of insurance or A health care plan provided by an 2,175
insurer, including a health maintenance organization INSURING 2,176
CORPORATION plan and a preferred provider organization plan, 2,177
provided by or through an insurer, or any combination thereof. 2,179
"Health benefit plan" does not include any of the following: 2,180
(1) A policy covering only accident, credit, dental, 2,182
disability income, long-term care, hospital indemnity, medicare 2,183
supplement, specified disease, OR vision care, or coverage issued 2,184
by a health care corporation, except where any of the foregoing 2,185
is offered as an addition, indorsement, or rider to a health 2,186
benefit plan; 2,187
(2) Coverage issued as a supplement to liability 2,189
insurance, insurance arising out of a workers' compensation or 2,190
similar law, automobile medical-payment insurance, or insurance 2,191
under which benefits are payable with or without regard to fault 2,192
and which is statutorily required to be contained in any 2,193
liability insurance policy or equivalent self-insurance; 2,194
(3) COVERAGE ISSUED BY A HEALTH INSURING CORPORATION 2,196
AUTHORIZED TO OFFER SUPPLEMENTAL HEALTH CARE SERVICES ONLY. 2,197
(F) "Insurer" means an insurance company authorized to do 2,199
the business of sickness and accident insurance in this state or, 2,200
for the purposes of this chapter, a health maintenance 2,201
organization INSURING CORPORATION authorized to issue health 2,202
benefit CARE plans in this state. 2,203
(G) "Participants" or "beneficiaries" means those eligible 2,205
employees, retirees, their dependents, and members of their 2,206
families who are covered by health benefit plans provided by an 2,207
insurer to enrolled small employers under an alliance program. 2,208
(H) "Provider" means a hospital, urgent care facility, 2,210
nursing home, physician, podiatrist, dentist, pharmacist, 2,211
chiropractor, certified registered nurse anesthetist, dietitian, 2,212
health maintenance organization, or other health care provider 2,213
licensed by this state, or group of such health care providers. 2,214
(I) "Qualified alliance program" means an alliance program 2,216
52
under which health care benefits are provided to two thousand 2,217
five hundred or more participants. 2,218
(J) "Small employer," regardless of its definition in any 2,220
other chapter of the Revised Code, in this chapter means an 2,221
employer that employs no more than one hundred fifty full-time 2,222
employees, at least a majority of whom are employed at locations 2,223
within this state. 2,224
(1) For this purpose: 2,226
(a) Each entity that is controlled by, controls, or is 2,228
under common control with, one or more other entities shall, 2,229
together with such other entities, be considered to be a single 2,230
employer. 2,231
(b) "Full-time employee" means a person who normally works 2,233
at least twenty-five hours per week and at least forty weeks per 2,234
year for the employer. 2,235
(c) An employer will be treated as having one hundred 2,237
fifty or fewer full-time employees on any day if, during the 2,238
prior calendar year or any twelve consecutive months during the 2,239
twenty-four full months immediately preceding that day, the mean 2,240
number of full-time employees employed by the employer does not 2,241
exceed one hundred fifty. 2,242
(2) An employer that qualifies as a small employer for 2,244
purposes of becoming an enrolled small employer continues to be 2,245
treated as a small employer for purposes of this chapter until 2,246
such time as it fails to meet the conditions described in 2,247
division (J)(1) of this section for any period of thirty-six 2,248
consecutive months after first becoming an enrolled small 2,249
employer, unless earlier disqualified under the terms of the 2,250
alliance program. 2,251
Sec. 1731.06. (A) No health benefit plan offered or 2,260
provided by an insurer to a small employer under a qualified 2,261
alliance program is subject to any law that does any of the 2,262
following: 2,263
(1) Inhibits the insurer from selectively contracting with 2,265
53
providers or groups of providers with respect to health care 2,266
service or benefits; 2,267
(2) Imposes any restrictions on the ability of the insurer 2,269
to negotiate with providers regarding the level or method of 2,270
reimbursing for care or services; 2,271
(3) Requires the insurer either to include a specific 2,273
provider or class of providers, or to exclude any class of 2,274
providers that are generally authorized by law to provide such 2,275
care, in connection with health care services or benefits under 2,276
such health benefit plan; 2,277
(4) Limits the financial incentives that a health benefit 2,279
plan may require a beneficiary to pay when a nonplan provider is 2,280
used on a nonemergency basis; 2,281
(5) Prohibits utilization review of any or all treatments 2,283
and conditions; 2,284
(6) Requires the use of specified standards of health care 2,286
practice in such reviews or requires the disclosure of the 2,287
specific criteria used in such reviews; 2,288
(7) Requires payments to providers for the expenses of 2,290
responding to utilization review requests; 2,291
(8) Imposes liability for delays in performing such 2,293
review. 2,294
(B) Notwithstanding division (A) of this section, every 2,296
health benefit plan offered or provided by an insurer, other than 2,297
a health maintenance organization INSURING CORPORATION, to a 2,298
small employer under a qualified alliance program is subject to 2,300
sections 3923.23, 3923.231, 3923.232, 3923.233, and 3923.234 of 2,301
the Revised Code and any other provision of the Revised Code that 2,302
requires the reimbursement, utilization, or consideration of a 2,303
specific category of licensed or certified health care 2,304
practitioner.
Sec. 1739.05. (A) A multiple employer welfare arrangement 2,313
that is created pursuant to sections 1739.01 to 1739.22 of the 2,314
Revised Code and that operates a group self-insurance program may 2,315
54
be established only if any of the following applies: 2,316
(1) The arrangement has and maintains a minimum enrollment 2,318
of three hundred employees of two or more employers. 2,319
(2) The arrangement has and maintains a minimum enrollment 2,321
of three hundred self-employed individuals. 2,322
(3) The arrangement has and maintains a minimum enrollment 2,324
of three hundred employees or self-employed individuals in any 2,325
combination of divisions (A)(1) and (2) of this section. 2,326
(B) A multiple employer welfare arrangement that is 2,328
created pursuant to sections 1739.01 to 1739.22 of the Revised 2,329
Code and that operates a group self-insurance program shall 2,330
comply with all laws applicable to self-funded programs in this 2,331
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 2,332
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 2,333
3923.301, and 3923.38 of the Revised Code. 2,334
(C) A multiple employer welfare arrangement created 2,336
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,337
solicit enrollments only through agents or solicitors licensed 2,338
pursuant to Chapter 3905. of the Revised Code to sell or solicit 2,339
sickness and accident insurance. 2,340
(D) A multiple employer welfare arrangement created 2,342
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,343
provide benefits only to individuals who are members, employees 2,344
of members, or the dependents of members or employees, or are 2,345
eligible for continuation of coverage under section 1742.34 2,346
1751.53 or 3923.38 of the Revised Code or under Title X of the 2,347
"Consolidated Omnibus Budget Reconciliation Act of 1985," 100 2,348
Stat. 227, 29 U.S.C.A. 1161, as amended. 2,349
Sec. 1751.01. AS USED IN THIS CHAPTER: 2,351
(A) "BASIC HEALTH CARE SERVICES" MEANS THE FOLLOWING 2,354
SERVICES WHEN MEDICALLY NECESSARY: 2,355
(1) PHYSICIAN'S SERVICES, EXCEPT WHEN SUCH SERVICES ARE 2,357
SUPPLEMENTAL UNDER DIVISION (B) OF THIS SECTION; 2,359
(2) INPATIENT HOSPITAL SERVICES; 2,361
55
(3) OUTPATIENT MEDICAL SERVICES; 2,363
(4) EMERGENCY HEALTH SERVICES; 2,365
(5) URGENT CARE SERVICES; 2,367
(6) DIAGNOSTIC LABORATORY SERVICES AND DIAGNOSTIC AND 2,369
THERAPEUTIC RADIOLOGIC SERVICES; 2,370
(7) PREVENTIVE HEALTH CARE SERVICES, INCLUDING, BUT NOT 2,372
LIMITED TO, VOLUNTARY FAMILY PLANNING SERVICES, INFERTILITY 2,373
SERVICES, PERIODIC PHYSICAL EXAMINATIONS, PRENATAL OBSTETRICAL 2,374
CARE, AND WELL-CHILD CARE. 2,375
"BASIC HEALTH CARE SERVICES" DOES NOT INCLUDE EXPERIMENTAL 2,377
PROCEDURES. 2,378
A HEALTH INSURING CORPORATION SHALL NOT OFFER COVERAGE FOR 2,380
A HEALTH CARE SERVICE, DEFINED AS A BASIC HEALTH CARE SERVICE BY 2,381
THIS DIVISION, UNLESS IT OFFERS COVERAGE FOR ALL LISTED BASIC 2,382
HEALTH CARE SERVICES. HOWEVER, THIS REQUIREMENT DOES NOT APPLY 2,384
TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XVIII OF THE 2,385
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 2,387
AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR MEDICARE COST 2,388
CONTRACT, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN THE 2,389
FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 2,391
8905, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XIX 2,392
OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,394
301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR 2,395
MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER 2,396
CHAPTER 5111. OF THE REVISED CODE, OR TO THE COVERAGE OF 2,398
BENEFICIARIES UNDER ANY FEDERAL HEALTH CARE PROGRAM REGULATED BY 2,399
A FEDERAL REGULATORY BODY.
(B) "SUPPLEMENTAL HEALTH CARE SERVICES" MEANS ANY HEALTH 2,402
CARE SERVICES OTHER THAN BASIC HEALTH CARE SERVICES THAT A HEALTH 2,403
INSURING CORPORATION MAY OFFER, ALONE OR IN COMBINATION WITH 2,404
EITHER BASIC HEALTH CARE SERVICES OR OTHER SUPPLEMENTAL HEALTH 2,405
CARE SERVICES, AND INCLUDES:
(1) SERVICES OF FACILITIES FOR INTERMEDIATE OR LONG-TERM 2,407
CARE, OR BOTH; 2,408
56
(2) DENTAL CARE SERVICES; 2,410
(3) VISION CARE AND OPTOMETRIC SERVICES INCLUDING LENSES 2,412
AND FRAMES; 2,413
(4) PODIATRIC CARE OR FOOT CARE SERVICES; 2,415
(5) MENTAL HEALTH SERVICES INCLUDING PSYCHOLOGICAL 2,417
SERVICES; 2,418
(6) SHORT-TERM OUTPATIENT EVALUATIVE AND 2,420
CRISIS-INTERVENTION MENTAL HEALTH SERVICES; 2,421
(7) MEDICAL OR PSYCHOLOGICAL TREATMENT AND REFERRAL 2,423
SERVICES FOR ALCOHOL AND DRUG ABUSE OR ADDICTION; 2,424
(8) HOME HEALTH SERVICES; 2,426
(9) PRESCRIPTION DRUG SERVICES; 2,428
(10) NURSING SERVICES; 2,430
(11) SERVICES OF A DIETITIAN LICENSED UNDER CHAPTER 4759. 2,433
OF THE REVISED CODE;
(12) PHYSICAL THERAPY SERVICES; 2,435
(13) CHIROPRACTIC SERVICES; 2,437
(14) ANY OTHER CATEGORY OF SERVICES APPROVED BY THE 2,439
SUPERINTENDENT OF INSURANCE. 2,440
(C) "SPECIALTY HEALTH CARE SERVICES" MEANS ONE OF THE 2,442
SUPPLEMENTAL HEALTH CARE SERVICES LISTED IN DIVISION (B)(1) TO 2,444
(13) OF THIS SECTION, WHEN PROVIDED BY A HEALTH INSURING 2,445
CORPORATION ON AN OUTPATIENT-ONLY BASIS AND NOT IN COMBINATION 2,446
WITH OTHER SUPPLEMENTAL HEALTH CARE SERVICES.
(D) "CLOSED PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,449
REQUIRES ENROLLEES TO USE PARTICIPATING PROVIDERS, OF WHICH 2,450
PARTICIPATING PROVIDERS, AT LEAST ONE RECEIVES COMPENSATION FROM 2,451
A HEALTH INSURING CORPORATION FOR FURNISHING THOSE HEALTH CARE 2,452
SERVICES COVERED BY THE HEALTH CARE PLAN TO THE HEALTH CARE 2,453
PLAN'S ENROLLEES. 2,454
(E) "COMPENSATION" MEANS REMUNERATION FOR THE PROVISION OF 2,458
HEALTH CARE SERVICES, DETERMINED ON OTHER THAN A FEE-FOR-SERVICE 2,459
OR DISCOUNTED-FEE-FOR-SERVICE BASIS.
(F) "CONTRACTUAL PERIODIC PREPAYMENT" MEANS THE FORMULA 2,462
57
FOR DETERMINING THE PREMIUM RATE FOR ALL SUBSCRIBERS OF A HEALTH 2,463
INSURING CORPORATION. 2,464
(G) "CORPORATION" MEANS A CORPORATION FORMED UNDER CHAPTER 2,467
1701. OR 1702. OF THE REVISED CODE OR THE SIMILAR LAWS OF ANOTHER 2,469
STATE.
(H) "EMERGENCY HEALTH SERVICES" MEANS THOSE HEALTH CARE 2,472
SERVICES THAT MUST BE AVAILABLE ON A SEVEN-DAYS-PER-WEEK, 2,473
TWENTY-FOUR-HOURS-PER-DAY BASIS IN ORDER TO PREVENT JEOPARDY TO 2,474
AN ENROLLEE'S HEALTH STATUS THAT WOULD OCCUR IF SUCH SERVICES 2,475
WERE NOT RECEIVED AS SOON AS POSSIBLE, AND INCLUDES, WHERE 2,476
APPROPRIATE, PROVISIONS FOR TRANSPORTATION AND INDEMNITY PAYMENTS 2,477
OR SERVICE AGREEMENTS FOR OUT-OF-AREA COVERAGE. 2,478
(I) "ENROLLEE" MEANS ANY NATURAL PERSON WHO IS ENTITLED TO 2,481
RECEIVE HEALTH CARE BENEFITS PROVIDED BY A HEALTH INSURING 2,482
CORPORATION.
(J) "EVIDENCE OF COVERAGE" MEANS ANY CERTIFICATE, 2,485
AGREEMENT, POLICY, OR CONTRACT ISSUED TO A SUBSCRIBER THAT SETS 2,486
OUT THE COVERAGE AND OTHER RIGHTS TO WHICH SUCH PERSON IS 2,487
ENTITLED UNDER A HEALTH CARE PLAN. 2,488
(K) "HEALTH CARE FACILITY" MEANS ANY FACILITY, EXCEPT A 2,491
HEALTH CARE PRACTITIONER'S OFFICE, THAT PROVIDES PREVENTIVE, 2,492
DIAGNOSTIC, THERAPEUTIC, ACUTE CONVALESCENT, REHABILITATION, 2,493
MENTAL HEALTH, MENTAL RETARDATION, INTERMEDIATE CARE, OR SKILLED 2,494
NURSING SERVICES. 2,495
(L) "HEALTH CARE SERVICES" MEANS ANY SERVICES INVOLVED IN 2,498
OR INCIDENT TO THE FURNISHING OF PREVENTIVE, DIAGNOSTIC, 2,499
THERAPEUTIC, OR REHABILITATIVE CARE. 2,500
(M) "HEALTH DELIVERY NETWORK" MEANS ANY GROUP OF PROVIDERS 2,503
OR HEALTH CARE FACILITIES, OR BOTH, OR ANY REPRESENTATIVE 2,504
THEREOF, THAT HAVE ENTERED INTO AN AGREEMENT TO OFFER HEALTH CARE 2,506
SERVICES IN A PANEL RATHER THAN ON AN INDIVIDUAL BASIS. 2,507
(N) "HEALTH INSURING CORPORATION" MEANS A CORPORATION, AS 2,510
DEFINED IN DIVISION (G) OF THIS SECTION, THAT, PURSUANT TO A 2,511
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT, PAYS FOR, 2,512
58
REIMBURSES, OR PROVIDES, DELIVERS, ARRANGES FOR, OR OTHERWISE 2,513
MAKES AVAILABLE, BASIC HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH 2,514
CARE SERVICES, OR SPECIALTY HEALTH CARE SERVICES, OR A 2,515
COMBINATION OF BASIC HEALTH CARE SERVICES AND EITHER SUPPLEMENTAL 2,516
HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE SERVICES, THROUGH 2,518
EITHER AN OPEN PANEL PLAN OR A CLOSED PANEL PLAN, IN EXCHANGE FOR 2,519
A PREMIUM RATE.
"HEALTH INSURING CORPORATION" DOES NOT INCLUDE A LIMITED 2,522
LIABILITY COMPANY FORMED PURSUANT TO CHAPTER 1705. OF THE REVISED 2,524
CODE, A CORPORATION FORMED BY OR ON BEHALF OF A POLITICAL 2,526
SUBDIVISION OR A DEPARTMENT, OFFICE, OR INSTITUTION OF THE STATE, 2,527
OR A CORPORATION FORMED BY OR ON BEHALF OF AN ALCOHOL AND DRUG 2,528
ADDICTION SERVICES BOARD, A BOARD OF ALCOHOL, DRUG ADDICTION, AND 2,530
MENTAL HEALTH SERVICES, OR A COMMUNITY MENTAL HEALTH BOARD, AS 2,531
THOSE TERMS ARE USED IN CHAPTER 340. OF THE REVISED CODE. UNLESS 2,532
OTHERWISE PROVIDED BY LAW, NO BOARD, COMMISSION, AGENCY, OR OTHER 2,534
ENTITY UNDER THE CONTROL OF A POLITICAL SUBDIVISION MAY ACCEPT 2,535
INSURANCE RISK IN PROVIDING FOR HEALTH CARE SERVICES. HOWEVER, 2,536
NOTHING IN THIS DIVISION SHALL BE CONSTRUED AS PROHIBITING SUCH 2,537
ENTITIES FROM PURCHASING THE SERVICES OF A HEALTH INSURING 2,538
CORPORATION OR A THIRD-PARTY ADMINISTRATOR LICENSED UNDER CHAPTER 2,539
3959. OF THE REVISED CODE. 2,540
(O) "INTERMEDIARY ORGANIZATION" MEANS A HEALTH DELIVERY 2,543
NETWORK OR OTHER ENTITY THAT CONTRACTS WITH LICENSED HEALTH 2,544
INSURING CORPORATIONS OR SELF-INSURED EMPLOYERS, OR BOTH, TO 2,545
PROVIDE HEALTH CARE SERVICES, AND THAT ENTERS INTO CONTRACTUAL 2,547
ARRANGEMENTS WITH OTHER ENTITIES FOR THE PROVISION OF HEALTH CARE 2,548
SERVICES FOR THE PURPOSE OF FULFILLING THE TERMS OF ITS CONTRACTS 2,549
WITH THE HEALTH INSURING CORPORATIONS AND SELF-INSURED EMPLOYERS. 2,550
(P) "INTERMEDIATE CARE" MEANS RESIDENTIAL CARE ABOVE THE 2,553
LEVEL OF ROOM AND BOARD FOR PATIENTS WHO REQUIRE PERSONAL 2,554
ASSISTANCE AND HEALTH-RELATED SERVICES, BUT WHO DO NOT REQUIRE 2,555
SKILLED NURSING CARE.
(Q) "MEDICAL RECORD" MEANS THE PERSONAL INFORMATION THAT 2,558
59
RELATES TO AN INDIVIDUAL'S PHYSICAL OR MENTAL CONDITION, MEDICAL 2,559
HISTORY, OR MEDICAL TREATMENT. 2,560
(R)(1)(a) "OPEN PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,562
PROVIDES INCENTIVES FOR ENROLLEES TO USE PARTICIPATING PROVIDERS, 2,564
WHICH PARTICIPATING PROVIDERS RECEIVE COMPENSATION FROM A HEALTH 2,565
INSURING CORPORATION FOR FURNISHING THOSE HEALTH CARE SERVICES 2,566
COVERED BY THE HEALTH CARE PLAN TO THE HEALTH CARE PLAN'S 2,567
ENROLLEES, AND THAT ALSO ALLOWS ENROLLEES TO USE PROVIDERS THAT 2,568
ARE NOT PARTICIPATING PROVIDERS IN EXCHANGE FOR A REDUCTION IN 2,569
BENEFITS.
(b) WITH RESPECT TO A HEALTH INSURING CORPORATION THAT, ON 2,572
THE EFFECTIVE DATE OF THIS SECTION, HOLDS A CERTIFICATE OF 2,573
AUTHORITY OR LICENSE TO OPERATE UNDER CHAPTER 1740. OF THE 2,575
REVISED CODE, "OPEN PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,576
REIMBURSES PROVIDERS ON A FEE-FOR-SERVICE OR 2,577
DISCOUNTED-FEE-FOR-SERVICE BASIS.
(2) NO HEALTH INSURING CORPORATION MAY OFFER AN OPEN PANEL 2,580
PLAN, UNLESS THE HEALTH INSURING CORPORATION IS ALSO LICENSED AS 2,581
AN INSURER UNDER TITLE XXXIX OF THE REVISED CODE, THE HEALTH 2,582
INSURING CORPORATION, ON THE EFFECTIVE DATE OF THIS SECTION, 2,583
HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO OPERATE UNDER 2,584
CHAPTER 1740. OF THE REVISED CODE, OR AN INSURER LICENSED UNDER 2,586
TITLE XXXIX OF THE REVISED CODE IS RESPONSIBLE FOR THE 2,587
OUT-OF-NETWORK RISK AS EVIDENCED BY BOTH AN EVIDENCE OF COVERAGE 2,588
FILING UNDER SECTION 1751.11 OF THE REVISED CODE AND A POLICY AND 2,589
CERTIFICATE FILING UNDER SECTION 3923.02 OF THE REVISED CODE. 2,591
(S) "PERSON" HAS THE SAME MEANING AS IN SECTION 1.59 OF 2,593
THE REVISED CODE, AND, UNLESS THE CONTEXT OTHERWISE REQUIRES, 2,594
INCLUDES ANY INSURANCE COMPANY HOLDING A CERTIFICATE OF AUTHORITY 2,595
UNDER TITLE XXXIX OF THE REVISED CODE, ANY SUBSIDIARY AND 2,597
AFFILIATE OF AN INSURANCE COMPANY, AND ANY GOVERNMENT AGENCY. 2,598
(T) "PREMIUM RATE" MEANS ANY SET FEE REGULARLY PAID BY A 2,601
SUBSCRIBER TO A HEALTH INSURING CORPORATION. A "PREMIUM RATE" 2,602
DOES NOT INCLUDE A ONE-TIME MEMBERSHIP FEE, AN ANNUAL
60
ADMINISTRATIVE FEE, OR A NOMINAL ACCESS FEE, PAID TO A MANAGED 2,603
HEALTH CARE SYSTEM UNDER WHICH THE RECIPIENT OF HEALTH CARE 2,604
SERVICES REMAINS SOLELY RESPONSIBLE FOR ANY CHARGES ACCESSED FOR 2,605
THOSE SERVICES BY THE PROVIDER OR HEALTH CARE FACILITY. 2,606
(U) "PRIMARY CARE PROVIDER" MEANS A PROVIDER THAT IS 2,609
DESIGNATED BY A HEALTH INSURING CORPORATION TO SUPERVISE, 2,610
COORDINATE, OR PROVIDE INITIAL CARE OR CONTINUING CARE TO AN 2,611
ENROLLEE, AND THAT MAY BE REQUIRED BY THE HEALTH INSURING 2,612
CORPORATION TO INITIATE A REFERRAL FOR SPECIALTY CARE AND TO 2,613
MAINTAIN SUPERVISION OF THE HEALTH CARE SERVICES RENDERED TO THE 2,614
ENROLLEE.
(V) "PROVIDER" MEANS ANY NATURAL PERSON OR PARTNERSHIP OF 2,617
NATURAL PERSONS WHO ARE LICENSED, CERTIFIED, ACCREDITED, OR 2,618
OTHERWISE AUTHORIZED IN THIS STATE TO FURNISH HEALTH CARE 2,619
SERVICES, OR ANY PROFESSIONAL ASSOCIATION ORGANIZED UNDER CHAPTER 2,620
1785. OF THE REVISED CODE, PROVIDED THAT NOTHING IN THIS CHAPTER 2,622
OR OTHER PROVISIONS OF LAW SHALL BE CONSTRUED TO PRECLUDE A 2,623
HEALTH INSURING CORPORATION, HEALTH CARE PRACTITIONER, OR 2,624
ORGANIZED HEALTH CARE GROUP ASSOCIATED WITH A HEALTH INSURING 2,625
CORPORATION FROM EMPLOYING NURSE PRACTITIONERS, DIETITIANS, 2,626
PHYSICIANS' ASSISTANTS, DENTAL ASSISTANTS, DENTAL HYGIENISTS, 2,627
OPTOMETRIC TECHNICIANS, OR OTHER ALLIED HEALTH PERSONNEL WHO ARE 2,628
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THIS 2,629
STATE TO FURNISH HEALTH CARE SERVICES.
(W) "SOLICITATION DOCUMENT" MEANS THE WRITTEN MATERIALS 2,631
PROVIDED TO PROSPECTIVE SUBSCRIBERS OR ENROLLEES, OR BOTH, AND 2,632
USED FOR ADVERTISING AND MARKETING TO INDUCE ENROLLMENT IN THE 2,633
HEALTH CARE PLANS OF A HEALTH INSURING CORPORATION. 2,634
(X) "SUBSCRIBER" MEANS A PERSON WHO IS RESPONSIBLE FOR 2,637
MAKING PAYMENTS TO A HEALTH INSURING CORPORATION FOR 2,638
PARTICIPATION IN A HEALTH CARE PLAN, OR AN ENROLLEE WHOSE 2,639
EMPLOYMENT OR OTHER STATUS IS THE BASIS OF ELIGIBILITY FOR 2,640
ENROLLMENT IN A HEALTH INSURING CORPORATION.
(Y) "URGENT CARE SERVICES" MEANS THOSE HEALTH CARE 2,643
61
SERVICES THAT ARE APPROPRIATELY PROVIDED FOR AN UNFORESEEN 2,644
CONDITION OF A KIND THAT USUALLY REQUIRES MEDICAL ATTENTION 2,645
WITHOUT DELAY BUT THAT DOES NOT POSE A THREAT TO THE LIFE, LIMB, 2,646
OR PERMANENT HEALTH OF THE INJURED OR ILL PERSON, AND MAY INCLUDE 2,648
SUCH HEALTH CARE SERVICES PROVIDED OUT OF THE HEALTH INSURING 2,649
CORPORATION'S APPROVED SERVICE AREA PURSUANT TO INDEMNITY 2,650
PAYMENTS OR SERVICE AGREEMENTS.
Sec. 1751.02. (A) NOTWITHSTANDING ANY LAW IN THIS STATE 2,652
TO THE CONTRARY, ANY CORPORATION, AS DEFINED IN SECTION 1751.01 2,654
OF THE REVISED CODE, MAY APPLY TO THE SUPERINTENDENT OF INSURANCE 2,656
FOR A CERTIFICATE OF AUTHORITY TO ESTABLISH AND OPERATE A HEALTH 2,657
INSURING CORPORATION. IF THE CORPORATION APPLYING FOR A 2,658
CERTIFICATE OF AUTHORITY IS A FOREIGN CORPORATION DOMICILED IN A 2,659
STATE WITHOUT LAWS SIMILAR TO THOSE OF THIS CHAPTER, THE 2,661
CORPORATION MUST FORM A DOMESTIC CORPORATION TO APPLY FOR,
OBTAIN, AND MAINTAIN A CERTIFICATE OF AUTHORITY UNDER THIS 2,662
CHAPTER.
(B) NO PERSON SHALL ESTABLISH, OPERATE, OR PERFORM THE 2,665
SERVICES OF A HEALTH INSURING CORPORATION IN THIS STATE WITHOUT 2,667
OBTAINING A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. 2,668
(C) NO POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR 2,670
INSTITUTION OF THIS STATE, OR CORPORATION FORMED BY OR ON BEHALF 2,671
OF ANY POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR 2,672
INSTITUTION OF THIS STATE, SHALL ESTABLISH, OPERATE, OR PERFORM 2,673
THE SERVICES OF A HEALTH INSURING CORPORATION. 2,674
(D) NO PUBLICLY OWNED, OPERATED, OR FUNDED HOSPITAL SHALL 2,676
DIRECTLY OBTAIN A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. 2,677
(E) A HEALTH INSURING CORPORATION SHALL OPERATE IN THIS 2,680
STATE IN COMPLIANCE WITH THIS CHAPTER AND WITH SECTIONS 3702.51 2,681
TO 3702.62 OF THE REVISED CODE, AND SHALL OPERATE IN CONFORMITY 2,684
WITH ITS FILINGS WITH THE SUPERINTENDENT UNDER THIS CHAPTER, 2,685
INCLUDING FILINGS MADE PURSUANT TO SECTIONS 1751.03, 1751.11, 2,686
1751.12, AND 1751.31 OF THE REVISED CODE. 2,688
(F) AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED 2,692
62
CODE NEED NOT OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,693
INSURING CORPORATION TO OFFER AN OPEN PANEL PLAN AS LONG AS THE 2,694
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE OPEN 2,695
PANEL PLAN RECEIVE THEIR COMPENSATION DIRECTLY FROM THE INSURER. 2,696
IF THE PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE 2,697
OPEN PANEL PLAN RECEIVE THEIR COMPENSATION FROM ANY PERSON OTHER 2,698
THAN THE INSURER, OR IF THE INSURER OFFERS A CLOSED PANEL PLAN, 2,699
THE INSURER MUST OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,700
INSURING CORPORATION.
(G) AN INTERMEDIARY ORGANIZATION NEED NOT OBTAIN A 2,703
CERTIFICATE OF AUTHORITY AS A HEALTH INSURING CORPORATION AS LONG 2,704
AS THE HEALTH INSURING CORPORATION OR THE SELF-INSURED EMPLOYER 2,705
MAINTAINS THE ULTIMATE RESPONSIBILITY FOR THE PERFORMANCE OF ALL 2,707
HEALTH CARE SERVICES REQUIRED BY THE CONTRACT BETWEEN THE HEALTH 2,708
INSURING CORPORATION AND THE SUBSCRIBER AND THE LAWS OF THIS 2,709
STATE OR BETWEEN THE SELF-INSURED EMPLOYER AND ITS EMPLOYEES. 2,710
(H) ANY HEALTH DELIVERY NETWORK DOING BUSINESS IN THIS 2,713
STATE THAT IS NOT REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY 2,714
UNDER THIS CHAPTER SHALL CERTIFY TO THE SUPERINTENDENT ANNUALLY, 2,715
NOT LATER THAN THE FIRST DAY OF JULY, AND SHALL PROVIDE A 2,717
STATEMENT SIGNED BY THE HIGHEST RANKING OFFICIAL WHICH INCLUDES 2,718
THE FOLLOWING INFORMATION:
(1) THE HEALTH DELIVERY NETWORK'S FULL NAME AND THE 2,720
ADDRESS OF ITS PRINCIPAL PLACE OF BUSINESS; 2,721
(2) A STATEMENT THAT THE HEALTH DELIVERY NETWORK IS NOT 2,723
REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 2,724
TO CONDUCT ITS BUSINESS. 2,725
(I) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO APPLY TO 2,727
ANY MULTIPLE EMPLOYER WELFARE ARRANGEMENT OPERATING PURSUANT TO 2,728
CHAPTER 1739. OF THE REVISED CODE. 2,729
(J) ANY PERSON WHO VIOLATES DIVISION (B) OF THIS SECTION, 2,733
AND ANY HEALTH DELIVERY NETWORK THAT FAILS TO COMPLY WITH 2,734
DIVISION (H) OF THIS SECTION, IS SUBJECT TO THE PENALTIES SET 2,735
FORTH IN SECTION 1751.45 OF THE REVISED CODE. 2,737
63
Sec. 1751.03. (A) EACH APPLICATION FOR A CERTIFICATE OF 2,740
AUTHORITY UNDER THIS CHAPTER SHALL BE VERIFIED BY AN OFFICER OR 2,741
AUTHORIZED REPRESENTATIVE OF THE APPLICANT, SHALL BE IN A FORMAT 2,742
PRESCRIBED BY THE SUPERINTENDENT OF INSURANCE, AND SHALL SET 2,743
FORTH OR BE ACCOMPANIED BY THE FOLLOWING: 2,744
(1) A CERTIFIED COPY OF THE APPLICANT'S ARTICLES OF 2,746
INCORPORATION AND ALL AMENDMENTS TO THE ARTICLES OF 2,747
INCORPORATION; 2,748
(2) A COPY OF ANY REGULATIONS ADOPTED FOR THE GOVERNMENT 2,750
OF THE CORPORATION, ANY BYLAWS, AND ANY SIMILAR DOCUMENTS, AND A 2,751
COPY OF ALL AMENDMENTS TO THESE REGULATIONS, BYLAWS, AND 2,752
DOCUMENTS. THE CORPORATE SECRETARY SHALL CERTIFY THAT THESE 2,753
REGULATIONS, BYLAWS, DOCUMENTS, AND AMENDMENTS HAVE BEEN PROPERLY 2,755
ADOPTED OR APPROVED.
(3) A LIST OF THE NAMES, ADDRESSES, AND OFFICIAL POSITIONS 2,758
OF THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE APPLICANT, 2,759
INCLUDING ALL MEMBERS OF THE BOARD, THE PRINCIPAL OFFICERS, AND 2,760
THE PERSON RESPONSIBLE FOR COMPLETING OR FILING FINANCIAL 2,761
STATEMENTS WITH THE DEPARTMENT OF INSURANCE, ACCOMPANIED BY A 2,762
COMPLETED ORIGINAL BIOGRAPHICAL AFFIDAVIT AND RELEASE OF 2,763
INFORMATION FOR EACH OF THESE PERSONS ON FORMS ACCEPTABLE TO THE 2,764
DEPARTMENT;
(4) A FULL AND COMPLETE DISCLOSURE OF THE EXTENT AND 2,766
NATURE OF ANY CONTRACTUAL OR OTHER FINANCIAL ARRANGEMENT BETWEEN 2,767
THE APPLICANT AND ANY PROVIDER OR A PERSON LISTED IN DIVISION 2,769
(A)(3) OF THIS SECTION, INCLUDING, BUT NOT LIMITED TO, A FULL AND 2,770
COMPLETE DISCLOSURE OF THE FINANCIAL INTEREST HELD BY ANY SUCH 2,771
PROVIDER OR PERSON IN ANY HEALTH CARE FACILITY, PROVIDER, OR 2,772
INSURER THAT HAS ENTERED INTO A FINANCIAL RELATIONSHIP WITH THE 2,773
HEALTH INSURING CORPORATION; 2,774
(5) A DESCRIPTION OF THE APPLICANT, ITS FACILITIES, AND 2,776
ITS PERSONNEL, INCLUDING, BUT NOT LIMITED TO, THE LOCATION, HOURS 2,778
OF OPERATION, AND TELEPHONE NUMBERS OF ALL CONTRACTED FACILITIES; 2,779
(6) THE APPLICANT'S PROJECTED ANNUAL ENROLLEE POPULATION 2,781
64
OVER A THREE-YEAR PERIOD; 2,782
(7) A CLEAR AND SPECIFIC DESCRIPTION OF THE HEALTH CARE 2,784
PLAN OR PLANS TO BE USED BY THE APPLICANT, INCLUDING A 2,785
DESCRIPTION OF THE PROPOSED PROVIDERS, PROCEDURES FOR ACCESSING 2,786
CARE, AND THE FORM OF ALL PROPOSED AND EXISTING CONTRACTS 2,787
RELATING TO THE ADMINISTRATION, DELIVERY, OR FINANCING OF HEALTH 2,788
CARE SERVICES; 2,789
(8) A COPY OF EACH TYPE OF EVIDENCE OF COVERAGE AND 2,791
IDENTIFICATION CARD OR SIMILAR DOCUMENT TO BE ISSUED TO 2,792
SUBSCRIBERS; 2,793
(9) A COPY OF EACH TYPE OF INDIVIDUAL OR GROUP POLICY, 2,795
CONTRACT, OR AGREEMENT TO BE USED; 2,796
(10) THE SCHEDULE OF THE PROPOSED CONTRACTUAL PERIODIC 2,798
PREPAYMENTS OR PREMIUM RATES, OR BOTH, ACCOMPANIED BY APPROPRIATE 2,799
SUPPORTING DATA; 2,800
(11) A FINANCIAL PLAN WHICH PROVIDES A THREE-YEAR 2,802
PROJECTION OF OPERATING RESULTS, INCLUDING THE PROJECTED 2,803
EXPENSES, INCOME, AND SOURCES OF WORKING CAPITAL; 2,804
(12) THE ENROLLEE COMPLAINT PROCEDURE TO BE UTILIZED AS 2,806
REQUIRED UNDER SECTION 1751.19 OF THE REVISED CODE; 2,809
(13) A DESCRIPTION OF THE PROCEDURES AND PROGRAMS TO BE 2,811
IMPLEMENTED ON AN ONGOING BASIS TO ASSURE THE QUALITY OF HEALTH 2,812
CARE SERVICES DELIVERED TO ENROLLEES; 2,813
(14) A STATEMENT DESCRIBING THE GEOGRAPHIC AREA OR AREAS 2,815
TO BE SERVED, BY COUNTY; 2,816
(15) A COPY OF ALL SOLICITATION DOCUMENTS; 2,818
(16) A BALANCE SHEET AND OTHER FINANCIAL STATEMENTS 2,820
SHOWING THE APPLICANT'S ASSETS, LIABILITIES, INCOME, AND OTHER 2,821
SOURCES OF FINANCIAL SUPPORT; 2,822
(17) A DESCRIPTION OF THE NATURE AND EXTENT OF ANY 2,824
REINSURANCE PROGRAM TO BE IMPLEMENTED, AND A DEMONSTRATION THAT 2,825
ERRORS AND OMISSION INSURANCE AND, IF APPROPRIATE, FIDELITY 2,826
INSURANCE, WILL BE IN PLACE UPON THE APPLICANT'S RECEIPT OF A 2,827
CERTIFICATE OF AUTHORITY; 2,828
65
(18) COPIES OF ALL PROPOSED OR IN FORCE RELATED-PARTY OR 2,830
INTERCOMPANY AGREEMENTS WITH AN EXPLANATION OF THE FINANCIAL 2,831
IMPACT OF THESE AGREEMENTS ON THE APPLICANT. IF THE APPLICANT 2,832
INTENDS TO ENTER INTO A CONTRACT FOR MANAGERIAL OR ADMINISTRATIVE 2,834
SERVICES, WITH EITHER AN AFFILIATED OR AN UNAFFILIATED PERSON,
THE APPLICANT SHALL PROVIDE A COPY OF THE CONTRACT AND A DETAILED 2,835
DESCRIPTION OF THE PERSON TO PROVIDE THESE SERVICES. THE 2,837
DESCRIPTION SHALL INCLUDE THAT PERSON'S EXPERIENCE IN MANAGING OR 2,838
ADMINISTERING HEALTH CARE PLANS, A COPY OF THAT PERSON'S MOST 2,839
RECENT AUDITED FINANCIAL STATEMENT, AND A COMPLETED BIOGRAPHICAL 2,840
AFFIDAVIT ON A FORM ACCEPTABLE TO THE SUPERINTENDENT FOR EACH OF 2,841
THAT PERSON'S PRINCIPAL OFFICERS AND BOARD MEMBERS AND FOR ANY 2,842
ADDITIONAL EMPLOYEE TO BE DIRECTLY INVOLVED IN PROVIDING 2,843
MANAGERIAL OR ADMINISTRATIVE SERVICES TO THE HEALTH INSURING 2,844
CORPORATION. IF THE PERSON TO PROVIDE MANAGERIAL OR 2,845
ADMINISTRATIVE SERVICES IS AFFILIATED WITH THE HEALTH INSURING 2,846
CORPORATION, THE CONTRACT MUST PROVIDE FOR PAYMENT FOR SERVICES 2,847
BASED ON ACTUAL COSTS.
(19) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,849
ADMITTED ASSETS OF THE APPLICANT HAVE NOT BEEN AND WILL NOT BE 2,850
PLEDGED OR HYPOTHECATED; 2,851
(20) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,853
APPLICANT WILL SUBMIT MONTHLY FINANCIAL STATEMENTS DURING THE 2,854
FIRST YEAR OF OPERATIONS; 2,855
(21) THE NAME AND ADDRESS OF THE APPLICANT'S OHIO 2,858
STATUTORY AGENT FOR SERVICE OF PROCESS, NOTICE, OR DEMAND; 2,859
(22) COPIES OF ALL DOCUMENTS THE APPLICANT FILED WITH THE 2,861
SECRETARY OF STATE; 2,862
(23) THE LOCATION OF THOSE BOOKS AND RECORDS OF THE 2,864
APPLICANT THAT MUST BE MAINTAINED IN OHIO; 2,865
(24) THE APPLICANT'S FEDERAL IDENTIFICATION NUMBER, 2,867
CORPORATE ADDRESS, AND MAILING ADDRESS; 2,868
(25) AN INTERNAL AND EXTERNAL ORGANIZATIONAL CHART; 2,871
(26) A LIST OF THE ASSETS REPRESENTING THE INITIAL NET 2,873
66
WORTH OF THE APPLICANT; 2,874
(27) IF THE APPLICANT HAS A PARENT COMPANY, THE PARENT 2,876
COMPANY'S GUARANTY, ON A FORM ACCEPTABLE TO THE SUPERINTENDENT, 2,877
THAT THE APPLICANT WILL MAINTAIN OHIO'S MINIMUM NET WORTH. IF NO 2,880
PARENT COMPANY EXISTS, A STATEMENT REGARDING THE AVAILABILITY OF 2,881
FUTURE FUNDS IF NEEDED.
(28) THE NAMES AND ADDRESSES OF THE APPLICANT'S ACTUARY 2,883
AND EXTERNAL AUDITORS; 2,884
(29) IF THE APPLICANT IS A FOREIGN CORPORATION, A COPY OF 2,886
THE MOST RECENT FINANCIAL STATEMENTS FILED WITH THE INSURANCE 2,887
REGULATORY AGENCY IN THE APPLICANT'S STATE OF DOMICILE; 2,888
(30) IF THE APPLICANT IS A FOREIGN CORPORATION, A 2,890
STATEMENT FROM THE INSURANCE REGULATORY AGENCY OF THE APPLICANT'S 2,891
STATE OF DOMICILE STATING THAT THE REGULATORY AGENCY HAS NO 2,892
OBJECTION TO THE APPLICANT APPLYING FOR AN OHIO LICENSE AND THAT 2,893
THE APPLICANT IS IN GOOD STANDING IN THE APPLICANT'S STATE OF 2,894
DOMICILE; 2,895
(31) ANY OTHER INFORMATION THAT THE SUPERINTENDENT MAY 2,897
REQUIRE. 2,898
(B)(1) A HEALTH INSURING CORPORATION, UNLESS OTHERWISE 2,901
PROVIDED FOR IN THIS CHAPTER, SHALL FILE A TIMELY NOTICE WITH THE 2,902
SUPERINTENDENT DESCRIBING ANY CHANGE TO THE CORPORATION'S 2,903
ARTICLES OF INCORPORATION OR REGULATIONS, OR ANY MAJOR 2,904
MODIFICATION TO ITS OPERATIONS AS SET OUT IN THE INFORMATION 2,905
REQUIRED BY DIVISION (A) OF THIS SECTION THAT AFFECTS ANY OF THE 2,907
FOLLOWING:
(a) THE SOLVENCY OF THE HEALTH INSURING CORPORATION; 2,910
(b) THE HEALTH INSURING CORPORATION'S CONTINUED PROVISION 2,913
OF SERVICES THAT IT HAS CONTRACTED TO PROVIDE; 2,914
(c) THE MANNER IN WHICH THE HEALTH INSURING CORPORATION 2,917
CONDUCTS ITS BUSINESS.
(2) IF THE CHANGE OR MODIFICATION IS TO BE THE RESULT OF 2,919
AN ACTION TO BE TAKEN BY THE HEALTH INSURING CORPORATION, THE 2,920
NOTICE SHALL BE FILED WITH THE SUPERINTENDENT PRIOR TO THE HEALTH 2,921
67
INSURING CORPORATION TAKING THE ACTION. THE ACTION SHALL BE 2,923
DEEMED APPROVED IF THE SUPERINTENDENT DOES NOT DISAPPROVE IT 2,924
WITHIN SIXTY DAYS OF FILING. 2,925
(C)(1) NO HEALTH INSURING CORPORATION SHALL EXPAND ITS 2,928
APPROVED SERVICE AREA UNTIL A COPY OF THE REQUEST FOR EXPANSION, 2,929
ACCOMPANIED BY DOCUMENTATION OF THE NETWORK OF PROVIDERS, 2,930
ENROLLMENT PROJECTIONS, PLAN OF OPERATION, AND ANY OTHER CHANGES 2,931
HAVE BEEN FILED WITH THE SUPERINTENDENT. 2,932
(2) WITHIN TEN CALENDAR DAYS AFTER RECEIPT OF A COMPLETE 2,934
FILING UNDER DIVISION (C)(1) OF THIS SECTION, THE SUPERINTENDENT 2,936
SHALL REFER THE APPROPRIATE JURISDICTIONAL ISSUES TO THE DIRECTOR 2,937
OF HEALTH PURSUANT TO SECTION 1751.04 OF THE REVISED CODE. 2,939
(3) WITHIN SEVENTY-FIVE DAYS AFTER THE SUPERINTENDENT'S 2,941
RECEIPT OF A COMPLETE FILING UNDER DIVISION (C)(1) OF THIS 2,943
SECTION, THE SUPERINTENDENT SHALL DETERMINE WHETHER THE PLAN FOR 2,944
EXPANSION IS LAWFUL, FAIR, AND REASONABLE. THE SUPERINTENDENT 2,945
MAY NOT MAKE A DETERMINATION UNTIL THE SUPERINTENDENT HAS 2,946
RECEIVED THE DIRECTOR'S CERTIFICATION OF COMPLIANCE, WHICH THE 2,947
DIRECTOR SHALL FURNISH WITHIN FORTY-FIVE DAYS AFTER REFERRAL 2,948
UNDER DIVISION (C)(2) OF THIS SECTION. THE DIRECTOR SHALL NOT 2,950
CERTIFY THAT THE REQUIREMENTS OF SECTION 1751.04 OF THE REVISED 2,952
CODE ARE NOT MET, UNLESS THE APPLICANT HAS BEEN GIVEN AN 2,953
OPPORTUNITY FOR A HEARING AS PROVIDED IN DIVISION (D) OF SECTION 2,955
1751.04 OF THE REVISED CODE. THE FORTY-FIVE-DAY AND 2,956
SEVENTY-FIVE-DAY REVIEW PERIODS PROVIDED FOR IN DIVISION (C)(3) 2,958
OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON WHICH THE 2,959
NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS MAILED 2,960
AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A FINAL 2,961
CERTIFICATION. 2,962
(4) IF THE SUPERINTENDENT HAS NOT APPROVED OR DISAPPROVED 2,964
ALL OR A PORTION OF A SERVICE AREA EXPANSION WITHIN THE 2,965
SEVENTY-FIVE-DAY PERIOD PROVIDED FOR IN DIVISION (C)(3) OF THIS 2,967
SECTION, THE FILING SHALL BE DEEMED APPROVED. 2,968
(5) DISAPPROVAL OF ALL OR A PORTION OF THE FILING SHALL BE 2,971
68
EFFECTED BY WRITTEN NOTICE, WHICH SHALL STATE THE GROUNDS FOR THE 2,972
ORDER OF DISAPPROVAL AND SHALL BE GIVEN IN ACCORDANCE WITH 2,973
CHAPTER 119. OF THE REVISED CODE.
Sec. 1751.04. (A) UPON THE RECEIPT BY THE SUPERINTENDENT 2,976
OF INSURANCE OF A COMPLETE APPLICATION FOR A CERTIFICATE OF 2,977
AUTHORITY TO ESTABLISH OR OPERATE A HEALTH INSURING CORPORATION, 2,978
WHICH APPLICATION SETS FORTH OR IS ACCOMPANIED BY THE INFORMATION 2,979
AND DOCUMENTS REQUIRED BY DIVISION (A) OF SECTION 1751.03 OF THE 2,981
REVISED CODE, THE SUPERINTENDENT SHALL TRANSMIT COPIES OF THE 2,983
APPLICATION AND ACCOMPANYING DOCUMENTS TO THE DIRECTOR OF HEALTH. 2,984
(B) THE DIRECTOR SHALL REVIEW THE APPLICATION AND 2,987
ACCOMPANYING DOCUMENTS AND MAKE FINDINGS AS TO WHETHER THE 2,988
APPLICANT FOR A CERTIFICATE OF AUTHORITY HAS DONE ALL OF THE 2,989
FOLLOWING WITH RESPECT TO ANY BASIC HEALTH CARE SERVICES AND 2,990
SUPPLEMENTAL HEALTH CARE SERVICES TO BE FURNISHED: 2,991
(1) DEMONSTRATED THE WILLINGNESS AND POTENTIAL ABILITY TO 2,993
ENSURE THAT ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL 2,994
HEALTH CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE WILL 2,996
BE PROVIDED TO ALL ITS ENROLLEES AS PROMPTLY AS IS APPROPRIATE 2,997
AND IN A MANNER THAT ASSURES CONTINUITY; 2,998
(2) MADE EFFECTIVE ARRANGEMENTS TO ENSURE THAT ITS 3,000
ENROLLEES HAVE RELIABLE ACCESS TO QUALIFIED PROVIDERS IN THOSE 3,001
SPECIALTIES THAT ARE GENERALLY AVAILABLE IN THE GEOGRAPHIC AREA 3,002
OR AREAS TO BE SERVED BY THE APPLICANT AND THAT ARE NECESSARY TO 3,003
PROVIDE ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 3,004
CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE; 3,006
(3) MADE APPROPRIATE ARRANGEMENTS FOR THE AVAILABILITY OF 3,008
SHORT-TERM HEALTH CARE SERVICES IN EMERGENCIES WITHIN THE 3,009
GEOGRAPHIC AREA OR AREAS TO BE SERVED BY THE APPLICANT, 3,010
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK, AND FOR THE 3,011
PROVISION OF ADEQUATE COVERAGE WHENEVER AN OUT-OF-AREA EMERGENCY 3,012
ARISES; 3,013
(4) MADE APPROPRIATE ARRANGEMENTS FOR AN ONGOING 3,015
EVALUATION AND ASSURANCE OF THE QUALITY OF HEALTH CARE SERVICES 3,016
69
PROVIDED TO ENROLLEES AND THE ADEQUACY OF THE PERSONNEL, 3,017
FACILITIES, AND EQUIPMENT BY OR THROUGH WHICH THE SERVICES ARE 3,018
RENDERED;
(5) DEVELOPED A PROCEDURE TO GATHER AND REPORT STATISTICS 3,020
RELATING TO THE COST AND EFFECTIVENESS OF ITS OPERATIONS, THE 3,021
PATTERN OF UTILIZATION OF ITS SERVICES, AND THE QUALITY, 3,022
AVAILABILITY, AND ACCESSIBILITY OF ITS SERVICES. 3,023
(C) WITHIN NINETY DAYS OF THE DIRECTOR'S RECEIPT OF THE 3,025
APPLICATION FOR ISSUANCE OF A CERTIFICATE OF AUTHORITY, THE 3,027
DIRECTOR SHALL CERTIFY TO THE SUPERINTENDENT WHETHER OR NOT THE 3,028
APPLICANT MEETS THE REQUIREMENTS OF DIVISION (B) OF THIS SECTION 3,029
AND SECTIONS 3702.51 TO 3702.62 OF THE REVISED CODE. IF THE 3,030
DIRECTOR CERTIFIES THAT THE APPLICANT DOES NOT MEET THESE 3,031
REQUIREMENTS, THE DIRECTOR SHALL SPECIFY IN WHAT RESPECTS IT IS 3,032
DEFICIENT. HOWEVER, THE DIRECTOR SHALL NOT CERTIFY THAT THE 3,033
REQUIREMENTS OF THIS SECTION ARE NOT MET UNLESS THE APPLICANT HAS 3,034
BEEN GIVEN AN OPPORTUNITY FOR A HEARING. 3,035
(D) IF THE APPLICANT REQUESTS A HEARING, THE DIRECTOR 3,038
SHALL HOLD A HEARING BEFORE CERTIFYING THAT THE APPLICANT DOES 3,039
NOT MEET THE REQUIREMENTS OF THIS SECTION. THE HEARING SHALL BE 3,040
HELD IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,042
(E) THE NINETY-DAY REVIEW PERIOD PROVIDED FOR UNDER 3,045
DIVISION (C) OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON 3,047
WHICH THE NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS 3,048
MAILED AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A 3,049
FINAL CERTIFICATION ORDER.
Sec. 1751.05. (A) THE SUPERINTENDENT OF INSURANCE SHALL 3,052
ISSUE OR DENY A CERTIFICATE OF AUTHORITY TO ESTABLISH OR OPERATE 3,053
A HEALTH INSURING CORPORATION TO ANY CORPORATION FILING AN 3,054
APPLICATION PURSUANT TO SECTION 1751.03 OF THE REVISED CODE 3,056
WITHIN FORTY-FIVE DAYS OF THE SUPERINTENDENT'S RECEIPT OF THE 3,057
CERTIFICATION FROM THE DIRECTOR OF HEALTH UNDER DIVISION (C) OF 3,058
SECTION 1751.04 OF THE REVISED CODE. A CERTIFICATE OF AUTHORITY 3,059
SHALL BE ISSUED UPON PAYMENT OF THE APPLICATION FEE PRESCRIBED IN 3,060
70
SECTION 1751.44 OF THE REVISED CODE IF THE SUPERINTENDENT IS 3,061
SATISFIED THAT THE FOLLOWING CONDITIONS ARE MET: 3,062
(1) THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS 3,065
OF THE APPLICANT ARE COMPETENT, TRUSTWORTHY, AND POSSESS GOOD 3,066
REPUTATIONS.
(2) THE DIRECTOR CERTIFIES, IN ACCORDANCE WITH DIVISION 3,068
(C) OF SECTION 1751.04 OF THE REVISED CODE, THAT THE 3,069
ORGANIZATION'S PROPOSED PLAN OF OPERATION MEETS THE REQUIREMENTS 3,070
OF DIVISION (B) OF THAT SECTION AND SECTIONS 3702.51 TO 3702.62 3,072
OF THE REVISED CODE. IF, AFTER THE DIRECTOR HAS CERTIFIED 3,073
COMPLIANCE, THE APPLICATION IS AMENDED IN A MANNER THAT AFFECTS 3,074
ITS APPROVAL UNDER SECTION 1751.04 OF THE REVISED CODE, THE 3,075
SUPERINTENDENT SHALL REQUEST THE DIRECTOR TO REVIEW AND RECERTIFY 3,076
THE AMENDED PLAN OF OPERATION. WITHIN FORTY-FIVE DAYS OF RECEIPT 3,077
OF THE AMENDED PLAN FROM THE SUPERINTENDENT, THE DIRECTOR SHALL 3,078
CERTIFY TO THE SUPERINTENDENT, PURSUANT TO SECTION 1751.04 OF THE 3,079
REVISED CODE, WHETHER OR NOT THE AMENDED PLAN MEETS THE 3,081
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. THE 3,082
SUPERINTENDENT'S FORTY-FIVE-DAY REVIEW PERIOD SHALL CEASE TO RUN 3,083
AS OF THE DATE ON WHICH THE AMENDED PLAN IS TRANSMITTED TO THE 3,084
DIRECTOR AND SHALL REMAIN SUSPENDED UNTIL THE SUPERINTENDENT 3,085
RECEIVES A NEW CERTIFICATION FROM THE DIRECTOR.
(3) THE APPLICANT CONSTITUTES AN APPROPRIATE MECHANISM TO 3,087
EFFECTIVELY PROVIDE OR ARRANGE FOR THE PROVISION OF THE BASIC 3,088
HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH CARE SERVICES, OR 3,089
SPECIALTY HEALTH CARE SERVICES TO BE PROVIDED TO ENROLLEES. 3,090
(4) THE APPLICANT IS FINANCIALLY RESPONSIBLE, COMPLIES 3,092
WITH SECTION 1751.28 OF THE REVISED CODE, AND MAY REASONABLY BE 3,094
EXPECTED TO MEET ITS OBLIGATIONS TO ENROLLEES AND PROSPECTIVE 3,095
ENROLLEES. IN MAKING THIS DETERMINATION, THE SUPERINTENDENT MAY 3,096
CONSIDER: 3,097
(a) THE FINANCIAL SOUNDNESS OF THE APPLICANT'S 3,099
ARRANGEMENTS FOR HEALTH CARE SERVICES, INCLUDING THE APPLICANT'S 3,100
PROPOSED CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUMS AND THE USE 3,101
71
OF COPAYMENTS OR DEDUCTIBLES; 3,102
(b) THE ADEQUACY OF WORKING CAPITAL; 3,104
(c) ANY AGREEMENT WITH AN INSURER, A GOVERNMENT, OR ANY 3,107
OTHER PERSON FOR INSURING THE PAYMENT OF THE COST OF HEALTH CARE 3,108
SERVICES OR PROVIDING FOR AUTOMATIC APPLICABILITY OF AN 3,109
ALTERNATIVE COVERAGE IN THE EVENT OF DISCONTINUANCE OF THE HEALTH 3,110
INSURING CORPORATION'S OPERATIONS; 3,111
(d) ANY AGREEMENT WITH PROVIDERS OR HEALTH CARE FACILITIES 3,113
FOR THE PROVISION OF HEALTH CARE SERVICES; 3,114
(e) ANY DEPOSIT OF SECURITIES SUBMITTED IN ACCORDANCE WITH 3,117
SECTION 1751.27 OF THE REVISED CODE AS A GUARANTEE THAT THE 3,118
OBLIGATIONS WILL BE PERFORMED. 3,119
(5) THE APPLICANT HAS SUBMITTED DOCUMENTATION OF AN 3,121
ARRANGEMENT TO PROVIDE HEALTH CARE SERVICES TO ITS ENROLLEES 3,122
UNTIL THE EXPIRATION OF THE ENROLLEES' CONTRACTS WITH THE 3,123
APPLICANT IF A HEALTH CARE PLAN OR THE OPERATIONS OF THE HEALTH 3,124
INSURING CORPORATION ARE DISCONTINUED PRIOR TO THE EXPIRATION OF 3,125
THE ENROLLEES' CONTRACTS. AN ARRANGEMENT TO PROVIDE HEALTH CARE 3,126
SERVICES MAY BE MADE BY USING ANY ONE, OR ANY COMBINATION, OF THE 3,128
FOLLOWING METHODS:
(a) THE MAINTENANCE OF INSOLVENCY INSURANCE; 3,130
(b) A PROVISION IN CONTRACTS WITH PROVIDERS AND HEALTH 3,133
CARE FACILITIES, BUT NO HEALTH INSURING CORPORATION SHALL RELY 3,134
SOLELY ON SUCH A PROVISION FOR MORE THAN THIRTY DAYS; 3,135
(c) AN AGREEMENT WITH OTHER HEALTH INSURING CORPORATIONS 3,138
OR INSURERS, PROVIDING ENROLLEES WITH AUTOMATIC CONVERSION RIGHTS 3,139
UPON THE DISCONTINUATION OF A HEALTH CARE PLAN OR THE HEALTH 3,140
INSURING CORPORATION'S OPERATIONS; 3,141
(d) SUCH OTHER METHODS AS APPROVED BY THE SUPERINTENDENT. 3,143
(6) NOTHING IN THE APPLICANT'S PROPOSED METHOD OF 3,145
OPERATION, AS SHOWN BY THE INFORMATION SUBMITTED PURSUANT TO 3,146
SECTION 1751.03 OF THE REVISED CODE OR BY INDEPENDENT 3,148
INVESTIGATION, WILL CAUSE HARM TO AN ENROLLEE OR TO THE PUBLIC AT 3,150
LARGE, AS DETERMINED BY THE SUPERINTENDENT.
72
(7) ANY DEFICIENCIES CERTIFIED BY THE DIRECTOR HAVE BEEN 3,152
CORRECTED. 3,153
(8) THE APPLICANT HAS DEPOSITED SECURITIES AS SET FORTH IN 3,156
SECTION 1751.27 OF THE REVISED CODE.
(B) IF AN APPLICANT ELECTS TO FULFILL THE REQUIREMENTS OF 3,159
DIVISION (A)(5) OF THIS SECTION THROUGH AN AGREEMENT WITH OTHER 3,161
HEALTH INSURING CORPORATIONS OR INSURERS, THE AGREEMENT SHALL 3,162
REQUIRE THOSE HEALTH INSURING CORPORATIONS OR INSURERS TO GIVE 3,163
THIRTY DAYS' NOTICE TO THE SUPERINTENDENT PRIOR TO CANCELLATION 3,164
OR DISCONTINUATION OF THE AGREEMENT FOR ANY REASON. 3,165
(C) A CERTIFICATE OF AUTHORITY SHALL BE DENIED ONLY AFTER 3,168
COMPLIANCE WITH THE REQUIREMENTS OF SECTION 1751.36 OF THE 3,169
REVISED CODE.
Sec. 1751.06. UPON OBTAINING A CERTIFICATE OF AUTHORITY AS 3,171
REQUIRED UNDER THIS CHAPTER, A HEALTH INSURING CORPORATION MAY DO 3,173
ALL OF THE FOLLOWING:
(A) ENROLL INDIVIDUALS AND THEIR DEPENDENTS IN EITHER OF 3,176
THE FOLLOWING CIRCUMSTANCES: 3,177
(1) THE INDIVIDUAL RESIDES IN THE APPROVED SERVICE AREA. 3,180
(2) THE INDIVIDUAL'S PLACE OF EMPLOYMENT IS LOCATED IN THE 3,183
APPROVED SERVICE AREA AND THE INDIVIDUAL HAS AGREED TO RECEIVE 3,184
HEALTH CARE SERVICES IN ACCORDANCE WITH THE EVIDENCE OF COVERAGE. 3,185
(B) CONTRACT WITH PROVIDERS AND HEALTH CARE FACILITIES FOR 3,188
THE HEALTH CARE SERVICES TO WHICH ENROLLEES ARE ENTITLED UNDER 3,189
THE TERMS OF THE HEALTH INSURING CORPORATION'S HEALTH CARE 3,190
CONTRACTS;
(C) CONTRACT WITH INSURANCE COMPANIES AUTHORIZED TO DO 3,193
BUSINESS IN THIS STATE FOR INSURANCE, INDEMNITY, OR REIMBURSEMENT 3,194
AGAINST THE COST OF PROVIDING EMERGENCY AND NONEMERGENCY HEALTH 3,195
CARE SERVICES FOR ENROLLEES, SUBJECT TO THE PROVISIONS SET FORTH 3,196
IN THIS CHAPTER AND THE LIMITATIONS SET FORTH IN THE REVISED 3,198
CODE;
(D) CONTRACT WITH ANY PERSON PURSUANT TO THE REQUIREMENTS 3,201
OF DIVISION (A)(18) OF SECTION 1751.03 OF THE REVISED CODE FOR 3,203
73
MANAGERIAL OR ADMINISTRATIVE SERVICES, OR FOR DATA PROCESSING, 3,204
ACTUARIAL ANALYSIS, BILLING SERVICES, OR ANY OTHER SERVICES 3,205
AUTHORIZED BY THE SUPERINTENDENT OF INSURANCE. HOWEVER, A HEALTH 3,207
INSURING CORPORATION SHALL NOT ENTER INTO A CONTRACT FOR ANY OF 3,208
THE SERVICES LISTED IN THIS DIVISION WITH AN INSURANCE COMPANY 3,209
THAT IS NOT AUTHORIZED TO ENGAGE IN THE BUSINESS OF INSURANCE IN 3,210
THIS STATE.
(E) ACCEPT FROM GOVERNMENTAL AGENCIES, PRIVATE AGENCIES, 3,213
CORPORATIONS, ASSOCIATIONS, GROUPS, INDIVIDUALS, OR OTHER 3,214
PERSONS, PAYMENTS COVERING ALL OR PART OF THE COSTS OF PLANNING, 3,215
DEVELOPMENT, CONSTRUCTION, AND THE PROVISION OF HEALTH CARE 3,216
SERVICES;
(F) PURCHASE, LEASE, CONSTRUCT, RENOVATE, OPERATE, OR 3,219
MAINTAIN HEALTH CARE FACILITIES, AND THEIR ANCILLARY EQUIPMENT, 3,220
AND ANY PROPERTY NECESSARY IN THE TRANSACTION OF THE BUSINESS OF 3,221
THE HEALTH INSURING CORPORATION. 3,222
NOTHING IN THIS SECTION SHALL BE CONSTRUED AS PROHIBITING A 3,224
HEALTH INSURING CORPORATION WITHOUT OTHER COMMERCIAL ENROLLMENT 3,225
FROM CONTRACTING SOLELY WITH FEDERAL HEALTH CARE PROGRAMS 3,226
REGULATED BY FEDERAL REGULATORY BODIES.
NOTHING IN THIS SECTION SHALL BE CONSTRUED TO LIMIT THE 3,228
AUTHORITY OF A HEALTH INSURING CORPORATION TO PERFORM THOSE 3,229
FUNCTIONS NOT OTHERWISE PROHIBITED BY LAW. 3,230
Sec. 1751.07. ANY TRUSTEE, DIRECTOR, OFFICER, OR EMPLOYEE 3,232
OF A HEALTH INSURING CORPORATION WHO RECEIVES, COLLECTS, 3,233
DISBURSES, OR INVESTS FUNDS IN CONNECTION WITH THE ACTIVITIES OF 3,234
THE HEALTH INSURING CORPORATION SHALL BE RESPONSIBLE FOR SUCH 3,235
FUNDS IN A FIDUCIARY RELATIONSHIP TO THE CORPORATION. 3,236
Sec. 1751.08. (A) EXCEPT AS OTHERWISE SPECIFICALLY 3,239
PROVIDED IN THIS CHAPTER OR TITLE XXXIX OF THE REVISED CODE, 3,241
PROVISIONS OF TITLE XXXIX OF THE REVISED CODE SHALL NOT BE 3,242
APPLICABLE TO ANY HEALTH INSURING CORPORATION HOLDING A 3,243
CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. THIS DIVISION SHALL 3,244
NOT APPLY TO AN INSURER LICENSED AND REGULATED PURSUANT TO TITLE 3,246
74
XXXIX OF THE REVISED CODE EXCEPT WITH RESPECT TO ITS HEALTH 3,248
INSURING CORPORATION ACTIVITIES AUTHORIZED AND REGULATED PURSUANT 3,249
TO THIS CHAPTER.
(B) FOR THE PURPOSE OF CLARIFYING JURISDICTION UNDER THE 3,253
"BANKRUPTCY REFORM ACT OF 1978," 92 STAT. 2549, 11 U.S.C.A. 101, 3,255
AND IN RECOGNITION OF THE RIGHT OF THIS STATE TO REGULATE
DOMESTIC INSURANCE COMPANIES UNDER THE "McCARRAN-FERGUSON ACT," 3,257
59 STAT. 33 (1945), 15 U.S.C.A. 1011, A HEALTH INSURING 3,260
CORPORATION IS DEEMED TO BE A DOMESTIC INSURANCE COMPANY. 3,261
(C) SOLICITATION OF ENROLLEES BY A HEALTH INSURING 3,264
CORPORATION HOLDING A CERTIFICATE OF AUTHORITY UNDER THIS 3,265
CHAPTER, OR ITS REPRESENTATIVES, SHALL NOT BE CONSTRUED TO 3,266
VIOLATE ANY PROVISION OF LAW RELATING TO SOLICITATION OR 3,267
ADVERTISING BY HEALTH PROFESSIONALS.
(D) ANY HEALTH INSURING CORPORATION HOLDING A CERTIFICATE 3,270
OF AUTHORITY UNDER THIS CHAPTER SHALL NOT BE CONSIDERED TO BE 3,271
PRACTICING MEDICINE. 3,272
Sec. 1751.11. (A) EVERY SUBSCRIBER OF A HEALTH INSURING 3,275
CORPORATION IS ENTITLED TO AN EVIDENCE OF COVERAGE FOR THE HEALTH 3,276
CARE PLAN UNDER WHICH HEALTH CARE BENEFITS ARE PROVIDED. 3,278
(B) EVERY SUBSCRIBER OF A HEALTH INSURING CORPORATION THAT 3,280
OFFERS BASIC HEALTH CARE SERVICES IS ENTITLED TO AN 3,281
IDENTIFICATION CARD OR SIMILAR DOCUMENT THAT SPECIFIES THE HEALTH 3,282
INSURING CORPORATION'S NAME AS STATED IN ITS ARTICLES OF 3,283
INCORPORATION, AND ANY TRADE OR FICTITIOUS NAMES USED BY THE 3,284
HEALTH INSURING CORPORATION. THE IDENTIFICATION CARD OR DOCUMENT 3,285
SHALL LIST AT LEAST ONE TELEPHONE NUMBER THAT PROVIDES THE 3,286
SUBSCRIBER WITH ACCESS TO HEALTH CARE ON A 3,287
TWENTY-FOUR-HOUR-PER-DAY, SEVEN-DAY-PER-WEEK BASIS.
(C) NO EVIDENCE OF COVERAGE, OR AMENDMENT TO THE EVIDENCE 3,289
OF COVERAGE, SHALL BE DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR 3,290
USED, UNTIL THE FORM OF THE EVIDENCE OF COVERAGE OR AMENDMENT HAS 3,291
BEEN FILED BY THE HEALTH INSURING CORPORATION WITH THE 3,292
SUPERINTENDENT OF INSURANCE. IF THE SUPERINTENDENT DOES NOT 3,293
75
DISAPPROVE THE EVIDENCE OF COVERAGE OR AMENDMENT WITHIN SIXTY 3,294
DAYS AFTER IT IS FILED IT SHALL BE DEEMED APPROVED, UNLESS THE 3,295
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE EVIDENCE OF COVERAGE 3,296
OR AMENDMENT. WITH RESPECT TO AN AMENDMENT TO AN APPROVED 3,297
EVIDENCE OF COVERAGE, THE SUPERINTENDENT ONLY MAY DISAPPROVE 3,298
PROVISIONS AMENDED OR ADDED TO THE EVIDENCE OF COVERAGE. IF THE 3,299
SUPERINTENDENT DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT ANY 3,300
EVIDENCE OF COVERAGE OR AMENDMENT FAILS TO MEET THE REQUIREMENTS 3,301
OF THIS SECTION, THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH 3,302
INSURING CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH 3,303
INSURING CORPORATION TO USE SUCH EVIDENCE OF COVERAGE OR 3,304
AMENDMENT. AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,306
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,307
WITHDRAW AN APPROVAL, DEEMED OR ACTUAL, OF ANY EVIDENCE OF
COVERAGE OR AMENDMENT ON ANY OF THE GROUNDS STATED IN THIS 3,308
SECTION. SUCH DISAPPROVAL SHALL BE EFFECTED BY A WRITTEN ORDER, 3,309
WHICH SHALL STATE THE GROUNDS FOR DISAPPROVAL AND SHALL BE ISSUED 3,311
IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,313
(D) NO EVIDENCE OF COVERAGE OR AMENDMENT SHALL BE 3,315
DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR USED: 3,316
(1) IF IT CONTAINS PROVISIONS OR STATEMENTS THAT ARE 3,318
INEQUITABLE, UNTRUE, MISLEADING, OR DECEPTIVE; 3,319
(2) UNLESS IT CONTAINS A CLEAR, CONCISE, AND COMPLETE 3,321
STATEMENT OF THE FOLLOWING: 3,322
(a) THE HEALTH CARE SERVICES AND INSURANCE OR OTHER 3,325
BENEFITS, IF ANY, TO WHICH THE ENROLLEE IS ENTITLED UNDER THE 3,326
HEALTH CARE PLAN;
(b) ANY EXCLUSIONS OR LIMITATIONS ON THE HEALTH CARE 3,329
SERVICES, TYPE OF HEALTH CARE SERVICES, BENEFITS, OR TYPE OF 3,330
BENEFITS TO BE PROVIDED, INCLUDING COPAYMENTS OR DEDUCTIBLES; 3,331
(c) THE ENROLLEE'S PERSONAL FINANCIAL OBLIGATION FOR 3,333
NON-COVERED SERVICES; 3,334
(d) WHERE AND IN WHAT MANNER GENERAL INFORMATION AND 3,337
INFORMATION AS TO HOW SERVICES MAY BE OBTAINED IS AVAILABLE, 3,338
76
INCLUDING THE TELEPHONE NUMBER; 3,339
(e) THE PREMIUM RATE WITH RESPECT TO INDIVIDUAL AND 3,341
CONVERSION CONTRACTS, AND RELEVANT COPAYMENT PROVISIONS WITH 3,342
RESPECT TO ALL CONTRACTS. THE STATEMENT OF THE PREMIUM RATE, 3,343
HOWEVER, MAY BE CONTAINED IN A SEPARATE INSERT. 3,344
(f) THE METHOD UTILIZED BY THE HEALTH INSURING CORPORATION 3,347
FOR RESOLVING ENROLLEE COMPLAINTS. 3,348
(3) UNLESS IT PROVIDES FOR THE CONTINUATION OF AN 3,350
ENROLLEE'S COVERAGE, IN THE EVENT THAT THE ENROLLEE'S COVERAGE 3,351
UNDER THE POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT TERMINATES 3,352
WHILE THE ENROLLEE IS RECEIVING INPATIENT CARE IN A HOSPITAL. 3,353
THIS CONTINUATION OF COVERAGE SHALL TERMINATE AT THE EARLIEST 3,354
OCCURRENCE OF ANY OF THE FOLLOWING: 3,355
(a) THE ENROLLEE'S DISCHARGE FROM THE HOSPITAL; 3,357
(b) THE DETERMINATION BY THE ENROLLEE'S ATTENDING 3,359
PHYSICIAN THAT INPATIENT CARE IS NO LONGER MEDICALLY INDICATED 3,360
FOR THE ENROLLEE;
(c) THE ENROLLEE'S REACHING THE LIMIT FOR CONTRACTUAL 3,362
BENEFITS. 3,363
(4) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,365
SUBSTANCE, THAT THE HEALTH INSURING CORPORATION IS NOT A MEMBER 3,366
OF ANY GUARANTY FUND, AND THAT IN THE EVENT OF THE HEALTH 3,367
INSURING CORPORATION'S INSOLVENCY, THE ENROLLEE IS PROTECTED ONLY 3,369
TO THE EXTENT THAT THE HOLD HARMLESS PROVISION REQUIRED BY
SECTION 1751.13 OF THE REVISED CODE APPLIES TO THE HEALTH CARE 3,371
SERVICES RENDERED; 3,372
(5) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,374
SUBSTANCE, THAT IN THE EVENT OF THE INSOLVENCY OF THE HEALTH 3,375
INSURING CORPORATION, THE ENROLLEE MAY BE FINANCIALLY RESPONSIBLE 3,377
FOR HEALTH CARE SERVICES RENDERED BY A PROVIDER OR HEALTH CARE 3,378
FACILITY THAT IS NOT UNDER CONTRACT TO THE HEALTH INSURING 3,379
CORPORATION, WHETHER OR NOT THE HEALTH INSURING CORPORATION 3,380
AUTHORIZED THE USE OF THE PROVIDER OR HEALTH CARE FACILITY. 3,381
(E) NOTWITHSTANDING DIVISION (D) OF THIS SECTION, A HEALTH 3,385
77
INSURING CORPORATION MAY USE AN EVIDENCE OF COVERAGE THAT
PROVIDES FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,387
XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,389
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 3,390
MEDICARE COST CONTRACT, OR AN EVIDENCE OF COVERAGE THAT PROVIDES 3,391
FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL 3,392
EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR 3,395
AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE OF 3,396
BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY ACT," 3,398
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS THE 3,399
MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 3,401
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 3,402
CODE, OR AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE 3,403
OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE PROGRAM 3,404
REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE FOLLOWING
APPLY: 3,405
(1) THE EVIDENCE OF COVERAGE HAS BEEN APPROVED BY THE 3,408
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 3,409
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 3,410
HUMAN SERVICES.
(2) THE EVIDENCE OF COVERAGE IS FILED WITH THE 3,412
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 3,413
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,415
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,416
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,417
Sec. 1751.12. (A)(1) NO CONTRACTUAL PERIODIC PREPAYMENT 3,420
AND NO PREMIUM RATE FOR NONGROUP AND CONVERSION POLICIES FOR 3,421
HEALTH CARE SERVICES, OR ANY AMENDMENT TO THEM, MAY BE USED BY 3,422
ANY HEALTH INSURING CORPORATION AT ANY TIME UNTIL THE CONTRACTUAL 3,423
PERIODIC PREPAYMENT AND PREMIUM RATE, OR AMENDMENT, HAVE BEEN 3,424
FILED WITH THE SUPERINTENDENT OF INSURANCE, AND SHALL NOT BE 3,425
EFFECTIVE UNTIL THE EXPIRATION OF SIXTY DAYS AFTER THEIR FILING 3,426
UNLESS THE SUPERINTENDENT SOONER GIVES APPROVAL. THE 3,427
SUPERINTENDENT SHALL DISAPPROVE THE FILING, IF THE SUPERINTENDENT 3,428
78
DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT THE CONTRACTUAL 3,429
PERIODIC PREPAYMENT OR PREMIUM RATE, OR AMENDMENT, IS NOT IN 3,430
ACCORDANCE WITH SOUND ACTUARIAL PRINCIPLES OR IS NOT REASONABLY 3,431
RELATED TO THE APPLICABLE COVERAGE AND CHARACTERISTICS OF THE 3,432
APPLICABLE CLASS OF ENROLLEES. THE SUPERINTENDENT SHALL NOTIFY 3,433
THE HEALTH INSURING CORPORATION OF THE DISAPPROVAL, AND IT SHALL 3,434
THEREAFTER BE UNLAWFUL FOR THE HEALTH INSURING CORPORATION TO USE 3,435
THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, OR 3,436
AMENDMENT.
(2) NO CONTRACTUAL PERIODIC PREPAYMENT FOR GROUP POLICIES 3,439
FOR HEALTH CARE SERVICES SHALL BE USED UNTIL THE CONTRACTUAL 3,440
PERIODIC PREPAYMENT HAS BEEN FILED WITH THE SUPERINTENDENT. THE 3,441
SUPERINTENDENT MAY REJECT A FILING MADE UNDER DIVISION (A)(2) OF 3,442
THIS SECTION AT ANY TIME, WITH AT LEAST THIRTY DAYS' WRITTEN 3,443
NOTICE TO A HEALTH INSURING CORPORATION, IF THE CONTRACTUAL 3,444
PERIODIC PREPAYMENT IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,446
PRINCIPLES OR IS NOT REASONABLY RELATED TO THE APPLICABLE 3,447
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,448
ENROLLEES.
(3) AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,450
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,451
WITHDRAW THE APPROVAL GIVEN UNDER DIVISION (A)(1) OF THIS 3,452
SECTION, DEEMED OR ACTUAL, OF ANY CONTRACTUAL PERIODIC PREPAYMENT 3,454
OR PREMIUM RATE, OR AMENDMENT, BASED ON INFORMATION THAT EITHER 3,455
OF THE FOLLOWING APPLIES:
(a) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,458
OR AMENDMENT, IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,459
PRINCIPLES.
(b) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,462
OR AMENDMENT, IS NOT REASONABLY RELATED TO THE APPLICABLE 3,463
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,464
ENROLLEES.
(4) ANY DISAPPROVAL UNDER DIVISION (A)(1) OF THIS SECTION, 3,466
ANY REJECTION OF A FILING MADE UNDER DIVISION (A)(2) OF THIS 3,468
79
SECTION, OR ANY WITHDRAWAL OF APPROVAL UNDER DIVISION (A)(3) OF 3,469
THIS SECTION, SHALL BE EFFECTED BY A WRITTEN NOTICE, WHICH SHALL 3,470
STATE THE SPECIFIC BASIS FOR THE DISAPPROVAL, REJECTION, OR 3,471
WITHDRAWAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. OF 3,472
THE REVISED CODE. 3,473
(B) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 3,476
INSURING CORPORATION MAY USE A CONTRACTUAL PERIODIC PREPAYMENT OR 3,477
PREMIUM RATE FOR POLICIES USED FOR THE COVERAGE OF BENEFICIARIES 3,478
ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 3,480
620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE 3,482
RISK CONTRACT OR MEDICARE COST CONTRACT, OR FOR POLICIES USED FOR 3,483
THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEES 3,484
HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR FOR 3,487
POLICIES USED FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,488
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,491
U.S.C.A. 301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM 3,493
OR MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES 3,494
UNDER CHAPTER 5111. OF THE REVISED CODE, OR FOR POLICIES USED FOR 3,495
THE COVERAGE OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE 3,496
PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE 3,497
FOLLOWING APPLY: 3,498
(1) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE 3,500
HAS BEEN APPROVED BY THE UNITED STATES DEPARTMENT OF HEALTH AND 3,501
HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL MANAGEMENT, 3,503
OR THE OHIO DEPARTMENT OF HUMAN SERVICES.
(2) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE IS 3,505
FILED WITH THE SUPERINTENDENT PRIOR TO USE AND IS ACCOMPANIED BY 3,506
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,508
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,510
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,512
(C) THE ADMINISTRATIVE EXPENSE PORTION OF ALL CONTRACTUAL 3,515
PERIODIC PREPAYMENT OR PREMIUM RATE FILINGS SUBMITTED TO THE 3,516
SUPERINTENDENT FOR REVIEW MUST REFLECT THE ACTUAL COST OF 3,517
ADMINISTERING THE PRODUCT. THE SUPERINTENDENT MAY REQUIRE THAT 3,518
80
THE ADMINISTRATIVE EXPENSE PORTION OF THE FILINGS BE ITEMIZED AND 3,519
SUPPORTED.
(D)(1) COPAYMENTS AND DEDUCTIBLES MUST BE REASONABLE AND 3,522
MUST NOT BE A BARRIER TO THE NECESSARY UTILIZATION OF SERVICES BY 3,523
ENROLLEES.
(2) A HEALTH INSURING CORPORATION MAY NOT IMPOSE COPAYMENT 3,526
CHARGES ON BASIC HEALTH CARE SERVICES THAT EXCEED THIRTY PER CENT 3,527
OF THE TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE 3,528
SERVICE, EXCEPT FOR EMERGENCY HEALTH SERVICES AND URGENT CARE 3,529
SERVICES. THE TOTAL COST OF PROVIDING A HEALTH CARE SERVICE IS 3,530
THE COST TO THE HEALTH INSURING CORPORATION OF PROVIDING THE 3,531
HEALTH CARE SERVICE TO THE ENROLLEE AS REDUCED BY ANY APPLICABLE 3,532
PROVIDER DISCOUNT. AN OPEN PANEL PLAN MAY NOT IMPOSE COPAYMENTS 3,533
ON OUT-OF-NETWORK BENEFITS THAT EXCEED FIFTY PER CENT OF THE 3,534
TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE SERVICE. 3,535
(3) TO ENSURE THAT COPAYMENTS ARE NOT A BARRIER TO THE 3,537
UTILIZATION OF BASIC HEALTH CARE SERVICES, A HEALTH INSURING 3,538
CORPORATION MAY NOT IMPOSE, IN ANY CONTRACT YEAR, ON ANY 3,539
SUBSCRIBER OR ENROLLEE, COPAYMENTS THAT EXCEED TWO HUNDRED PER 3,540
CENT OF THE TOTAL ANNUAL PREMIUM RATE TO THE SUBSCRIBER OR 3,541
ENROLLEES. THIS LIMITATION OF TWO HUNDRED PER CENT DOES NOT 3,543
INCLUDE ANY REASONABLE COPAYMENTS THAT ARE NOT A BARRIER TO THE 3,544
NECESSARY UTILIZATION OF HEALTH CARE SERVICES BY ENROLLEES AND 3,545
THAT ARE IMPOSED ON PHYSICIAN OFFICE VISITS, EMERGENCY HEALTH 3,546
SERVICES, URGENT CARE SERVICES, SUPPLEMENTAL HEALTH CARE 3,547
SERVICES, OR SPECIALTY HEALTH CARE SERVICES.
(E) A HEALTH INSURING CORPORATION SHALL NOT IMPOSE 3,550
LIFETIME MAXIMUMS ON BASIC HEALTH CARE SERVICES. HOWEVER, A 3,551
HEALTH INSURING CORPORATION MAY ESTABLISH A BENEFIT LIMIT FOR 3,552
INPATIENT HOSPITAL SERVICES THAT ARE PROVIDED PURSUANT TO A 3,553
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT FOR SUPPLEMENTAL 3,554
HEALTH CARE SERVICES.
Sec. 1751.13. (A)(1) A HEALTH INSURING CORPORATION SHALL, 3,557
EITHER DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS FOR THE 3,558
81
PROVISION OF HEALTH CARE SERVICES WITH A SUFFICIENT NUMBER AND 3,559
TYPES OF PROVIDERS AND HEALTH CARE FACILITIES TO ENSURE THAT ALL 3,560
COVERED HEALTH CARE SERVICES WILL BE ACCESSIBLE TO ENROLLEES FROM 3,561
A CONTRACTED PROVIDER OR HEALTH CARE FACILITY. 3,562
(2) WHEN A HEALTH INSURING CORPORATION IS UNABLE TO 3,564
PROVIDE A COVERED HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,565
OR HEALTH CARE FACILITY, THE HEALTH INSURING CORPORATION MUST 3,566
PROVIDE THAT HEALTH CARE SERVICE FROM A NONCONTRACTED PROVIDER OR 3,568
HEALTH CARE FACILITY CONSISTENT WITH THE TERMS OF THE ENROLLEE'S 3,569
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT. THE HEALTH INSURING 3,570
CORPORATION SHALL EITHER ENSURE THAT THE HEALTH CARE SERVICE BE 3,571
PROVIDED AT NO GREATER COST TO THE ENROLLEE THAN IF THE ENROLLEE 3,572
HAD OBTAINED THE HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,573
OR HEALTH CARE FACILITY, OR MAKE OTHER ARRANGEMENTS ACCEPTABLE TO 3,574
THE SUPERINTENDENT OF INSURANCE. 3,575
(3) NOTHING IN THIS SECTION SHALL PROHIBIT A HEALTH 3,577
INSURING CORPORATION FROM ENTERING INTO CONTRACTS WITH 3,578
OUT-OF-STATE PROVIDERS OR HEALTH CARE FACILITIES THAT ARE 3,579
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THAT 3,580
STATE. 3,581
(B)(1) A HEALTH INSURING CORPORATION SHALL, EITHER 3,584
DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS WITH ALL PROVIDERS 3,585
AND HEALTH CARE FACILITIES THROUGH WHICH HEALTH CARE SERVICES ARE 3,586
PROVIDED TO ITS ENROLLEES.
(2) A HEALTH INSURING CORPORATION, UPON WRITTEN REQUEST, 3,588
SHALL ASSIST ITS CONTRACTED PROVIDERS IN FINDING STOP-LOSS OR 3,589
REINSURANCE CARRIERS.
(C) A HEALTH INSURING CORPORATION SHALL FILE AN ANNUAL 3,590
CERTIFICATE WITH THE SUPERINTENDENT CERTIFYING THAT ALL PROVIDER 3,591
CONTRACTS AND CONTRACTS WITH HEALTH CARE FACILITIES THROUGH WHICH 3,592
HEALTH CARE SERVICES ARE BEING PROVIDED CONTAIN THE FOLLOWING: 3,593
(1) A DESCRIPTION OF THE METHOD BY WHICH THE PROVIDER OR 3,595
HEALTH CARE FACILITY WILL BE NOTIFIED OF THE SPECIFIC HEALTH CARE 3,597
SERVICES FOR WHICH THE PROVIDER OR HEALTH CARE FACILITY WILL BE 3,598
82
RESPONSIBLE, INCLUDING ANY LIMITATIONS OR CONDITIONS ON SUCH 3,599
SERVICES;
(2) THE SPECIFIC HOLD HARMLESS PROVISION SPECIFYING 3,601
PROTECTION OF ENROLLEES SET FORTH AS FOLLOWS: 3,602
"[PROVIDER/HEALTH CARE FACILITY< AGREES THAT IN NO EVENT, 3,605
INCLUDING BUT NOT LIMITED TO NONPAYMENT BY THE HEALTH INSURING 3,606
CORPORATION, INSOLVENCY OF THE HEALTH INSURING CORPORATION, OR 3,607
BREACH OF THIS AGREEMENT, SHALL [PROVIDER/HEALTH CARE FACILITY< 3,609
BILL, CHARGE, COLLECT A DEPOSIT FROM, SEEK REMUNERATION OR 3,610
REIMBURSEMENT FROM, OR HAVE ANY RECOURSE AGAINST, A SUBSCRIBER, 3,611
ENROLLEE, PERSON TO WHOM HEALTH CARE SERVICES HAVE BEEN PROVIDED, 3,613
OR PERSON ACTING ON BEHALF OF THE COVERED ENROLLEE, FOR HEALTH 3,614
CARE SERVICES PROVIDED PURSUANT TO THIS AGREEMENT. THIS DOES NOT 3,615
PROHIBIT [PROVIDER/HEALTH CARE FACILITY< FROM COLLECTING 3,616
CO-INSURANCE, DEDUCTIBLES, OR COPAYMENTS AS SPECIFICALLY PROVIDED 3,618
IN THE EVIDENCE OF COVERAGE, OR FEES FOR UNCOVERED HEALTH CARE 3,619
SERVICES DELIVERED ON A FEE-FOR-SERVICE BASIS TO PERSONS 3,620
REFERENCED ABOVE, NOR FROM ANY RECOURSE AGAINST THE HEALTH 3,621
INSURING CORPORATION OR ITS SUCCESSOR."
(3) PROVISIONS REQUIRING THE PROVIDER OR HEALTH CARE 3,623
FACILITY TO CONTINUE TO PROVIDE COVERED HEALTH CARE SERVICES TO 3,624
ENROLLEES IN THE EVENT OF THE HEALTH INSURING CORPORATION'S 3,625
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. THE PROVISIONS SHALL 3,627
REQUIRE THE PROVIDER OR HEALTH CARE FACILITY TO CONTINUE TO 3,628
PROVIDE COVERED HEALTH CARE SERVICES TO ENROLLEES AS NEEDED TO 3,629
COMPLETE ANY MEDICALLY NECESSARY PROCEDURES COMMENCED BUT 3,630
UNFINISHED AT THE TIME OF THE HEALTH INSURING CORPORATION'S
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. IF AN ENROLLEE IS 3,631
RECEIVING NECESSARY INPATIENT CARE AT A HOSPITAL, THE PROVISIONS 3,632
MAY LIMIT THE REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES 3,633
RELATING TO THAT INPATIENT CARE IN ACCORDANCE WITH DIVISION 3,635
(D)(3) OF SECTION 1751.11 OF THE REVISED CODE, AND MAY ALSO LIMIT 3,636
SUCH REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES TO THE 3,637
PERIOD ENDING THIRTY DAYS AFTER THE HEALTH INSURING CORPORATION'S 3,638
83
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. 3,639
THE PROVISIONS REQUIRED BY DIVISION (C)(3) OF THIS SECTION 3,642
SHALL NOT REQUIRE ANY PROVIDER OR HEALTH CARE FACILITY TO 3,643
CONTINUE TO PROVIDE ANY COVERED HEALTH CARE SERVICE AFTER THE
OCCURRENCE OF ANY OF THE FOLLOWING: 3,644
(a) THE END OF THE THIRTY-DAY PERIOD FOLLOWING THE ENTRY OF 3,647
A LIQUIDATION ORDER UNDER CHAPTER 3903. OF THE REVISED CODE; 3,648
(b) THE END OF THE ENROLLEE'S PERIOD OF COVERAGE FOR A 3,650
CONTRACTUAL PREPAYMENT OR PREMIUM; 3,651
(c) THE ENROLLEE OBTAINS EQUIVALENT COVERAGE WITH ANOTHER 3,653
HEALTH INSURING CORPORATION OR INSURER, OR THE ENROLLEE'S 3,654
EMPLOYER OBTAINS SUCH COVERAGE FOR THE ENROLLEE; 3,655
(d) THE ENROLLEE OR THE ENROLLEE'S EMPLOYER TERMINATES 3,657
COVERAGE UNDER THE CONTRACT; 3,658
(e) A LIQUIDATOR EFFECTS A TRANSFER OF THE HEALTH INSURING 3,661
CORPORATION'S OBLIGATIONS UNDER THE CONTRACT UNDER DIVISION 3,662
(A)(8) OF SECTION 3903.21 OF THE REVISED CODE. 3,663
(4) A PROVISION CLEARLY STATING THE RIGHTS AND 3,665
RESPONSIBILITIES OF THE HEALTH INSURING CORPORATION, AND OF THE 3,666
CONTRACTED PROVIDERS AND HEALTH CARE FACILITIES, WITH RESPECT TO 3,667
ADMINISTRATIVE POLICIES AND PROGRAMS, INCLUDING, BUT NOT LIMITED 3,668
TO, PAYMENTS SYSTEMS, UTILIZATION REVIEW, QUALITY ASSESSMENT AND 3,669
IMPROVEMENT PROGRAMS, CREDENTIALING, CONFIDENTIALITY 3,670
REQUIREMENTS, AND ANY APPLICABLE FEDERAL OR STATE PROGRAMS. 3,672
(5) A PROVISION REGARDING THE AVAILABILITY AND 3,674
CONFIDENTIALITY OF THOSE HEALTH RECORDS MAINTAINED BY PROVIDERS 3,675
AND HEALTH CARE FACILITIES TO MONITOR AND EVALUATE THE QUALITY OF 3,677
CARE, TO CONDUCT EVALUATIONS AND AUDITS, AND TO DETERMINE ON A 3,678
CONCURRENT OR RETROSPECTIVE BASIS THE NECESSITY OF AND
APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED TO ENROLLEES. 3,679
THE PROVISION SHALL INCLUDE TERMS REQUIRING THE PROVIDER OR 3,680
HEALTH CARE FACILITY TO MAKE THESE HEALTH RECORDS AVAILABLE TO 3,681
APPROPRIATE STATE AND FEDERAL AUTHORITIES INVOLVED IN ASSESSING 3,682
THE QUALITY OF CARE OR IN INVESTIGATING THE GRIEVANCES OR 3,683
84
COMPLAINTS OF ENROLLEES, AND REQUIRING THE PROVIDER OR HEALTH 3,684
CARE FACILITY TO COMPLY WITH APPLICABLE STATE AND FEDERAL LAWS 3,685
RELATED TO THE CONFIDENTIALITY OF MEDICAL OR HEALTH RECORDS. 3,687
(6) A PROVISION THAT STATES THAT CONTRACTUAL RIGHTS AND 3,689
RESPONSIBILITIES MAY NOT BE ASSIGNED OR DELEGATED BY THE PROVIDER 3,691
OR HEALTH CARE FACILITY WITHOUT THE PRIOR WRITTEN CONSENT OF THE 3,692
HEALTH INSURING CORPORATION;
(7) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,694
FACILITY TO MAINTAIN ADEQUATE PROFESSIONAL LIABILITY AND 3,695
MALPRACTICE INSURANCE. THE PROVISION SHALL ALSO REQUIRE THE 3,696
PROVIDER OR HEALTH CARE FACILITY TO NOTIFY THE HEALTH INSURING 3,697
CORPORATION NOT MORE THAN TEN DAYS AFTER THE PROVIDER'S OR HEALTH 3,699
CARE FACILITY'S RECEIPT OF NOTICE OF ANY REDUCTION OR
CANCELLATION OF SUCH COVERAGE. 3,700
(8) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,702
FACILITY TO OBSERVE, PROTECT, AND PROMOTE THE RIGHTS OF ENROLLEES 3,704
AS PATIENTS;
(9) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,706
FACILITY TO PROVIDE HEALTH CARE SERVICES WITHOUT DISCRIMINATION 3,707
ON THE BASIS OF A PATIENT'S PARTICIPATION IN THE HEALTH CARE 3,708
PLAN, AGE, SEX, ETHNICITY, RELIGION, SEXUAL PREFERENCE, HEALTH 3,709
STATUS, OR DISABILITY, AND WITHOUT REGARD TO THE SOURCE OF 3,710
PAYMENTS MADE FOR HEALTH CARE SERVICES RENDERED TO A PATIENT. 3,711
THIS REQUIREMENT SHALL NOT APPLY TO CIRCUMSTANCES WHEN THE 3,712
PROVIDER OR HEALTH CARE FACILITY APPROPRIATELY DOES NOT RENDER 3,713
SERVICES DUE TO LIMITATIONS ARISING FROM THE PROVIDER'S OR HEALTH 3,715
CARE FACILITY'S LACK OF TRAINING, EXPERIENCE, OR SKILL, OR DUE TO 3,716
LICENSING RESTRICTIONS.
(10) A PROVISION CONTAINING THE SPECIFICS OF ANY 3,718
OBLIGATION ON THE PROVIDER OR HEALTH CARE FACILITY TO PROVIDE, OR 3,720
TO ARRANGE FOR THE PROVISION OF, COVERED HEALTH CARE SERVICES
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK; 3,721
(11) A PROVISION SETTING FORTH PROCEDURES FOR THE 3,723
RESOLUTION OF DISPUTES ARISING OUT OF THE CONTRACT; 3,724
85
(12) A PROVISION STATING THAT THE HOLD HARMLESS PROVISION 3,726
REQUIRED BY DIVISION (C)(2) OF THIS SECTION SHALL SURVIVE THE 3,728
TERMINATION OF THE CONTRACT WITH RESPECT TO SERVICES COVERED AND 3,729
PROVIDED UNDER THE CONTRACT DURING THE TIME THE CONTRACT WAS IN 3,730
EFFECT, REGARDLESS OF THE REASON FOR THE TERMINATION, INCLUDING
THE INSOLVENCY OF THE HEALTH INSURING CORPORATION; 3,731
(13) A PROVISION REQUIRING THOSE TERMS THAT ARE USED IN 3,733
THE CONTRACT AND THAT ARE DEFINED BY THIS CHAPTER, BE USED IN THE 3,735
CONTRACT IN A MANNER CONSISTENT WITH THOSE DEFINITIONS. 3,736
(D) NO HEALTH INSURING CORPORATION CONTRACT WITH A 3,739
PROVIDER OR HEALTH CARE FACILITY SHALL DO EITHER OF THE 3,740
FOLLOWING:
(1) OFFER AN INDUCEMENT TO THE PROVIDER OR HEALTH CARE 3,742
FACILITY, DIRECTLY OR INDIRECTLY, TO REDUCE OR LIMIT MEDICALLY 3,743
NECESSARY HEALTH CARE SERVICES TO A COVERED ENROLLEE; 3,744
(2) PENALIZE A PROVIDER OR HEALTH CARE FACILITY THAT 3,746
ASSISTS AN ENROLLEE TO SEEK A RECONSIDERATION OF THE HEALTH 3,747
INSURING CORPORATION'S DECISION TO DENY OR LIMIT BENEFITS TO THE 3,748
ENROLLEE. 3,749
(E) ANY CONTRACT BETWEEN A HEALTH INSURING CORPORATION AND 3,752
AN INTERMEDIARY ORGANIZATION SHALL CLEARLY SPECIFY THAT THE 3,753
HEALTH INSURING CORPORATION MUST APPROVE OR DISAPPROVE THE 3,754
PARTICIPATION OF ANY PROVIDER OR HEALTH CARE FACILITY WITH WHICH 3,755
THE INTERMEDIARY ORGANIZATION CONTRACTS. 3,756
(F) IF AN INTERMEDIARY ORGANIZATION THAT IS NOT A HEALTH 3,758
DELIVERY NETWORK CONTRACTING SOLELY WITH SELF-INSURED EMPLOYERS 3,759
SUBCONTRACTS WITH A PROVIDER OR HEALTH CARE FACILITY, THE 3,760
SUBCONTRACT WITH THE PROVIDER OR HEALTH CARE FACILITY SHALL DO 3,761
ALL OF THE FOLLOWING:
(1) CONTAIN THE PROVISIONS REQUIRED BY DIVISIONS (C) AND 3,764
(G) OF THIS SECTION, AS MADE APPLICABLE TO AN INTERMEDIARY 3,765
ORGANIZATION, WITHOUT THE INCLUSION OF INDUCEMENTS OR PENALTIES 3,766
DESCRIBED IN DIVISION (D) OF THIS SECTION; 3,767
(2) ACKNOWLEDGE THAT THE HEALTH INSURING CORPORATION IS A 3,769
86
THIRD-PARTY BENEFICIARY TO THE AGREEMENT; 3,770
(3) ACKNOWLEDGE THE HEALTH INSURING CORPORATION'S ROLE IN 3,772
APPROVING THE PARTICIPATION OF THE PROVIDER OR HEALTH CARE 3,773
FACILITY, PURSUANT TO DIVISION (E) OF THIS SECTION. 3,775
(G) ANY PROVIDER CONTRACT OR CONTRACT WITH A HEALTH CARE 3,778
FACILITY SHALL CLEARLY SPECIFY THE HEALTH INSURING CORPORATION'S 3,779
STATUTORY RESPONSIBILITY TO MONITOR AND OVERSEE THE OFFERING OF 3,780
COVERED HEALTH CARE SERVICES TO ITS ENROLLEES. 3,781
(H)(1) A HEALTH INSURING CORPORATION SHALL MAINTAIN ITS 3,784
PROVIDER CONTRACTS AND ITS CONTRACTS WITH HEALTH CARE FACILITIES 3,785
AT ONE OR MORE OF ITS PLACES OF BUSINESS IN THIS STATE, AND SHALL 3,786
PROVIDE COPIES OF THESE CONTRACTS TO FACILITATE REGULATORY REVIEW 3,787
UPON WRITTEN NOTICE BY THE SUPERINTENDENT OF INSURANCE. 3,788
(2) ANY CONTRACT WITH AN INTERMEDIARY ORGANIZATION SHALL 3,790
INCLUDE PROVISIONS REQUIRING THE INTERMEDIARY ORGANIZATION TO 3,791
PROVIDE THE SUPERINTENDENT WITH REGULATORY ACCESS TO ALL BOOKS, 3,792
RECORDS, FINANCIAL INFORMATION, AND DOCUMENTS RELATED TO THE 3,793
PROVISION OF HEALTH CARE SERVICES TO SUBSCRIBERS AND ENROLLEES 3,794
UNDER THE CONTRACT. THE CONTRACT SHALL REQUIRE THE INTERMEDIARY 3,795
ORGANIZATION TO MAINTAIN SUCH BOOKS, RECORDS, FINANCIAL 3,796
INFORMATION, AND DOCUMENTS AT ITS PRINCIPAL PLACE OF BUSINESS IN 3,797
THIS STATE AND TO PRESERVE THEM FOR AT LEAST THREE YEARS IN A 3,798
MANNER THAT FACILITATES REGULATORY REVIEW. 3,799
(I) A HEALTH INSURING CORPORATION SHALL PROVIDE NOTICE OF 3,802
THE TERMINATION OF ANY CONTRACT WITH A PRIMARY CARE PHYSICIAN OR 3,803
HOSPITAL.
(J) DIVISIONS (A) AND (B) OF THIS SECTION DO NOT APPLY TO 3,806
ANY HEALTH INSURING CORPORATION THAT, ON THE EFFECTIVE DATE OF 3,807
THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO 3,808
OPERATE UNDER CHAPTER 1740. OF THE REVISED CODE. 3,809
Sec. 1751.14. (A) ANY POLICY, CONTRACT, OR AGREEMENT FOR 3,812
HEALTH CARE SERVICES AUTHORIZED BY THIS CHAPTER THAT IS ISSUED, 3,813
DELIVERED, OR RENEWED IN THIS STATE AND THAT PROVIDES THAT 3,814
COVERAGE OF AN UNMARRIED DEPENDENT CHILD WILL TERMINATE UPON 3,815
87
ATTAINMENT OF THE LIMITING AGE FOR DEPENDENT CHILDREN SPECIFIED 3,816
IN THE POLICY, CONTRACT, OR AGREEMENT, SHALL ALSO PROVIDE IN 3,817
SUBSTANCE THAT ATTAINMENT OF THE LIMITING AGE SHALL NOT OPERATE 3,818
TO TERMINATE THE COVERAGE OF THE CHILD IF THE CHILD IS AND 3,819
CONTINUES TO BE BOTH:
(1) INCAPABLE OF SELF-SUSTAINING EMPLOYMENT BY REASON OF 3,821
MENTAL RETARDATION OR PHYSICAL HANDICAP; 3,822
(2) PRIMARILY DEPENDENT UPON THE SUBSCRIBER FOR SUPPORT 3,824
AND MAINTENANCE. 3,825
(B) PROOF OF INCAPACITY AND DEPENDENCE FOR PURPOSES OF 3,827
DIVISION (A) OF THIS SECTION SHALL BE FURNISHED TO THE HEALTH 3,828
INSURING CORPORATION WITHIN THIRTY-ONE DAYS OF THE CHILD'S 3,830
ATTAINMENT OF THE LIMITING AGE. UPON REQUEST, BUT NOT MORE 3,831
FREQUENTLY THAN ANNUALLY, THE HEALTH INSURING CORPORATION MAY 3,832
REQUIRE PROOF SATISFACTORY TO IT OF THE CONTINUANCE OF SUCH 3,833
INCAPACITY AND DEPENDENCY.
(C) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 3,836
A HEALTH INSURING CORPORATION TO COVER A DEPENDENT CHILD WHO IS 3,837
MENTALLY RETARDED OR PHYSICALLY HANDICAPPED IF THE POLICY, 3,838
CONTRACT, OR AGREEMENT IS UNDERWRITTEN ON EVIDENCE OF 3,839
INSURABILITY BASED ON HEALTH FACTORS SET FORTH IN THE 3,840
APPLICATION, OR IF THE DEPENDENT CHILD DOES NOT SATISFY THE 3,841
CONDITIONS OF THE POLICY, CONTRACT, OR AGREEMENT AS TO ANY 3,842
REQUIREMENT FOR EVIDENCE OF INSURABILITY OR ANY OTHER PROVISION 3,843
OF THE POLICY, CONTRACT, OR AGREEMENT, SATISFACTION OF WHICH IS 3,844
REQUIRED FOR COVERAGE THEREUNDER TO TAKE EFFECT. IN ANY SUCH 3,845
CASE, THE TERMS OF THE POLICY, CONTRACT, OR AGREEMENT SHALL APPLY 3,846
WITH REGARD TO THE COVERAGE OR EXCLUSION OF THE DEPENDENT FROM 3,847
SUCH COVERAGE.
(D) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 3,850
CORPORATION, POLICY, CONTRACT, OR AGREEMENT OFFERING ONLY 3,851
SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE
SERVICES. 3,852
Sec. 1751.15. (A) AFTER A HEALTH INSURING CORPORATION HAS 3,855
88
FURNISHED, DIRECTLY OR INDIRECTLY, BASIC HEALTH CARE SERVICES FOR 3,856
A PERIOD OF TWENTY-FOUR MONTHS, AND IF IT CURRENTLY MEETS THE 3,857
FINANCIAL REQUIREMENTS SET FORTH IN SECTION 1751.28 OF THE 3,859
REVISED CODE AND HAD NET INCOME AS REPORTED TO THE SUPERINTENDENT 3,860
OF INSURANCE FOR AT LEAST ONE OF THE PRECEDING FOUR CALENDAR 3,861
QUARTERS, IT SHALL HOLD AN ANNUAL OPEN ENROLLMENT PERIOD OF NOT 3,862
LESS THAN THIRTY DAYS DURING ITS MONTH OF LICENSURE. 3,863
(B) DURING THE OPEN ENROLLMENT PERIOD DESCRIBED IN 3,865
DIVISION (A) OF THIS SECTION, THE HEALTH INSURING CORPORATION 3,866
SHALL ACCEPT APPLICANTS AND THEIR DEPENDENTS IN THE ORDER IN 3,867
WHICH THEY APPLY FOR ENROLLMENT AND IN ACCORDANCE WITH ANY OF THE 3,868
FOLLOWING:
(1) UP TO ITS CAPACITY, AS DETERMINED BY THE HEALTH 3,870
INSURING CORPORATION SUBJECT TO REVIEW BY THE SUPERINTENDENT; 3,871
(2) IF LESS THAN ITS CAPACITY, ONE PER CENT OF THE HEALTH 3,873
INSURING CORPORATION'S TOTAL NUMBER OF SUBSCRIBERS RESIDING IN 3,874
THIS STATE AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF 3,876
DECEMBER.
(C) WHERE A HEALTH INSURING CORPORATION DEMONSTRATES TO 3,879
THE SATISFACTION OF THE SUPERINTENDENT THAT SUCH OPEN ENROLLMENT 3,880
WOULD JEOPARDIZE ITS ECONOMIC VIABILITY, THE SUPERINTENDENT MAY 3,881
DO ANY OF THE FOLLOWING: 3,882
(1) WAIVE THE REQUIREMENT FOR OPEN ENROLLMENT; 3,884
(2) IMPOSE A LIMIT ON THE NUMBER OF APPLICANTS AND THEIR 3,886
DEPENDENTS THAT MUST BE ENROLLED; 3,887
(3) AUTHORIZE SUCH UNDERWRITING RESTRICTIONS UPON OPEN 3,889
ENROLLMENT AS ARE NECESSARY TO DO ANY OF THE FOLLOWING: 3,890
(a) PRESERVE ITS FINANCIAL STABILITY; 3,892
(b) PREVENT EXCESSIVE ADVERSE SELECTION; 3,894
(c) AVOID UNREASONABLY HIGH OR UNMARKETABLE CHARGES FOR 3,896
COVERAGE OF HEALTH CARE SERVICES. 3,897
(D)(1) A REQUEST TO THE SUPERINTENDENT UNDER DIVISION (C) 3,900
OF THIS SECTION FOR ANY RESTRICTION, LIMIT, OR WAIVER DURING AN
OPEN ENROLLMENT PERIOD MUST BE ACCOMPANIED BY SUPPORTING 3,902
89
DOCUMENTATION, INCLUDING FINANCIAL DATA. IN REVIEWING THE 3,903
REQUEST, THE SUPERINTENDENT MAY CONSIDER VARIOUS FACTORS, 3,904
INCLUDING THE SIZE OF THE HEALTH INSURING CORPORATION, THE HEALTH 3,905
INSURING CORPORATION'S NET WORTH AND PROFITABILITY, THE HEALTH 3,906
INSURING CORPORATION'S DELIVERY SYSTEM STRUCTURE, AND THE EFFECT 3,907
ON PROFITABILITY OF PRIOR OPEN ENROLLMENTS. 3,908
(2) ANY ACTION TAKEN BY THE SUPERINTENDENT UNDER DIVISION 3,910
(C) OF THIS SECTION SHALL BE EFFECTIVE FOR A PERIOD OF NOT MORE 3,912
THAN ONE YEAR. AT THE EXPIRATION OF SUCH TIME, A NEW 3,913
DEMONSTRATION OF THE HEALTH INSURING CORPORATION'S NEED FOR THE 3,914
RESTRICTION, LIMIT, OR WAIVER SHALL BE MADE BEFORE A NEW 3,915
RESTRICTION, LIMIT, OR WAIVER IS GRANTED BY THE SUPERINTENDENT. 3,916
(3) IRRESPECTIVE OF THE GRANTING OF ANY RESTRICTION, 3,918
LIMIT, OR WAIVER BY THE SUPERINTENDENT, A HEALTH INSURING 3,919
CORPORATION MAY REJECT AN APPLICANT OR A DEPENDENT OF THE 3,920
APPLICANT DURING ITS OPEN ENROLLMENT PERIOD IF THE APPLICANT OR 3,921
DEPENDENT: 3,922
(a) WAS ELIGIBLE FOR AND WAS COVERED UNDER ANY 3,925
EMPLOYER-SPONSORED HEALTH CARE COVERAGE, OR IF EMPLOYER-SPONSORED 3,926
HEALTH CARE COVERAGE WAS AVAILABLE AT THE TIME OF OPEN 3,927
ENROLLMENT;
(b) IS ELIGIBLE FOR CONVERSION OR CONTINUATION COVERAGE 3,930
UNDER STATE OR FEDERAL LAW; 3,931
(c) IS ELIGIBLE FOR MEDICARE, AND THE HEALTH INSURING 3,934
CORPORATION DOES NOT HAVE AN AGREEMENT ON APPROPRIATE PAYMENT 3,935
MECHANISMS WITH THE GOVERNMENTAL AGENCY ADMINISTERING THE 3,936
MEDICARE PROGRAM.
(E) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED 3,939
EITHER TO ENROLL APPLICANTS OR THEIR DEPENDENTS WHO ARE CONFINED 3,940
TO A HEALTH CARE FACILITY BECAUSE OF CHRONIC ILLNESS, PERMANENT 3,941
INJURY, OR OTHER INFIRMITY THAT WOULD CAUSE ECONOMIC IMPAIRMENT 3,942
TO THE HEALTH INSURING CORPORATION IF SUCH APPLICANTS OR THEIR 3,943
DEPENDENTS WERE ENROLLED OR TO MAKE THE EFFECTIVE DATE OF 3,944
BENEFITS FOR APPLICANTS OR THEIR DEPENDENTS ENROLLED UNDER THIS 3,945
90
SECTION EARLIER THAN NINETY DAYS AFTER THE DATE OF ENROLLMENT. 3,946
(F) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO 3,949
COVER THE FEES OR COSTS, OR BOTH, FOR ANY BASIC HEALTH CARE 3,950
SERVICE RELATED TO A TRANSPLANT OF A BODY ORGAN IF THE TRANSPLANT 3,951
OCCURS WITHIN ONE YEAR AFTER THE EFFECTIVE DATE OF AN ENROLLEE'S 3,952
COVERAGE UNDER THIS SECTION. THIS LIMITATION ON COVERAGE DOES 3,953
NOT APPLY TO A NEWLY BORN CHILD WHO MEETS THE REQUIREMENTS FOR 3,954
COVERAGE UNDER SECTION 1751.61 OF THE REVISED CODE. 3,956
(G) EACH HEALTH INSURING CORPORATION REQUIRED TO HOLD AN 3,959
OPEN ENROLLMENT PURSUANT TO DIVISION (A) OF THIS SECTION SHALL 3,961
FILE WITH THE SUPERINTENDENT, NOT LATER THAN SIXTY DAYS PRIOR TO 3,962
THE COMMENCEMENT OF THE PROPOSED OPEN ENROLLMENT PERIOD, THE 3,963
FOLLOWING DOCUMENTS:
(1) THE PROPOSED PUBLIC NOTICE OF OPEN ENROLLMENT; 3,965
(2) THE EVIDENCE OF COVERAGE APPROVED PURSUANT TO SECTION 3,967
1751.11 OF THE REVISED CODE THAT WILL BE USED DURING OPEN 3,970
ENROLLMENT;
(3) THE CONTRACTUAL PERIODIC PREPAYMENT AND PREMIUM RATE 3,972
APPROVED PURSUANT TO SECTION 1751.12 OF THE REVISED CODE THAT 3,975
WILL BE APPLICABLE DURING OPEN ENROLLMENT; 3,976
(4) ANY SOLICITATION DOCUMENT APPROVED PURSUANT TO SECTION 3,979
1751.31 OF THE REVISED CODE TO BE SENT TO APPLICANTS, INCLUDING 3,981
THE APPLICATION FORM THAT WILL BE USED DURING OPEN ENROLLMENT; 3,982
(5) A LIST OF THE PROPOSED DATES OF PUBLICATION OF THE 3,984
PUBLIC NOTICE, AND THE NAMES OF THE NEWSPAPERS IN WHICH THE 3,985
NOTICE WILL APPEAR; 3,986
(6) ANY REQUEST FOR A RESTRICTION, LIMIT, OR WAIVER WITH 3,988
RESPECT TO THE OPEN ENROLLMENT PERIOD, ALONG WITH ANY SUPPORTING 3,989
DOCUMENTATION. 3,990
(H)(1) AN OPEN ENROLLMENT PERIOD SHALL NOT SATISFY THE 3,993
REQUIREMENTS OF THIS SECTION UNLESS THE HEALTH INSURING 3,994
CORPORATION PROVIDES ADEQUATE PUBLIC NOTICE IN ACCORDANCE WITH 3,995
DIVISIONS (H)(2) AND (3) OF THIS SECTION. NO PUBLIC NOTICE SHALL 3,997
BE USED UNTIL THE FORM OF THE PUBLIC NOTICE HAS BEEN FILED BY THE 3,998
91
HEALTH INSURING CORPORATION WITH THE SUPERINTENDENT. IF THE 3,999
SUPERINTENDENT DOES NOT DISAPPROVE THE PUBLIC NOTICE WITHIN SIXTY 4,000
DAYS AFTER IT IS FILED, IT SHALL BE DEEMED APPROVED, UNLESS THE 4,001
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE PUBLIC NOTICE. IF 4,002
THE SUPERINTENDENT DETERMINES WITHIN THIS SIXTY-DAY PERIOD THAT 4,003
THE PUBLIC NOTICE FAILS TO MEET THE REQUIREMENTS OF THIS SECTION, 4,004
THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH INSURING 4,005
CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH INSURING 4,006
CORPORATION TO USE THE PUBLIC NOTICE. SUCH DISAPPROVAL SHALL BE 4,007
EFFECTED BY A WRITTEN ORDER, WHICH SHALL STATE THE GROUNDS FOR 4,008
DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. 4,010
OF THE REVISED CODE. 4,012
(2) A PUBLIC NOTICE PURSUANT TO DIVISION (H)(1) OF THIS 4,015
SECTION SHALL BE PUBLISHED IN AT LEAST ONE NEWSPAPER OF GENERAL 4,016
CIRCULATION IN EACH COUNTY IN THE HEALTH INSURING CORPORATION'S 4,017
SERVICE AREA, AT LEAST ONCE IN EACH OF THE TWO WEEKS IMMEDIATELY 4,018
PRECEDING THE MONTH IN WHICH THE OPEN ENROLLMENT IS TO OCCUR AND 4,019
IN EACH WEEK OF THAT MONTH, OR UNTIL THE ENROLLMENT LIMITATION IS 4,020
REACHED, WHICHEVER OCCURS FIRST. THE NOTICE PUBLISHED DURING THE 4,021
LAST WEEK OF OPEN ENROLLMENT SHALL APPEAR NOT LESS THAN FIVE DAYS 4,022
BEFORE THE END OF THE OPEN ENROLLMENT PERIOD. IT SHALL BE AT 4,023
LEAST TWO NEWSPAPER COLUMNS WIDE OR TWO AND ONE-HALF INCHES WIDE, 4,025
WHICHEVER IS LARGER. THE FIRST TWO LINES OF THE TEXT SHALL BE 4,026
PUBLISHED IN NOT LESS THAN TWELVE-POINT, BOLDFACE TYPE. THE 4,027
REMAINDER OF THE TEXT OF THE NOTICE SHALL BE PUBLISHED IN NOT 4,028
LESS THAN EIGHT-POINT TYPE. THE ENTIRE PUBLIC NOTICE SHALL BE 4,029
SURROUNDED BY A CONTINUOUS BLACK LINE NOT LESS THAN ONE-EIGHTH OF 4,030
AN INCH WIDE.
(3) THE FOLLOWING INFORMATION SHALL BE INCLUDED IN THE 4,032
PUBLIC NOTICE PROVIDED UNDER DIVISION (H)(2) OF THIS SECTION: 4,034
(a) THE DATES THAT OPEN ENROLLMENT WILL BE HELD AND THE 4,037
DATE COVERAGE OBTAINED UNDER THE OPEN ENROLLMENT WILL BECOME 4,038
EFFECTIVE;
(b) NOTICE THAT AN APPLICANT OR THE APPLICANT'S DEPENDENTS 4,041
92
WILL NOT BE DENIED COVERAGE DURING OPEN ENROLLMENT BECAUSE OF A 4,042
PREEXISTING HEALTH CONDITION, BUT THAT SOME LIMITATIONS AND 4,043
RESTRICTIONS MAY APPLY; 4,044
(c) THE ADDRESS WHERE A PERSON MAY OBTAIN AN APPLICATION; 4,047
(d) THE TELEPHONE NUMBER THAT A PERSON MAY CALL TO REQUEST 4,050
AN APPLICATION OR TO ASK QUESTIONS; 4,051
(e) THE DATE THE FIRST PAYMENT WILL BE DUE; 4,054
(f) THE ACTUAL RATES OR RANGE OF RATES THAT WILL BE 4,057
APPLICABLE FOR APPLICANTS;
(g) ANY LIMITATION GRANTED BY THE SUPERINTENDENT ON THE 4,060
NUMBER OF APPLICATIONS THAT WILL BE ACCEPTED BY THE HEALTH 4,061
INSURING CORPORATION.
(4) WITHIN THIRTY DAYS AFTER THE END OF AN OPEN ENROLLMENT 4,064
PERIOD, THE HEALTH INSURING CORPORATION SHALL SUBMIT TO THE 4,065
SUPERINTENDENT PROOF OF PUBLICATION FOR THE PUBLIC NOTICES, AND 4,066
SHALL REPORT THE TOTAL NUMBER OF APPLICANTS AND THEIR DEPENDENTS 4,067
ENROLLED DURING THE OPEN ENROLLMENT PERIOD. 4,068
(I)(1) NO HEALTH INSURING CORPORATION MAY EMPLOY ANY 4,071
SCHEME, PLAN, OR DEVICE THAT RESTRICTS THE ABILITY OF ANY PERSON 4,072
TO ENROLL DURING OPEN ENROLLMENT. 4,073
(2) NO HEALTH INSURING CORPORATION MAY REQUIRE ENROLLMENT 4,075
TO BE MADE IN PERSON. EVERY HEALTH INSURING CORPORATION SHALL 4,076
PERMIT APPLICATION FOR COVERAGE BY MAIL. A REPRESENTATIVE OF THE 4,078
HEALTH INSURING CORPORATION MAY VISIT AN APPLICANT WHO HAS
SUBMITTED AN APPLICATION BY MAIL, IN ORDER TO EXPLAIN THE 4,079
OPERATIONS OF THE HEALTH INSURING CORPORATION AND TO ANSWER ANY 4,080
QUESTIONS THE APPLICANT MAY HAVE. EVERY HEALTH INSURING 4,081
CORPORATION SHALL MAKE OPEN ENROLLMENT APPLICATIONS AND 4,082
SOLICITATION DOCUMENTS READILY AVAILABLE TO ANY POTENTIAL 4,083
APPLICANT WHO REQUESTS SUCH MATERIAL. 4,084
(J) AN APPLICATION POSTMARKED ON THE LAST DAY OF AN OPEN 4,087
ENROLLMENT PERIOD SHALL QUALIFY AS A VALID APPLICATION, 4,088
REGARDLESS OF THE DATE ON WHICH IT IS RECEIVED BY THE HEALTH 4,089
INSURING CORPORATION.
93
(K) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 4,091
CORPORATION THAT OFFERS ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR 4,093
SPECIALTY HEALTH CARE SERVICES, OR TO ANY HEALTH INSURING
CORPORATION THAT OFFERS PLANS ONLY THROUGH TITLE XVIII OR TITLE 4,096
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,098
U.S.C.A. 301, AS AMENDED, AND THAT HAS NO OTHER COMMERCIAL 4,099
ENROLLMENT, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 4,100
PLANS ONLY THROUGH OTHER FEDERAL HEALTH CARE PROGRAMS REGULATED 4,101
BY FEDERAL REGULATORY BODIES AND THAT HAS NO OTHER COMMERCIAL 4,102
ENROLLMENT.
Sec. 1751.16. (A) EXCEPT AS PROVIDED IN DIVISION (F) OF 4,105
THIS SECTION, EVERY GROUP CONTRACT ISSUED BY A HEALTH INSURING 4,106
CORPORATION SHALL PROVIDE AN OPTION FOR CONVERSION TO AN 4,107
INDIVIDUAL CONTRACT ISSUED ON A DIRECT-PAYMENT BASIS TO ANY 4,108
SUBSCRIBER COVERED BY THE GROUP CONTRACT WHO TERMINATES 4,109
EMPLOYMENT OR MEMBERSHIP IN THE GROUP, UNLESS: 4,110
(1) TERMINATION OF THE CONVERSION OPTION OR CONTRACT IS 4,112
BASED UPON NONPAYMENT OF PREMIUM AFTER REASONABLE NOTICE IN 4,113
WRITING HAS BEEN GIVEN BY THE HEALTH INSURING CORPORATION TO THE 4,114
SUBSCRIBER. 4,115
(2) THE SUBSCRIBER IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,117
BENEFITS AT LEAST COMPARABLE TO THE GROUP CONTRACT UNDER ANY OF 4,118
THE FOLLOWING: 4,119
(a) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,122
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,123
(b) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,126
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,128
TO THE BENEFITS UNDER DIVISION (A)(2)(a) OF THIS SECTION; 4,129
(c) ANY POLICY OF INSURANCE OR HEALTH CARE PLAN PROVIDING 4,132
COVERAGE AT LEAST COMPARABLE TO THE BENEFITS UNDER DIVISION 4,133
(A)(2)(a) OF THIS SECTION. 4,134
(B) THE DIRECT-PAYMENT CONTRACT OFFERED BY THE HEALTH 4,137
INSURING CORPORATION PURSUANT TO DIVISION (A) OF THIS SECTION 4,138
SHALL PROVIDE BENEFITS COMPARABLE TO THE BENEFITS BEING PROVIDED 4,139
94
BY ANY OF THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO 4,140
INDIVIDUAL SUBSCRIBERS BY THE HEALTH INSURING CORPORATION. THE 4,141
CONTRACT MAY CONTAIN A COORDINATION OF BENEFITS PROVISION AS 4,142
APPROVED BY THE SUPERINTENDENT OF INSURANCE. 4,143
(C) THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,146
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,148
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,149
COVERED BY THE GROUP CONTRACT; 4,150
(2) TO A CHILD SOLELY WITH RESPECT TO THE CHILD UPON THE 4,152
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE GROUP 4,153
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT; 4,154
(3) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,156
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,157
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER. 4,159
(D) NO HEALTH INSURING CORPORATION SHALL DO ANY OF THE 4,162
FOLLOWING:
(1) USE AGE AS THE BASIS FOR REFUSING TO RENEW A CONVERTED 4,165
CONTRACT;
(2) REQUIRE A SUBSCRIBER TO PRODUCE EVIDENCE OF 4,167
INSURABILITY IN ORDER TO EXERCISE THE OPTION FOR CONVERSION 4,168
PROVIDED BY THIS SECTION; 4,169
(3) INCLUDE PREEXISTING CONDITION LIMITATIONS IN A 4,171
CONVERTED CONTRACT. 4,172
(E) WRITTEN NOTICE OF THE CONVERSION OPTION PROVIDED BY 4,175
THIS SECTION SHALL BE GIVEN TO THE SUBSCRIBER BY THE HEALTH 4,176
INSURING CORPORATION BY MAIL. THE NOTICE SHALL BE SENT TO THE 4,177
SUBSCRIBER'S ADDRESS IN THE RECORDS OF THE EMPLOYER UPON RECEIPT 4,178
OF NOTICE FROM THE EMPLOYER OF THE EVENT GIVING RISE TO THE 4,179
CONVERSION OPTION. IF THE SUBSCRIBER HAS NOT RECEIVED NOTICE OF 4,180
THE CONVERSION PRIVILEGE AT LEAST FIFTEEN DAYS PRIOR TO THE 4,181
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD, THEN THE 4,182
SUBSCRIBER SHALL HAVE AN ADDITIONAL PERIOD WITHIN WHICH TO 4,183
EXERCISE THE PRIVILEGE. THIS ADDITIONAL PERIOD SHALL EXPIRE 4,184
FIFTEEN DAYS AFTER THE SUBSCRIBER RECEIVES NOTICE, BUT IN NO 4,185
95
EVENT SHALL THE PERIOD EXTEND BEYOND SIXTY DAYS AFTER THE 4,186
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD. 4,187
(F) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 4,190
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,191
HEALTH CARE SERVICES.
Sec. 1751.17. (A) AS USED IN THIS SECTION, "NONGROUP 4,194
CONTRACT" MEANS A CONTRACT ISSUED BY A HEALTH INSURING 4,195
CORPORATION TO AN INDIVIDUAL WHO MAKES DIRECT APPLICATION FOR 4,196
COVERAGE UNDER THE CONTRACT AND WHO, IF REQUIRED BY THE HEALTH 4,197
INSURING CORPORATION, SUBMITS TO MEDICAL UNDERWRITING. "NONGROUP 4,198
CONTRACT" DOES NOT INCLUDE GROUP CONVERSION COVERAGE, COVERAGE 4,199
OBTAINED THROUGH OPEN ENROLLMENT, OR COVERAGE ISSUED ON THE BASIS 4,200
OF MEMBERSHIP IN A GROUP. 4,201
(B) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 4,205
EVERY NONGROUP CONTRACT THAT IS ISSUED BY A HEALTH INSURING 4,206
CORPORATION AND THAT MAKES AVAILABLE BASIC HEALTH CARE SERVICES 4,207
SHALL PROVIDE AN OPTION FOR CONVERSION TO A CONTRACT ISSUED ON A 4,208
DIRECT-PAYMENT BASIS TO AN ENROLLEE COVERED BY THE NONGROUP 4,209
CONTRACT. THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,210
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,212
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,213
COVERED BY THE NONGROUP CONTRACT; 4,214
(2) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,216
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,217
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER; 4,219
(3) TO A CHILD SOLELY WITH RESPECT TO THE CHILD, UPON THE 4,221
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE NONGROUP 4,223
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT. 4,224
(C) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,227
DIVISION (B) OF THIS SECTION SHALL NOT BE MADE AVAILABLE TO AN 4,229
ENROLLEE IF ANY OF THE FOLLOWING APPLIES: 4,230
(1) THE ENROLLEE IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,232
BENEFITS AT LEAST COMPARABLE TO THE NONGROUP CONTRACT UNDER ANY 4,233
OF THE FOLLOWING: 4,234
96
(a) THE MEDICAL ASSISTANCE PROGRAM UNDER CHAPTER 5111. OF 4,237
THE REVISED CODE;
(b) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,240
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,241
(c) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,243
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,245
TO THE BENEFITS OFFERED UNDER DIVISION (C)(1)(a) OR (b) OF THIS 4,246
SECTION.
(2) THE NONGROUP CONTRACT UNDER WHICH THE ENROLLEE WAS 4,248
COVERED WAS TERMINATED DUE TO NONPAYMENT OF A PREMIUM RATE. 4,249
(3) THE ENROLLEE IS ELIGIBLE FOR GROUP COVERAGE PROVIDED 4,251
BY, OR AVAILABLE THROUGH, AN EMPLOYER OR ASSOCIATION AND THE 4,252
GROUP COVERAGE PROVIDES BENEFITS COMPARABLE TO THE BENEFITS 4,253
PROVIDED UNDER A DIRECT PAYMENT CONTRACT. 4,254
(D) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,256
DIVISION (B) OF THIS SECTION SHALL PROVIDE BENEFITS THAT ARE AT 4,257
LEAST COMPARABLE TO THE BENEFITS PROVIDED BY THE NONGROUP 4,259
CONTRACT UNDER WHICH THE ENROLLEE WAS COVERED AT THE TIME OF THE 4,260
OCCURRENCE OF ANY OF THE EVENTS SET FORTH IN DIVISION (B) OF THIS 4,261
SECTION. THE COVERAGE PROVIDED UNDER THE DIRECT PAYMENT CONTRACT 4,263
SHALL BE CONTINUOUS, PROVIDED THAT THE ENROLLEE MAKES THE 4,264
REQUIRED PREMIUM RATE PAYMENT WITHIN THE THIRTY-DAY PERIOD 4,265
IMMEDIATELY FOLLOWING THE OCCURRENCE OF THE EVENT, AND MAY BE 4,266
TERMINATED FOR NONPAYMENT OF ANY REQUIRED PREMIUM RATE PAYMENT. 4,267
(E) THE EVIDENCE OF COVERAGE OF EVERY NONGROUP CONTRACT 4,270
SHALL CONTAIN NOTICE THAT AN OPTION FOR CONVERSION TO A CONTRACT 4,271
ISSUED ON A DIRECT-PAYMENT BASIS IS AVAILABLE, IN ACCORDANCE WITH 4,272
THIS SECTION, TO ANY ENROLLEE COVERED BY THE CONTRACT. 4,273
(F) BENEFITS OTHERWISE PAYABLE TO AN ENROLLEE UNDER A 4,276
DIRECT PAYMENT CONTRACT SHALL BE REDUCED BY THE AMOUNT OF ANY 4,277
BENEFITS AVAILABLE TO THE ENROLLEE UNDER ANY APPLICABLE GROUP 4,278
HEALTH INSURING CORPORATION CONTRACT OR GROUP SICKNESS AND 4,279
ACCIDENT INSURANCE POLICY.
(G) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 4,282
97
REQUIRING A HEALTH INSURING CORPORATION TO OFFER NONGROUP 4,283
CONTRACTS.
(H) THIS SECTION DOES NOT APPLY TO ANY NONGROUP CONTRACT 4,286
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,287
HEALTH CARE SERVICES. 4,288
Sec. 1751.18. (A)(1) NO HEALTH INSURING CORPORATION SHALL 4,291
CANCEL OR FAIL TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE 4,292
BECAUSE OF THE SUBSCRIBER'S OR ENROLLEE'S HEALTH STATUS OR 4,293
REQUIREMENT FOR HEALTH CARE SERVICES, OR FOR ANY OTHER REASON 4,294
DESIGNATED UNDER RULES ADOPTED BY THE SUPERINTENDENT OF
INSURANCE. 4,295
(2) UNLESS OTHERWISE REQUIRED BY STATE OR FEDERAL LAW, NO 4,297
HEALTH INSURING CORPORATION, OR HEALTH CARE FACILITY OR PROVIDER 4,298
THROUGH WHICH THE HEALTH INSURING CORPORATION HAS MADE 4,299
ARRANGEMENTS TO PROVIDE HEALTH CARE SERVICES, SHALL DISCRIMINATE 4,300
AGAINST ANY INDIVIDUAL WITH REGARD TO ENROLLMENT, DISENROLLMENT, 4,301
OR THE QUALITY OF HEALTH CARE SERVICES RENDERED, ON THE BASIS OF 4,302
THE INDIVIDUAL'S RACE, COLOR, SEX, AGE, RELIGION, STATE OF 4,303
HEALTH, OR STATUS AS A RECIPIENT OF MEDICARE OR MEDICAL 4,304
ASSISTANCE UNDER TITLE XVIII OR XIX OF THE "SOCIAL SECURITY ACT," 4,306
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. HOWEVER, A 4,309
HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO ACCEPT A 4,310
RECIPIENT OF MEDICARE OR MEDICAL ASSISTANCE, IF AN AGREEMENT HAS 4,311
NOT BEEN REACHED ON APPROPRIATE PAYMENT MECHANISMS BETWEEN THE 4,312
HEALTH INSURING CORPORATION AND THE GOVERNMENTAL AGENCY 4,313
ADMINISTERING THESE PROGRAMS. FURTHER, EXCEPT DURING A PERIOD OF 4,314
OPEN ENROLLMENT UNDER SECTION 1751.15 OF THE REVISED CODE, A 4,316
HEALTH INSURING CORPORATION MAY REJECT AN APPLICANT FOR NONGROUP 4,317
ENROLLMENT ON THE BASIS OF THE STATE OF HEALTH OF THE APPLICANT. 4,318
(B) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 4,321
TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE FOR ANY OF THE 4,322
FOLLOWING REASONS:
(1) FAILURE OF THE SUBSCRIBER OR ENROLLEE TO PAY, OR TO 4,324
HAVE PAID ON THE SUBSCRIBER'S OR ENROLLEE'S BEHALF, THE REQUIRED 4,325
98
PREMIUM RATE OR OTHER CHARGE; 4,326
(2) FRAUD OR FORGERY; 4,328
(3) ANY MATERIAL MISREPRESENTATION ON THE APPLICATION FOR 4,330
COVERAGE; 4,331
(4) THE SUBSCRIBER'S OR ENROLLEE'S PERMITTING THE USE OF 4,333
AN IDENTIFICATION CARD OR SIMILAR DOCUMENTS BY ANOTHER PERSON, 4,334
ALLOWING THAT PERSON TO RECEIVE SERVICES FOR WHICH THAT PERSON IS 4,336
NOT ENTITLED;
(5) THE SUBSCRIBER'S OR ENROLLEE'S INABILITY TO ESTABLISH 4,338
OR MAINTAIN A PROVIDER-PATIENT RELATIONSHIP WITH ANY PROVIDER 4,339
ASSOCIATED WITH THE HEALTH INSURING CORPORATION, WHICH INABILITY 4,340
MAY INCLUDE THE SUBSCRIBER'S OR ENROLLEE'S DISRUPTIVE OR ABUSIVE 4,341
BEHAVIOR TOWARD PROVIDERS OR THE STAFF OF THE HEALTH CARE PLAN. 4,343
(C) A SUBSCRIBER OR ENROLLEE MAY APPEAL ANY ACTION OR 4,346
DECISION OF THE HEALTH INSURING CORPORATION UNDER DIVISION (B) OF 4,348
THIS SECTION. TO APPEAL, THE SUBSCRIBER OR ENROLLEE MAY SUBMIT A 4,349
WRITTEN COMPLAINT TO THE HEALTH INSURING CORPORATION PURSUANT TO 4,350
SECTION 1751.19 OF THE REVISED CODE. THE SUBSCRIBER OR ENROLLEE 4,351
MAY, WITHIN THIRTY DAYS AFTER RECEIVING A WRITTEN RESPONSE FROM 4,352
THE HEALTH INSURING CORPORATION, APPEAL THE HEALTH INSURING 4,353
CORPORATION'S ACTION OR DECISION TO THE SUPERINTENDENT. 4,354
Sec. 1751.19. (A) A HEALTH INSURING CORPORATION SHALL 4,357
ESTABLISH AND MAINTAIN A COMPLAINT SYSTEM THAT HAS BEEN APPROVED 4,358
BY THE SUPERINTENDENT OF INSURANCE TO PROVIDE ADEQUATE AND 4,359
REASONABLE PROCEDURES FOR THE EXPEDITIOUS RESOLUTION OF WRITTEN 4,360
COMPLAINTS INITIATED BY SUBSCRIBERS OR ENROLLEES CONCERNING ANY 4,361
MATTER RELATING TO SERVICES PROVIDED, DIRECTLY OR INDIRECTLY, BY 4,362
THE HEALTH INSURING CORPORATION, INCLUDING, BUT NOT LIMITED TO, 4,363
CLAIMS REGARDING THE SCOPE OF COVERAGE FOR HEALTH CARE SERVICES, 4,364
AND DENIALS, CANCELLATIONS, OR NONRENEWALS OF COVERAGE. 4,365
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE A TIMELY 4,368
WRITTEN RESPONSE TO EACH WRITTEN COMPLAINT IT RECEIVES. 4,369
RESPONSES TO WRITTEN COMPLAINTS RELATING TO QUALITY OR 4,370
APPROPRIATENESS OF CARE SHALL SET FORTH A STATEMENT INFORMING THE 4,371
99
COMPLAINANT IN DETAIL OF ANY RIGHTS THE COMPLAINANT MAY HAVE TO 4,372
SUBMIT SUCH COMPLAINT TO ANY PROFESSIONAL PEER REVIEW 4,373
ORGANIZATION OR HEALTH INSURING CORPORATION PEER REVIEW COMMITTEE 4,374
THAT HAS BEEN SET UP TO MONITOR THE QUALITY OR APPROPRIATENESS OF 4,375
PROVIDER SERVICES RENDERED. SUCH STATEMENT SHALL SET FORTH THE 4,376
NAME OF THE PEER REVIEW ORGANIZATION OR HEALTH INSURING 4,377
CORPORATION PEER REVIEW COMMITTEE, ITS ADDRESS, TELEPHONE NUMBER, 4,378
AND ANY OTHER PERTINENT DATA THAT WILL ENABLE THE COMPLAINANT TO 4,379
SEEK FURTHER INDEPENDENT REVIEW OF THE COMPLAINT. SUCH APPEAL 4,380
SHALL NOT BE MADE TO THE PEER REVIEW CORPORATION OR HEALTH 4,381
INSURING CORPORATION PEER REVIEW COMMITTEE UNTIL THE COMPLAINT 4,382
SYSTEM OF THE HEALTH INSURING CORPORATION HAS BEEN EXHAUSTED. 4,383
(C) COPIES OF COMPLAINTS AND RESPONSES, INCLUDING MEDICAL 4,386
RECORDS RELATED TO THOSE COMPLAINTS, SHALL BE AVAILABLE TO THE 4,387
SUPERINTENDENT AND THE DIRECTOR OF HEALTH FOR INSPECTION FOR 4,388
THREE YEARS. ANY DOCUMENT OR INFORMATION PROVIDED TO THE 4,389
SUPERINTENDENT PURSUANT TO THIS DIVISION THAT CONTAINS A MEDICAL 4,390
RECORD IS CONFIDENTIAL, AND IS NOT A PUBLIC RECORD SUBJECT TO 4,391
SECTION 149.43 OF THE REVISED CODE.
(D) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 4,394
MAINTAIN A PROCEDURE TO ACCEPT COMPLAINTS OVER THE TELEPHONE OR 4,395
IN PERSON. THESE COMPLAINTS ARE NOT SUBJECT TO THE REPORTING 4,396
REQUIREMENT UNDER DIVISION (C) OF SECTION 1751.32 OF THE REVISED 4,398
CODE.
Sec. 1751.20. (A) NO HEALTH INSURING CORPORATION, OR 4,401
AGENT, EMPLOYEE, OR REPRESENTATIVE OF A HEALTH INSURING 4,402
CORPORATION, SHALL USE ANY ADVERTISEMENT OR SOLICITATION 4,403
DOCUMENT, OR SHALL ENGAGE IN ANY ACTIVITY, THAT IS UNFAIR, 4,404
UNTRUE, MISLEADING, OR DECEPTIVE.
(B) NO HEALTH INSURING CORPORATION SHALL USE A NAME THAT 4,407
IS DECEPTIVELY SIMILAR TO THE NAME OR DESCRIPTION OF ANY 4,408
INSURANCE OR SURETY CORPORATION DOING BUSINESS IN THIS STATE. 4,409
(C) ALL SOLICITATION DOCUMENTS, ADVERTISEMENTS, EVIDENCES 4,412
OF COVERAGE, AND ENROLLEE IDENTIFICATION CARDS USED BY A HEALTH 4,413
100
INSURING CORPORATION SHALL CONTAIN THE HEALTH INSURING 4,414
CORPORATION'S NAME. THE USE OF A TRADE NAME, AN INSURANCE GROUP 4,415
DESIGNATION, THE NAME OF A PARENT COMPANY, THE NAME OF A DIVISION 4,416
OF AN AFFILIATED INSURANCE COMPANY, A SERVICE MARK, A SLOGAN, A 4,417
SYMBOL, OR OTHER DEVICE, WITHOUT THE NAME OF THE HEALTH INSURING 4,418
CORPORATION AS STATED IN ITS ARTICLES OF INCORPORATION, SHALL NOT 4,419
SATISFY THIS REQUIREMENT IF THE USAGE WOULD HAVE THE CAPACITY AND 4,420
TENDENCY TO MISLEAD OR DECEIVE PERSONS AS TO THE TRUE IDENTITY OF 4,421
THE HEALTH INSURING CORPORATION. 4,422
(D) NO SOLICITATION DOCUMENT OR ADVERTISEMENT USED BY A 4,425
HEALTH INSURING CORPORATION SHALL CONTAIN ANY WORDS, SYMBOLS, OR 4,426
PHYSICAL MATERIALS THAT ARE SO SIMILAR IN CONTENT, PHRASEOLOGY, 4,427
SHAPE, COLOR, OR OTHER CHARACTERISTIC TO THOSE USED BY AN AGENCY 4,428
OF THE FEDERAL GOVERNMENT OR THIS STATE, THAT PROSPECTIVE 4,429
ENROLLEES MAY BE LED TO BELIEVE THAT THE SOLICITATION DOCUMENT OR 4,430
ADVERTISEMENT IS CONNECTED WITH AN AGENCY OF THE FEDERAL 4,431
GOVERNMENT OR THIS STATE. 4,432
(E) THIS SECTION DOES NOT APPLY TO THE COVERAGE OF 4,434
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 4,436
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 4,439
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 4,440
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 4,441
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 4,443
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 4,444
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 4,446
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 4,447
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 4,449
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 4,450
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY. 4,451
Sec. 1751.21. (A) A PEER REVIEW COMMITTEE OF A HOSPITAL 4,454
OR OTHER HEALTH CARE FACILITY OR PROVIDER, OR OF AN INTERMEDIARY 4,455
ORGANIZATION OR HEALTH DELIVERY NETWORK, WITH WHICH A HEALTH 4,456
INSURING CORPORATION HAS A CONTRACT FOR HEALTH CARE SERVICES MAY 4,457
PROVIDE TO A PEER REVIEW COMMITTEE OF THE HEALTH INSURING 4,458
101
CORPORATION ANY INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,459
RECORDS RELATING TO ANY MATTER THAT IS THE SUBJECT OF EVALUATION 4,460
OR REVIEW BY THE PEER REVIEW COMMITTEES, IF CONSENT IS PROVIDED 4,461
BY THE HEALTH CARE FACILITY AND ANY PHYSICIAN OR OTHER PROVIDER 4,462
WHOSE PROFESSIONAL QUALIFICATIONS OR ACTIVITIES ARE THE SUBJECT 4,463
OF EVALUATION OR REVIEW. 4,464
(B) ANY IMMUNITY FROM LIABILITY FOR DAMAGES THAT IS 4,467
PROVIDED UNDER SECTION 2305.25 OF THE REVISED CODE AND THAT WOULD 4,469
OTHERWISE APPLY WITH RESPECT TO THE CONDUCT OF ANY PEER REVIEW 4,470
COMMITTEE DESCRIBED IN DIVISION (A) OF THIS SECTION SHALL 4,472
CONTINUE TO APPLY, NOTWITHSTANDING THE PROVISION OF INFORMATION 4,473
AS PERMITTED UNDER DIVISION (A) OF THIS SECTION. 4,474
(C) THE INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,477
RECORDS DESCRIBED IN DIVISION (A) OF THIS SECTION, IF OTHERWISE 4,479
PROTECTED UNDER SECTION 2305.251 OF THE REVISED CODE, SHALL NOT 4,481
BE CONSTRUED AS BEING AVAILABLE FOR DISCOVERY OR FOR USE IN ANY 4,482
CIVIL ACTION SOLELY ON THE BASIS THAT THEY WERE PROVIDED BY THE 4,483
PEER REVIEW COMMITTEE AS PERMITTED UNDER DIVISION (A) OF THIS 4,484
SECTION. 4,485
Sec. 1751.25. THE FUNDS OF A HEALTH INSURING CORPORATION 4,487
SHALL BE INVESTED ONLY IN SECURITIES OR OTHER INVESTMENTS OR 4,488
ASSETS THAT CONSTITUTE PERMISSIBLE INVESTMENTS UNDER SECTION 4,489
1751.26 OR 3925.08 OF THE REVISED CODE. 4,490
Sec. 1751.26. (A) FOR PURPOSES OF THIS SECTION, REAL 4,493
ESTATE USED FOR "THE ACCOMMODATION OF THE HEALTH INSURING 4,494
CORPORATION'S BUSINESS OPERATIONS" INCLUDES THE HEALTH INSURING 4,495
CORPORATION'S HOME OFFICE, BRANCH OFFICE, MEDICAL FACILITIES, AND 4,496
FIELD OFFICE OPERATIONS. 4,497
(B) NO HEALTH INSURING CORPORATION SHALL PURCHASE, HOLD, 4,500
OR CONVEY REAL ESTATE, OR ANY INTEREST IN REAL ESTATE, TO BE USED 4,501
AS AN INVESTMENT FOR THE PRODUCTION OF INCOME, TO BE DEVELOPED 4,502
FOR THE PRODUCTION OF INCOME, OR TO BE OTHERWISE USED FOR 4,503
PURPOSES OTHER THAN THE ACCOMMODATION OF THE HEALTH INSURING 4,504
CORPORATION'S BUSINESS OPERATIONS, WITHOUT THE PRIOR APPROVAL OF 4,505
102
THE SUPERINTENDENT OF INSURANCE. 4,506
(C)(1) NO HEALTH INSURING CORPORATION SHALL INVEST, 4,509
WITHOUT THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT 4,510
EXCEEDS FORTY PER CENT OF ITS ADMITTED ASSETS AS OF THE 4,511
IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE 4,512
USED FOR THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S 4,513
BUSINESS OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION 4,514
PROVIDES HEALTH CARE SERVICES. 4,515
(2) NO HEALTH INSURING CORPORATION SHALL INVEST, WITHOUT 4,517
THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT EXCEEDS 4,518
TWENTY-FIVE PER CENT OF ITS ADMITTED ASSETS AS OF THE IMMEDIATELY 4,520
PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE USED FOR 4,522
THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S BUSINESS 4,523
OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION DOES NOT 4,524
PROVIDE HEALTH CARE SERVICES.
Sec. 1751.27. (A) EACH HEALTH INSURING CORPORATION 4,527
HOLDING A CERTIFICATE OF AUTHORITY TO OPERATE IN THIS STATE SHALL 4,528
HAVE DEPOSITED SECURITIES WITH THE SUPERINTENDENT OF INSURANCE OR 4,529
AN APPROVED CUSTODIAN IN THE AMOUNT REQUIRED BY THIS DIVISION. 4,530
(1) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,533
BASIC HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS 4,534
THAN TWO HUNDRED FIFTY THOUSAND DOLLARS.
(2) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,537
ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT 4,538
OF NOT LESS THAN ONE HUNDRED FIFTY THOUSAND DOLLARS.
(3) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,540
ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF 4,541
NOT LESS THAN SEVENTY-FIVE THOUSAND DOLLARS. 4,542
(4) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,545
BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH CARE 4,546
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN FOUR HUNDRED 4,547
THOUSAND DOLLARS.
(5) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,549
BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,550
103
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN THREE HUNDRED 4,551
TWENTY-FIVE THOUSAND DOLLARS. 4,552
(B) THE SECURITIES DEPOSITED UNDER DIVISION (A) OF THIS 4,556
SECTION SHALL BE HELD AS SECURITY FOR THE FULFILLMENT OF THE 4,557
OBLIGATIONS OF THE HEALTH INSURING CORPORATION TO ITS ENROLLEES 4,558
UNDER THIS CHAPTER.
(C) THE INTEREST FROM THE DEPOSIT MADE UNDER DIVISION (A) 4,562
OF THIS SECTION SHALL ACCRUE TO THE HEALTH INSURING CORPORATION 4,563
THAT MADE THE DEPOSIT. THE DEPOSIT SHALL BE CONSIDERED TO BE AN 4,564
ADMITTED ASSET OF THE HEALTH INSURING CORPORATION. 4,565
(D) THE SUPERINTENDENT SHALL ADOPT RULES SETTING FORTH THE 4,568
QUALIFICATIONS AND RESPONSIBILITIES OF AN APPROVED CUSTODIAN. 4,569
Sec. 1751.28. (A) AS USED IN THIS SECTION: 4,572
(1) "ADMITTED ASSETS" INCLUDES THE INVESTMENTS AUTHORIZED 4,574
BY SECTION 1751.25 OF THE REVISED CODE, AND, IN ADDITION TO THESE 4,576
INVESTMENTS, ONLY THE FOLLOWING:
(a) PETTY CASH AND OTHER CASH FUNDS THAT ARE IN THE HEALTH 4,579
INSURING CORPORATION'S PRINCIPAL OFFICE OR ANY OFFICIAL BRANCH 4,580
OFFICE AND THAT ARE UNDER THE CONTROL OF THE CORPORATION; 4,581
(b) IMMEDIATELY WITHDRAWABLE FUNDS ON DEPOSIT IN DEMAND 4,583
ACCOUNTS IN A BANK OR TRUST COMPANY, OR SIMILAR FUNDS THAT ARE 4,584
ACTUALLY IN THE HEALTH INSURING CORPORATION'S PRINCIPAL OFFICE OR 4,585
ANY OFFICIAL BRANCH OFFICE AT STATEMENT DATE AND THAT ARE IN 4,586
TRANSIT TO THE BANK OR TRUST COMPANY WITH AUTHENTIC DEPOSIT 4,587
CREDIT GIVEN PRIOR TO THE CLOSE OF BUSINESS ON THE FIFTH BANK 4,588
BUSINESS DAY FOLLOWING THE STATEMENT DATE; 4,589
(c) THE AMOUNT FAIRLY ESTIMATED AS RECOVERABLE ON CASH 4,592
DEPOSITED IN A BANK OR TRUST COMPANY THE OPERATIONS OF WHICH HAVE 4,593
BEEN SUSPENDED OR FOR WHICH A RECEIVER HAS BEEN APPOINTED, IF 4,594
QUALIFYING UNDER THIS SECTION PRIOR TO THE SUSPENSION OF 4,595
OPERATIONS OF OR THE APPOINTMENT OF A RECEIVER FOR THE BANK OR 4,596
TRUST COMPANY;
(d) BILLS AND ACCOUNTS RECEIVABLE COLLATERALIZED BY 4,599
SECURITIES OF THE KIND IN WHICH THE HEALTH INSURING CORPORATION 4,600
104
MAY INVEST;
(e) PREMIUMS RECEIVABLE FROM GROUPS OR INDIVIDUALS THAT 4,603
ARE NOT MORE THAN NINETY DAYS PAST DUE; 4,604
(f) ACCOUNTS RECEIVABLE THAT ARE NOT MORE THAN NINETY DAYS 4,607
PAST DUE;
(g) AMOUNTS DUE UNDER REINSURANCE ARRANGEMENTS FROM 4,610
INSURANCE COMPANIES AUTHORIZED TO DO BUSINESS IN THIS STATE; 4,611
(h) TAX REFUNDS DUE FROM THE UNITED STATES OR ANY STATE; 4,615
(i) THE INTEREST ACCRUED ON MORTGAGE LOANS THAT CONFORM TO 4,618
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON AN 4,619
INDIVIDUAL LOAN AN AGGREGATE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,620
ACCRUED INTEREST; 4,621
(j) THE RENTS ACCRUED AND OWING TO THE HEALTH INSURING 4,624
CORPORATION ON REAL AND PERSONAL PROPERTY, DIRECTLY OR 4,625
BENEFICIALLY OWNED, NOT EXCEEDING ON EACH INDIVIDUAL PROPERTY THE 4,626
AMOUNT OF ONE YEAR'S TOTAL DUE AND ACCRUED RENT; 4,627
(k) INTEREST OR RENTS ACCRUED ON CONDITIONAL SALES 4,630
AGREEMENTS, SECURITY INTERESTS, CHATTEL MORTGAGES, AND REAL OR 4,631
PERSONAL PROPERTY UNDER LEASE TO OTHER CORPORATIONS, THAT CONFORM 4,632
TO SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON ANY 4,634
INDIVIDUAL INVESTMENT THE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,635
ACCRUED INTEREST OR RENT; 4,636
(l) THE FIXED AND REQUIRED INTEREST DUE AND ACCRUED ON 4,639
BONDS AND OTHER SIMILAR EVIDENCES OF INDEBTEDNESS, THAT CONFORM 4,640
TO SECTION 3925.08 OF THE REVISED CODE, AND NOT IN DEFAULT; 4,641
(m) DIVIDENDS RECEIVABLE ON SHARES OF STOCK THAT CONFORM 4,644
TO SECTION 3925.08 OF THE REVISED CODE, PROVIDED THAT THE MARKET 4,645
PRICE TAKEN FOR VALUATION PURPOSES DOES NOT INCLUDE THE VALUE OF 4,646
THE DIVIDEND;
(n) THE INTEREST OR DIVIDENDS DUE AND PAYABLE, BUT NOT 4,649
CREDITED, ON DEPOSITS IN BANKS AND TRUST COMPANIES OR ON ACCOUNTS 4,650
WITH SAVINGS AND LOAN ASSOCIATIONS; 4,651
(o) INTEREST ACCRUED ON SECURED LOANS THAT CONFORM TO 4,654
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING THE AMOUNT OF 4,657
105
ONE YEAR'S INTEREST ON ANY LOAN;
(p) INTEREST ACCRUED ON TAX ANTICIPATION WARRANTS; 4,660
(q) THE AMORTIZED VALUE OF ELECTRONIC COMPUTER OR DATA 4,663
PROCESSING MACHINES OR SYSTEMS PURCHASED FOR USE IN CONNECTION 4,664
WITH THE BUSINESS OF THE HEALTH INSURING CORPORATION, INCLUDING 4,665
SOFTWARE PURCHASED AND DEVELOPED SPECIFICALLY FOR THE USE AND 4,666
PURPOSES OF THE CORPORATION;
(r) THE COST OF FURNITURE, EQUIPMENT, AND MEDICAL 4,669
EQUIPMENT, LESS ACCUMULATED DEPRECIATION ON THE FURNITURE AND 4,670
EQUIPMENT TO BE APPLIED PRO RATA OVER A PERIOD NOT TO EXCEED FIVE 4,671
YEARS, AND OF MEDICAL AND PHARMACEUTICAL SUPPLIES, THAT ARE UNDER 4,672
THE CONTROL OF THE HEALTH INSURING CORPORATION, PROVIDED THESE 4,673
ASSETS DO NOT EXCEED FIFTEEN PER CENT OF ADMITTED ASSETS; 4,674
(s) AMOUNTS DUE FROM AFFILIATES TO THE EXTENT THAT THE 4,677
AFFILIATE HAS LIQUID ASSETS WITH WHICH TO PAY THE BALANCE AND 4,678
MAINTAIN ITS ACCOUNTS ON A CURRENT BASIS. ANY AMOUNT OUTSTANDING 4,679
MORE THAN THREE MONTHS SHALL BE CONSIDERED NOT CURRENT. 4,680
(2) "LIABILITIES" MEANS THE LIABILITIES OF THE HEALTH 4,682
INSURING CORPORATION AS DETERMINED BY THE SUPERINTENDENT OF 4,683
INSURANCE. 4,684
(B) ALL ADMITTED ASSETS OF A HEALTH INSURING CORPORATION 4,687
MUST BE HELD IN THE HEALTH INSURING CORPORATION'S NAME AND MUST 4,688
BE FREE AND CLEAR OF ANY ENCUMBRANCES, PLEDGES, OR HYPOTHECATION. 4,689
(C)(1) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,692
PROVIDE BASIC HEALTH CARE SERVICES SHALL MAINTAIN TOTAL ADMITTED 4,693
ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE 4,694
LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL THE 4,695
CORPORATION'S NET WORTH BE LESS THAN ONE MILLION DOLLARS. 4,696
(2) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,698
PROVIDE ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN 4,699
TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT 4,700
OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL 4,702
THE CORPORATION'S NET WORTH BE LESS THAN FIVE HUNDRED THOUSAND 4,703
DOLLARS.
106
(3) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,705
PROVIDE ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN TOTAL 4,706
ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE 4,707
LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL THE 4,708
CORPORATION'S NET WORTH BE LESS THAN TWO HUNDRED FIFTY THOUSAND 4,709
DOLLARS. 4,710
(4) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,712
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 4,713
CARE SERVICES SHALL MAINTAIN TOTAL ADMITTED ASSETS EQUAL TO AT 4,714
LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF THE 4,715
CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,716
WORTH BE LESS THAN ONE MILLION FIVE HUNDRED THOUSAND DOLLARS. 4,718
(5) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,720
BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,721
SERVICES SHALL MAINTAIN TOTAL ADMITTED ASSETS EQUAL TO AT LEAST 4,722
ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF THE CORPORATION. 4,723
HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET WORTH BE LESS 4,724
THAN ONE MILLION TWO HUNDRED FIFTY THOUSAND DOLLARS. 4,725
(D) THE ADMITTED VALUE OF ANY REAL ESTATE OWNED BY A 4,728
HEALTH INSURING CORPORATION, WHETHER USED FOR THE ACCOMMODATION 4,729
OF THE HEALTH INSURING CORPORATION'S BUSINESS OPERATIONS OR 4,730
OTHERWISE, SHALL BE THE ORIGINAL COST PLUS THE COST OF 4,731
IMPROVEMENTS, LESS ENCUMBRANCES AND ACCUMULATED DEPRECIATION. 4,732
(E) THE NET WORTH OTHERWISE REQUIRED BY THIS SECTION SHALL 4,734
BE REDUCED BY AN AMOUNT REPRESENTING CREDIT GIVEN TO RESERVE 4,735
LIABILITIES WHEN A HEALTH INSURING CORPORATION CARRIES 4,736
REINSURANCE WITH AN ADMITTED REINSURER. HOWEVER, SUCH AN AMOUNT 4,737
SHALL NOT AFFECT THE MINIMUM AMOUNTS SET FORTH IN THIS SECTION 4,738
AND SECTION 1751.27 OF THE REVISED CODE.
Sec. 1751.31. (A) ANY CHANGES IN A HEALTH INSURING 4,741
CORPORATION'S SOLICITATION DOCUMENT SHALL BE FILED WITH THE 4,742
SUPERINTENDENT OF INSURANCE. THE SUPERINTENDENT, WITHIN SIXTY 4,743
DAYS OF FILING, MAY DISAPPROVE ANY SOLICITATION DOCUMENT OR 4,744
AMENDMENT TO IT ON ANY OF THE GROUNDS STATED IN THIS SECTION. 4,745
107
SUCH DISAPPROVAL SHALL BE EFFECTED BY WRITTEN NOTICE TO THE 4,746
HEALTH INSURING CORPORATION. THE NOTICE SHALL STATE THE GROUNDS 4,747
FOR DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 4,748
119. OF THE REVISED CODE. 4,749
(B) THE SOLICITATION DOCUMENT SHALL CONTAIN ALL 4,752
INFORMATION NECESSARY TO ENABLE A CONSUMER TO MAKE AN INFORMED 4,753
CHOICE AS TO WHETHER OR NOT TO ENROLL IN THE HEALTH INSURING 4,754
CORPORATION. THE INFORMATION SHALL INCLUDE A SPECIFIC 4,755
DESCRIPTION OF THE HEALTH CARE SERVICES TO BE AVAILABLE AND THE 4,756
APPROXIMATE NUMBER AND TYPE OF FULL-TIME EQUIVALENT MEDICAL 4,757
PRACTITIONERS. THE INFORMATION SHALL BE PRESENTED IN THE 4,758
SOLICITATION DOCUMENT IN A MANNER THAT IS CLEAR, CONCISE, AND 4,759
INTELLIGIBLE TO PROSPECTIVE APPLICANTS IN THE PROPOSED SERVICE 4,760
AREA.
(C) EVERY POTENTIAL APPLICANT WHOSE SUBSCRIPTION TO A 4,763
HEALTH CARE PLAN IS SOLICITED SHALL RECEIVE, AT OR BEFORE THE 4,764
TIME OF SOLICITATION, A SOLICITATION DOCUMENT APPROVED BY THE 4,765
SUPERINTENDENT.
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 4,768
INSURING CORPORATION MAY USE A SOLICITATION DOCUMENT THAT THE 4,769
CORPORATION USES IN CONNECTION WITH POLICIES FOR BENEFICIARIES OF 4,770
TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,772
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 4,774
MEDICARE COST CONTRACT, OR FOR POLICIES FOR BENEFICIARIES OF THE 4,775
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 4,777
8905, OR FOR POLICIES FOR BENEFICIARIES OF TITLE XIX OF THE 4,779
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 4,782
AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, 4,783
PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 4,784
5111. OF THE REVISED CODE, OR FOR POLICIES FOR BENEFICIARIES OF 4,785
ANY OTHER FEDERAL HEALTH CARE PROGRAM REGULATED BY A FEDERAL 4,786
REGULATORY BODY, IF BOTH OF THE FOLLOWING APPLY: 4,787
(1) THE SOLICITATION DOCUMENT HAS BEEN APPROVED BY THE 4,789
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 4,790
108
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 4,792
HUMAN SERVICES.
(2) THE SOLICITATION DOCUMENT IS FILED WITH THE 4,794
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 4,795
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 4,798
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 4,800
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 4,802
(E) NO HEALTH INSURING CORPORATION, OR ITS AGENTS OR 4,805
REPRESENTATIVES, SHALL USE MONETARY OR OTHER VALUABLE 4,806
CONSIDERATION, ENGAGE IN MISLEADING OR DECEPTIVE PRACTICES, OR 4,807
MAKE UNTRUE, MISLEADING, OR DECEPTIVE REPRESENTATIONS TO INDUCE 4,808
ENROLLMENT. NOTHING IN THIS DIVISION SHALL PROHIBIT INCENTIVE 4,809
FORMS OF REMUNERATION SUCH AS COMMISSION SALES PROGRAMS FOR THE 4,810
HEALTH INSURING CORPORATION'S EMPLOYEES AND AGENTS. 4,811
(F) ANY PERSON OBLIGATED FOR ANY PART OF A PREMIUM RATE IN 4,814
CONNECTION WITH AN ENROLLMENT AGREEMENT, IN ADDITION TO ANY RIGHT 4,815
OTHERWISE AVAILABLE TO REVOKE AN OFFER, MAY CANCEL SUCH AGREEMENT 4,816
WITHIN SEVENTY-TWO HOURS AFTER HAVING SIGNED THE AGREEMENT OR 4,817
OFFER TO ENROLL. CANCELLATION OCCURS WHEN WRITTEN NOTICE OF THE 4,818
CANCELLATION IS GIVEN TO THE HEALTH INSURING CORPORATION OR ITS 4,819
AGENTS OR OTHER REPRESENTATIVES. A NOTICE OF CANCELLATION MAILED 4,820
TO THE HEALTH INSURING CORPORATION SHALL BE CONSIDERED TO HAVE 4,821
BEEN FILED ON ITS POSTMARK DATE. 4,822
(G) NOTHING IN THIS SECTION SHALL PROHIBIT HEALTHY 4,824
LIFESTYLE PROGRAMS. 4,825
Sec. 1751.32. EACH HEALTH INSURING CORPORATION, ANNUALLY, 4,827
ON OR BEFORE THE FIRST DAY OF MARCH, SHALL FILE A REPORT WITH THE 4,829
SUPERINTENDENT OF INSURANCE AND THE DIRECTOR OF HEALTH, COVERING 4,830
THE PRECEDING CALENDAR YEAR.
THE REPORT SHALL BE VERIFIED BY AN OFFICER OF THE HEALTH 4,832
INSURING CORPORATION, SHALL BE IN THE FORM THE SUPERINTENDENT 4,833
PRESCRIBES, AND SHALL INCLUDE: 4,834
(A) A FINANCIAL STATEMENT OF THE HEALTH INSURING 4,837
CORPORATION, INCLUDING ITS BALANCE SHEET AND RECEIPTS AND 4,838
109
DISBURSEMENTS FOR THE PRECEDING YEAR, WHICH REFLECT, AT A 4,839
MINIMUM:
(1) ALL PREMIUM RATE AND OTHER PAYMENTS RECEIVED FOR 4,841
HEALTH CARE SERVICES RENDERED; 4,842
(2) EXPENDITURES WITH RESPECT TO ALL CATEGORIES OF 4,844
PROVIDERS, FACILITIES, INSURANCE COMPANIES, AND OTHER PERSONS 4,845
ENGAGED TO FULFILL OBLIGATIONS OF THE HEALTH INSURING CORPORATION 4,847
ARISING OUT OF ITS HEALTH CARE POLICIES, CONTRACTS, CERTIFICATES, 4,848
AND AGREEMENTS;
(3) EXPENDITURES FOR CAPITAL IMPROVEMENTS OR ADDITIONS 4,850
THERETO, INCLUDING, BUT NOT LIMITED TO, CONSTRUCTION, RENOVATION, 4,852
OR PURCHASE OF FACILITIES AND EQUIPMENT.
(B) A DESCRIPTION OF THE ENROLLEE POPULATION AND 4,855
COMPOSITION, GROUP AND NONGROUP;
(C) A SUMMARY OF ENROLLEE WRITTEN COMPLAINTS AND THEIR 4,858
DISPOSITION;
(D) A STATEMENT OF THE NUMBER OF SUBSCRIBER POLICIES, 4,861
CONTRACTS, CERTIFICATES, AND AGREEMENTS THAT HAVE BEEN TERMINATED 4,862
BY ACTION OF THE HEALTH INSURING CORPORATION, INCLUDING THE 4,863
NUMBER OF ENROLLEES AFFECTED; 4,864
(E) A SUMMARY OF THE INFORMATION COMPILED PURSUANT TO 4,867
DIVISION (B)(5) OF SECTION 1751.04 OF THE REVISED CODE; 4,868
(F) A CURRENT REPORT OF THE NAMES AND ADDRESSES OF THE 4,871
PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS OF THE HEALTH 4,872
INSURING CORPORATION AS REQUIRED BY SECTION 1751.03 OF THE 4,873
REVISED CODE. ADDITIONALLY, THE REPORT SHALL INCLUDE THE AMOUNT 4,875
OF WAGES, EXPENSE REIMBURSEMENTS, AND OTHER PAYMENTS TO THESE 4,876
PERSONS FOR SERVICES TO THE HEALTH INSURING CORPORATION, AND 4,877
SHALL INCLUDE A FULL DISCLOSURE OF THE FINANCIAL INTERESTS 4,878
RELATED TO THE OPERATIONS OF THE HEALTH INSURING CORPORATION 4,879
ACQUIRED BY THESE PERSONS DURING THE PRECEDING YEAR. 4,880
(G) AN AUDIT REPORT CERTIFIED BY AN INDEPENDENT CERTIFIED 4,883
PUBLIC ACCOUNTANT IN THE FORM PRESCRIBED BY THE SUPERINTENDENT BY 4,884
RULE;
110
(H) AN ACTUARIAL OPINION IN THE FORM PRESCRIBED BY THE 4,887
SUPERINTENDENT BY RULE;
(I) ANY OTHER INFORMATION RELATING TO THE PERFORMANCE OF 4,890
THE HEALTH INSURING CORPORATION THAT IS NECESSARY TO ENABLE THE 4,891
SUPERINTENDENT TO CARRY OUT THE SUPERINTENDENT'S DUTIES UNDER 4,892
THIS CHAPTER.
Sec. 1751.33. (A) EACH HEALTH INSURING CORPORATION SHALL 4,894
PROVIDE TO ITS SUBSCRIBERS, BY MAIL, A DESCRIPTION OF THE HEALTH 4,895
INSURING CORPORATION, ITS METHOD OF OPERATION, ITS SERVICE AREA, 4,896
ITS MOST RECENT PROVIDER LIST, AND ITS COMPLAINT PROCEDURE 4,897
ESTABLISHED PURSUANT TO SECTION 1751.19 OF THE REVISED CODE. A 4,899
HEALTH INSURING CORPORATION PROVIDING BASIC HEALTH CARE SERVICES 4,900
OR SUPPLEMENTAL HEALTH CARE SERVICES SHALL PROVIDE THIS 4,901
INFORMATION ANNUALLY. A HEALTH INSURING CORPORATION PROVIDING
ONLY SPECIALTY HEALTH CARE SERVICES SHALL PROVIDE THIS 4,902
INFORMATION BIENNIALLY.
(B) EACH HEALTH INSURING CORPORATION, UPON THE REQUEST OF 4,905
A SUBSCRIBER, SHALL MAKE AVAILABLE ITS MOST RECENT STATUTORY 4,906
FINANCIAL STATEMENT.
Sec. 1751.34. (A) EACH HEALTH INSURING CORPORATION AND 4,909
EACH APPLICANT FOR A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 4,910
SHALL BE SUBJECT TO EXAMINATION BY THE SUPERINTENDENT OF 4,911
INSURANCE IN ACCORDANCE WITH SECTION 3901.07 OF THE REVISED CODE. 4,913
SECTION 3901.07 OF THE REVISED CODE SHALL GOVERN EVERY ASPECT OF 4,915
THE EXAMINATION, INCLUDING THE CIRCUMSTANCES UNDER AND FREQUENCY 4,916
WITH WHICH IT IS CONDUCTED, THE AUTHORITY OF THE SUPERINTENDENT 4,917
AND ANY EXAMINER OR OTHER PERSON APPOINTED BY THE SUPERINTENDENT, 4,918
THE LIABILITY FOR THE ASSESSMENT OF EXPENSES INCURRED IN 4,919
CONDUCTING THE EXAMINATION, AND THE REMITTANCE OF THE ASSESSMENT 4,920
TO THE SUPERINTENDENT'S EXAMINATION FUND.
(B) THE DIRECTOR OF HEALTH SHALL MAKE AN EXAMINATION 4,923
CONCERNING THE MATTERS SUBJECT TO THE DIRECTOR'S CONSIDERATION IN 4,924
SECTION 1751.04 OF THE REVISED CODE AS OFTEN AS THE DIRECTOR 4,925
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF THE 4,927
111
PEOPLE OF THIS STATE, BUT NOT LESS FREQUENTLY THAN ONCE EVERY 4,928
THREE YEARS. THE EXPENSES OF SUCH EXAMINATIONS SHALL BE ASSESSED 4,929
AGAINST THE HEALTH INSURING CORPORATION BEING EXAMINED IN THE 4,930
MANNER IN WHICH EXPENSES OF EXAMINATIONS ARE ASSESSED AGAINST AN 4,931
INSURANCE COMPANY UNDER SECTION 3901.07 OF THE REVISED CODE. 4,932
(C) AN EXAMINATION, PURSUANT TO SECTION 3901.07 OF THE 4,935
REVISED CODE, OF AN INSURANCE COMPANY HOLDING A CERTIFICATE OF 4,936
AUTHORITY UNDER THIS CHAPTER TO ORGANIZE AND OPERATE A HEALTH 4,937
INSURING CORPORATION SHALL INCLUDE AN EXAMINATION OF THE HEALTH 4,938
INSURING CORPORATION PURSUANT TO THIS SECTION AND THE EXAMINATION 4,939
SHALL SATISFY THE REQUIREMENTS OF DIVISIONS (A) AND (B) OF THIS 4,941
SECTION.
(D) THE SUPERINTENDENT MAY CONDUCT MARKET CONDUCT 4,944
EXAMINATIONS PURSUANT TO SECTION 3901.011 OF THE REVISED CODE OF 4,946
ANY HEALTH INSURING CORPORATION AS OFTEN AS THE SUPERINTENDENT 4,947
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF 4,948
SUBSCRIBERS AND ENROLLEES. THE EXPENSES OF SUCH MARKET CONDUCT 4,949
EXAMINATIONS SHALL BE ASSESSED AGAINST THE HEALTH INSURING 4,950
CORPORATION BEING EXAMINED. ALL COSTS, ASSESSMENTS, OR FINES 4,951
COLLECTED UNDER THIS DIVISION SHALL BE PAID INTO THE STATE 4,952
TREASURY TO THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING 4,953
FUND.
Sec. 1751.35. (A) THE SUPERINTENDENT OF INSURANCE MAY 4,956
SUSPEND OR REVOKE ANY CERTIFICATE OF AUTHORITY ISSUED TO A HEALTH 4,957
INSURING CORPORATION UNDER THIS CHAPTER IF THE SUPERINTENDENT 4,958
FINDS THAT:
(1) THE HEALTH INSURING CORPORATION IS OPERATING IN 4,960
CONTRAVENTION OF ITS ARTICLES OF INCORPORATION, ITS HEALTH CARE 4,961
PLAN OR PLANS, OR IN A MANNER CONTRARY TO THAT DESCRIBED IN AND 4,962
REASONABLY INFERRED FROM ANY OTHER INFORMATION SUBMITTED UNDER 4,963
SECTION 1751.03 OF THE REVISED CODE, UNLESS AMENDMENTS TO SUCH 4,965
SUBMISSIONS HAVE BEEN FILED AND HAVE TAKEN EFFECT IN COMPLIANCE 4,966
WITH THIS CHAPTER. 4,967
(2) THE HEALTH INSURING CORPORATION FAILS TO ISSUE 4,969
112
EVIDENCES OF COVERAGE IN COMPLIANCE WITH THE REQUIREMENTS OF 4,970
SECTION 1751.11 OF THE REVISED CODE. 4,972
(3) THE CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUM RATES 4,974
USED DO NOT COMPLY WITH THE REQUIREMENTS OF SECTION 1751.12 OF 4,975
THE REVISED CODE. 4,976
(4) THE HEALTH INSURING CORPORATION ENTERS INTO A 4,978
CONTRACT, AGREEMENT, OR OTHER ARRANGEMENT WITH ANY HEALTH CARE 4,979
FACILITY OR PROVIDER, THAT DOES NOT COMPLY WITH THE REQUIREMENTS 4,980
OF SECTION 1751.13 OF THE REVISED CODE, OR THE CORPORATION FAILS 4,982
TO PROVIDE AN ANNUAL CERTIFICATE AS REQUIRED BY SECTION 1751.13 4,983
OF THE REVISED CODE. 4,985
(5) THE DIRECTOR OF HEALTH HAS CERTIFIED, AFTER A HEARING 4,987
CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, 4,989
THAT THE HEALTH INSURING CORPORATION NO LONGER MEETS THE 4,990
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. 4,992
(6) THE HEALTH INSURING CORPORATION IS NO LONGER 4,994
FINANCIALLY RESPONSIBLE AND MAY REASONABLY BE EXPECTED TO BE 4,995
UNABLE TO MEET ITS OBLIGATIONS TO ENROLLEES OR PROSPECTIVE 4,996
ENROLLEES. 4,997
(7) THE HEALTH INSURING CORPORATION HAS FAILED TO 4,999
IMPLEMENT THE COMPLAINT SYSTEM THAT COMPLIES WITH THE 5,000
REQUIREMENTS OF SECTION 1751.19 OF THE REVISED CODE. 5,003
(8) THE HEALTH INSURING CORPORATION, OR ANY AGENT OR 5,005
REPRESENTATIVE OF THE CORPORATION, HAS ADVERTISED, MERCHANDISED, 5,006
OR SOLICITED ON ITS BEHALF IN CONTRAVENTION OF THE REQUIREMENTS 5,007
OF SECTION 1751.31 OF THE REVISED CODE. 5,008
(9) THE HEALTH INSURING CORPORATION HAS UNLAWFULLY 5,010
DISCRIMINATED AGAINST ANY ENROLLEE OR PROSPECTIVE ENROLLEE WITH 5,011
RESPECT TO ENROLLMENT, DISENROLLMENT, OR PRICE OR QUALITY OF 5,012
HEALTH CARE SERVICES. 5,013
(10) THE CONTINUED OPERATION OF THE HEALTH INSURING 5,015
CORPORATION WOULD BE HAZARDOUS OR OTHERWISE DETRIMENTAL TO ITS 5,016
ENROLLEES. 5,017
(11) THE HEALTH INSURING CORPORATION HAS SUBMITTED FALSE 5,019
113
INFORMATION IN ANY FILING OR SUBMISSION REQUIRED UNDER THIS 5,020
CHAPTER OR ANY RULE ADOPTED UNDER THIS CHAPTER. 5,021
(12) THE HEALTH INSURING CORPORATION HAS OTHERWISE FAILED 5,023
TO SUBSTANTIALLY COMPLY WITH THIS CHAPTER OR ANY RULE ADOPTED 5,024
UNDER THIS CHAPTER. 5,025
(13) THE HEALTH INSURING CORPORATION IS NOT OPERATING A 5,027
HEALTH CARE PLAN. 5,028
(B) A CERTIFICATE OF AUTHORITY SHALL BE SUSPENDED OR 5,031
REVOKED ONLY AFTER COMPLIANCE WITH THE REQUIREMENTS OF CHAPTER 5,032
119. OF THE REVISED CODE. 5,033
(C) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,036
CORPORATION IS SUSPENDED, THE HEALTH INSURING CORPORATION, DURING 5,037
THE PERIOD OF SUSPENSION, SHALL NOT ENROLL ANY ADDITIONAL 5,038
SUBSCRIBERS OR ENROLLEES EXCEPT NEWBORN CHILDREN OR OTHER NEWLY 5,039
ACQUIRED DEPENDENTS OF EXISTING SUBSCRIBERS OR ENROLLEES, AND 5,040
SHALL NOT ENGAGE IN ANY ADVERTISING OR SOLICITATION WHATSOEVER. 5,041
(D) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,044
CORPORATION IS REVOKED, THE HEALTH INSURING CORPORATION, 5,045
FOLLOWING THE EFFECTIVE DATE OF THE ORDER OF REVOCATION, SHALL 5,046
CONDUCT NO FURTHER BUSINESS EXCEPT AS MAY BE ESSENTIAL TO THE 5,047
ORDERLY CONCLUSION OF THE AFFAIRS OF THE HEALTH INSURING 5,048
CORPORATION. THE HEALTH INSURING CORPORATION SHALL ENGAGE IN NO 5,049
FURTHER ADVERTISING OR SOLICITATION WHATSOEVER. THE 5,050
SUPERINTENDENT, BY WRITTEN ORDER, MAY PERMIT SUCH FURTHER 5,051
OPERATION OF THE HEALTH INSURING CORPORATION AS THE 5,052
SUPERINTENDENT MAY FIND TO BE IN THE BEST INTEREST OF ENROLLEES, 5,053
TO THE END THAT ENROLLEES WILL BE AFFORDED THE GREATEST PRACTICAL 5,054
OPPORTUNITY TO OBTAIN CONTINUING HEALTH CARE COVERAGE. 5,055
Sec. 1751.36. (A) WHEN THE SUPERINTENDENT OF INSURANCE 5,058
HAS CAUSE TO BELIEVE THAT GROUNDS FOR THE DENIAL OF AN 5,059
APPLICATION FOR A CERTIFICATE OF AUTHORITY EXIST, OR THAT GROUNDS 5,060
FOR THE SUSPENSION OR REVOCATION OF A CERTIFICATE OF AUTHORITY 5,061
EXIST, THE SUPERINTENDENT SHALL NOTIFY THE APPLICANT OR HEALTH 5,062
INSURING CORPORATION AND THE DIRECTOR OF HEALTH IN WRITING, 5,063
114
SPECIFICALLY STATING THE GROUNDS FOR THE DENIAL, SUSPENSION, OR 5,064
REVOCATION AND SETTING A DATE OF AT LEAST THIRTY DAYS AFTER THE 5,065
NOTIFICATION FOR A HEARING ON THE MATTER.
(B) THE RECOMMENDATIONS AND FINDINGS OF THE DIRECTOR OF 5,068
HEALTH WITH RESPECT TO MATTERS SUBJECT TO THE DIRECTOR'S 5,069
CONSIDERATION UNDER SECTION 1751.04 OF THE REVISED CODE, PROVIDED 5,071
IN CONNECTION WITH ANY DECISION REGARDING THE DENIAL, SUSPENSION, 5,072
OR REVOCATION OF A CERTIFICATE OF AUTHORITY, SHALL BE REVIEWED 5,073
AND CONSIDERED BY THE SUPERINTENDENT. AFTER THE HEARING 5,074
AUTHORIZED BY DIVISION (A) OF THIS SECTION, OR UPON THE FAILURE 5,076
OF THE APPLICANT OR HEALTH INSURING CORPORATION TO APPEAR AT THE 5,077
HEARING, THE SUPERINTENDENT SHALL TAKE SUCH ACTION AS IN 5,078
ACCORDANCE WITH LAW AND THE EVIDENCE. THE ACTION SHALL BE SET 5,079
OUT IN WRITTEN FINDINGS WHICH SHALL BE MAILED TO THE APPLICANT OR 5,080
HEALTH INSURING CORPORATION WITH A COPY TO THE DIRECTOR OF
HEALTH. THE ACTION OF THE SUPERINTENDENT IS SUBJECT TO REVIEW IN 5,082
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, EXCEPT THAT A 5,084
CERTIFICATION BY THE DIRECTOR UNDER DIVISION (D) OF SECTION 5,086
1751.04 OR DIVISION (A)(5) OF SECTION 1751.35 OF THE REVISED CODE 5,088
THAT WAS MADE IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE 5,089
SHALL BE FINAL AS TO THE MATTERS CERTIFIED.
(C) CHAPTER 119. OF THE REVISED CODE APPLIES TO 5,091
PROCEEDINGS UNDER THIS SECTION TO THE EXTENT THAT IT IS NOT IN 5,092
CONFLICT WITH DIVISIONS (A) AND (B) OF THIS SECTION. 5,093
Sec. 1751.38. (A) AS USED IN THIS SECTION, "AGENT" MEANS 5,096
A PERSON APPOINTED BY A HEALTH INSURING CORPORATION TO ENGAGE IN 5,097
THE SOLICITATION OR ENROLLMENT OF SUBSCRIBERS OR ENROLLEES. 5,098
(B) AGENTS OF HEALTH INSURING CORPORATIONS SHALL BE 5,101
LICENSED PURSUANT TO SECTION 3905.01 OR 3905.18 OF THE REVISED 5,104
CODE.
(C) SECTIONS 3905.01, 3905.03, 3905.05, 3905.16 TO 5,107
3905.18, 3905.181, 3905.19, 3905.23, 3905.40, 3905.41, 3905.42, 5,108
3905.46 TO 3905.48, 3905.481, 3905.482, 3905.486, 3905.49, 5,109
3905.50, 3905.71 TO 3905.79, AND 3905.99 OF THE REVISED CODE 5,110
115
SHALL APPLY TO HEALTH INSURING CORPORATIONS AND THE AGENTS OF 5,111
HEALTH INSURING CORPORATIONS IN THE SAME MANNER IN WHICH THESE 5,112
SECTIONS APPLY TO INSURERS AND AGENTS OF INSURERS. 5,113
Sec. 1751.40. (A) NOTWITHSTANDING ANY PROVISION OF TITLE 5,115
XXXIX OF THE REVISED CODE, ANY INSURANCE COMPANY HOLDING A 5,119
CERTIFICATE OF AUTHORITY ISSUED PURSUANT TO TITLE XXXIX OF THE 5,121
REVISED CODE, OR ANY CORPORATION THAT IS A SUBSIDIARY OR 5,122
AFFILIATE OF THE INSURANCE COMPANY, MAY APPLY FOR AND OBTAIN A 5,123
CERTIFICATE OF AUTHORITY TO ORGANIZE AND OPERATE A HEALTH 5,124
INSURING CORPORATION IN COMPLIANCE WITH THIS CHAPTER. 5,125
NOTWITHSTANDING ANY OTHER LAW THAT MAY BE INCONSISTENT WITH THIS 5,126
DIVISION, ANY TWO OR MORE SUCH INSURANCE COMPANIES, OR
SUBSIDIARIES OR AFFILIATES THEREOF, MAY JOINTLY ORGANIZE AND 5,127
OPERATE A HEALTH INSURING CORPORATION UNDER THIS CHAPTER. THE 5,128
BUSINESS OF INSURANCE IS DEEMED TO INCLUDE THE PROVIDING OF 5,129
HEALTH CARE BY A HEALTH INSURING CORPORATION OWNED OR OPERATED BY 5,131
AN INSURANCE COMPANY OR A SUBSIDIARY OR AFFILIATE OF AN INSURANCE 5,132
COMPANY.
(B) NOTWITHSTANDING ANY PROVISION OF ANY INSURANCE LAWS OF 5,135
THIS STATE, AN INSURANCE COMPANY MAY CONTRACT WITH A HEALTH 5,136
INSURING CORPORATION TO PROVIDE INSURANCE OR SIMILAR PROTECTION 5,137
AGAINST THE COST OF CARE PROVIDED THROUGH HEALTH INSURING 5,138
CORPORATIONS AND TO PROVIDE COVERAGE IN THE EVENT OF THE FAILURE 5,139
OF THE HEALTH INSURING CORPORATION TO MEET ITS OBLIGATIONS. THE 5,140
ENROLLEES OF A HEALTH INSURING CORPORATION CONSTITUTE A 5,141
PERMISSIBLE GROUP UNDER SUCH LAWS. AMONG OTHER THINGS, UNDER 5,142
SUCH CONTRACTS, THE INSURER MAY MAKE BENEFIT PAYMENTS TO HEALTH 5,143
INSURING CORPORATIONS FOR HEALTH CARE SERVICES RENDERED BY 5,144
FACILITIES AND PROVIDERS PURSUANT TO A HEALTH CARE PLAN. 5,145
Sec. 1751.42. ANY REHABILITATION, LIQUIDATION, 5,147
SUPERVISION, OR CONSERVATION OF A HEALTH INSURING CORPORATION 5,148
SHALL BE DEEMED TO BE THE REHABILITATION, LIQUIDATION, 5,149
SUPERVISION, OR CONSERVATION OF AN INSURANCE COMPANY AND SHALL BE 5,150
CONDUCTED UNDER THE SUPERVISION OF THE SUPERINTENDENT OF 5,151
116
INSURANCE PURSUANT TO CHAPTER 3903. OF THE REVISED CODE. 5,154
Sec. 1751.44. (A) EACH HEALTH INSURING CORPORATION SHALL 5,157
PAY TO THE SUPERINTENDENT OF INSURANCE THE FOLLOWING FEES: 5,158
(1) FOR FILING AN APPLICATION FOR A CERTIFICATE OF 5,160
AUTHORITY, FIFTEEN HUNDRED DOLLARS; 5,161
(2) FOR FILING A REQUEST FOR A SERVICE AREA EXPANSION 5,163
UNDER SECTION 1751.03 OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,165
(3) FOR FILING A MAJOR MODIFICATION UNDER SECTION 1751.03 5,167
OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,170
(4) FOR FILING EACH ANNUAL REPORT, TWENTY-FIVE DOLLARS; 5,173
(5) FOR ALL OTHER REQUIRED FILINGS FOR WHICH NO FILING FEE 5,176
IS OTHERWISE PROVIDED FOR BY THIS CHAPTER, FIFTY DOLLARS. 5,177
(B) ALL FEES COLLECTED UNDER THIS SECTION SHALL BE PAID 5,180
INTO THE STATE TREASURY TO THE CREDIT OF THE DEPARTMENT OF 5,181
INSURANCE OPERATING FUND.
Sec. 1751.45. (A) IN LIEU OF THE SUSPENSION OR REVOCATION 5,184
OF A CERTIFICATE OF AUTHORITY UNDER SECTION 1751.35 OF THE 5,185
REVISED CODE, THE SUPERINTENDENT OF INSURANCE, PURSUANT TO AN 5,187
ADJUDICATION HEARING INITIATED AND CONDUCTED IN ACCORDANCE WITH 5,188
CHAPTER 119. OF THE REVISED CODE, OR BY CONSENT OF THE HEALTH 5,190
INSURING CORPORATION WITHOUT AN ADJUDICATION HEARING, MAY LEVY AN 5,191
ADMINISTRATIVE PENALTY. THE ADMINISTRATIVE PENALTY SHALL BE IN
AN AMOUNT DETERMINED BY THE SUPERINTENDENT, BUT THE 5,193
ADMINISTRATIVE PENALTY SHALL NOT EXCEED ONE HUNDRED THOUSAND 5,194
DOLLARS PER VIOLATION. ADDITIONALLY, THE SUPERINTENDENT MAY 5,195
REQUIRE THE HEALTH INSURING CORPORATION TO CORRECT ANY DEFICIENCY 5,197
THAT MAY BE THE BASIS FOR THE SUSPENSION OR REVOCATION OF THE 5,198
HEALTH INSURING CORPORATION'S CERTIFICATE OF AUTHORITY. ALL 5,199
PENALTIES COLLECTED SHALL BE PAID INTO THE STATE TREASURY TO THE 5,200
CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING FUND. 5,201
(B) IF THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH FOR 5,204
ANY REASON HAS CAUSE TO BELIEVE THAT ANY VIOLATION OF THIS 5,205
CHAPTER HAS OCCURRED OR IS THREATENED, THE SUPERINTENDENT OR THE 5,206
DIRECTOR MAY GIVE NOTICE TO THE HEALTH INSURING CORPORATION AND 5,207
117
TO THE REPRESENTATIVES OR OTHER PERSONS WHO APPEAR TO BE INVOLVED 5,208
IN THE SUSPECTED VIOLATION TO ARRANGE A CONFERENCE WITH THE 5,209
SUSPECTED VIOLATORS OR THEIR AUTHORIZED REPRESENTATIVES FOR THE 5,210
PURPOSE OF ATTEMPTING TO ASCERTAIN THE FACTS RELATING TO THE 5,211
SUSPECTED VIOLATION, AND, IF IT APPEARS THAT ANY VIOLATION HAS 5,212
OCCURRED OR IS THREATENED, TO ARRIVE AT AN ADEQUATE AND EFFECTIVE 5,214
MEANS OF CORRECTING OR PREVENTING THE VIOLATION.
PROCEEDINGS UNDER THIS DIVISION SHALL NOT BE COVERED BY ANY 5,217
FORMAL PROCEDURAL REQUIREMENTS, AND MAY BE CONDUCTED IN THE
MANNER THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH MAY CONSIDER 5,218
APPROPRIATE UNDER THE CIRCUMSTANCES. 5,219
(C)(1) THE SUPERINTENDENT MAY ISSUE AN ORDER DIRECTING A 5,222
HEALTH INSURING CORPORATION OR A REPRESENTATIVE OF THE HEALTH 5,223
INSURING CORPORATION TO CEASE AND DESIST FROM ENGAGING IN ANY ACT 5,224
OR PRACTICE IN VIOLATION OF THIS CHAPTER. WITHIN THIRTY DAYS 5,225
AFTER SERVICE OF THE ORDER TO CEASE AND DESIST, THE RESPONDENT 5,226
MAY REQUEST A HEARING ON THE QUESTION OF WHETHER ACTS OR 5,227
PRACTICES IN VIOLATION OF THIS CHAPTER HAVE OCCURRED. SUCH 5,228
HEARINGS SHALL BE CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF 5,229
THE REVISED CODE AND JUDICIAL REVIEW SHALL BE AVAILABLE AS 5,231
PROVIDED BY THAT CHAPTER.
(2) IF THE SUPERINTENDENT HAS REASONABLE CAUSE TO BELIEVE 5,233
THAT AN ORDER ISSUED PURSUANT TO THIS DIVISION HAS BEEN VIOLATED 5,234
IN WHOLE OR IN PART, THE SUPERINTENDENT MAY REQUEST THE ATTORNEY 5,235
GENERAL TO COMMENCE AND PROSECUTE ANY APPROPRIATE ACTION OR 5,236
PROCEEDING IN THE NAME OF THE STATE AGAINST THE VIOLATORS IN THE 5,237
COURT OF COMMON PLEAS OF FRANKLIN COUNTY. THE COURT IN ANY SUCH 5,240
ACTION OR PROCEEDING MAY LEVY CIVIL PENALTIES, NOT TO EXCEED ONE 5,241
HUNDRED THOUSAND DOLLARS PER VIOLATION, IN ADDITION TO ANY OTHER 5,242
APPROPRIATE RELIEF, INCLUDING REQUIRING A VIOLATOR TO PAY THE 5,243
EXPENSES REASONABLY INCURRED BY THE SUPERINTENDENT IN ENFORCING 5,244
THE ORDER. THE PENALTIES AND FEES COLLECTED UNDER THIS DIVISION 5,245
SHALL BE PAID INTO THE STATE TREASURY TO THE CREDIT OF THE 5,246
DEPARTMENT OF INSURANCE OPERATING FUND.
118
Sec. 1751.46. (A) THE SUPERINTENDENT OF INSURANCE AND THE 5,249
DIRECTOR OF HEALTH MAY CONTRACT WITH QUALIFIED PERSONS TO MAKE 5,250
RECOMMENDATIONS CONCERNING THE DETERMINATIONS REQUIRED TO BE MADE 5,251
BY THE SUPERINTENDENT OR THE DIRECTOR RELATIVE TO AN EXPANSION OF 5,252
A SERVICE AREA PURSUANT TO DIVISION (C) OF SECTION 1751.03 OF THE 5,254
REVISED CODE, AN APPLICATION FOR A CERTIFICATE OF AUTHORITY 5,256
PURSUANT TO SECTIONS 1751.04 AND 1751.05 OF THE REVISED CODE, A 5,258
CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE PURSUANT TO 5,259
SECTION 1751.12 OF THE REVISED CODE, AND AN EXAMINATION PURSUANT 5,261
TO DIVISION (B) OF SECTION 1751.34 OF THE REVISED CODE. THE 5,263
RECOMMENDATIONS MAY BE ACCEPTED IN FULL OR IN PART, OR MAY BE 5,264
REJECTED, BY THE SUPERINTENDENT OR DIRECTOR. 5,265
(B) NO QUALIFIED PERSON PLACED ON CONTRACT BY THE 5,268
SUPERINTENDENT OR THE DIRECTOR PURSUANT TO DIVISION (A) OF THIS 5,270
SECTION SHALL HAVE A CONFLICT OF INTEREST WITH THE DEPARTMENT OF 5,271
INSURANCE, THE DEPARTMENT OF HEALTH, OR THE HEALTH INSURING 5,272
CORPORATION.
Sec. 1751.47. (A) THE SUPERINTENDENT OF INSURANCE SHALL 5,274
ADOPT THE FORMS, INSTRUCTIONS, AND MANUALS PRESCRIBED BY THE 5,276
NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS FOR THE 5,277
PREPARATION AND FILING OF STATUTORY FINANCIAL STATEMENTS AND 5,278
OTHER FINANCIAL INFORMATION. HOWEVER, THE SUPERINTENDENT MAY BY 5,279
RULE ADOPT MODIFICATIONS TO SUCH PRESCRIBED FORMS, INSTRUCTIONS, 5,280
AND MANUALS AS THE SUPERINTENDENT CONSIDERS TO BE NECESSARY. 5,281
(B) FOR PURPOSES OF PREPARING STATUTORY FINANCIAL 5,284
STATEMENTS AND OTHER FINANCIAL INFORMATION INVOLVING 5,285
CIRCUMSTANCES NOT ADDRESSED BY THE FORMS, INSTRUCTIONS, AND 5,286
MANUALS PRESCRIBED BY THE NATIONAL ASSOCIATION OF INSURANCE 5,287
COMMISSIONERS, THE SUPERINTENDENT MAY DETERMINE ACCOUNTING 5,288
PRACTICES AND METHODS TO BE USED BY HEALTH INSURING CORPORATIONS. 5,289
(C) THE SUPERINTENDENT SHALL FURNISH EACH DOMESTIC HEALTH 5,292
INSURING CORPORATION A COPY OF THE FORMS FOR THE FILING OF THOSE 5,293
STATUTORY FINANCIAL STATEMENTS AND OTHER FINANCIAL INFORMATION AS 5,294
THE CORPORATION IS REQUIRED TO FILE WITH THE SUPERINTENDENT. 5,295
119
Sec. 1751.48. (A) THE SUPERINTENDENT OF INSURANCE MAY 5,298
ADOPT RULES AS ARE NECESSARY TO CARRY OUT THE PROVISIONS OF THIS 5,299
CHAPTER. THESE RULES SHALL BE ADOPTED IN ACCORDANCE WITH CHAPTER 5,300
119. OF THE REVISED CODE. 5,301
(B) THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS TO THE 5,304
SUPERINTENDENT FOR RULES THAT ARE NECESSARY TO ENABLE THE 5,305
DIRECTOR TO CARRY OUT THE DIRECTOR'S RESPONSIBILITIES UNDER THIS 5,306
CHAPTER, INCLUDING RULES THAT PRESCRIBE STANDARDS RELATING TO THE 5,307
REQUIREMENTS SET FORTH IN DIVISION (B) OF SECTION 1751.04 OF THE 5,309
REVISED CODE. IN ADOPTING ANY RULES PERTAINING TO THE DIRECTOR'S 5,311
RESPONSIBILITIES, THE SUPERINTENDENT SHALL CONSIDER THE 5,312
RECOMMENDATIONS OF THE DIRECTOR. 5,313
Sec. 1751.51. IF A HEALTH CARE PLAN OF A HEALTH INSURING 5,315
CORPORATION COVERS HEALTH CARE SERVICES THAT MAY BE LEGALLY 5,316
PERFORMED BY A CLASS OF PROVIDERS REFERRED TO IN SECTION 3923.23 5,317
OR 3923.231 OF THE REVISED CODE BUT WOULD RESTRICT AN ENROLLEE'S 5,320
ABILITY TO RECEIVE THESE HEALTH CARE SERVICES FROM MEMBERS OF 5,321
THAT CLASS IN ANY MANNER THAT DIFFERS FROM AN ENROLLEE'S ABILITY 5,322
UNDER THE HEALTH CARE PLAN TO RECEIVE THESE HEALTH CARE SERVICES 5,323
FROM ANY OTHER CLASS OF PROVIDERS THAT MAY LEGALLY PERFORM THESE 5,324
HEALTH CARE SERVICES, THEN THE HEALTH INSURING CORPORATION SHALL 5,325
DO BOTH OF THE FOLLOWING:
(A) SET FORTH, WITHIN ANY EVIDENCE OF COVERAGE PERTAINING 5,328
TO THE HEALTH CARE PLAN, UNDER A HEADING THAT READS "RESTRICTIONS 5,329
ON CHOICE OF PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT 5,331
OF THE RESTRICTION THAT CONFORMS TO THE REQUIREMENTS OF SECTION 5,332
1751.11 OF THE REVISED CODE; 5,333
(B) SET FORTH, WITHIN ANY SOLICITATION DOCUMENT PERTAINING 5,336
TO THE HEALTH CARE PLAN AND WITHIN ANY SOLICITATION MATERIALS 5,337
PERTAINING TO THE HEALTH CARE PLAN THAT THE HEALTH INSURING 5,338
CORPORATION PROVIDES TO ANY EMPLOYER OR ANY EMPLOYEE BENEFIT 5,339
FUND, UNDER A HEADING THAT READS "RESTRICTIONS ON CHOICE OF 5,340
PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT OF THE 5,342
RESTRICTION, SUCH STATEMENT BEING SUBJECT TO PRIOR APPROVAL BY 5,343
120
THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH THE SAME FORM 5,344
AND CONTENT REQUIREMENTS THAT ARE SPECIFIED IN SECTION 1751.11 OF 5,345
THE REVISED CODE WITH REGARD TO EVIDENCE OF COVERAGE. 5,346
Sec. 1751.52. (A) ALL APPLICATIONS, FILINGS, AND REPORTS 5,349
REQUIRED UNDER THIS CHAPTER SHALL BE TREATED AS PUBLIC DOCUMENTS 5,350
AFTER THE DATE THE APPLICATION, FILING, OR REPORT BECOMES 5,351
EFFECTIVE, REGARDLESS OF THE APPLICATION OF THE UNIFORM TRADE 5,352
SECRETS ACT SET FORTH IN SECTIONS 1333.61 TO 1333.69 OF THE 5,354
REVISED CODE.
(B) ANY DATA OR INFORMATION PERTAINING TO THE DIAGNOSIS, 5,357
TREATMENT, OR HEALTH OF ANY ENROLLEE OR APPLICANT FOR ENROLLMENT 5,358
THAT IS OBTAINED BY THE HEALTH INSURING CORPORATION FROM THE 5,359
ENROLLEE OR APPLICANT, OR FROM ANY HEALTH CARE FACILITY OR 5,360
PROVIDER, SHALL BE HELD IN CONFIDENCE AND SHALL NOT BE DISCLOSED 5,361
TO ANY PERSON EXCEPT UNDER ONE OF THE FOLLOWING CIRCUMSTANCES: 5,362
(1) TO THE EXTENT THAT IT MAY BE NECESSARY TO CARRY OUT 5,364
THE PURPOSES OF THIS CHAPTER; 5,365
(2) UPON THE EXPRESS CONSENT OF THE ENROLLEE OR APPLICANT; 5,368
(3) PURSUANT TO STATUTE OR COURT ORDER FOR THE PRODUCTION 5,370
OF EVIDENCE; 5,371
(4) IN THE EVENT OF CLAIM LITIGATION BETWEEN SUCH PERSON 5,373
AND THE HEALTH INSURING CORPORATION WHEREIN SUCH DATA OR 5,374
INFORMATION IS PERTINENT. 5,375
(C) A HEALTH INSURING CORPORATION SHALL BE ENTITLED TO 5,378
CLAIM ANY STATUTORY PRIVILEGES AGAINST DISCLOSURE UNDER DIVISION 5,379
(B) OF THIS SECTION THAT THE FACILITY OR PROVIDER WHO FURNISHED 5,381
THE DATA OR INFORMATION TO THE HEALTH INSURING CORPORATION IS 5,382
ENTITLED TO CLAIM.
Sec. 1751.53. (A) AS USED IN THIS SECTION: 5,384
(1) "GROUP CONTRACT" MEANS A GROUP HEALTH INSURING 5,386
CORPORATION CONTRACT COVERING EMPLOYEES THAT MEETS EITHER OF THE 5,387
FOLLOWING CONDITIONS: 5,388
(a) THE CONTRACT WAS ISSUED BY AN ENTITY THAT, ON THE 5,391
EFFECTIVE DATE OF THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY 5,392
121
OR LICENSE TO OPERATE UNDER CHAPTER 1738. OR 1742. OF THE REVISED 5,394
CODE, AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S 5,395
EMPLOYMENT IS TERMINATED.
(b) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,398
RENEWED IN THIS STATE AFTER THE EFFECTIVE DATE OF THIS SECTION 5,399
AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S EMPLOYMENT IS 5,400
TERMINATED.
(2) "ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE TO WHOM ALL OF 5,402
THE FOLLOWING APPLY: 5,403
(a) THE EMPLOYEE HAS BEEN CONTINUOUSLY COVERED UNDER A 5,406
GROUP CONTRACT OR UNDER THE CONTRACT AND ANY PRIOR SIMILAR GROUP 5,407
COVERAGE REPLACED BY THE CONTRACT, DURING THE ENTIRE THREE-MONTH 5,408
PERIOD PRECEDING THE TERMINATION OF THE EMPLOYEE'S EMPLOYMENT. 5,409
(b) THE EMPLOYEE IS ENTITLED, AT THE TIME OF THE 5,412
TERMINATION OF THIS EMPLOYMENT, TO UNEMPLOYMENT COMPENSATION 5,413
BENEFITS UNDER CHAPTER 4141. OF THE REVISED CODE. 5,414
(c) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,417
OR ELIGIBLE FOR COVERAGE BY MEDICARE UNDER TITLE XVIII OF THE 5,419
"SOCIAL SECURITY ACT, "49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 5,421
AMENDED.
(d) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,424
OR ELIGIBLE FOR COVERAGE BY ANY OTHER INSURED OR UNINSURED 5,425
ARRANGEMENT THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL COVERAGE 5,426
FOR INDIVIDUALS IN A GROUP AND UNDER WHICH THE EMPLOYEE WAS NOT 5,427
COVERED IMMEDIATELY PRIOR TO THE TERMINATION OF EMPLOYMENT. A 5,428
PERSON ELIGIBLE FOR CONTINUATION OF COVERAGE UNDER THIS SECTION, 5,429
WHO IS ALSO ELIGIBLE FOR COVERAGE UNDER SECTION 3923.123 OF THE 5,431
REVISED CODE, MAY ELECT EITHER COVERAGE, BUT NOT BOTH. A PERSON 5,432
WHO ELECTS CONTINUATION OF COVERAGE MAY ELECT ANY COVERAGE 5,433
AVAILABLE UNDER SECTION 3923.123 OF THE REVISED CODE UPON THE 5,435
TERMINATION OF THE CONTINUATION OF COVERAGE. 5,436
(B) A GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,439
EMPLOYEE MAY CONTINUE THE COVERAGE UNDER THE CONTRACT, FOR THE 5,440
EMPLOYEE AND THE EMPLOYEE'S ELIGIBLE DEPENDENTS, FOR A PERIOD OF 5,441
122
SIX MONTHS AFTER THE DATE THAT THE GROUP COVERAGE WOULD OTHERWISE 5,442
TERMINATE BY REASON OF THE TERMINATION OF THE EMPLOYEE'S 5,443
EMPLOYMENT. EACH CERTIFICATE OF COVERAGE ISSUED TO EMPLOYEES 5,444
UNDER THE CONTRACT SHALL INCLUDE A NOTICE OF THE EMPLOYEE'S 5,445
PRIVILEGE OF CONTINUATION.
(C) ALL OF THE FOLLOWING APPLY TO THE CONTINUATION OF 5,448
GROUP COVERAGE REQUIRED UNDER DIVISION (B) OF THIS SECTION: 5,450
(1) CONTINUATION NEED NOT INCLUDE ANY SUPPLEMENTAL HEALTH 5,452
CARE SERVICES BENEFITS OR SPECIALTY HEALTH CARE SERVICES BENEFITS 5,453
PROVIDED BY THE GROUP CONTRACT. 5,454
(2) THE EMPLOYER SHALL NOTIFY THE EMPLOYEE OF THE RIGHT OF 5,457
CONTINUATION AT THE TIME THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,458
THE TERMINATION OF EMPLOYMENT. THE NOTICE SHALL INFORM THE
EMPLOYEE OF THE AMOUNT OF CONTRIBUTION REQUIRED BY THE EMPLOYER 5,459
UNDER DIVISION (C)(4) OF THIS SECTION. 5,461
(3) THE EMPLOYEE SHALL FILE A WRITTEN ELECTION OF 5,463
CONTINUATION WITH THE EMPLOYER AND PAY THE EMPLOYER THE FIRST 5,464
CONTRIBUTION REQUIRED UNDER DIVISION (C)(4) OF THIS SECTION. THE 5,466
REQUEST AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER 5,467
THAN THE EARLIER OF ANY OF THE FOLLOWING DATES: 5,468
(a) THIRTY-ONE DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,471
COVERAGE WOULD OTHERWISE TERMINATE; 5,472
(b) TEN DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,475
COVERAGE WOULD OTHERWISE TERMINATE, IF THE EMPLOYER HAS NOTIFIED 5,476
THE EMPLOYEE OF THE RIGHT OF CONTINUATION PRIOR TO THIS DATE; 5,477
(c) TEN DAYS AFTER THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,480
THE RIGHT OF CONTINUATION, IF THE NOTICE IS GIVEN AFTER THE DATE 5,481
ON WHICH THE EMPLOYEE'S COVERAGE WOULD OTHERWISE TERMINATE. 5,482
(4) THE EMPLOYEE MUST PAY TO THE EMPLOYER, ON A MONTHLY 5,484
BASIS, IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED BY THE 5,485
EMPLOYER. THE AMOUNT REQUIRED SHALL NOT EXCEED THE GROUP RATE 5,486
FOR THE INSURANCE BEING CONTINUED UNDER THE POLICY ON THE DUE 5,487
DATE OF EACH PAYMENT. 5,488
(5) THE EMPLOYEE'S PRIVILEGE TO CONTINUE COVERAGE AND THE 5,490
123
COVERAGE UNDER ANY CONTINUATION CEASES IF ANY OF THE FOLLOWING 5,491
OCCURS: 5,492
(a) THE EMPLOYEE CEASES TO BE AN ELIGIBLE EMPLOYEE UNDER 5,494
DIVISION (A)(2)(c) OR (d) OF THIS SECTION; 5,496
(b) A PERIOD OF SIX MONTHS EXPIRES AFTER THE DATE THAT THE 5,499
EMPLOYEE'S COVERAGE UNDER THE GROUP CONTRACT WOULD OTHERWISE HAVE 5,500
TERMINATED BECAUSE OF THE TERMINATION OF EMPLOYMENT; 5,501
(c) THE EMPLOYEE FAILS TO MAKE A TIMELY PAYMENT OF A 5,504
REQUIRED CONTRIBUTION, IN WHICH EVENT THE COVERAGE SHALL CEASE AT 5,505
THE END OF THE COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE; 5,506
(d) THE GROUP CONTRACT IS TERMINATED, OR THE EMPLOYER 5,509
TERMINATES PARTICIPATION UNDER THE CONTRACT, UNLESS THE EMPLOYER 5,510
REPLACES THE COVERAGE BY SIMILAR COVERAGE UNDER ANOTHER CONTRACT 5,511
OR OTHER GROUP HEALTH ARRANGEMENT. IF THE EMPLOYER REPLACES THE 5,512
CONTRACT WITH SIMILAR GROUP HEALTH COVERAGE, ALL OF THE FOLLOWING 5,513
APPLY:
(i) THE MEMBER SHALL BE COVERED UNDER THE REPLACEMENT 5,516
COVERAGE, FOR THE BALANCE OF THE PERIOD THAT THE MEMBER WOULD 5,517
HAVE REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT 5,518
BEEN TERMINATED.
(ii) THE MINIMUM LEVEL OF BENEFITS UNDER THE REPLACEMENT 5,521
COVERAGE SHALL BE THE APPLICABLE LEVEL OF BENEFITS OF THE 5,522
CONTRACT REPLACED REDUCED BY ANY BENEFITS PAYABLE UNDER THE 5,523
CONTRACT REPLACED.
(iii) THE CONTRACT REPLACED SHALL CONTINUE TO PROVIDE 5,526
BENEFITS TO THE EXTENT OF ITS ACCRUED LIABILITIES AND EXTENSIONS 5,527
OF BENEFITS AS IF THE REPLACEMENT HAD NOT OCCURRED. 5,528
(D) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,531
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,532
HEALTH CARE SERVICES.
Sec. 1751.54. (A) AS USED IN THIS SECTION: 5,534
(1) "ELIGIBLE PERSON" MEANS ANY PERSON WHO, AT THE TIME A 5,536
RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, IS COVERED UNDER A 5,538
GROUP CONTRACT AND IS EITHER OF THE FOLLOWING:
124
(a) AN EMPLOYEE WHO IS A RESERVIST CALLED OR ORDERED TO 5,541
ACTIVE DUTY;
(b) THE SPOUSE OR A DEPENDENT CHILD OF AN EMPLOYEE 5,544
DESCRIBED IN DIVISION (A)(1)(a) OF THIS SECTION. 5,545
(2) "GROUP CONTRACT" INCLUDES ANY GROUP HEALTH INSURING 5,547
CORPORATION CONTRACT THAT SATISFIES ALL OF THE FOLLOWING: 5,548
(a) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,551
RENEWED IN THIS STATE ON OR AFTER THE EFFECTIVE DATE OF THIS 5,552
SECTION.
(b) THE CONTRACT COVERS EMPLOYEES FOR HEALTH CARE 5,555
SERVICES, INCLUDING BASIC HEALTH CARE SERVICES. 5,556
(c) THE CONTRACT IS IN EFFECT AND COVERS AN ELIGIBLE 5,559
PERSON AT THE TIME A RESERVIST IS CALLED OR ORDERED TO ACTIVE 5,560
DUTY.
(3) "RESERVIST" MEANS A MEMBER OF A RESERVE COMPONENT OF 5,562
THE ARMED FORCES OF THE UNITED STATES. "RESERVIST" INCLUDES A 5,564
MEMBER OF THE OHIO NATIONAL GUARD AND THE OHIO AIR NATIONAL 5,566
GUARD. 5,567
(B) EVERY GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,570
PERSON MAY CONTINUE THE COVERAGE UNDER THE CONTRACT FOR A PERIOD 5,571
OF EIGHTEEN MONTHS AFTER THE DATE ON WHICH THE COVERAGE WOULD 5,572
OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR ORDERED TO 5,573
ACTIVE DUTY.
(C)(1) AN ELIGIBLE PERSON MAY EXTEND THE EIGHTEEN-MONTH 5,576
PERIOD OF CONTINUATION OF COVERAGE TO A THIRTY-SIX-MONTH PERIOD 5,577
OF CONTINUATION OF COVERAGE, IF ANY OF THE FOLLOWING OCCURS 5,578
DURING THE EIGHTEEN-MONTH PERIOD: 5,579
(a) THE DEATH OF THE RESERVIST; 5,582
(b) THE DIVORCE OR SEPARATION OF A RESERVIST FROM THE 5,585
RESERVIST'S SPOUSE;
(c) THE CESSATION OF DEPENDENCY OF A CHILD PURSUANT TO THE 5,588
TERMS OF THE CONTRACT. 5,589
(2) THE THIRTY-SIX-MONTH PERIOD OF CONTINUATION OF 5,591
COVERAGE IS DEEMED TO BEGIN ON THE DATE ON WHICH THE COVERAGE 5,592
125
WOULD OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR 5,593
ORDERED TO ACTIVE DUTY. 5,594
(3) THE EMPLOYER MAY BEGIN THE THIRTY-SIX-MONTH PERIOD ON 5,596
THE DATE OF ANY OCCURRENCE DESCRIBED IN DIVISION (C)(1) OF THIS 5,598
SECTION.
(D) ALL OF THE FOLLOWING APPLY TO ANY CONTINUATION OF 5,601
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,602
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION: 5,604
(1) THE CONTINUATION OF COVERAGE SHALL PROVIDE THE SAME 5,606
BENEFITS AS THOSE PROVIDED TO ANY SIMILARLY SITUATED ELIGIBLE 5,607
PERSON WHO IS COVERED UNDER THE SAME GROUP CONTRACT AND AN 5,608
EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE DUTY. 5,610
(2) AN EMPLOYER SHALL NOTIFY EACH EMPLOYEE OF THE RIGHT OF 5,613
CONTINUATION OF COVERAGE AT THE TIME OF EMPLOYMENT. AT THE TIME 5,614
THE RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, THE EMPLOYER 5,615
SHALL NOTIFY EACH ELIGIBLE PERSON OF THE REQUIREMENTS FOR THE 5,616
CONTINUATION OF COVERAGE.
(3) EACH CERTIFICATE OF COVERAGE ISSUED BY A HEALTH 5,618
INSURING CORPORATION TO AN EMPLOYEE UNDER THE GROUP CONTRACT 5,619
SHALL INCLUDE A NOTICE OF THE ELIGIBLE PERSON'S RIGHT OF 5,620
CONTINUATION OF COVERAGE. 5,621
(4) AN ELIGIBLE PERSON SHALL FILE A WRITTEN ELECTION OF 5,623
CONTINUATION OF COVERAGE WITH THE EMPLOYER AND PAY THE EMPLOYER 5,624
THE FIRST CONTRIBUTION REQUIRED UNDER DIVISION (D)(5) OF THIS 5,626
SECTION. THE WRITTEN ELECTION AND PAYMENT MUST BE RECEIVED BY 5,627
THE EMPLOYER NO LATER THAN THIRTY-ONE DAYS AFTER THE DATE ON 5,628
WHICH THE ELIGIBLE PERSON'S COVERAGE WOULD OTHERWISE TERMINATE. 5,629
IF THE EMPLOYER NOTIFIES THE ELIGIBLE PERSON OF THE RIGHT OF 5,630
CONTINUATION OF COVERAGE AFTER THE DATE ON WHICH THE ELIGIBLE 5,631
PERSON'S COVERAGE WOULD OTHERWISE TERMINATE, THE WRITTEN ELECTION 5,632
AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER THAN 5,633
THIRTY-ONE DAYS AFTER THE DATE OF THE NOTIFICATION. 5,634
(5)(a) EXCEPT AS PROVIDED IN DIVISION (D)(5)(b) OF THIS 5,637
SECTION, THE ELIGIBLE PERSON SHALL PAY TO THE EMPLOYER, ON A 5,638
126
MONTHLY BASIS AND IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED 5,639
BY THE EMPLOYER. THE AMOUNT SHALL NOT EXCEED ONE HUNDRED TWO PER 5,640
CENT OF THE GROUP RATE FOR THE COVERAGE BEING CONTINUED UNDER THE 5,641
GROUP CONTRACT ON THE DUE DATE OF EACH PAYMENT. 5,642
(b) THE EMPLOYER MAY PAY A PORTION OR ALL OF THE ELIGIBLE 5,645
PERSON'S CONTRIBUTION.
(E) THE ELIGIBLE PERSON'S RIGHT TO ANY CONTINUATION OF 5,648
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,649
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION CEASES ON THE 5,652
DATE ON WHICH ANY OF THE FOLLOWING OCCURS:
(1) THE ELIGIBLE PERSON, WHETHER AS AN EMPLOYEE OR 5,654
OTHERWISE, BECOMES COVERED BY ANOTHER GROUP CONTRACT OR OTHER 5,655
GROUP HEALTH PLAN OR ARRANGEMENT THAT DOES NOT CONTAIN ANY 5,656
EXCLUSION OR LIMITATION WITH RESPECT TO ANY PREEXISTING CONDITION 5,658
OF THAT ELIGIBLE PERSON. FOR PURPOSES OF DIVISION (E)(1) OF THIS 5,659
SECTION, A GROUP CONTRACT OR OTHER GROUP HEALTH PLAN OR 5,660
ARRANGEMENT DOES NOT INCLUDE THE CIVILIAN HEALTH AND MEDICAL 5,661
PROGRAM OF THE UNIFORMED SERVICES AS DEFINED IN PUBLIC LAW 5,663
99-661, 100 STAT. 3898 (1986), 10 U.S.C.A. 1072. 5,665
(2) THE PERIOD OF EITHER EIGHTEEN MONTHS PROVIDED UNDER 5,667
DIVISION (B) OF THIS SECTION OR THIRTY-SIX MONTHS PROVIDED UNDER 5,669
DIVISION (C) OF THIS SECTION EXPIRES. 5,671
(3) THE ELIGIBLE PERSON FAILS TO MAKE A TIMELY PAYMENT OF 5,673
A REQUIRED CONTRIBUTION, IN WHICH CASE THE COVERAGE CEASES AT THE 5,675
END OF THE PERIOD OF COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE. 5,676
(4) THE GROUP CONTRACT, OR PARTICIPATION UNDER THE GROUP 5,678
CONTRACT, IS TERMINATED, UNLESS THE EMPLOYER, IN ACCORDANCE WITH 5,679
DIVISION (F) OF THIS SECTION, REPLACES THE COVERAGE WITH SIMILAR 5,681
COVERAGE UNDER ANOTHER GROUP CONTRACT OR OTHER GROUP HEALTH PLAN 5,682
OR ARRANGEMENT.
(F) IF THE EMPLOYER REPLACES THE GROUP CONTRACT WITH 5,685
SIMILAR COVERAGE AS DESCRIBED IN DIVISION (E)(4) OF THIS SECTION, 5,687
BOTH OF THE FOLLOWING APPLY:
(1) THE ELIGIBLE PERSON IS COVERED UNDER THE REPLACEMENT 5,689
127
COVERAGE FOR THE BALANCE OF THE PERIOD THAT THE PERSON WOULD HAVE 5,691
REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT BEEN 5,692
TERMINATED.
(2) THE LEVEL OF BENEFITS UNDER THE REPLACEMENT COVERAGE 5,694
IS THE SAME AS THE LEVEL OF BENEFITS PROVIDED TO ANY SIMILARLY 5,695
SITUATED ELIGIBLE PERSON WHO IS COVERED UNDER THE GROUP CONTRACT 5,696
AND AN EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE 5,697
DUTY. 5,698
(G) UPON THE RESERVIST'S RELEASE FROM ACTIVE DUTY AND THE 5,701
RESERVIST'S RETURN TO EMPLOYMENT FOR THE EMPLOYER BY WHOM THE 5,702
RESERVIST WAS EMPLOYED AT THE TIME THE RESERVIST WAS CALLED OR 5,703
ORDERED TO ACTIVE DUTY, BOTH OF THE FOLLOWING APPLY: 5,704
(1) EVERY ELIGIBLE PERSON IS ENTITLED, WITHOUT ANY WAITING 5,707
PERIOD, TO COVERAGE UNDER THE EMPLOYER'S GROUP CONTRACT THAT IS 5,708
IN EFFECT AT THE TIME OF THE RESERVIST'S RETURN TO EMPLOYMENT. 5,709
(2) EVERY ELIGIBLE PERSON IS ENTITLED TO ALL BENEFITS 5,711
UNDER THE GROUP CONTRACT DESCRIBED IN DIVISION (G)(1) OF THIS 5,713
SECTION FROM THE DATE OF THE ORIGINAL COVERAGE UNDER THE 5,714
CONTRACT.
(H)(1) NO HEALTH INSURING CORPORATION SHALL FAIL TO 5,717
PROVIDE FOR A CONTINUATION OF COVERAGE, OR AN EXTENSION OF A 5,718
CONTINUATION OF COVERAGE, IN A GROUP CONTRACT AS REQUIRED BY AND 5,719
IN ACCORDANCE WITH THE TERMS AND CONDITIONS SET FORTH UNDER THIS 5,720
SECTION.
(2) NO HEALTH INSURING CORPORATION SHALL FAIL TO ISSUE A 5,722
CERTIFICATE OF COVERAGE IN COMPLIANCE WITH DIVISION (D)(3) OF 5,724
THIS SECTION.
(3) NO EMPLOYER SHALL FAIL TO PROVIDE AN EMPLOYEE OR 5,726
ELIGIBLE PERSON WITH NOTICE OF THE RIGHT TO A CONTINUATION OF 5,727
COVERAGE UNDER A GROUP CONTRACT IN ACCORDANCE WITH DIVISION 5,729
(D)(2) OF THIS SECTION.
(I) WHOEVER VIOLATES DIVISION (H)(1), (2), OR (3) OF THIS 5,733
SECTION IS DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT 5,734
OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 5,735
128
TO 3901.26 OF THE REVISED CODE. 5,736
(J) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT THAT 5,739
IS SUBJECT TO SECTION 5923.051 OF THE REVISED CODE. 5,741
(K) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,744
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,745
HEALTH CARE SERVICES.
Sec. 1751.55. A HEALTH INSURING CORPORATION POLICY, 5,747
CONTRACT, OR AGREEMENT SHALL NOT BE CONSTRUED TO EXCLUDE ILLNESS 5,748
OR INJURY UPON THE GROUND THAT THE SUBSCRIBER MIGHT HAVE ELECTED 5,749
TO HAVE SUCH ILLNESS OR INJURY COVERED BY WORKERS' COMPENSATION 5,750
UNDER DIVISION (A)(3) OF SECTION 4123.01 OF THE REVISED CODE 5,753
UNLESS THE POLICY, CONTRACT, OR AGREEMENT CLEARLY EXCLUDES WORK 5,754
OR OCCUPATIONAL RELATED ILLNESS OR INJURY, OR THE POLICY, 5,755
CONTRACT, OR AGREEMENT, OR A SEPARATE WRITING SIGNED BY THE 5,756
SUBSCRIBER, INFORMS THE SUBSCRIBER THAT SUCH COVERAGE IS EXCLUDED 5,757
AND MAY BE AVAILABLE TO THE SUBSCRIBER UNDER WORKERS' 5,758
COMPENSATION AS THE SOLE PROPRIETOR OF A BUSINESS, A MEMBER OF A 5,759
PARTNERSHIP, OR AN OFFICER OF A FAMILY FARM CORPORATION. 5,760
Sec. 1751.56. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,763
CORPORATION POLICY, CONTRACT, OR AGREEMENT SHALL BE DELIVERED, 5,764
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE, IF THE POLICY, 5,765
CONTRACT, OR AGREEMENT EXCLUDES OR REDUCES THE BENEFITS PAYABLE 5,766
TO OR ON BEHALF OF AN INSURED BECAUSE BENEFITS ARE ALSO PAYABLE 5,767
OR HAVE BEEN PAID UNDER A SUPPLEMENTAL SICKNESS AND ACCIDENT 5,768
INSURANCE POLICY TO WHICH ALL OF THE FOLLOWING APPLY: 5,769
(1) THE POLICY COVERS A SPECIFIED DISEASE OR A LIMITED 5,771
PLAN OF COVERAGE. 5,772
(2) THE POLICY IS SPECIFICALLY DESIGNED, ADVERTISED, 5,774
REPRESENTED, AND SOLD AS A SUPPLEMENT TO OTHER BASIC SICKNESS AND 5,776
ACCIDENT INSURANCE COVERAGE.
(3) THE ENTIRE PREMIUM FOR THE POLICY IS PAID BY THE 5,778
INSURED, THE INSURED'S FAMILY, OR THE INSURED'S GUARDIAN. 5,779
(B) THIS SECTION APPLIES TO SUPPLEMENTAL SICKNESS AND 5,782
ACCIDENT INSURANCE POLICIES IRRESPECTIVE OF THE MODE OR CHANNEL 5,783
129
OF PREMIUM PAYMENT TO THE INSURER OR OF ANY REDUCTION IN THE 5,784
PREMIUM BY VIRTUE OF THE INSURED'S MEMBERSHIP IN ANY HEALTH 5,785
INSURING CORPORATION OR THE INSURED'S STATUS AS AN EMPLOYEE. 5,786
Sec. 1751.59. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,789
CORPORATION POLICY, CONTRACT, OR AGREEMENT PROVIDING FAMILY 5,790
COVERAGE MAY BE DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 5,791
THIS STATE, UNLESS THE POLICY, CONTRACT, OR AGREEMENT COVERS 5,792
ADOPTED CHILDREN OF THE SUBSCRIBER ON THE SAME BASIS AS OTHER 5,793
DEPENDENTS.
(B) THE COVERAGE REQUIRED BY THIS SECTION IS SUBJECT TO 5,796
THE REQUIREMENTS AND RESTRICTIONS SET FORTH IN SECTION 3924.51 OF 5,797
THE REVISED CODE. COVERAGE FOR DEPENDENT CHILDREN LIVING OUTSIDE 5,800
THE HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA MUST BE 5,801
PROVIDED IF A COURT ORDER REQUIRES THE SUBSCRIBER TO PROVIDE 5,802
HEALTH CARE COVERAGE.
Sec. 1751.60. (A) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) 5,805
AND (F) OF THIS SECTION, EVERY PROVIDER OR HEALTH CARE FACILITY 5,807
THAT CONTRACTS WITH A HEALTH INSURING CORPORATION TO PROVIDE 5,808
HEALTH CARE SERVICES TO THE HEALTH INSURING CORPORATION'S 5,809
ENROLLEES OR SUBSCRIBERS SHALL SEEK COMPENSATION FOR COVERED 5,810
SERVICES SOLELY FROM THE HEALTH INSURING CORPORATION AND NOT, 5,811
UNDER ANY CIRCUMSTANCES, FROM THE ENROLLEES OR SUBSCRIBERS, 5,812
EXCEPT FOR APPROVED DEDUCTIBLES AND COPAYMENTS. 5,813
(B) NO SUBSCRIBER OR ENROLLEE OF A HEALTH INSURING 5,816
CORPORATION IS LIABLE TO ANY CONTRACTING PROVIDER OR HEALTH CARE 5,817
FACILITY FOR THE COST OF ANY COVERED HEALTH CARE SERVICES, IF THE 5,818
SUBSCRIBER OR ENROLLEE HAS ACTED IN ACCORDANCE WITH THE EVIDENCE 5,819
OF COVERAGE.
(C) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) AND (F) OF 5,823
THIS SECTION, EVERY CONTRACT BETWEEN A HEALTH INSURING 5,824
CORPORATION AND PROVIDER OR HEALTH CARE FACILITY SHALL CONTAIN A 5,825
PROVISION APPROVED BY THE SUPERINTENDENT OF INSURANCE REQUIRING 5,826
THE PROVIDER OR HEALTH CARE FACILITY TO SEEK COMPENSATION SOLELY 5,827
FROM THE HEALTH INSURING CORPORATION AND NOT, UNDER ANY 5,828
130
CIRCUMSTANCES, FROM THE SUBSCRIBER OR ENROLLEE, EXCEPT FOR 5,829
APPROVED DEDUCTIBLES AND COPAYMENTS. 5,830
(D) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 5,833
PREVENTING A PROVIDER OR HEALTH CARE FACILITY FROM BILLING THE 5,834
ENROLLEE OR SUBSCRIBER OF A HEALTH INSURING CORPORATION FOR 5,835
NONCOVERED SERVICES.
(E) UPON APPLICATION BY A HEALTH INSURING CORPORATION AND 5,838
A PROVIDER OR HEALTH CARE FACILITY, THE SUPERINTENDENT MAY WAIVE 5,839
THE REQUIREMENTS OF DIVISIONS (A) AND (C) OF THIS SECTION WHEN, 5,841
IN ADDITION TO THE RESERVE REQUIREMENTS CONTAINED IN SECTION 5,842
1751.28 OF THE REVISED CODE, THE HEALTH INSURING CORPORATION 5,845
PROVIDES SUFFICIENT ASSURANCES TO THE SUPERINTENDENT THAT THE 5,846
PROVIDER OR HEALTH CARE FACILITY HAS BEEN PROVIDED WITH FINANCIAL 5,847
GUARANTEES. NO WAIVER OF THE REQUIREMENTS OF DIVISIONS (A) AND 5,849
(C) OF THIS SECTION IS EFFECTIVE AS TO ENROLLEES OR SUBSCRIBERS 5,850
FOR WHOM THE HEALTH INSURING CORPORATION IS COMPENSATED UNDER A 5,851
PROVIDER AGREEMENT OR RISK CONTRACT ENTERED INTO PURSUANT TO 5,853
CHAPTER 5111. OR 5115. OF THE REVISED CODE. 5,855
(F) THE REQUIREMENTS OF DIVISIONS (A) TO (C) OF THIS 5,859
SECTION APPLY ONLY TO HEALTH CARE SERVICES PROVIDED TO AN 5,860
ENROLLEE OR SUBSCRIBER PRIOR TO THE EFFECTIVE DATE OF A 5,861
TERMINATION OF A CONTRACT BETWEEN THE HEALTH INSURING CORPORATION 5,862
AND THE PROVIDER OR HEALTH CARE FACILITY. 5,863
Sec. 1751.61. (A) EACH INDIVIDUAL OR GROUP EVIDENCE OF 5,866
COVERAGE THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED BY A 5,867
HEALTH INSURING CORPORATION IN THIS STATE, AND THAT PROVIDES 5,868
COVERAGE FOR FAMILY MEMBERS OF A SUBSCRIBER, ALSO SHALL PROVIDE 5,869
THAT COVERAGE APPLICABLE TO CHILDREN IS PAYABLE FROM THE MOMENT 5,870
OF BIRTH WITH RESPECT TO A NEWLY BORN CHILD OF THE SUBSCRIBER OR 5,871
SUBSCRIBER'S SPOUSE. 5,872
(B) COVERAGE FOR A NEWLY BORN CHILD IS EFFECTIVE FOR A 5,875
PERIOD OF THIRTY-ONE DAYS FROM THE DATE OF BIRTH. 5,876
(C) TO CONTINUE COVERAGE FOR A NEWLY BORN CHILD BEYOND THE 5,879
THIRTY-ONE DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION, 5,881
131
THE SUBSCRIBER SHALL NOTIFY THE HEALTH INSURING CORPORATION 5,882
WITHIN THAT PERIOD.
(D) IF PAYMENT OF A SPECIFIC PREMIUM RATE IS REQUIRED TO 5,885
PROVIDE COVERAGE UNDER THIS SECTION FOR AN ADDITIONAL CHILD, THE 5,886
EVIDENCE OF COVERAGE MAY REQUIRE THE SUBSCRIBER TO MAKE THIS 5,887
PAYMENT TO THE HEALTH INSURING CORPORATION WITHIN THE THIRTY-ONE 5,888
DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION IN ORDER TO 5,890
CONTINUE THE COVERAGE BEYOND THAT PERIOD. 5,891
Sec. 1751.62. (A) AS USED IN THIS SECTION, "SCREENING 5,894
MAMMOGRAPHY" MEANS A RADIOLOGIC EXAMINATION UTILIZED TO DETECT 5,895
UNSUSPECTED BREAST CANCER AT AN EARLY STAGE IN AN ASYMPTOMATIC 5,896
WOMAN AND INCLUDES THE X-RAY EXAMINATION OF THE BREAST USING 5,897
EQUIPMENT THAT IS DEDICATED SPECIFICALLY FOR MAMMOGRAPHY, 5,898
INCLUDING THE X-RAY TUBE, FILTER, COMPRESSION DEVICE, SCREENS, 5,899
FILM, AND CASSETTES, AND THAT HAS AN AVERAGE RADIATION EXPOSURE 5,900
DELIVERY OF LESS THAN ONE RAD MID-BREAST. "SCREENING 5,901
MAMMOGRAPHY" INCLUDES TWO VIEWS FOR EACH BREAST. THE TERM ALSO 5,902
INCLUDES THE PROFESSIONAL INTERPRETATION OF THE FILM. 5,903
"SCREENING MAMMOGRAPHY" DOES NOT INCLUDE DIAGNOSTIC 5,905
MAMMOGRAPHY. 5,906
(B) EVERY INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION 5,909
POLICY, CONTRACT, OR AGREEMENT PROVIDING BASIC HEALTH CARE 5,910
SERVICES THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 5,911
THIS STATE SHALL PROVIDE BENEFITS FOR THE EXPENSES OF BOTH OF THE 5,912
FOLLOWING: 5,913
(1) SCREENING MAMMOGRAPHY TO DETECT THE PRESENCE OF BREAST 5,916
CANCER IN ADULT WOMEN;
(2) CYTOLOGIC SCREENING FOR THE PRESENCE OF CERVICAL 5,918
CANCER. 5,919
(C) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 5,923
SECTION SHALL COVER EXPENSES IN ACCORDANCE WITH ALL OF THE 5,924
FOLLOWING:
(1) IF A WOMAN IS AT LEAST THIRTY-FIVE YEARS OF AGE BUT 5,926
UNDER FORTY YEARS OF AGE, ONE SCREENING MAMMOGRAPHY; 5,927
132
(2) IF A WOMAN IS AT LEAST FORTY YEARS OF AGE BUT UNDER 5,929
FIFTY YEARS OF AGE, EITHER OF THE FOLLOWING: 5,930
(a) ONE SCREENING MAMMOGRAPHY EVERY TWO YEARS; 5,933
(b) IF A LICENSED PHYSICIAN HAS DETERMINED THAT THE WOMAN 5,936
HAS RISK FACTORS TO BREAST CANCER, ONE SCREENING MAMMOGRAPHY 5,937
EVERY YEAR.
(3) IF A WOMAN IS AT LEAST FIFTY YEARS OF AGE BUT UNDER 5,939
SIXTY-FIVE YEARS OF AGE, ONE SCREENING MAMMOGRAPHY EVERY YEAR. 5,941
(D)(1) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 5,945
SECTION SHALL NOT EXCEED EIGHTY-FIVE DOLLARS PER YEAR UNLESS A 5,946
LOWER AMOUNT IS ESTABLISHED PURSUANT TO A PROVIDER CONTRACT. 5,947
(2) THE BENEFIT PAID IN ACCORDANCE WITH DIVISION (D)(1) OF 5,950
THIS SECTION SHALL CONSTITUTE FULL PAYMENT. NO INSTITUTIONAL OR 5,951
PROFESSIONAL HEALTH CARE PROVIDER SHALL SEEK OR RECEIVE 5,952
REMUNERATION IN EXCESS OF THE PAYMENT MADE IN ACCORDANCE WITH 5,953
DIVISION (D)(1) OF THIS SECTION, EXCEPT FOR APPROVED DEDUCTIBLES 5,955
AND COPAYMENTS.
(E) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 5,959
SECTION SHALL BE PROVIDED ONLY FOR SCREENING MAMMOGRAPHIES THAT 5,960
ARE PERFORMED IN A HEALTH CARE FACILITY OR MOBILE MAMMOGRAPHY 5,961
SCREENING UNIT THAT IS ACCREDITED UNDER THE AMERICAN COLLEGE OF 5,962
RADIOLOGY MAMMOGRAPHY ACCREDITATION PROGRAM OR IN A HOSPITAL AS 5,963
DEFINED IN SECTION 3727.01 OF THE REVISED CODE. 5,965
(F) THE BENEFITS PROVIDED UNDER DIVISIONS (B)(1) AND (2) 5,969
OF THIS SECTION SHALL BE PROVIDED ACCORDING TO THE TERMS OF THE 5,970
SUBSCRIBER CONTRACT.
(G) THE BENEFITS PROVIDED UNDER DIVISION (B)(2) OF THIS 5,974
SECTION SHALL BE PROVIDED ONLY FOR CYTOLOGIC SCREENINGS THAT ARE 5,975
PROCESSED AND INTERPRETED IN A LABORATORY CERTIFIED BY THE 5,976
COLLEGE OF AMERICAN PATHOLOGISTS OR IN A HOSPITAL AS DEFINED IN 5,977
SECTION 3727.01 OF THE REVISED CODE. 5,979
Sec. 1751.63. SECTIONS 3923.41 TO 3923.48 OF THE REVISED 5,982
CODE APPLY TO EVERY HEALTH INSURING CORPORATION THAT OFFERS 5,983
LONG-TERM CARE AND THAT HOLDS A CERTIFICATE OF AUTHORITY UNDER 5,984
133
THIS CHAPTER.
Sec. 1751.64. (A) AS USED IN THIS SECTION, "GENETIC 5,987
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 5,988
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 5,989
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 5,990
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 5,991
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 5,992
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 5,993
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 5,994
DISORDERS.
(B) NO HEALTH INSURING CORPORATION, IN PROCESSING AN 5,997
APPLICATION FOR COVERAGE FOR HEALTH CARE SERVICES UNDER AN 5,998
INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, CONTRACT, 5,999
OR AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,000
CONTRACT, OR AGREEMENT, SHALL DO ANY OF THE FOLLOWING: 6,001
(1) REQUIRE AN INDIVIDUAL SEEKING COVERAGE TO SUBMIT TO 6,003
GENETIC SCREENING OR TESTING; 6,004
(2) TAKE INTO CONSIDERATION, OTHER THAN IN ACCORDANCE WITH 6,007
DIVISION (F) OF THIS SECTION, THE RESULTS OF GENETIC SCREENING OR 6,008
TESTING;
(3) MAKE ANY INQUIRY TO DETERMINE THE RESULTS OF GENETIC 6,010
SCREENING OR TESTING; 6,011
(4) MAKE A DECISION ADVERSE TO THE APPLICANT BASED ON 6,013
ENTRIES IN MEDICAL RECORDS OR OTHER REPORTS OF GENETIC SCREENING 6,014
OR TESTING. 6,015
(C) IN DEVELOPING AND ASKING QUESTIONS REGARDING MEDICAL 6,018
HISTORIES OF APPLICANTS FOR COVERAGE UNDER AN INDIVIDUAL OR GROUP 6,019
HEALTH INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT, NO 6,020
HEALTH INSURING CORPORATION SHALL ASK FOR THE RESULTS OF GENETIC 6,021
SCREENING OR TESTING OR ASK QUESTIONS DESIGNED TO ASCERTAIN THE 6,022
RESULTS OF GENETIC SCREENING OR TESTING. 6,023
(D) NO HEALTH INSURING CORPORATION SHALL CANCEL OR REFUSE 6,026
TO ISSUE OR RENEW COVERAGE FOR HEALTH CARE SERVICES BASED ON THE 6,027
RESULTS OF GENETIC SCREENING OR TESTING. 6,028
134
(E) NO HEALTH INSURING CORPORATION SHALL DELIVER, ISSUE 6,031
FOR DELIVERY, OR RENEW AN INDIVIDUAL OR GROUP POLICY, CONTRACT, 6,032
OR AGREEMENT IN THIS STATE THAT LIMITS BENEFITS BASED ON THE 6,033
RESULTS OF GENETIC SCREENING OR TESTING. 6,034
(F) A HEALTH INSURING CORPORATION MAY CONSIDER THE RESULTS 6,037
OF GENETIC SCREENING OR TESTING IF THE RESULTS ARE VOLUNTARILY 6,038
SUBMITTED BY AN APPLICANT FOR COVERAGE OR RENEWAL OF COVERAGE AND 6,039
THE RESULTS ARE FAVORABLE TO THE APPLICANT. 6,040
(G) A VIOLATION OF THIS SECTION IS AN UNFAIR AND DECEPTIVE 6,043
ACT OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 6,044
3901.19 TO 3901.26 OF THE REVISED CODE. 6,046
Sec. 1751.65. (A) AS USED IN THIS SECTION, "GENETIC 6,049
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 6,050
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 6,051
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 6,052
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 6,053
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 6,054
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 6,055
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 6,056
DISORDERS. 6,057
(B) UPON THE REPEAL OF SECTION 1751.64 OF THE REVISED 6,061
CODE, NO HEALTH INSURING CORPORATION SHALL DO EITHER OF THE 6,062
FOLLOWING:
(1) CONSIDER, IN A MANNER ADVERSE TO AN APPLICANT OR 6,064
INSURED, ANY INFORMATION OBTAINED FROM GENETIC SCREENING OR 6,065
TESTING CONDUCTED PRIOR TO THE REPEAL OF SECTION 1751.64 OF THE 6,067
REVISED CODE IN PROCESSING AN APPLICATION FOR COVERAGE FOR HEALTH 6,069
CARE SERVICES UNDER AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,070
AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,071
CONTRACT, OR AGREEMENT; 6,072
(2) INQUIRE, DIRECTLY OR INDIRECTLY, INTO THE RESULTS OF 6,074
GENETIC SCREENING OR TESTING CONDUCTED PRIOR TO THE REPEAL OF 6,075
SECTION 1751.64 OF THE REVISED CODE, OR USE SUCH INFORMATION, IN 6,078
WHOLE OR IN PART, TO CANCEL, REFUSE TO ISSUE OR RENEW, OR LIMIT 6,079
135
BENEFITS UNDER, AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,080
AGREEMENT.
(C) ANY HEALTH INSURING CORPORATION THAT HAS ENGAGED IN, 6,083
IS ENGAGED IN, OR IS ABOUT TO ENGAGE IN A VIOLATION OF DIVISION 6,085
(B) OF THIS SECTION IS SUBJECT TO THE JURISDICTION OF THE 6,086
SUPERINTENDENT OF INSURANCE UNDER SECTION 3901.04 OF THE REVISED 6,087
CODE.
Sec. 1751.66. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 6,090
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES COVERAGE 6,091
FOR PRESCRIPTION DRUGS SHALL LIMIT OR EXCLUDE COVERAGE FOR ANY 6,092
DRUG APPROVED BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION 6,093
ON THE BASIS THAT THE DRUG HAS NOT BEEN APPROVED BY THE UNITED 6,094
STATES FOOD AND DRUG ADMINISTRATION FOR THE TREATMENT OF THE 6,095
PARTICULAR INDICATION FOR WHICH THE DRUG HAS BEEN PRESCRIBED, 6,096
PROVIDED THE DRUG HAS BEEN RECOGNIZED AS SAFE AND EFFECTIVE FOR 6,097
TREATMENT OF THAT INDICATION IN ONE OR MORE OF THE STANDARD 6,098
MEDICAL REFERENCE COMPENDIA SPECIFIED IN DIVISION (B)(1) OF THIS 6,100
SECTION OR IN MEDICAL LITERATURE THAT MEETS THE CRITERIA 6,101
SPECIFIED IN DIVISION (B)(2) OF THIS SECTION. 6,102
(B)(1) THE COMPENDIA ACCEPTED FOR PURPOSES OF DIVISION (A) 6,105
OF THIS SECTION ARE THE FOLLOWING:
(a) THE "AMA DRUG EVALUATIONS," A PUBLICATION OF THE 6,108
AMERICAN MEDICAL ASSOCIATION;
(b) THE "AHFS (AMERICAN HOSPITAL FORMULARY SERVICE) DRUG 6,111
INFORMATION," A PUBLICATION OF THE AMERICAN SOCIETY OF HEALTH 6,112
SYSTEM PHARMACISTS;
(c) "DRUG INFORMATION FOR THE HEALTH CARE PROVIDER," A 6,115
PUBLICATION OF THE UNITED STATES PHARMACOPOEIA CONVENTION. 6,116
(2) MEDICAL LITERATURE MAY BE ACCEPTED FOR PURPOSES OF 6,118
DIVISION (A) OF THIS SECTION ONLY IF ALL OF THE FOLLOWING APPLY: 6,120
(a) TWO ARTICLES FROM MAJOR PEER-REVIEWED PROFESSIONAL 6,123
MEDICAL JOURNALS HAVE RECOGNIZED, BASED ON SCIENTIFIC OR MEDICAL 6,124
CRITERIA, THE DRUG'S SAFETY AND EFFECTIVENESS FOR TREATMENT OF 6,125
THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,126
136
(b) NO ARTICLE FROM A MAJOR PEER-REVIEWED PROFESSIONAL 6,129
MEDICAL JOURNAL HAS CONCLUDED, BASED ON SCIENTIFIC OR MEDICAL 6,130
CRITERIA, THAT THE DRUG IS UNSAFE OR INEFFECTIVE OR THAT THE 6,131
DRUG'S SAFETY AND EFFECTIVENESS CANNOT BE DETERMINED FOR THE 6,132
TREATMENT OF THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,133
(c) EACH ARTICLE MEETS THE UNIFORM REQUIREMENTS FOR 6,136
MANUSCRIPTS SUBMITTED TO BIOMEDICAL JOURNALS ESTABLISHED BY THE 6,137
INTERNATIONAL COMMITTEE OF MEDICAL JOURNAL EDITORS OR IS 6,138
PUBLISHED IN A JOURNAL SPECIFIED BY THE UNITED STATES DEPARTMENT 6,139
OF HEALTH AND HUMAN SERVICES PURSUANT TO SECTION 1861(t)(2)(B) OF 6,140
THE "SOCIAL SECURITY ACT," 107 STAT. 591 (1993), 42 U.S.C. 1395 6,143
(x)(t)(2)(B), AS AMENDED, AS ACCEPTED PEER-REVIEWED MEDICAL 6,144
LITERATURE.
(C) COVERAGE OF A DRUG REQUIRED BY DIVISION (A) OF THIS 6,148
SECTION INCLUDES MEDICALLY NECESSARY SERVICES ASSOCIATED WITH THE 6,149
ADMINISTRATION OF THE DRUG.
(D) DIVISION (A) OF THIS SECTION SHALL NOT BE CONSTRUED TO 6,153
DO ANY OF THE FOLLOWING:
(1) REQUIRE COVERAGE FOR ANY DRUG IF THE UNITED STATES 6,157
FOOD AND DRUG ADMINISTRATION HAS DETERMINED ITS USE TO BE 6,158
CONTRAINDICATED FOR THE TREATMENT OF THE PARTICULAR INDICATION 6,159
FOR WHICH THE DRUG HAS BEEN PRESCRIBED; 6,160
(2) REQUIRE COVERAGE FOR EXPERIMENTAL DRUGS NOT APPROVED 6,162
FOR ANY INDICATION BY THE UNITED STATES FOOD AND DRUG 6,165
ADMINISTRATION; 6,166
(3) ALTER ANY LAW WITH REGARD TO PROVISIONS LIMITING THE 6,168
COVERAGE OF DRUGS THAT HAVE NOT BEEN APPROVED BY THE UNITED 6,171
STATES FOOD AND DRUG ADMINISTRATION; 6,172
(4) REQUIRE REIMBURSEMENT OR COVERAGE FOR ANY DRUG NOT 6,174
INCLUDED IN THE DRUG FORMULARY OR LIST OF COVERED DRUGS SPECIFIED 6,176
IN A HEALTH INSURING CORPORATION CONTRACT;
(5) PROHIBIT A HEALTH INSURING CORPORATION FROM LIMITING 6,178
OR EXCLUDING COVERAGE OF A DRUG, PROVIDED THAT THE DECISION TO 6,179
LIMIT OR EXCLUDE COVERAGE OF THE DRUG IS NOT BASED PRIMARILY ON 6,180
137
THE COVERAGE OF DRUGS REQUIRED BY THIS SECTION. 6,181
(E) THIS SECTION APPLIES ONLY TO HEALTH INSURING 6,184
CORPORATION POLICIES, CONTRACTS, AND AGREEMENTS THAT ARE 6,185
DESCRIBED IN DIVISION (A) OF THIS SECTION AND THAT ARE DELIVERED, 6,187
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE ON OR AFTER JULY 1, 6,188
1997.
Sec. 1751.67. (A) EACH INDIVIDUAL OR GROUP HEALTH 6,190
INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT DELIVERED, 6,191
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE THAT PROVIDES 6,192
MATERNITY BENEFITS SHALL PROVIDE COVERAGE OF INPATIENT CARE AND 6,193
FOLLOW-UP CARE FOR A MOTHER AND HER NEWBORN AS FOLLOWS: 6,194
(1) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,196
MINIMUM OF FORTY-EIGHT HOURS OF INPATIENT CARE FOLLOWING A NORMAL 6,197
VAGINAL DELIVERY AND A MINIMUM OF NINETY-SIX HOURS OF INPATIENT 6,198
CARE FOLLOWING A CESAREAN DELIVERY. SERVICES COVERED AS 6,199
INPATIENT CARE SHALL INCLUDE MEDICAL, EDUCATIONAL, AND ANY OTHER 6,200
SERVICES THAT ARE CONSISTENT WITH THE INPATIENT CARE RECOMMENDED 6,201
IN THE PROTOCOLS AND GUIDELINES DEVELOPED BY NATIONAL 6,202
ORGANIZATIONS THAT REPRESENT PEDIATRIC, OBSTETRIC, AND NURSING 6,203
PROFESSIONALS.
(2) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,205
PHYSICIAN-DIRECTED SOURCE OF FOLLOW-UP CARE. SERVICES COVERED AS 6,207
FOLLOW-UP CARE SHALL INCLUDE PHYSICAL ASSESSMENT OF THE MOTHER 6,208
AND NEWBORN, PARENT EDUCATION, ASSISTANCE AND TRAINING IN BREAST 6,209
OR BOTTLE FEEDING, ASSESSMENT OF THE HOME SUPPORT SYSTEM,
PERFORMANCE OF ANY MEDICALLY NECESSARY AND APPROPRIATE CLINICAL 6,210
TESTS, AND ANY OTHER SERVICES THAT ARE CONSISTENT WITH THE 6,211
FOLLOW-UP CARE RECOMMENDED IN THE PROTOCOLS AND GUIDELINES 6,212
DEVELOPED BY NATIONAL ORGANIZATIONS THAT REPRESENT PEDIATRIC, 6,213
OBSTETRIC, AND NURSING PROFESSIONALS. THE COVERAGE SHALL APPLY 6,214
TO SERVICES PROVIDED IN A MEDICAL SETTING OR THROUGH HOME HEALTH 6,215
CARE VISITS. THE COVERAGE SHALL APPLY TO A HOME HEALTH CARE 6,216
VISIT ONLY IF THE PROVIDER WHO CONDUCTS THE VISIT IS 6,217
KNOWLEDGEABLE AND EXPERIENCED IN MATERNITY AND NEWBORN CARE. 6,218
138
WHEN A DECISION IS MADE IN ACCORDANCE WITH DIVISION (B) OF 6,221
THIS SECTION TO DISCHARGE A MOTHER OR NEWBORN PRIOR TO THE
EXPIRATION OF THE APPLICABLE NUMBER OF HOURS OF INPATIENT CARE 6,222
REQUIRED TO BE COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL 6,223
APPLY TO ALL FOLLOW-UP CARE THAT IS PROVIDED WITHIN FORTY-EIGHT 6,224
HOURS AFTER DISCHARGE. WHEN A MOTHER OR NEWBORN RECEIVES AT 6,225
LEAST THE NUMBER OF HOURS OF INPATIENT CARE REQUIRED TO BE 6,226
COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL APPLY TO FOLLOW-UP 6,227
CARE THAT IS DETERMINED TO BE MEDICALLY NECESSARY BY THE PROVIDER 6,229
RESPONSIBLE FOR DISCHARGING THE MOTHER OR NEWBORN.
(B) ANY DECISION TO SHORTEN THE LENGTH OF INPATIENT STAY 6,231
TO LESS THAN THAT SPECIFIED UNDER DIVISION (A)(1) OF THIS SECTION 6,233
SHALL BE MADE BY THE PHYSICIAN ATTENDING THE MOTHER OR NEWBORN, 6,234
EXCEPT THAT IF A NURSE-MIDWIFE IS ATTENDING THE MOTHER IN 6,235
COLLABORATION WITH A PHYSICIAN, THE DECISION MAY BE MADE BY THE 6,236
NURSE-MIDWIFE. DECISIONS REGARDING EARLY DISCHARGE SHALL BE MADE 6,237
ONLY AFTER CONFERRING WITH THE MOTHER OR A PERSON RESPONSIBLE FOR 6,238
THE MOTHER OR NEWBORN. FOR PURPOSES OF THIS DIVISION, A PERSON 6,239
RESPONSIBLE FOR THE MOTHER OR NEWBORN MAY INCLUDE A PARENT, 6,240
GUARDIAN, OR ANY OTHER PERSON WITH AUTHORITY TO MAKE MEDICAL 6,241
DECISIONS FOR THE MOTHER OR NEWBORN.
(C)(1) NO HEALTH INSURING CORPORATION MAY DO EITHER OF THE 6,244
FOLLOWING:
(a) TERMINATE THE PARTICIPATION OF A PROVIDER OR HEALTH 6,246
CARE FACILITY IN AN INDIVIDUAL OR GROUP HEALTH CARE PLAN SOLELY 6,247
FOR MAKING RECOMMENDATIONS FOR INPATIENT OR FOLLOW-UP CARE FOR A 6,248
PARTICULAR MOTHER OR NEWBORN THAT ARE CONSISTENT WITH THE CARE 6,249
REQUIRED TO BE COVERED BY THIS SECTION; 6,250
(b) ESTABLISH OR OFFER MONETARY OR OTHER FINANCIAL 6,252
INCENTIVES FOR THE PURPOSE OF ENCOURAGING A PERSON TO DECLINE THE 6,254
INPATIENT OR FOLLOW-UP CARE REQUIRED TO BE COVERED BY THIS
SECTION. 6,255
(2) WHOEVER VIOLATES DIVISION (C)(1)(a) OR (b) OF THIS 6,258
SECTION HAS ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE IN 6,259
139
THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 6,260
THE REVISED CODE.
(D) THIS SECTION DOES NOT DO ANY OF THE FOLLOWING: 6,262
(1) REQUIRE A POLICY, CONTRACT, OR AGREEMENT TO COVER 6,264
INPATIENT OR FOLLOW-UP CARE THAT IS NOT RECEIVED IN ACCORDANCE 6,265
WITH THE POLICY'S, CONTRACT'S, OR AGREEMENT'S TERMS PERTAINING TO 6,266
THE PROVIDERS AND FACILITIES FROM WHICH AN INDIVIDUAL IS 6,267
AUTHORIZED TO RECEIVE HEALTH CARE SERVICES; 6,268
(2) REQUIRE A MOTHER OR NEWBORN TO STAY IN A HOSPITAL OR 6,270
OTHER INPATIENT SETTING FOR A FIXED PERIOD OF TIME FOLLOWING 6,271
DELIVERY;
(3) REQUIRE A CHILD TO BE DELIVERED IN A HOSPITAL OR OTHER 6,273
INPATIENT SETTING; 6,274
(4) AUTHORIZE A NURSE-MIDWIFE TO PRACTICE BEYOND THE 6,276
AUTHORITY TO PRACTICE NURSE-MIDWIFERY IN ACCORDANCE WITH CHAPTER 6,277
4723. OF THE REVISED CODE; 6,278
(5) ESTABLISH MINIMUM STANDARDS OF MEDICAL DIAGNOSIS, 6,280
CARE, OR TREATMENT FOR INPATIENT OR FOLLOW-UP CARE FOR A MOTHER 6,281
OR NEWBORN. A DEVIATION FROM THE CARE REQUIRED TO BE COVERED 6,282
UNDER THIS SECTION SHALL NOT, SOLELY ON THE BASIS OF THIS 6,283
SECTION, GIVE RISE TO A MEDICAL CLAIM OR TO DERIVATIVE CLAIMS FOR 6,284
RELIEF, AS THOSE TERMS ARE DEFINED IN SECTION 2305.11 OF THE 6,286
REVISED CODE.
Sec. 1751.70. (A) AN EMPLOYEE OF THE STATE, OF ANY 6,289
POLITICAL SUBDIVISION OF THE STATE, OR OF ANY INSTITUTION 6,290
SUPPORTED IN WHOLE OR IN PART BY THE STATE, MAY AUTHORIZE THE 6,291
DEDUCTION FROM THE EMPLOYEE'S SALARY OR WAGES OF THE AMOUNT OF 6,292
THE EMPLOYEE'S PREMIUM RATE TO ANY HEALTH INSURING CORPORATION 6,293
HOLDING A CERTIFICATE OF AUTHORITY PURSUANT TO THIS CHAPTER. THE 6,295
EMPLOYEE'S AUTHORIZATION SHALL BE EVIDENCED BY APPROVAL OF THE 6,296
HEAD OF THE DEPARTMENT, DIVISION, OFFICE, OR INSTITUTION IN WHICH 6,297
THE EMPLOYEE IS EMPLOYED.
(B) IN THE CASE OF EMPLOYEES OF THE STATE, THE EMPLOYEE'S 6,300
AUTHORIZATION SHALL BE DIRECTED TO AND FILED WITH THE DIRECTOR OF 6,301
140
ADMINISTRATIVE SERVICES. IN THE CASE OF EMPLOYEES OF A POLITICAL 6,302
SUBDIVISION, THE EMPLOYEE'S AUTHORIZATION SHALL BE DIRECTED TO 6,303
AND FILED WITH THE FISCAL OFFICER OF SUCH POLITICAL SUBDIVISION. 6,304
IN THE CASE OF EMPLOYEES OF ANY INSTITUTION SUPPORTED IN WHOLE OR 6,305
IN PART BY THE STATE, THE EMPLOYEE'S AUTHORIZATION SHALL BE 6,306
DIRECTED TO AND FILED WITH THE FISCAL OFFICER OF SUCH 6,307
INSTITUTION.
(C) UPON THE FILING OF THE EMPLOYEE'S AUTHORIZATION IN 6,310
ACCORDANCE WITH DIVISION (B) OF THIS SECTION, THE DIRECTOR OR 6,312
FISCAL OFFICER SHALL PROVIDE FOR PAYMENT TO THE HEALTH INSURING 6,313
CORPORATION REFERRED TO IN THE EMPLOYEE'S AUTHORIZATION, FOR THE 6,314
AMOUNT COVERING THE SUM OF THE DEDUCTIONS THEREBY AUTHORIZED. 6,315
Sec. 1751.71. EACH HEALTH INSURING CORPORATION SUBJECT TO 6,317
THIS CHAPTER MAY ACCEPT FROM GOVERNMENTAL AGENCIES, OR FROM 6,318
PRIVATE PERSONS, PAYMENTS COVERING ALL OR PART OF THE COST OF 6,319
POLICIES, CONTRACTS, AND AGREEMENTS ENTERED INTO BETWEEN THE 6,320
HEALTH INSURING CORPORATION AND ITS SUBSCRIBERS OR GROUPS OF 6,321
SUBSCRIBERS.
Sec. 1901.111. (A) As used in this section, "health care 6,330
coverage" means sickness and accident insurance or other coverage 6,331
of hospitalization, surgical care, major medical care, 6,332
disability, dental care, eye care, medical care, hearing aids, 6,333
and prescription drugs, or any combination of those benefits or 6,334
services. 6,335
(B) The legislative authority, after consultation with the 6,337
judges of the municipal court, shall negotiate and contract for, 6,338
purchase, or otherwise procure group health care coverage for the 6,339
judges and their spouses and dependents from insurance companies 6,340
authorized to engage in the business of insurance in this state 6,341
under Title XXXIX of the Revised Code, medical care corporations 6,342
organized under Chapter 1737. of the Revised Code, OR health care 6,344
INSURING corporations organized HOLDING CERTIFICATES OF AUTHORITY 6,345
under Chapter 1738. 1751. of the Revised Code, or health 6,346
maintenance organizations organized under Chapter 1742. of the 6,347
141
Revised Code, except that if the county or municipal corporation 6,348
served by the legislative authority provides group health care 6,349
coverage for its employees, the group health care coverage 6,350
required by this section shall be provided, if possible, through 6,351
the policy or plan under which the group health care coverage is 6,352
provided for the county or municipal corporation employees. 6,353
(C) The portion of the costs, premiums, or charges for the 6,355
group health care coverage procured pursuant to division (B) of 6,356
this section that is not paid by the judges of the municipal 6,357
court, or all of the costs, premiums, or charges for the group 6,358
health care coverage if the judges will not be paying any such 6,359
portion, shall be paid as follows: 6,360
(1) If the municipal court is a county-operated municipal 6,362
court, the portion of the costs, premiums, or charges or all of 6,363
the costs, premiums, or charges shall be paid out of the treasury 6,364
of the county. 6,365
(2) If the municipal court is not a county-operated 6,367
municipal court, the portion of the costs, premiums, or charges 6,368
or all of the costs, premiums, or charges shall be paid in 6,369
three-fifths and two-fifths shares from the city treasury and 6,370
appropriate county treasuries as described in division (C) of 6,371
section 1901.11 of the Revised Code. The three-fifths share of a 6,372
city treasury is subject to apportionment under section 1901.026 6,373
of the Revised Code. 6,374
Sec. 1901.312. (A) As used in this section, "health care 6,383
coverage" has the same meaning as in section 1901.111 of the 6,384
Revised Code. 6,385
(B) The legislative authority, after consultation with 6,387
the clerk and deputy clerks of the municipal court, shall 6,388
negotiate and contract for, purchase, or otherwise procure group 6,389
health care coverage for the clerk and deputy clerks and their 6,390
spouses and dependents from insurance companies authorized to 6,391
engage in the business of insurance in this state under Title 6,392
XXXIX of the Revised Code, medical care corporations organized 6,393
142
under Chapter 1737. of the Revised Code, OR health care INSURING 6,395
corporations organized HOLDING CERTIFICATES OF AUTHORITY under 6,396
Chapter 1738. 1751. of the Revised Code, or health maintenance 6,398
organizations organized under Chapter 1742. of the Revised Code, 6,399
except that if the county or municipal corporation served by the 6,400
legislative authority provides group health care coverage for its 6,401
employees, the group health care coverage required by this 6,402
section shall be provided, if possible, through the policy or 6,403
plan under which the group health care coverage is provided for 6,404
the county or municipal corporation employees.
(C) The portion of the costs, premiums, or charges for the 6,406
group health care coverage procured pursuant to division (B) of 6,407
this section that is not paid by the clerk and deputy clerks of 6,408
the municipal court, or all of the costs, premiums, or charges 6,409
for the group health care coverage if the clerk and deputy clerks 6,410
will not be paying any such portion, shall be paid as follows: 6,411
(1) If the municipal court is a county-operated municipal 6,413
court, the portion of the costs, premiums, or charges or all of 6,414
the costs, premiums, or charges shall be paid out of the treasury 6,415
of the county. 6,416
(2)(a) If the municipal court is not a county-operated 6,418
municipal court, the portion of the costs, premiums, or charges 6,419
in connection with the clerk or all of the costs, premiums, or 6,420
charges in connection with the clerk shall be paid in 6,421
three-fifths and two-fifths shares from the city treasury and 6,422
appropriate county treasuries as described in division (C) of 6,423
section 1901.31 of the Revised Code. The three-fifths share of a 6,424
city treasury is subject to apportionment under section 1901.026 6,425
of the Revised Code. 6,426
(b) If the municipal court is not a county-operated 6,428
municipal court, the portion of the costs, premiums, or charges 6,429
in connection with the deputy clerks or all of the costs, 6,430
premiums, or charges in connection with the deputy clerks shall 6,431
be paid from the city treasury and shall be subject to 6,432
143
apportionment under section 1901.026 of the Revised Code. 6,433
(D) This section does not apply to the clerk of the 6,435
Auglaize county, Hamilton county, Portage county, or Wayne county 6,436
municipal court, if health care coverage is provided to the clerk 6,437
by virtue of his THE CLERK'S employment as the clerk of the court 6,439
of common pleas of Auglaize county, Hamilton county, Portage
county, or Wayne county. 6,440
Sec. 2133.12. (A) The death of a qualified patient or 6,449
other patient resulting from the withholding or withdrawal of 6,450
life-sustaining treatment in accordance with this chapter does 6,451
not constitute a suicide, aggravated murder, murder, or any other 6,452
homicide offense for any purpose. 6,453
(B)(1) The execution of a declaration shall not do either 6,455
of the following: 6,456
(a) Affect the sale, procurement, issuance, or renewal of 6,458
any policy of life insurance or annuity, notwithstanding any term 6,459
of a policy or annuity to the contrary; 6,460
(b) Be deemed to modify or invalidate the terms of any 6,462
policy of life insurance or annuity that is in effect on October 6,463
10, 1991. 6,464
(2) Notwithstanding any term of a policy of life insurance 6,466
or annuity to the contrary, the withholding or withdrawal of 6,467
life-sustaining treatment from an insured, qualified patient or 6,468
other patient in accordance with this chapter shall not impair or 6,469
invalidate any policy of life insurance or annuity. 6,470
(3) Notwithstanding any term of a policy or plan to the 6,472
contrary, the use or continuation, or the withholding or 6,473
withdrawal, of life-sustaining treatment from an insured, 6,474
qualified patient or other patient in accordance with this 6,475
chapter shall not impair or invalidate any policy of health 6,476
insurance or any health care benefit plan. 6,477
(4) No physician, health care facility, other health care 6,479
provider, person authorized to engage in the business of 6,480
insurance in this state under Title XXXIX of the Revised Code, 6,481
144
medical care corporation, health care INSURING corporation, 6,483
health maintenance organization, other health care plan, legal 6,484
entity that is self-insured and provides benefits to its 6,485
employees or members, or other person shall require any 6,486
individual to execute or refrain from executing a declaration, or 6,487
shall require an individual to revoke or refrain from revoking a 6,488
declaration, as a condition of being insured or of receiving 6,489
health care benefits or services. 6,490
(C)(1) This chapter does not create any presumption 6,492
concerning the intention of an individual who has revoked or has 6,493
not executed a declaration with respect to the use or 6,494
continuation, or the withholding or withdrawal, of 6,495
life-sustaining treatment if he THE INDIVIDUAL should be in a 6,496
terminal condition or in a permanently unconscious state at any 6,497
time.
(2) This chapter does not affect the right of a qualified 6,499
patient or other patient to make informed decisions regarding the 6,500
use or continuation, or the withholding or withdrawal, of 6,501
life-sustaining treatment as long as he THE QUALIFIED PATIENT OR 6,502
OTHER PATIENT is able to make those decisions. 6,505
(3) This chapter does not require a physician, other 6,507
health care personnel, or a health care facility to take action 6,508
that is contrary to reasonable medical standards. 6,509
(4) This chapter and, if applicable, a declaration do not 6,511
affect or limit the authority of a physician or a health care 6,512
facility to provide or not to provide life-sustaining treatment 6,513
to a person in accordance with reasonable medical standards 6,514
applicable in an emergency situation. 6,515
(D) Nothing in this chapter condones, authorizes, or 6,517
approves of mercy killing, assisted suicide, or euthanasia. 6,518
(E)(1) This chapter does not affect the responsibility of 6,520
the attending physician of a qualified patient or other patient, 6,521
or other health care personnel acting under the direction of the 6,522
patient's attending physician, to provide comfort care to the 6,523
145
patient. Nothing in this chapter precludes the attending 6,524
physician of a qualified patient or other patient who carries out 6,525
the responsibility to provide comfort care to the patient in good 6,526
faith and while acting within the scope of his THE ATTENDING 6,527
PHYSICIAN'S authority from prescribing, dispensing, 6,530
administering, or causing to be administered any particular 6,531
medical procedure, treatment, intervention, or other measure to 6,532
the patient, including, but not limited to, prescribing, 6,533
dispensing, administering, or causing to be administered by 6,534
judicious titration or in another manner any form of medication, 6,535
for the purpose of diminishing his THE QUALIFIED PATIENT'S OR 6,536
OTHER PATIENT'S pain or discomfort and not for the purpose of 6,537
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,538
PATIENT'S death, even though the medical procedure, treatment, 6,540
intervention, or other measure may appear to hasten or increase 6,541
the risk of the patient's death. Nothing in this chapter 6,542
precludes health care personnel acting under the direction of the 6,543
patient's attending physician who carry out the responsibility to 6,544
provide comfort care to the patient in good faith and while 6,545
acting within the scope of their authority from dispensing, 6,546
administering, or causing to be administered any particular 6,547
medical procedure, treatment, intervention, or other measure to 6,548
the patient, including, but not limited to, dispensing, 6,549
administering, or causing to be administered by judicious 6,550
titration or in another manner any form of medication, for the 6,551
purpose of diminishing his THE QUALIFIED PATIENT'S OR OTHER 6,552
PATIENT'S pain or discomfort and not for the purpose of 6,554
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,555
PATIENT'S death, even though the medical procedure, treatment, 6,556
intervention, or other measure may appear to hasten or increase 6,557
the risk of the patient's death.
(2)(a) If, at any time, a person described in division 6,559
(A)(2)(a)(i) of section 2133.05 of the Revised Code or the 6,560
individual or a majority of the individuals in either of the 6,561
146
first two classes of individuals that pertain to a declarant in 6,562
the descending order of priority set forth in division 6,563
(A)(2)(a)(ii) of section 2133.05 of the Revised Code believes in 6,564
good faith that both of the following circumstances apply, the 6,565
person or the individual or majority of individuals in either of 6,566
the first two classes of individuals may commence an action in 6,567
the probate court of the county in which a declarant who is in a 6,568
terminal condition or permanently unconscious state is located 6,569
for the issuance of an order mandating the use or continuation of 6,570
comfort care in connection with the declarant in a manner that is 6,571
consistent with division (E)(1) of this section: 6,572
(i) Comfort care is not being used or continued in 6,574
connection with the declarant. 6,575
(ii) The withholding or withdrawal of the comfort care is 6,577
contrary to division (E)(1) of this section. 6,578
(b) If a declarant did not designate in his THE 6,580
DECLARANT'S declaration a person as described in division 6,581
(A)(2)(a)(i) of section 2133.05 of the Revised Code and if, at 6,582
any time, a priority individual or any member of a priority class 6,583
of individuals under division (A)(2)(a)(ii) of section 2133.05 of 6,584
the Revised Code or, at any time, the individual or a majority of 6,585
the individuals in the next class of individuals that pertains to 6,586
the declarant in the descending order of priority set forth in 6,587
that division believes in good faith that both of the following 6,588
circumstances apply, the priority individual, the member of the 6,589
priority class of individuals, or the individual or majority of 6,590
individuals in the next class of individuals that pertains to the 6,591
declarant may commence an action in the probate court of the 6,592
county in which a declarant who is in a terminal condition or 6,593
permanently unconscious state is located for the issuance of an 6,594
order mandating the use or continuation of comfort care in 6,595
connection with the declarant in a manner that is consistent with 6,596
division (E)(1) of this section: 6,597
(i) Comfort care is not being used or continued in 6,599
147
connection with the declarant. 6,600
(ii) The withholding or withdrawal of the comfort care is 6,602
contrary to division (E)(1) of this section. 6,603
(c) If, at any time, a priority individual or any member 6,605
of a priority class of individuals under division (B) of section 6,606
2133.08 of the Revised Code or, at any time, the individual or a 6,607
majority of the individuals in the next class of individuals that 6,608
pertains to the patient in the descending order of priority set 6,609
forth in that division believes in good faith that both of the 6,610
following circumstances apply, the priority individual, the 6,611
member of the priority class of individuals, or the individual or 6,612
majority of individuals in the next class of individuals that 6,613
pertains to the patient may commence an action in the probate 6,614
court of the county in which a patient as described in division 6,615
(A) of section 2133.08 of the Revised Code is located for the 6,616
issuance of an order mandating the use or continuation of comfort 6,617
care in connection with the patient in a manner that is 6,618
consistent with division (E)(1) of this section: 6,619
(i) Comfort care is not being used or continued in 6,621
connection with the patient. 6,622
(ii) The withholding or withdrawal of the comfort care is 6,624
contrary to division (E)(1) of this section. 6,625
Sec. 2305.25. (A) No health care entity and no individual 6,635
who is a member of or works on behalf of any of the following
boards or committees of a health care entity or of any of the 6,636
following corporations shall be liable in damages to any person 6,637
for any acts, omissions, decisions, or other conduct within the 6,638
scope of the functions of the board, committee, or corporation: 6,639
(1) A peer review committee of a hospital, a nonprofit 6,641
health care corporation which is a member of the hospital or of 6,642
which the hospital is a member, or a community mental health 6,643
center; 6,644
(2) A board or committee of a hospital or of a nonprofit 6,647
health care corporation which is a member of the hospital or of 6,648
148
which the hospital is a member reviewing professional
qualifications or activities of the hospital medical staff or 6,649
applicants for admission to the medical staff; 6,650
(3) A utilization committee of a state or local society 6,652
composed of doctors of medicine or doctors of osteopathic 6,653
medicine and surgery or doctors of podiatric medicine; 6,654
(4) A peer review committee of nursing home providers or 6,656
administrators, including a corporation engaged in performing the 6,658
functions of a peer review committee of nursing home providers or 6,659
administrators, or a corporation engaged in the functions of
another type of peer review or professional standards review 6,660
committee; 6,661
(5) A peer review committee, professional standards review 6,663
committee, or arbitration committee of a state or local society 6,664
composed of doctors of medicine, doctors of osteopathic medicine 6,665
and surgery, doctors of dentistry, doctors of optometry, doctors 6,666
of podiatric medicine, psychologists, or registered pharmacists; 6,667
(6) A peer review committee of a health maintenance 6,669
organization INSURING CORPORATION that has at least a two-thirds 6,670
majority of member physicians in active practice and that 6,672
conducts professional credentialing and quality review activities 6,673
involving the competence or professional conduct of health care 6,674
providers, which conduct adversely affects, or could adversely 6,675
affect, the health or welfare of any patient. For purposes of 6,676
this division, "health maintenance organization INSURING 6,677
CORPORATION" includes wholly owned subsidiaries of a health 6,679
maintenance organization INSURING CORPORATION. 6,680
(7) A peer review committee of any insurer authorized 6,682
under Title XXXIX of the Revised Code to do the business of 6,683
sickness and accident insurance in this state that has at least a 6,684
two-thirds majority of physicians in active practice and that 6,685
conducts professional credentialing and quality review activities 6,686
involving the competence or professional conduct of health care 6,687
providers, which conduct adversely affects, or could adversely 6,688
149
affect, the health or welfare of any patient; 6,689
(8) A peer review committee of any insurer authorized 6,691
under Title XXXIX of the Revised Code to do the business of 6,692
sickness and accident insurance in this state that has at least a 6,693
two-thirds majority of physicians in active practice and that 6,694
conducts professional credentialing and quality review activities 6,695
involving the competence or professional conduct of a health care 6,696
facility that has contracted with the insurer to provide health 6,697
care services to insureds, which conduct adversely affects, or 6,698
could adversely affect, the health or welfare of any patient; 6,699
(9) A quality assurance committee of a state correctional 6,701
institution operated by the department of rehabilitation and 6,703
correction;
(10) A quality assurance committee of the central office 6,705
of the department of rehabilitation and correction or department 6,707
of mental health.
(11) A peer review committee of an insurer authorized 6,709
under Title XXXIX of the Revised Code to do the business of 6,710
medical professional liability insurance in this state and that 6,711
conducts professional quality review activities involving the 6,712
competence or professional conduct of health care providers, 6,713
which conduct adversely affects, or could affect, the health or
welfare of any patient; 6,714
(12) A peer review committee of a health care entity. 6,716
(B)(1) A hospital shall be presumed to not be negligent in 6,718
the credentialing of a qualified person if the hospital proves by 6,719
a preponderance of the evidence that at the time of the alleged 6,720
negligent credentialing of the qualified person it was accredited 6,721
by the joint commission on accreditation of health care 6,722
organizations, the American osteopathic association, or the
national committee for quality assurance. 6,723
(2) The presumption that a hospital is not negligent as 6,725
provided in division (B)(1) of this section may be rebutted only 6,726
by proof, by a preponderance of the evidence, of any of the 6,727
150
following:
(a) The credentialing and review requirements of the 6,729
accrediting organization did not apply to the hospital, the 6,730
qualified person, or the type of professional care that is the 6,731
basis of the claim against the hospital.
(b) The hospital failed to comply with all material 6,733
credentialing and review requirements of the accrediting 6,734
organization that applied to the qualified person. 6,735
(c) The hospital, through its medical staff executive 6,737
committee or its governing body and sufficiently in advance to 6,738
take appropriate action, knew that a previously competent 6,739
qualified person with staff privileges at the hospital had 6,740
developed a pattern of incompetence that indicated that the 6,741
qualified person's privileges should have been limited prior to 6,742
treating the plaintiff at the hospital. 6,743
(d) The hospital, through its medical staff executive 6,745
committee or its governing body and sufficiently in advance to 6,746
take appropriate action, knew that a previously competent 6,747
qualified person with staff privileges at the hospital would 6,748
provide fraudulent medical treatment but failed to limit the 6,749
qualified person's privileges prior to treating the plaintiff at 6,750
the hospital. 6,751
(3) If the plaintiff fails to rebut the presumption 6,753
provided in division (B)(1) of this section, upon the motion of 6,754
the hospital, the court shall enter judgment in favor of the 6,755
hospital on the claim of negligent credentialing.
(C) Nothing in this section otherwise shall relieve any 6,757
individual or health care entity from liability arising from 6,758
treatment of a patient. Nothing in this section shall be 6,759
construed as creating an exception to section 2305.251 of the 6,760
Revised Code.
(D) No person who provides information under this section 6,762
without malice and in the reasonable belief that the information 6,764
is warranted by the facts known to the person shall be subject to 6,765
151
suit for civil damages as a result of providing the information. 6,766
(E) For purposes of this section: 6,768
(1) "Peer review committee" means a utilization review 6,770
committee, quality assurance committee, quality improvement 6,771
committee, tissue committee, credentialing committee, or other 6,772
committee that conducts professional credentialing and quality 6,773
review activities involving the competence or professional 6,774
conduct of health care practitioners.
(2) "Health care entity" means a government entity, a 6,776
for-profit or nonprofit corporation, a limited liability company, 6,777
a partnership, a professional corporation, a state or local 6,778
society as described in division (A)(3) of this section, or other 6,779
health care organization, including, but not limited to, health 6,780
care entities described in division (A) of this section, whether 6,781
acting on its own behalf or on behalf of or in affiliation with 6,782
other health care entities, that conducts, as part of its
purpose, professional credentialing or quality review activities 6,783
involving the competence or professional conduct of health care 6,784
practitioners or providers. 6,785
(3) "Hospital" means either of the following: 6,787
(a) An institution that has been registered or licensed by 6,789
the Ohio department of health as a hospital; 6,790
(b) An entity, other than an insurance company authorized 6,792
to do business in this state, that owns, controls, or is 6,793
affiliated with an institution that has been registered or 6,795
licensed by the Ohio department of health as a hospital.
(4) "Qualified person" means a member of the medical staff 6,797
of a hospital or a person who has professional privileges at a 6,798
hospital pursuant to section 3701.351 of the Revised Code. 6,799
(F) This section shall be considered to be purely remedial 6,802
in its operation and shall be applied in a remedial manner in any 6,803
civil action in which this section is relevant, whether the civil 6,804
action is pending in court or commenced on or after the effective 6,805
date of this section, regardless of when the cause of action 6,806
152
accrued and notwithstanding any other section of the Revised Code 6,808
or prior rule of law of this state.
Sec. 2913.47. (A) As used in this section: 6,818
(1) "Data" has the same meaning as in section 2913.01 of 6,820
the Revised Code and additionally includes any other 6,821
representation of information, knowledge, facts, concepts, or 6,822
instructions that are being or have been prepared in a formalized 6,823
manner. 6,824
(2) "Deceptive" means that a statement, in whole or in 6,826
part, would cause another to be deceived because it contains a 6,827
misleading representation, withholds information, prevents the 6,828
acquisition of information, or by any other conduct, act, or 6,829
omission creates, confirms, or perpetuates a false impression, 6,830
including, but not limited to, a false impression as to law, 6,831
value, state of mind, or other objective or subjective fact. 6,832
(3) "Insurer" means any person that is authorized to 6,834
engage in the business of insurance in this state under Title 6,835
XXXIX of the Revised Code;, the Ohio fair plan underwriting 6,836
association created under section 3929.43 of the Revised Code;, 6,837
any prepaid dental plan, medical care corporation, health care 6,840
INSURING corporation, dental care corporation, or health 6,842
maintenance organization; and any legal entity that is
self-insured and provides benefits to its employees or members. 6,843
(4) "Policy" means a policy, certificate, contract, or 6,845
plan that is issued by an insurer. 6,846
(5) "Statement" includes, but is not limited to, any 6,848
notice, letter, or memorandum; proof of loss; bill of lading; 6,849
receipt for payment; invoice, account, or other financial 6,850
statement; estimate of property damage; bill for services; 6,851
diagnosis or prognosis; prescription; hospital, medical, or 6,852
dental chart or other record; x-ray, photograph, videotape, or 6,853
movie film; test result; other evidence of loss, injury, or 6,854
expense; computer-generated document; and data in any form. 6,855
(B) No person, with purpose to defraud or knowing that the 6,857
153
person is facilitating a fraud, shall do either of the following: 6,858
(1) Present to, or cause to be presented to, an insurer 6,860
any written or oral statement that is part of, or in support of, 6,861
an application for insurance, a claim for payment pursuant to a 6,862
policy, or a claim for any other benefit pursuant to a policy, 6,863
knowing that the statement, or any part of the statement, is 6,864
false or deceptive; 6,865
(2) Assist, aid, abet, solicit, procure, or conspire with 6,867
another to prepare or make any written or oral statement that is 6,868
intended to be presented to an insurer as part of, or in support 6,869
of, an application for insurance, a claim for payment pursuant to 6,870
a policy, or a claim for any other benefit pursuant to a policy, 6,871
knowing that the statement, or any part of the statement, is 6,872
false or deceptive. 6,873
(C) Whoever violates this section is guilty of insurance 6,875
fraud. Except as otherwise provided in this division, insurance 6,876
fraud is a misdemeanor of the first degree. If the amount of the 6,877
claim that is false or deceptive is five hundred dollars or more 6,878
and is less than five thousand dollars, insurance fraud is a 6,879
felony of the fifth degree. If the amount of the claim that is
false or deceptive is five thousand dollars or more and is less 6,881
than one hundred thousand dollars, insurance fraud is a felony of 6,882
the fourth degree. If the amount of the claim that is false or 6,884
deceptive is one hundred thousand dollars or more, insurance 6,885
fraud is a felony of the third degree.
(D) This section shall not be construed to abrogate, 6,887
waive, or modify division (A) of section 2317.02 of the Revised 6,888
Code. 6,889
Sec. 3105.71. (A) If a party to an action for divorce, 6,898
annulment, dissolution of marriage, or legal separation was the 6,899
named insured or subscriber under, or the policyholder, 6,900
certificate holder, or contract holder of, a policy, contract, or 6,901
plan of health insurance that provided health insurance coverage 6,902
for his THAT PARTY'S spouse and dependents immediately prior to 6,903
154
the filing of the action, that party shall not cancel or 6,904
otherwise terminate or cause the termination of such coverage for 6,905
which the spouse and dependents would otherwise be eligible until 6,906
the court determines that the party is no longer responsible for 6,907
providing such health insurance coverage for his THAT PARTY'S 6,908
spouse and dependents.
(B) If the party responsible for providing health 6,910
insurance coverage for his THAT PARTY'S spouse and dependents 6,911
under division (A) of this section fails to provide that coverage 6,912
in accordance with that division, the court shall issue an order 6,913
that includes all of the following: 6,914
(1) A requirement that the party make payment to his THAT 6,916
PARTY'S spouse in the amount of any premium he THAT PARTY failed 6,918
to pay or contribution he THAT PARTY failed to make that resulted 6,919
in his THAT PARTY'S failure to provide health insurance coverage 6,920
in compliance with division (A) of this section;
(2) A requirement that the party make payment to his THAT 6,922
PARTY'S spouse for reimbursement of any hospital, surgical, and 6,923
medical expenses incurred as a result of his THAT PARTY'S failure 6,924
to comply with division (A) of this section; 6,925
(3) A requirement that, if the party fails to comply with 6,927
divisions (B)(1) and (2) of this section, the employer of the 6,928
party deduct from the party's earnings an amount necessary to 6,929
make any payments required under divisions (B)(1) and (2) of this 6,930
section. 6,931
(C) If the party responsible for providing health 6,933
insurance coverage for his THAT PARTY'S spouse and dependents 6,934
under division (A) of this section cancels or otherwise 6,935
terminates or causes the termination of such coverage for which 6,936
the spouse and dependents would otherwise be eligible, the spouse 6,937
may apply to the insurer, health maintenance organization 6,938
INSURING CORPORATION, or other third-party payer that provided 6,939
the coverage for a policy or contract of health insurance. The 6,940
spouse and dependents shall have the same rights and be subject 6,941
155
to the same limitations as a person applying for or covered under 6,942
a converted or separate policy under section 3923.32 of the 6,943
Revised Code upon the divorce, annulment, dissolution of 6,944
marriage, or the legal separation of the spouse from the named 6,945
insured.
Sec. 3111.241. (A) As used in this section, "insurer" 6,954
means any person that is authorized to engage in the business of 6,955
insurance in this state under Title XXXIX of the Revised Code;, 6,956
any prepaid dental plan, medical care corporation, health care 6,957
INSURING corporation, dental care corporation, or health 6,958
maintenance organization; and any legal entity that is 6,959
self-insured and provides benefits to its employees or members. 6,960
(B) If an administrative officer of a child support 6,962
enforcement agency issues an administrative support order under 6,963
section 3111.20, 3111.21, or 3111.22 of the Revised Code, in 6,964
addition to any requirements in those sections, the agency also 6,966
shall issue a separate order that includes all of the following: 6,967
(1) A requirement that the obligor under the child support 6,969
order obtain health insurance coverage for the children who are 6,970
the subject of the administrative child support order from an 6,971
insurer that provides a group health insurance or health care 6,972
policy, contract, or plan that is specified in the order and a 6,973
requirement that the obligor, no later than thirty days after the 6,974
issuance of the order under division (B)(1) of this section, 6,975
furnish written proof to the child support enforcement agency 6,976
that the required health insurance coverage has been obtained, if 6,977
that coverage is available at a reasonable cost through a group 6,978
health insurance or health care policy, contract, or plan offered 6,979
by the obligor's employer or through any other group health 6,980
insurance or health care policy, contract, or plan available to 6,981
the obligor and if health insurance coverage for the children is 6,982
not available for a more reasonable cost through a group health 6,983
insurance or health care policy, contract, or plan available to 6,984
the obligee under the administrative child support order; 6,985
156
(2) If the obligor is required under division (B)(1) of 6,987
this section to obtain health insurance coverage for the children 6,988
who are the subject of the administrative child support order, a 6,989
requirement that the obligor supply the obligee with information 6,990
regarding the benefits, limitations, and exclusions of the health 6,991
insurance coverage, copies of any insurance forms necessary to 6,992
receive reimbursement, payment, or other benefits under the 6,993
health insurance coverage, and a copy of any necessary insurance 6,994
cards, a requirement that the obligor submit a copy of the 6,995
administrative order issued pursuant to division (B) of this 6,996
section to the insurer at the time that the obligor makes 6,997
application to enroll the children in the health insurance or 6,998
health care policy, contract, or plan, and a requirement that the 6,999
obligor, no later than thirty days after the issuance of the 7,000
administrative order under division (B)(2) of this section, 7,001
furnish written proof to the child support enforcement agency 7,002
that division (B)(2) of this section has been complied with; 7,003
(3) A requirement that the obligee under the 7,005
administrative child support order obtain health insurance 7,006
coverage for the children who are the subject of the 7,007
administrative child support order from an insurer that provides 7,008
a group health insurance or health care policy, contract, or plan 7,009
that is specified in the administrative order and a requirement 7,010
that the obligee, no later than thirty days after the issuance of 7,011
the administrative order under division (B)(1) of this section, 7,012
furnish written proof to the child support enforcement agency 7,013
that the required health insurance coverage has been obtained, if 7,014
that coverage is available through a group health insurance or 7,015
health care policy, contract, or plan offered by the obligee's 7,016
employer or through any other group health insurance or health 7,017
care policy, contract, or plan available to the obligee and if 7,018
that coverage is available at a more reasonable cost than health 7,019
insurance coverage for the children through a group health 7,020
insurance or health care policy, contract, or plan available to 7,021
157
the obligor; 7,022
(4) If the obligee is required under division (B)(3) of 7,024
this section to obtain health insurance coverage for the children 7,025
who are the subject of the administrative child support order, a 7,026
requirement that the obligee submit a copy of the administrative 7,027
order issued pursuant to division (B) of this section to the 7,028
insurer at the time that the obligee makes application to enroll 7,029
the children in the health insurance or health care policy, 7,030
contract, or plan; 7,031
(5) A list of the group health insurance and health care 7,033
policies, contracts, and plans that the child support enforcement 7,034
agency determines are available at a reasonable cost to the 7,035
obligor or to the obligee and the name of the insurer that issues 7,036
each policy, contract, or plan; 7,037
(6) A statement setting forth the name, address, and 7,039
telephone number of the individual who is to be reimbursed for 7,040
out-of-pocket medical, optical, hospital, dental, or prescription 7,041
expenses paid for each child who is the subject of the 7,042
administrative child support order and a statement that the 7,043
insurer that provides the health insurance coverage for the 7,044
children may continue making payment for medical, optical, 7,045
hospital, dental, or prescription services directly to any health 7,046
care provider in accordance with the applicable health insurance 7,047
or health care policy, contract, or plan; 7,048
(7) A requirement that the obligor and the obligee 7,050
designate the children who are the subject of the administrative 7,051
child support order as covered dependents under any health 7,052
insurance or health care policy, contract, or plan for which they 7,053
contract; 7,054
(8) A requirement that the obligor, the obligee, or both 7,056
of them under a formula established by the child support 7,057
enforcement agency pay copayment or deductible costs required 7,058
under the health insurance or health care policy, contract, or 7,059
plan that covers the children; 7,060
158
(9) If health insurance coverage for the children who are 7,062
the subject of the administrative order is not available at a 7,063
reasonable cost through a group health insurance or health care 7,064
policy, contract, or plan offered by the obligor's employer or 7,065
through any other group health insurance or health care policy, 7,066
contract, or plan available to the obligor and is not available 7,067
at a reasonable cost through a group health insurance or health 7,068
care policy, contract, or plan offered by the obligee's employer 7,069
or through any other group health insurance or health care 7,070
policy, contract, or plan available to the obligee, a requirement 7,071
that the obligor and the obligee share liability for the cost of 7,072
the medical and health care needs of the children who are the 7,073
subject of the administrative order, under an equitable formula 7,074
established by the agency, and a requirement that if, after the 7,075
issuance of the order, health insurance coverage for the children 7,076
who are the subject of the administrative order becomes available 7,077
at a reasonable cost through a group health insurance or health 7,078
care policy, contract, or plan offered by the obligor's or 7,079
obligee's employer or through any other group health insurance or 7,080
health care policy, contract, or plan available to the obligor or 7,081
obligee, the obligor or obligee to whom the coverage becomes 7,082
available immediately inform the agency of that fact. 7,083
(10) A notice that, if the obligor is required under 7,085
divisions (B)(1) and (2) of this section to obtain health 7,086
insurance coverage for the children who are the subject of the 7,087
administrative child support order and if the obligor fails to 7,088
comply with the requirements of those divisions, the child 7,089
support enforcement agency immediately shall issue an 7,090
administrative order to the employer of the obligor, upon written 7,091
notice from the child support enforcement agency, requiring the 7,092
employer to take whatever action is necessary to make application 7,093
to enroll the obligor in any available group health insurance or 7,094
health care policy, contract, or plan with coverage for the 7,095
children who are the subject of the administrative child support 7,096
159
order, to submit a copy of the administrative order issued 7,097
pursuant to division (B) of this section to the insurer at the 7,098
time that the employer makes application to enroll the children 7,099
in the health insurance or health care policy, contract, or plan, 7,100
and, if the obligor's application is accepted, to deduct any 7,101
additional amount from the obligor's earnings necessary to pay 7,102
any additional cost for that health insurance coverage; 7,103
(11) A notice that during the time that an order under 7,105
this section is in effect, the employer of the obligor is 7,106
required to release to the obligee or the child support 7,107
enforcement agency upon written request any necessary information 7,108
on the health insurance coverage of the obligor, including, but 7,109
not limited to, the name and address of the insurer and any 7,110
policy, contract, or plan number, and to otherwise comply with 7,111
this section and any court order issued under this section; 7,112
(12) A statement setting forth the full name and date of 7,114
birth of each child who is the subject of the administrative 7,115
child support order; 7,116
(13) A requirement that the obligor and the obligee comply 7,118
with any requirement described in division (B)(1), (2), (3), (4), 7,119
or (7) of this section that is contained in the order issued 7,120
under this section no later than thirty days after the issuance 7,121
of the order. 7,122
(C) If an administrative officer of a child support 7,124
enforcement agency issues an administrative support order under 7,125
section 3111.20, 3111.21, or 3111.22 of the Revised Code, the 7,126
child support enforcement agency, in addition to any requirements 7,128
in those sections and in lieu of an order issued under division 7,129
(B) of this section, may issue a separate order requiring both 7,130
the obligor and the obligee to obtain health insurance coverage 7,131
for the children who are the subject of the administrative child 7,132
support order, if health insurance coverage is available for the 7,133
children and if the agency determines that the coverage is 7,134
available at a reasonable cost to both the obligor and the 7,135
160
obligee and that the dual coverage by both parents would provide 7,136
for coordination of medical benefits without unnecessary 7,137
duplication of coverage. If the agency issues an order under 7,138
this division, it shall include in the order any of the 7,139
requirements, notices, and information set forth in divisions 7,140
(B)(1) to (13) of this section that are applicable. 7,141
(D) Any administrative order issued under this section 7,143
shall be binding upon the obligor and the obligee, their 7,144
employers, and any insurer that provides health insurance 7,145
coverage for either of them or their children. The agency shall 7,146
send a copy of any administrative order issued under this section 7,147
that contains any requirement or notice described in division 7,148
(B)(1), (2), (3), (4), (7), (8), or (10) of this section by 7,149
ordinary mail to the obligor, the obligee, and any employer that 7,150
is subject to the administrative order. The agency shall send a 7,151
copy of any administrative order issued under this section that 7,152
contains any requirement contained in division (B)(9) of this 7,153
section by ordinary mail to the obligor and obligee. 7,154
(E) If an obligor does not comply with any administrative 7,156
order issued under this section that contains any requirement or 7,157
notice described in division (B)(1), (2), (4), (7), (8), or (10) 7,158
of this section within thirty days after the administrative order 7,159
is issued, the child support enforcement agency shall notify the 7,160
court of common pleas of the county in which the agency is 7,161
located in writing of the failure of the obligor to comply with 7,162
the administrative order. Upon receipt of the notice from the 7,163
agency, the court shall issue an order to the employer of the 7,164
obligor requiring the employer to take whatever action is 7,165
necessary to make application to enroll the obligor in any 7,166
available group health insurance or health care policy, contract, 7,167
or plan with coverage for the children who are the subject of the 7,168
administrative child support order, to submit a copy of the 7,169
administrative order issued pursuant to division (B) of this 7,170
section to the insurer at the time that the employer makes 7,171
161
application to enroll the children in the health insurance or 7,172
health care policy, contract, or plan, and, if the obligor's 7,173
application is accepted, to deduct from the wages or other income 7,174
of the obligor the cost of the coverage for the children. Upon 7,175
receipt of any court order under this division, the employer 7,176
shall take whatever action is necessary to comply with the court 7,177
order. 7,178
During the time that any administrative or court order 7,180
issued under this section is in effect and after the employer has 7,181
received a copy of the administrative or court order, the 7,182
employer of the obligor who is the subject of the administrative 7,183
or court order shall comply with the administrative or court 7,184
order and, upon request from the obligee or agency, shall release 7,185
to the obligee and the child support enforcement agency all 7,186
information about the obligor's health insurance coverage that is 7,187
necessary to ensure compliance with this section or any 7,188
administrative or court order issued under this section, 7,189
including, but not limited to, the name and address of the 7,190
insurer and any policy, contract, or plan number. Any 7,191
information provided by an employer pursuant to this division 7,192
shall be used only for the purpose of the enforcement of an 7,193
administrative or court order issued under this section. 7,194
Any employer who receives a copy of an administrative or 7,196
court order issued under this section shall notify the child 7,197
support enforcement agency of any change in or the termination of 7,198
the obligor's health insurance coverage that is maintained 7,199
pursuant to an order issued under this section. 7,200
(F) Any insurer that receives a copy of an administrative 7,202
order issued under this section shall comply with this section 7,203
and any administrative order issued under this section, 7,204
regardless of the residence of the children. If an insurer 7,205
provides health insurance coverage for the children who are the 7,206
subject of an administrative child support order in accordance 7,207
with an order issued under this section, the insurer shall 7,208
162
reimburse the parent, who is designated to receive reimbursement 7,209
in the administrative order issued under this section, for 7,210
covered out-of-pocket medical, optical, hospital, dental, or 7,211
prescription expenses incurred on behalf of the children subject 7,212
to the administrative order. 7,213
(G) If an obligee under an administrative child support 7,215
order is eligible for medical assistance under Chapter 5111. or 7,216
5115. of the Revised Code and the obligor has obtained health 7,217
insurance coverage pursuant to an administrative order issued 7,218
under division (B) of this section, the obligee shall notify any 7,219
physician, hospital, or other provider of medical services for 7,220
which medical assistance is available of the name and address of 7,221
the obligor's insurer and of the number of the obligor's health 7,222
insurance or health care policy, contract, or plan. Any 7,223
physician, hospital, or other provider of medical services for 7,224
which medical assistance is available under Chapter 5111. or 7,225
5115. of the Revised Code who is notified under this division of 7,226
the existence of a health insurance or health care policy, 7,227
contract, or plan with coverage for children who are eligible for 7,228
medical assistance first shall bill the insurer for any services 7,229
provided for those children. If the insurer fails to pay all or 7,230
any part of a claim filed under this division by the physician, 7,231
hospital, or other medical services provider and the services for 7,232
which the claim is filed are covered by Chapter 5111. or 5115. of 7,233
the Revised Code, the physician, hospital, or other medical 7,235
services provider shall bill the remaining unpaid costs of the 7,236
services in accordance with Chapter 5111. or 5115. of the Revised 7,237
Code.
(H) Any obligor who fails to comply with an administrative 7,239
order issued under this section is liable to the obligee for any 7,240
medical expenses incurred as a result of the failure to comply 7,241
with the administrative order. 7,242
(I) Nothing in this section shall be construed to require 7,244
an insurer to accept for enrollment any child who does not meet 7,245
163
the underwriting standards of the health insurance or health care 7,246
policy, contract, or plan for which application is made. 7,247
(J) If any person fails to comply with an administrative 7,249
order issued under this section, the agency may bring an action 7,250
under section 3111.242 of the Revised Code in the juvenile court 7,251
of the county in which the agency is located requesting the court 7,252
to find the obligor or any other person in contempt pursuant to 7,254
section 2705.02 of the Revised Code.
Sec. 3113.217. (A) As used in this section: 7,263
(1) "Obligor," "obligee," and "child support enforcement 7,265
agency" have the same meanings as in section 3113.21 of the 7,266
Revised Code. 7,267
(2) "Insurer" means any person that is authorized to 7,269
engage in the business of insurance in this state under Title 7,270
XXXIX of the Revised Code;, any prepaid dental plan, medical care 7,272
corporation, health care INSURING corporation, dental care 7,274
corporation, or health maintenance organization; and any legal 7,275
entity that is self-insured and provides benefits to its 7,276
employees or members.
(B) In any action or proceeding in which a child support 7,278
order is issued or modified on or after July 1, 1990, under 7,279
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,280
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,282
3113.07, 3113.216, or 3113.31 of the Revised Code, the child 7,284
support enforcement agency shall determine whether the obligor or 7,285
obligee has satisfactory health insurance coverage, other than 7,286
medical assistance under Title XIX of the "Social Security Act," 7,287
49 Stat. 620 (1935), 42 U.S.C. 301, as amended, for the children 7,288
who are the subject of the child support order. If the agency 7,289
determines that neither the obligor nor the obligee has 7,290
satisfactory health insurance coverage for the children, it shall 7,291
file a motion with the court requesting the court to issue an 7,292
order in accordance with divisions (C) to (K) of this section. 7,293
(C) In any action or proceeding in which a child support 7,295
164
order is issued or modified on or after July 1, 1990, under 7,296
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,297
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,299
3113.07, 3113.216, or 3113.31 of the Revised Code, in addition to 7,301
any requirements in those sections, the court also shall issue a 7,302
separate order that includes all of the following: 7,303
(1) A requirement that the obligor under the child support 7,305
order obtain health insurance coverage for the children who are 7,306
the subject of the child support order from an insurer that 7,307
provides a group health insurance or health care policy, 7,308
contract, or plan that is specified in the order and a 7,309
requirement that the obligor, no later than thirty days after the 7,310
issuance of the order under division (C)(1) of this section, 7,311
furnish written proof to the child support enforcement agency 7,312
that the required health insurance coverage has been obtained, if 7,313
that coverage is available at a reasonable cost through a group 7,314
health insurance or health care policy, contract, or plan offered 7,315
by the obligor's employer or through any other group health 7,316
insurance or health care policy, contract, or plan available to 7,317
the obligor and if health insurance coverage for the children is 7,318
not available for a more reasonable cost through a group health 7,319
insurance or health care policy, contract, or plan available to 7,320
the obligee under the child support order; 7,321
(2) If the obligor is required under division (C)(1) of 7,323
this section to obtain health insurance coverage for the children 7,324
who are the subject of the child support order, a requirement 7,325
that the obligor supply the obligee with information regarding 7,326
the benefits, limitations, and exclusions of the health insurance 7,327
coverage, copies of any insurance forms necessary to receive 7,328
reimbursement, payment, or other benefits under the health 7,329
insurance coverage, and a copy of any necessary insurance cards, 7,330
a requirement that the obligor submit a copy of the court order 7,331
issued pursuant to division (C) of this section to the insurer at 7,332
the time that the obligor makes application to enroll the 7,333
165
children in the health insurance or health care policy, contract, 7,334
or plan, and a requirement that the obligor, no later than thirty 7,335
days after the issuance of the order under division (C)(2) of 7,336
this section, furnish written proof to the child support 7,337
enforcement agency that division (C)(2) of this section has been 7,338
complied with; 7,339
(3) A requirement that the obligee under the child support 7,341
order obtain health insurance coverage for the children who are 7,342
the subject of the child support order from an insurer that 7,343
provides a group health insurance or health care policy, 7,344
contract, or plan that is specified in the order and a 7,345
requirement that the obligee, no later than thirty days after the 7,346
issuance of the order under division (C)(1) of this section, 7,347
furnish written proof to the child support enforcement agency 7,348
that the required health insurance coverage has been obtained, if 7,349
that coverage is available through a group health insurance or 7,350
health care policy, contract, or plan offered by the obligee's 7,351
employer or through any other group health insurance or health 7,352
care policy, contract, or plan available to the obligee and if 7,353
that coverage is available at a more reasonable cost than health 7,354
insurance coverage for the children through a group health 7,355
insurance or health care policy, contract, or plan available to 7,356
the obligor; 7,357
(4) If the obligee is required under division (C)(3) of 7,359
this section to obtain health insurance coverage for the children 7,360
who are the subject of the child support order, a requirement 7,361
that the obligee submit a copy of the court order issued pursuant 7,362
to division (C) of this section to the insurer at the time that 7,363
the obligee makes application to enroll the children in the 7,364
health insurance or health care policy, contract, or plan; 7,365
(5) A list of the group health insurance and health care 7,367
policies, contracts, and plans that the court determines are 7,368
available at a reasonable cost to the obligor or to the obligee 7,369
and the name of the insurer that issues each policy, contract, or 7,370
166
plan; 7,371
(6) A statement setting forth the name, address, and 7,373
telephone number of the individual who is to be reimbursed for 7,374
out-of-pocket medical, optical, hospital, dental, or prescription 7,375
expenses paid for each child who is the subject of the support 7,376
order and a statement that the insurer that provides the health 7,377
insurance coverage for the children may continue making payment 7,378
for medical, optical, hospital, dental, or prescription services 7,379
directly to any health care provider in accordance with the 7,380
applicable health insurance or health care policy, contract, or 7,381
plan; 7,382
(7) A requirement that the obligor and the obligee 7,384
designate the children who are the subject of the child support 7,385
order as covered dependents under any health insurance or health 7,386
care policy, contract, or plan for which they contract; 7,387
(8) A requirement that the obligor, the obligee, or both 7,389
of them under a formula established by the court pay co-payment 7,390
or deductible costs required under the health insurance or health 7,391
care policy, contract, or plan that covers the children; 7,392
(9) If health insurance coverage for the children who are 7,394
the subject of the order is not available at a reasonable cost 7,395
through a group health insurance or health care policy, contract, 7,396
or plan offered by the obligor's employer or through any other 7,397
group health insurance or health care policy, contract, or plan 7,398
available to the obligor and is not available at a reasonable 7,399
cost through a group health insurance or health care policy, 7,400
contract, or plan offered by the obligee's employer or through 7,401
any other group health insurance or health care policy, contract, 7,402
or plan available to the obligee, a requirement that the obligor 7,403
and the obligee share liability for the cost of the medical and 7,404
health care needs of the children who are the subject of the 7,405
order, under an equitable formula established by the court, and a 7,406
requirement that if, after the issuance of the order, health 7,407
insurance coverage for the children who are the subject of the 7,408
167
order becomes available at a reasonable cost through a group 7,409
health insurance or health care policy, contract, or plan offered 7,410
by the obligor's or obligee's employer or through any other group 7,411
health insurance or health care policy, contract, or plan 7,412
available to the obligor or obligee, the obligor or obligee to 7,413
whom the coverage becomes available immediately inform the court 7,414
of that fact. 7,415
(10) A notice that, if the obligor is required under 7,417
divisions (C)(1) and (2) of this section to obtain health 7,418
insurance coverage for the children who are the subject of the 7,419
child support order and if the obligor fails to comply with the 7,420
requirements of those divisions, the court immediately shall 7,421
issue an order to the employer of the obligor, upon written 7,422
notice from the child support enforcement agency, requiring the 7,423
employer to take whatever action is necessary to make application 7,424
to enroll the obligor in any available group health insurance or 7,425
health care policy, contract, or plan with coverage for the 7,426
children who are the subject of the child support order, to 7,427
submit a copy of the court order issued pursuant to division (C) 7,428
of this section to the insurer at the time that the employer 7,429
makes application to enroll the children in the health insurance 7,430
or health care policy, contract, or plan, and, if the obligor's 7,431
application is accepted, to deduct any additional amount from the 7,432
obligor's earnings necessary to pay any additional cost for that 7,433
health insurance coverage; 7,434
(11) A notice that during the time that an order under 7,436
this section is in effect, the employer of the obligor is 7,437
required to release to the obligee or the child support 7,438
enforcement agency upon written request any necessary information 7,439
on the health insurance coverage of the obligor, including, but 7,440
not limited to, the name and address of the insurer and any 7,441
policy, contract, or plan number, and to otherwise comply with 7,442
this section and any court order issued under this section; 7,443
(12) A statement setting forth the full name and date of 7,445
168
birth of each child who is the subject of the child support 7,446
order; 7,447
(13) A requirement that the obligor and the obligee comply 7,449
with any requirement described in division (C)(1), (2), (3), (4), 7,450
or (7) of this section that is contained in the order issued 7,451
under this section no later than thirty days after the issuance 7,452
of the order. 7,453
(D) In any action in which a child support order is issued 7,455
or modified on or after July 1, 1990, under Chapter 3115. or 7,456
section 2151.23, 2151.231, 2151.33, 2151.36, 2151.49, 3105.18, 7,457
3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 3113.07, 3113.216, 7,459
or 3113.31 of the Revised Code, the court, in addition to any 7,460
requirements in those sections and in lieu of an order issued 7,461
under division (C) of this section, may issue a separate order 7,462
requiring both the obligor and the obligee to obtain health 7,463
insurance coverage for the children who are the subject of the 7,464
child support order, if health insurance coverage is available 7,465
for the children and if the court determines that the coverage is 7,466
available at a reasonable cost to both the obligor and the 7,467
obligee and that the dual coverage by both parents would provide 7,468
for coordination of medical benefits without unnecessary 7,469
duplication of coverage. If the court issues an order under this 7,470
division, it shall include in the order any of the requirements, 7,471
notices, and information set forth in divisions (C)(1) to (13) of 7,472
this section that are applicable. 7,473
(E) Any order issued under this section shall be binding 7,475
upon the obligor and the obligee, their employers, and any 7,476
insurer that provides health insurance coverage for either of 7,477
them or their children. The court shall send a copy of any order 7,478
issued under this section that contains any requirement or notice 7,479
described in division (C)(1), (2), (3), (4), (7), (8), or (10) of 7,480
this section by ordinary mail to the obligor, the obligee, and 7,481
any employer that is subject to the order. The court shall send 7,482
a copy of any order issued under this section that contains any 7,483
169
requirement contained in division (C)(9) of this section by 7,484
ordinary mail to the obligor and obligee. 7,485
(F) If an obligor does not comply with any order issued 7,487
under this section that contains any requirement or notice 7,488
described in division (C)(1), (2), (4), (7), (8), or (10) of this 7,489
section within thirty days after the order is issued, the child 7,490
support enforcement agency shall notify the court in writing of 7,491
the failure of the obligor to comply with the order. Upon 7,492
receipt of the notice from the agency, the court shall issue an 7,493
order to the employer of the obligor requiring the employer to 7,494
take whatever action is necessary to make application to enroll 7,495
the obligor in any available group health insurance or health 7,496
care policy, contract, or plan with coverage for the children who 7,497
are the subject of the child support order, to submit a copy of 7,498
the court order issued pursuant to division (C) of this section 7,499
to the insurer at the time that the employer makes application to 7,500
enroll the children in the health insurance or health care 7,501
policy, contract, or plan, and, if the obligor's application is 7,502
accepted, to deduct from the wages or other income of the obligor 7,503
the cost of the coverage for the children. Upon receipt of any 7,504
order under this division, the employer shall take whatever 7,505
action is necessary to comply with the order. 7,506
During the time that any order issued under this section is 7,508
in effect and after the employer has received a copy of the 7,509
order, the employer of the obligor who is the subject of the 7,510
order shall comply with the order and, upon request from the 7,511
obligee or agency, shall release to the obligee and the child 7,512
support enforcement agency all information about the obligor's 7,513
health insurance coverage that is necessary to ensure compliance 7,514
with this section or any order issued under this section, 7,515
including, but not limited to, the name and address of the 7,516
insurer and any policy, contract, or plan number. Any 7,517
information provided by an employer pursuant to this division 7,518
shall be used only for the purpose of the enforcement of an order 7,519
170
issued under this section. 7,520
Any employer who receives a copy of an order issued under 7,522
this section shall notify the child support enforcement agency of 7,523
any change in or the termination of the obligor's health 7,524
insurance coverage that is maintained pursuant to an order issued 7,525
under this section. 7,526
(G) Any insurer that receives a copy of an order issued 7,528
under this section shall comply with this section and any order 7,529
issued under this section, regardless of the residence of the 7,530
children. If an insurer provides health insurance coverage for 7,531
the children who are the subject of a child support order in 7,532
accordance with an order issued under this section, the insurer 7,533
shall reimburse the parent, who is designated to receive 7,534
reimbursement in the order issued under this section, for covered 7,535
out-of-pocket medical, optical, hospital, dental, or prescription 7,536
expenses incurred on behalf of the children subject to the order. 7,537
(H) If an obligee under a child support order is eligible 7,539
for medical assistance under Chapter 5111. or 5115. of the 7,540
Revised Code and the obligor has obtained health insurance 7,541
coverage pursuant to an order issued under division (C) of this 7,542
section, the obligee shall notify any physician, hospital, or 7,543
other provider of medical services for which medical assistance 7,544
is available of the name and address of the obligor's insurer and 7,545
of the number of the obligor's health insurance or health care 7,546
policy, contract, or plan. Any physician, hospital, or other 7,547
provider of medical services for which medical assistance is 7,548
available under Chapter 5111. or 5115. of the Revised Code who is 7,549
notified under this division of the existence of a health 7,550
insurance or health care policy, contract, or plan with coverage 7,551
for children who are eligible for medical assistance first shall 7,552
bill the insurer for any services provided for those children. 7,553
If the insurer fails to pay all or any part of a claim filed 7,554
under this division by the physician, hospital, or other medical 7,555
services provider and the services for which the claim is filed 7,556
171
are covered by Chapter 5111. or 5115. of the Revised Code, the 7,557
physician, hospital, or other medical services provider shall 7,558
bill the remaining unpaid costs of the services in accordance 7,559
with Chapter 5111. or 5115. of the Revised Code. 7,560
(I) Any obligor who fails to comply with an order issued 7,562
under this section is liable to the obligee for any medical 7,563
expenses incurred as a result of the failure to comply with the 7,564
order. 7,565
(J) Whoever violates an order issued under this section 7,567
may be punished as for contempt under Chapter 2705. of the 7,568
Revised Code. If an obligor is found in contempt under that 7,569
chapter for failing to comply with an order issued under this 7,570
section and if the obligor previously has been found in contempt 7,571
under that chapter, the court shall consider the obligor's 7,572
failure to comply with the court's order as a change in 7,573
circumstances for the purpose of modification of the amount of 7,574
support due under the child support order that is the basis of 7,575
the order issued under this section. 7,576
(K) Nothing in this section shall be construed to require 7,578
an insurer to accept for enrollment any child who does not meet 7,579
the underwriting standards of the health insurance or health care 7,580
policy, contract, or plan for which application is made. 7,581
(L) Notwithstanding section 3109.01 of the Revised Code, 7,583
if a court issues an order under this section requiring a parent 7,584
to obtain health insurance coverage for the children who are the 7,585
subject of a child support order, the order shall remain in 7,586
effect beyond the child's eighteenth birthday as long as the 7,587
child continuously attends on a full-time basis any recognized 7,588
and accredited high school. Any parent ordered to obtain health 7,589
insurance coverage for the children who are the subject of a 7,590
child support order shall continue to obtain the coverage for the 7,591
children under the order, including during seasonal vacation 7,592
periods, until the order terminates. 7,593
Sec. 3307.74. (A) The state teachers retirement board may 7,602
172
enter into an agreement with insurance companies, medical or 7,603
health care INSURING corporations, health maintenance 7,604
organizations, or government agencies authorized to do business 7,606
in the state for issuance of a policy or contract of health, 7,607
medical, hospital, or surgical benefits, or any combination 7,608
thereof, for those individuals receiving service retirement or a 7,609
disability or survivor benefit subscribing to the plan. 7,611
Notwithstanding any other provision of this chapter, the policy 7,613
or contract may also include coverage for any eligible
individual's spouse and dependent children and for any of the 7,615
individual's sponsored dependents as the board considers 7,616
appropriate. If all or any portion of the policy or contract 7,617
premium is to be paid by any individual receiving service 7,618
retirement or a disability or survivor benefit, the individual 7,619
shall, by written authorization, instruct the board to deduct the 7,621
premium agreed to be paid by the individual to the companies, 7,622
associations, corporations, or agencies. 7,623
The board may contract for coverage on the basis of part or 7,626
all of the cost of the coverage to be paid from appropriate funds 7,627
of the state teachers retirement system. The cost paid from the 7,628
funds of the system shall be included in the employer's 7,630
contribution rate provided by section 3307.53 of the Revised 7,631
Code.
The board may provide for self-insurance of risk or level 7,633
of risk as set forth in the contract with the companies, 7,634
corporations, or agencies, and may provide through the 7,635
self-insurance method specific benefits as authorized by the 7,636
rules of the board. 7,637
(B) If the board provides health, medical, hospital, or 7,639
surgical benefits through any means other than a health 7,640
maintenance organization INSURING CORPORATION, it shall offer to 7,641
each individual eligible for the benefits the alternative of 7,644
receiving benefits through enrollment in a health maintenance
organization INSURING CORPORATION, if all of the following apply: 7,646
173
(1) The health maintenance organization INSURING 7,648
CORPORATION provides HEALTH CARE services in the geographical 7,650
area in which the individual lives; 7,651
(2) The eligible individual was receiving health care 7,653
benefits through a health maintenance organization OR A HEALTH 7,655
INSURING CORPORATION before retirement; 7,656
(3) The rate and coverage provided by the health 7,658
maintenance organization INSURING CORPORATION to eligible 7,659
individuals is comparable to that currently provided by the board 7,662
under division (A) of this section. If the rate or coverage 7,663
provided by the health maintenance organization INSURING 7,664
CORPORATION is not comparable to that currently provided by the 7,666
board under division (A) of this section, the board may deduct 7,667
the additional cost from the eligible individual's monthly 7,668
benefit.
The health maintenance organization INSURING CORPORATION 7,670
shall accept as an enrollee any eligible individual who requests 7,672
enrollment.
The board shall permit each eligible individual to change 7,674
from one plan to another at least once a year at a time 7,675
determined by the board. 7,676
(C) The board shall, beginning the month following receipt 7,678
of satisfactory evidence of the payment for coverage, make a 7,679
monthly payment to each recipient of service retirement, or a 7,680
disability or survivor benefit under the state teachers 7,681
retirement system who is eligible for insurance coverage under 7,682
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,683
42 U.S.C.A. 1395j, as amended. The payment shall be the lesser 7,684
of an amount equal to the basic premium for such coverage, or an 7,686
amount equal to the basic premium in effect on April 10, 1991. 7,687
(D) The board shall establish by rule requirements for the 7,689
coordination of any coverage, payment, or benefit provided under 7,691
this section or section 3307.405 of the Revised Code with any 7,693
similar coverage, payment, or benefit made available to the same 7,694
174
individual by the public employees retirement system, police and 7,695
firemen's disability and pension fund, school employees 7,696
retirement system, or state highway patrol retirement system. 7,697
(E) The board shall make all other necessary rules 7,699
pursuant to the purpose and intent of this section. 7,700
Sec. 3307.741. The state teachers retirement board shall 7,709
establish a program under which members of the retirement system, 7,710
employers on behalf of members, and persons receiving service, 7,711
disability, or survivor benefits are permitted to participate in 7,712
contracts for long-term health care insurance. Participation may 7,713
include dependents and family members. If a participant in a 7,714
contract for long-term care insurance leaves his employment, he 7,715
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 7,717
members may, at their election, continue to participate in a 7,719
program established under this section in the same manner as if 7,720
he THE PARTICIPANT had not left his employment, except that no 7,722
part of the cost of the insurance shall be paid by his THE 7,723
PARTICIPANT'S former employer.
Such program may be established independently or jointly 7,725
with one or more of the other retirement systems. For purposes 7,726
of this section, "retirement systems" has the same meaning as in 7,727
division (A) of section 145.581 of the Revised Code. 7,728
The board may enter into an agreement with insurance 7,730
companies, medical or health care INSURING corporations, health 7,732
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 7,733
insurance policy or contract. However, prior to entering into 7,734
such an agreement with an insurance company, medical or health 7,735
care INSURING corporation, or health maintenance organization, 7,737
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 7,739
or organization. The board shall not enter into the agreement 7,740
if, according to that certification, the company, OR corporation, 7,741
or organization is insolvent, is determined by the superintendent 7,742
175
to be potentially unable to fulfill its contractual obligations, 7,744
or is placed under an order of rehabilitation or conservation by 7,745
a court of competent jurisdiction or under an order of 7,746
supervision by the superintendent. 7,747
The board shall adopt rules in accordance with section 7,749
111.15 of the Revised Code governing the program. The rules 7,750
shall establish methods of payment for participation under this 7,751
section, which may include establishment of a payroll deduction 7,752
plan under section 3307.281 of the Revised Code, deduction of the 7,753
full premium charged from a person's service, disability, or 7,754
survivor benefit, or any other method of payment considered 7,755
appropriate by the board. If the program is established jointly 7,756
with one or more of the other retirement systems, the rules also 7,757
shall establish the terms and conditions of such joint 7,758
participation. 7,759
Sec. 3309.69. (A) As used in this section, "ineligible 7,768
individual" means all of the following: 7,769
(1) A former member receiving benefits pursuant to section 7,771
3309.34, 3309.35, 3309.36, 3309.38, or 3309.381 of the Revised 7,772
Code for whom eligibility is established more than five years 7,773
after June 13, 1981, and who, at the time of establishing 7,774
eligibility, has accrued less than ten years of service credit, 7,775
exclusive of credit obtained after January 29, 1981, pursuant to 7,776
sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised 7,777
Code; 7,778
(2) The spouse of the former member; 7,780
(3) The beneficiary of the former member receiving 7,782
benefits pursuant to section 3309.46 of the Revised Code. 7,783
(B) The school employees retirement board may enter into 7,785
an agreement with insurance companies, medical or health care 7,786
INSURING corporations, health maintenance organizations, or 7,788
government agencies authorized to do business in the state for 7,789
issuance of a policy or contract of health, medical, hospital, or 7,790
surgical benefits, or any combination thereof, for those 7,791
176
individuals receiving service retirement or a disability or 7,792
survivor benefit subscribing to the plan and their eligible 7,794
dependents.
If all or any portion of the policy or contract premium is 7,796
to be paid by any individual receiving service retirement or a 7,798
disability or survivor benefit, the person shall, by written 7,799
authorization, instruct the board to deduct the premiums agreed 7,800
to be paid by the individual to the companies, corporations, or 7,802
agencies.
The board may contract for coverage on the basis of part or 7,805
all of the cost of the coverage to be paid from appropriate funds 7,806
of the school employees retirement system. The cost paid from 7,807
the funds of the system shall be included in the employer's 7,809
contribution rate provided by sections 3309.49 and 3309.491 of 7,810
the Revised Code. The board shall not pay or reimburse the cost 7,811
for health care under this section or section 3309.375 of the 7,812
Revised Code for any ineligible individual. 7,813
The board may provide for self-insurance of risk or level 7,815
of risk as set forth in the contract with the companies, 7,816
corporations, or agencies, and may provide through the 7,817
self-insurance method specific benefits as authorized by the 7,818
rules of the board. 7,819
(C) If the board provides health, medical, hospital, or 7,821
surgical benefits through any means other than a health 7,822
maintenance organization INSURING CORPORATION, it shall offer to 7,823
each individual eligible for the benefits the alternative of 7,826
receiving benefits through enrollment in a health maintenance 7,828
organization INSURING CORPORATION, if all of the following apply: 7,830
(1) The health maintenance organization INSURING 7,832
CORPORATION provides HEALTH CARE services in the geographical 7,834
area in which the individual lives; 7,835
(2) The eligible individual was receiving health care 7,837
benefits through a health maintenance organization OR A HEALTH 7,838
INSURING CORPORATION before retirement; 7,840
177
(3) The rate and coverage provided by the health 7,842
maintenance organization INSURING CORPORATION to eligible 7,843
individuals is comparable to that currently provided by the board 7,845
under division (B) of this section. If the rate or coverage 7,846
provided by the health maintenance organization INSURING 7,847
CORPORATION is not comparable to that currently provided by the 7,849
board under division (B) of this section, the board may deduct 7,850
the additional cost from the eligible individual's monthly 7,851
benefit.
The health maintenance organization INSURING CORPORATION 7,853
shall accept as an enrollee any eligible individual who requests 7,855
enrollment.
The board shall permit each eligible individual to change 7,857
from one plan to another at least once a year at a time 7,858
determined by the board. 7,859
(D) The board shall, beginning the month following receipt 7,861
of satisfactory evidence of the payment for coverage, make a 7,862
monthly payment to each recipient of service retirement, or a 7,863
disability or survivor benefit under the school employees 7,864
retirement system who is eligible for insurance coverage under 7,865
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,866
42 U.S.C.A. 1395j, as amended, except that the board shall make 7,867
no such payment to any ineligible individual. The amount of the 7,868
payment shall be the lesser of an amount equal to the basic 7,869
premium for such coverage, or an amount equal to the basic 7,871
premium in effect on January 1, 1988.
(E) The board shall establish by rule requirements for the 7,873
coordination of any coverage, payment, or benefit provided under 7,875
this section or section 3309.375 of the Revised Code with any 7,877
similar coverage, payment, or benefit made available to the same 7,878
individual by the public employees retirement system, police and 7,879
firemen's disability and pension fund, state teachers retirement 7,880
system, or state highway patrol retirement system. 7,881
(F) The board shall make all other necessary rules 7,883
178
pursuant to the purpose and intent of this section. 7,884
Sec. 3309.691. The school employees retirement board shall 7,893
establish a program under which members of the retirement system, 7,894
employers on behalf of members, and persons receiving service, 7,895
disability, or survivor benefits are permitted to participate in 7,896
contracts for long-term health care insurance. Participation may 7,897
include dependents and family members. If a participant in a 7,898
contract for long-term care insurance leaves his employment, he 7,899
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 7,901
members may, at their election, continue to participate in a
program established under this section in the same manner as if 7,902
he THE PARTICIPANT had not left his employment, except that no 7,903
part of the cost of the insurance shall be paid by his THE 7,904
PARTICIPANT'S former employer. 7,905
Such program may be established independently or jointly 7,907
with one or more of the other retirement systems. For purposes 7,908
of this section, "retirement systems" has the same meaning as in 7,909
division (A) of section 145.581 of the Revised Code. 7,910
The board may enter into an agreement with insurance 7,912
companies, medical or health care INSURING corporations, health 7,914
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 7,915
insurance policy or contract. However, prior to entering into 7,916
such an agreement with an insurance company, medical or health 7,917
care INSURING corporation, or health maintenance organization, 7,919
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 7,921
or organization. The board shall not enter into the agreement 7,922
if, according to that certification, the company, OR corporation, 7,923
or organization is insolvent, is determined by the superintendent 7,924
to be potentially unable to fulfill its contractual obligations, 7,926
or is placed under an order of rehabilitation or conservation by 7,927
a court of competent jurisdiction or under an order of 7,928
supervision by the superintendent. 7,929
179
The board shall adopt rules in accordance with section 7,931
111.15 of the Revised Code governing the program. The rules 7,932
shall establish methods of payment for participation under this 7,933
section, which may include establishment of a payroll deduction 7,934
plan under section 3309.27 of the Revised Code, deduction of the 7,935
full premium charged from a person's service, disability, or 7,936
survivor benefit, or any other method of payment considered 7,937
appropriate by the board. If the program is established jointly 7,938
with one or more of the other retirement systems, the rules also 7,939
shall establish the terms and conditions of such joint 7,940
participation. 7,941
Sec. 3313.202. (A) The board of education of a school 7,950
district may procure and pay all or part of the cost of group 7,951
term life, hospitalization, surgical care, or major medical 7,952
insurance, disability, dental care, vision care, medical care, 7,953
hearing aids, prescription drugs, sickness and accident 7,954
insurance, group legal services, or a combination of any of the 7,955
foregoing types of insurance or coverage, whether issued by an 7,956
insurance company or a medical care corporation, health care 7,957
INSURING corporation, dental care corporation, or health 7,959
maintenance organization duly licensed by this state, covering 7,960
the teaching or nonteaching employees of the school district, or 7,961
a combination of both, or the dependent children and spouses of 7,962
such employees, provided if such coverage affects only the 7,963
teaching employees of the district such coverage shall be with 7,964
the consent of a majority of such employees of the school 7,965
district, or if such coverage affects only the nonteaching 7,966
employees of the district such coverage shall be with the consent 7,967
of a majority of such employees. If such coverage is proposed to 7,968
cover all the employees of a school district, both teaching and 7,969
nonteaching employees, such coverage shall be with the consent of 7,970
a majority of all the employees of a school district. A board of 7,971
education shall continue to carry, on payroll records, all school 7,972
employees whose sick leave accumulation has expired, or who are 7,973
180
on a disability leave of absence or an approved leave of absence, 7,974
for the purpose of group term life, hospitalization, surgical, 7,975
major medical, or any other insurance. A board of education may 7,976
pay all or part of such coverage except when such employees are 7,977
on an approved leave of absence, or on a disability leave of 7,978
absence for that period exceeding two years. As used in this 7,979
section, "teaching employees" means any person employed in the 7,980
public schools of this state in a position for which the person 7,981
is required to have a certificate or license pursuant to sections 7,982
3319.22 to 3319.31 of the Revised Code. "Nonteaching employees" 7,983
as used in this section means any person employed in the public 7,984
schools of the state in a position for which the person is not 7,985
required to have a certificate or license issued pursuant to 7,986
sections 3319.22 to 3319.31 of the Revised Code. 7,987
(B) The board of education of a school district may enter 7,989
into an agreement with a jointly administered trust fund which 7,990
receives contributions pursuant to a collective bargaining 7,991
agreement entered into between the board and any collective 7,992
bargaining representative of the employees of the board for the 7,993
purpose of providing for self-insurance of all risk in the 7,994
provision of fringe benefits similar to those that may be paid 7,995
pursuant to division (A) of this section, and may provide through 7,996
the self-insurance method specific fringe benefits as authorized 7,997
by the rules of the board of trustees of the jointly administered 7,998
trust fund. Benefits provided under this section include, but 7,999
are not limited to, hospitalization, surgical care, major medical 8,000
care, disability, dental care, vision care, medical care, hearing 8,001
aids, prescription drugs, group life insurance, sickness and 8,002
accident insurance, group legal services, or a combination of the 8,003
above benefits, for the employees and their dependents. 8,004
(C) Notwithstanding any other provision of the Revised 8,006
Code, the board of education and any collective bargaining 8,007
representative of employees of the board may agree in a 8,008
collective bargaining agreement that any mutually agreed fringe 8,009
181
benefit, including, but not limited to, hospitalization, surgical 8,010
care, major medical care, disability, dental care, vision care, 8,011
medical care, hearing aids, prescription drugs, group life 8,012
insurance, sickness and accident insurance, group legal services, 8,013
or a combination thereof, for employees and their dependents be 8,014
provided through a mutually agreed upon contribution to a jointly 8,015
administered trust fund. The amount, type, and structure of 8,016
fringe benefits provided under this division are subject to the 8,017
determination of the board of trustees of the jointly 8,018
administered trust fund. Notwithstanding any other provision of 8,019
the Revised Code, competitive bidding does not apply to the 8,020
purchase of fringe benefits for employees under this division 8,021
through a jointly administered trust fund. 8,022
(D) Any elected or appointed member of the board of 8,024
education and the dependent children and spouse of the member may 8,025
be covered, at the option of the member, as an employee of the 8,026
school district under any benefit plan adopted under this 8,027
section. The member shall pay to the school district the amount 8,028
certified for that coverage under division (D)(1) or (2) of this 8,029
section. Payments for such coverage shall be made, in advance, 8,030
in a manner prescribed by the board. The member's exercise of an 8,031
option to be covered under this section shall be in writing, 8,032
announced at a regular public meeting of the board, and recorded 8,033
as a public record in the minutes of the board. 8,034
For the purposes of determining the cost to board members 8,036
under this division: 8,037
(1) In the case of a benefit plan purchased under division 8,039
(A) of this section, the provider of the benefits shall certify 8,040
to the board the provider's charge for coverage under each option 8,041
available to employees under that benefit plan; 8,042
(2) In the case of benefits provided under division (B) or 8,044
(C) of this section, the board of trustees of the jointly 8,045
administered trust fund shall certify to the board of education 8,046
the trustees' charge for coverage under each option available to 8,047
182
employees under each benefit plan. 8,048
(E) The board may provide the benefits described in this 8,050
section through an individual self-insurance program or a joint 8,051
self-insurance program as provided in section 9.833 of the 8,052
Revised Code. 8,053
Sec. 3375.40. Each board of library trustees appointed 8,062
pursuant to sections 3375.06, 3375.10, 3375.12, 3375.15, 3375.22, 8,063
and 3375.30 of the Revised Code may: 8,064
(A) Hold title to and have the custody of all real and 8,066
personal property of the free public library under its 8,067
jurisdiction; 8,068
(B) Expend for library purposes, and in the exercise of 8,070
the power enumerated in this section, all moneys, whether derived 8,071
from the county library and local government support fund or 8,072
otherwise, credited to the free public library under its 8,073
jurisdiction and generally do all things it considers necessary 8,074
for the establishment, maintenance, and improvement of the public 8,075
library under its jurisdiction; 8,076
(C) Purchase, lease, construct, remodel, renovate, or 8,078
otherwise improve, equip, and furnish buildings or parts of 8,079
buildings and other real property, and purchase, lease, or 8,080
otherwise acquire motor vehicles and other personal property, 8,082
necessary for the proper maintenance and operation of the free 8,083
public libraries under its jurisdiction, and pay the costs 8,084
thereof in installments or otherwise. Financing of these costs 8,085
may be provided through the issuance of notes, through an 8,086
installment sale, or through a lease-purchase agreement. Any
such notes shall be issued pursuant to section 3375.404 of the 8,087
Revised Code.
(D) Purchase, lease, lease with an option to purchase, or 8,089
erect buildings or parts of buildings to be used as main 8,090
libraries, branch libraries, or library stations pursuant to 8,091
section 3375.41 of the Revised Code; 8,092
(E) Establish and maintain a main library, branches, 8,094
183
library stations, and traveling library service within the 8,095
territorial boundaries of the subdivision or district over which 8,096
it has jurisdiction of free public library service; 8,097
(F) Establish and maintain branches, library stations, and 8,099
traveling library service in any school district, outside the 8,100
territorial boundaries of the subdivision or district over which 8,101
it has jurisdiction of free public library service, upon 8,102
application to and approval of the state library board, pursuant 8,103
to section 3375.05 of the Revised Code; provided the board of 8,104
trustees of any free public library maintaining branches, 8,105
stations, or traveling-book service, outside the territorial 8,106
boundaries of the subdivision or district over which it has 8,107
jurisdiction of free public library service, on September 4, 8,108
1947, may continue to maintain and operate such branches, 8,109
stations, and traveling library service without the approval of 8,110
the state library board; 8,111
(G) Appoint and fix the compensation of all of the 8,113
employees of the free public library under its jurisdiction; pay 8,114
the reasonable cost of tuition for any of its employees who 8,115
enroll in a course of study the board considers essential to the 8,116
duties of the employee or to the improvement of the employee's 8,117
performance; and reimburse applicants for employment for any 8,118
reasonable expenses they incur by appearing for a personal 8,119
interview; 8,120
(H) Make and publish rules for the proper operation and 8,122
management of the free public library and facilities under its 8,123
jurisdiction, including rules pertaining to the provision of 8,124
library services to individuals, corporations, or institutions 8,125
that are not inhabitants of the county; 8,126
(I) Establish and maintain a museum in connection with and 8,128
as an adjunct to the free public library under its jurisdiction; 8,129
(J) By the adoption of a resolution accept any bequest, 8,131
gift, or endowment upon the conditions connected with such 8,132
bequest, gift, or endowment; provided no such bequest, gift, or 8,133
184
endowment shall be accepted by such board if the conditions 8,134
thereof remove any portion of the free public library under its 8,135
jurisdiction from the control of such board or if such 8,136
conditions, in any manner, limit the free use of such library or 8,137
any part thereof by the residents of the counties in which such 8,138
library is located; 8,139
(K) At the end of any fiscal year by a two-thirds vote of 8,141
its full membership set aside any unencumbered surplus remaining 8,142
in the general fund of the library under its jurisdiction for any 8,143
purpose including creating or increasing a special building and 8,144
repair fund, or for operating the library or acquiring equipment 8,145
and supplies; 8,146
(L) Procure and pay all or part of the cost of group life, 8,148
hospitalization, surgical, major medical, disability benefit, 8,149
dental care, eye care, hearing aids, or prescription drug 8,150
insurance, or a combination of any of the foregoing types of 8,151
insurance or coverage, whether issued by an insurance company, or 8,152
nonprofit medical or dental care A HEALTH INSURING corporation 8,153
duly licensed by the state, covering its employees and in the 8,154
case of hospitalization, surgical, major medical, dental care, 8,155
eye care, hearing aids, or prescription drug insurance, also 8,156
covering the dependents and spouses of such employees, and in the 8,157
case of disability benefits, also covering spouses of such 8,158
employees. With respect to life insurance, coverage for any 8,159
employee shall not exceed the greater of the sum of ten thousand 8,160
dollars or the annual salary of the employee, exclusive of any 8,161
double indemnity clause that is a part of the policy. 8,162
(M) Pay reasonable dues and expenses for the free public 8,164
library and library trustees in library associations. 8,165
Sec. 3381.14. A regional arts and cultural district may 8,174
procure and pay all or any part of the cost of group 8,175
hospitalization, surgical, major medical, or sickness and 8,176
accident insurance or a combination of any of the foregoing for 8,177
the employees of the district and their immediate dependents, 8,178
185
whether issued by an insurance company, nonprofit medical care OR 8,179
A HEALTH INSURING corporation, or hospital service association 8,180
duly authorized to do business in this state. 8,181
Sec. 3501.141. (A) The board of elections of any county 8,190
may contract, purchase, or otherwise procure and pay all or any 8,191
part of the cost of group insurance policies that may provide 8,192
benefits for hospitalization, surgical care, major medical care, 8,193
disability, dental care, eye care, medical care, hearing aids, or 8,194
prescription drugs, and that may provide sickness and accident 8,195
insurance, or group life insurance, or a combination of any of 8,196
the foregoing types of insurance or coverage for the full-time 8,197
employees of such board and their immediate dependents, whether 8,198
issued by an insurance company, a health or medical care 8,199
corporation, a dental care corporation, or a health maintenance 8,200
organization INSURING CORPORATION, duly authorized to do business 8,201
in this state. 8,202
(B) The board of elections of any county may procure and 8,204
pay all or any part of the cost of group hospitalization, 8,205
surgical, major medical, or sickness and accident insurance or a 8,206
combination of any of the foregoing types of insurance or 8,207
coverage for the members appointed to the board of elections 8,208
under section 3501.06 of the Revised Code and their immediate 8,209
dependents when each member's term begins, whether issued by an 8,210
insurance company or a health or medical care INSURING 8,211
corporation, duly authorized to do business in this state. 8,212
Sec. 3701.24. (A) As used in this section and sections 8,221
3701.241 to 3701.249 of the Revised Code: 8,222
(1) "AIDS" means the illness designated as acquired 8,224
immunodeficiency syndrome. 8,225
(2) "HIV" means the human immunodeficiency virus 8,227
identified as the causative agent of AIDS. 8,228
(3) "AIDS-related condition" means symptoms of illness 8,230
related to HIV infection, including AIDS-related complex, that 8,232
are confirmed by a positive HIV test. 8,233
186
(4) "HIV test" means any test for the antibody or antigen 8,235
to HIV that has been approved by the director of health under 8,236
division (B) of section 3701.241 of the Revised Code. 8,237
(5) "Health care facility" has the same meaning as in 8,239
section 1742.01 1751.01 of the Revised Code. 8,240
(6) "Director" means the director of health or any 8,242
employee of the department of health acting on his THE DIRECTOR'S 8,244
behalf.
(7) "Physician" means a person who holds a current, valid 8,246
certificate issued under Chapter 4731. of the Revised Code 8,247
authorizing the practice of medicine or surgery and osteopathic 8,248
medicine and surgery. 8,249
(8) "Nurse" means a registered nurse or licensed practical 8,251
nurse who holds a license or certificate issued under Chapter 8,252
4723. of the Revised Code. 8,253
(9) "Anonymous test" means an HIV test administered so 8,255
that the individual to be tested can give informed consent to the 8,256
test and receive the results by means of a code system that does 8,257
not link his THE identity OF THE INDIVIDUAL TESTED to the request 8,259
for the test or the test results.
(10) "Confidential test" means an HIV test administered so 8,261
that the identity of the individual tested is linked to the test 8,262
but is held in confidence to the extent provided by section 8,263
3701.24 to 3701.248 of the Revised Code. 8,264
(11) "Health care provider" means an individual who 8,266
provides diagnostic, evaluative, or treatment services. Pursuant 8,267
to Chapter 119. of the Revised Code, the public health council 8,268
may adopt rules further defining the scope of the term "health 8,269
care provider." 8,270
(12) "Significant exposure to body fluids" means a 8,272
percutaneous or mucous membrane exposure of an individual to the 8,273
blood, semen, vaginal secretions, or spinal, synovial, pleural, 8,274
peritoneal, pericardial, or amniotic fluid of another individual. 8,275
(13) "Emergency medical services worker" means all of the 8,277
187
following: 8,278
(a) A peace officer; 8,280
(b) An employee of an emergency medical service 8,282
organization as defined in section 4765.01 of the Revised Code; 8,283
(c) A firefighter employed by a political subdivision; 8,285
(d) A volunteer firefighter, emergency operator, or rescue 8,287
operator; 8,288
(e) An employee of a private organization that renders 8,290
rescue services, emergency medical services, or emergency medical 8,291
transportation to accident victims and persons suffering serious 8,292
illness or injury. 8,293
(14) "Peace officer" has the same meaning as in division 8,295
(A) of section 109.71 of the Revised Code, except that it also 8,296
includes a sheriff and the superintendent and troopers of the 8,297
state highway patrol. 8,298
(B) Boards of health, health authorities or officials, and 8,300
physicians in localities in which there are no health authorities 8,301
or officials, shall report promptly to the department of health 8,302
the existence of any one of the following diseases: 8,303
(1) Asiatic cholera; 8,305
(2) Yellow fever; 8,307
(3) Diphtheria; 8,309
(4) Typhus or typhoid fever; 8,311
(5) Any other contagious or infectious diseases that the 8,313
public health council specifies. 8,314
(C) Persons designated by rule adopted by the public 8,316
health council under section 3701.241 of the Revised Code shall 8,317
report promptly every case of AIDS, every AIDS-related condition, 8,319
and every confirmed positive HIV test to the department of health 8,320
on forms and in a manner prescribed by the director. In each 8,321
county the director shall designate the health commissioner of a 8,322
health district in the county to receive the reports. 8,323
Information reported under this division that identifies an 8,325
individual is confidential and may be released only with the 8,326
188
written consent of the individual except as the director 8,327
determines necessary to ensure the accuracy of the information, 8,328
as necessary to provide treatment to the individual, as ordered 8,329
by a court pursuant to section 3701.243 or 3701.247 of the 8,330
Revised Code, or pursuant to a search warrant or a subpoena 8,331
issued by or at the request of a grand jury, prosecuting 8,332
attorney, city director of law or similar chief legal officer of 8,333
a municipal corporation, or village solicitor, in connection with 8,334
a criminal investigation or prosecution. Information that does 8,335
not identify an individual may be released in summary, 8,336
statistical, or other form. 8,337
Sec. 3701.76. (A) The director of health shall establish 8,346
and maintain a statewide public information campaign on the 8,347
effects of diethylstilbestrol or other nonsteroidal synthetic 8,348
estrogens for the purpose of educating the public concerning the 8,349
potential hazards related to exposure to diethylstilbestrol or 8,350
other nonsteroidal synthetic estrogens and encouraging persons 8,351
exposed to diethylstilbestrol or other nonsteroidal synthetic 8,352
estrogens, including those exposed before birth, to seek medical 8,353
attention for the identification and treatment of any conditions 8,354
resulting from this exposure. 8,355
(B) The director shall maintain a registry of hospitals, 8,357
clinics, physicians, or other health care providers to whom he 8,358
THE DIRECTOR shall refer persons who make inquiries to the 8,359
department of health regarding possible exposure to 8,360
diethylstilbestrol or other nonsteroidal synthetic estrogens. In 8,361
order to be eligible for listing in the registry, a health care 8,362
provider shall make an application to the director, and shall 8,363
have the necessary experience, facilities, and equipment to make 8,364
examinations for possible effects of diethylstilbestrol or other 8,365
nonsteroidal synthetic estrogens. 8,366
(C) The director shall maintain a registry of persons who 8,368
have been exposed to diethylstilbestrol or other nonsteroidal 8,369
synthetic estrogens, including persons exposed before birth, for 8,370
189
the purpose of studying and monitoring conditions caused by 8,371
exposure to diethylstilbestrol or other nonsteroidal synthetic 8,372
estrogen. No person shall be listed in the registry without his 8,373
THE DIRECTOR'S consent. 8,374
(D) The director shall make an annual report to the 8,376
general assembly on the effectiveness of the programs established 8,377
under this section, and shall make recommendations concerning the 8,378
programs and possible legislation relating to them. 8,379
(E) No insurance company doing business under Title XXXIX 8,381
and no HEALTH INSURING corporation holding a certificate of 8,382
authority or license under Chapter 1737., 1738., or 1742. 1751. 8,383
of the Revised Code shall cancel or refuse to renew a policy or 8,385
subscription, contract, CERTIFICATE, OR AGREEMENT or limit 8,386
benefits provided under a policy or subscription, contract, 8,387
CERTIFICATE, OR AGREEMENT solely because a policyholder, 8,388
subscriber, or applicant for a policy or subscription, contract, 8,389
CERTIFICATE, OR AGREEMENT has been exposed to diethylstilbestrol 8,390
or other nonsteroidal synthetic estrogens. 8,391
Sec. 3702.51. As used in sections 3702.51 to 3702.62 of 8,400
the Revised Code: 8,401
(A) "Applicant" means any person that submits an 8,403
application for a certificate of need and who is designated in 8,404
the application as the applicant. 8,405
(B) "Person" means any individual, corporation, business 8,407
trust, estate, firm, partnership, association, joint stock 8,408
company, insurance company, government unit, or other entity. 8,409
(C) "Certificate of need" means a written approval granted 8,411
by the director of health to an applicant to authorize conducting 8,412
a reviewable activity. 8,413
(D) "Health service area" means a geographic region 8,415
designated by the director of health under section 3702.58 of the 8,416
Revised Code. 8,417
(E) "Health service" means a clinically related service, 8,419
such as a diagnostic, treatment, rehabilitative, or preventive 8,420
190
service. 8,421
(F) "Health service agency" means an agency designated to 8,423
serve a health service area in accordance with section 3702.58 of 8,424
the Revised Code. 8,425
(G) "Health care facility" means: 8,427
(1) A hospital registered under section 3701.07 of the 8,429
Revised Code; 8,430
(2) A nursing home licensed under section 3721.02 of the 8,432
Revised Code, or by a political subdivision certified under 8,433
section 3721.09 of the Revised Code; 8,434
(3) A county home or a county nursing home as defined in 8,436
section 5155.31 of the Revised Code that is certified under Title 8,437
XVIII or XIX of the "Social Security Act," 49 Stat. 620 (1935), 8,438
42 U.S.C.A. 301, as amended; 8,439
(4) A freestanding dialysis center; 8,441
(5) A freestanding inpatient rehabilitation facility; 8,443
(6) An ambulatory surgical facility; 8,445
(7) A freestanding cardiac catheterization facility; 8,447
(8) A freestanding birthing center; 8,449
(9) A freestanding or mobile diagnostic imaging center; 8,451
(10) A freestanding radiation therapy center. 8,453
A health care facility does not include the offices of 8,455
private physicians and dentists whether for individual or group 8,456
practice, Christian Science sanitoriums operated or listed and 8,457
certified by the First Church of Christ, Scientist, Boston, 8,458
Massachusetts, residential facilities licensed under section 8,459
5123.19 of the Revised Code, or habilitation centers certified by 8,460
the director of mental retardation and developmental disabilities 8,461
under section 5123.041 of the Revised Code. 8,462
(H) "Medical equipment" means a single unit of medical 8,464
equipment or a single system of components with related functions 8,465
that is used to provide health services. 8,466
(I) "Third-party payer" means a medical care corporation 8,468
or health care INSURING corporation licensed under Chapter 1737. 8,470
191
or 1738. 1751. of the Revised Code, a health maintenance 8,471
organization AS DEFINED IN DIVISION (K) OF THIS SECTION, an 8,472
insurance company that issues sickness and accident insurance in 8,473
conformity with Chapter 3923. of the Revised Code, a 8,474
state-financed health insurance program under Chapter 3701., 8,475
4123., or 5111. of the Revised Code, or any self-insurance plan. 8,476
(J) "Government unit" means the state and any county, 8,478
municipal corporation, township, or other political subdivision 8,479
of the state, or any department, division, board, or other agency 8,480
of the state or a political subdivision. 8,481
(K) "Health maintenance organization" means a public or 8,483
private organization organized under the law of any state that is 8,484
qualified under section 1310(d) of Title XIII of the "Public 8,485
Health Service Act," 87 Stat. 931 (1973), 42 U.S.C. 300e--9 or 8,486
that does all of the following: 8,487
(1) Provides or otherwise makes available to enrolled 8,489
participants health care services including at least the 8,490
following basic health care services: usual physician services, 8,491
hospitalization, laboratory, x-ray, emergency and preventive 8,492
services, and out-of-area coverage; 8,493
(2) Is compensated, except for copayments, for the 8,495
provision of basic health care services listed in division (K)(1) 8,496
of this section to enrolled participants by a payment that is 8,497
paid on a periodic basis without regard to the date the health 8,498
care services are provided and that is fixed without regard to 8,499
the frequency, extent, or kind of health service actually 8,500
provided; 8,501
(3) Provides physician services primarily either: 8,503
(a) Directly through physicians who are either employees 8,505
or partners of the organization; 8,506
(b) Through arrangements with individual physicians or one 8,508
or more groups of physicians organized on a group practice or 8,509
individual practice basis. 8,510
(L) "Existing health care facility" means a health care 8,512
192
facility that is licensed or otherwise approved to practice in 8,513
this state, in accordance with applicable law, is staffed and 8,514
equipped to provide health care services, and actively provides 8,515
health services or has not been actively providing health 8,516
services for less than twelve consecutive months. 8,517
(M) "State" means the state of Ohio, including, but not 8,519
limited to, the general assembly, the supreme court, the offices 8,520
of all elected state officers, and all departments, boards, 8,521
offices, commissions, agencies, institutions, and other 8,522
instrumentalities of the state of Ohio. "State" does not include 8,523
political subdivisions. 8,524
(N) "Political subdivision" means a municipal corporation, 8,526
township, county, school district, and all other bodies corporate 8,527
and politic responsible for governmental activities only in 8,528
geographic areas smaller than that of the state to which the 8,529
sovereign immunity of the state attaches. 8,530
(O) "Affected person" means: 8,532
(1) An applicant for a certificate of need, including an 8,534
applicant whose application was reviewed comparatively with the 8,535
application in question; 8,536
(2) The person that requested the reviewability ruling in 8,538
question;
(3) Any person that resides or regularly uses health care 8,540
facilities within the geographic area served or to be served by 8,541
the health care services that would be provided under the 8,542
certificate of need or reviewability ruling in question; 8,543
(4) Any health care facility that is located in the health 8,545
service area where the health care services would be provided 8,546
under the certificate of need or reviewability ruling in 8,547
question;
(5) Third-party payers that reimburse health care 8,549
facilities for services in the health service area where the 8,550
health care services would be provided under the certificate of 8,551
need or reviewability ruling in question; 8,552
193
(6) Any other person who testified at a public hearing 8,554
held under division (B) of section 3702.52 of the Revised Code or 8,555
submitted written comments in the course of review of the 8,556
certificate of need application in question. 8,557
(P) "Osteopathic hospital" means a hospital registered 8,559
under section 3701.07 of the Revised Code that advocates 8,560
osteopathic principles and the practice and perpetuation of 8,561
osteopathic medicine by doing any of the following: 8,562
(1) Maintaining a department or service of osteopathic 8,564
medicine or a committee on the utilization of osteopathic 8,565
principles and methods, under the supervision of an osteopathic 8,566
physician; 8,567
(2) Maintaining an active medical staff, the majority of 8,569
which is comprised of osteopathic physicians; 8,570
(3) Maintaining a medical staff executive committee that 8,572
has osteopathic physicians as a majority of its members. 8,573
(Q) "Ambulatory surgical facility" has the same meaning as 8,575
in section 3702.30 of the Revised Code. 8,576
(R) Except as otherwise provided in division (T) of this 8,578
section, and until the termination date specified in section 8,579
3702.511 of the Revised Code, "reviewable activity" means any of 8,580
the following:
(1) The addition by any person of any of the following 8,583
health services, regardless of the amount of operating costs or 8,584
capital expenditures: 8,585
(a) A heart, heart-lung, lung, liver, kidney, bowel, 8,587
pancreas, or bone marrow transplantation service, a stem cell 8,588
harvesting and reinfusion service, or a service for 8,589
transplantation of any other organ unless transplantation of the 8,590
organ is designated by public health council rule not to be a 8,591
reviewable activity; 8,592
(b) A cardiac catheterization service; 8,594
(c) An open-heart surgery service; 8,596
(d) Any new, experimental medical technology that is 8,599
194
designated by rule of the public health council.
(2) The acceptance of high-risk patients, as defined in 8,601
rules adopted under section 3702.57 of the Revised Code, by any 8,602
cardiac catheterization service that was initiated without a 8,603
certificate of need pursuant to division (R)(3)(b) of the version 8,605
of this section in effect immediately prior to April 20, 1995; 8,607
(3)(a) The establishment, development, or construction of 8,609
a new health care facility other than a new long-term care 8,610
facility or a new hospital; 8,611
(b) The establishment, development, or construction of a 8,613
new hospital or the relocation of an existing hospital; 8,614
(c) The relocation of hospital beds, other than long-term 8,616
care, perinatal, or pediatric intensive care beds, into or out of 8,617
a rural area. 8,618
(4)(a) The replacement of an existing hospital; 8,620
(b) The replacement of an existing hospital obstetric or 8,622
newborn care unit or freestanding birthing center. 8,624
(5)(a) The renovation of a hospital that involves a 8,628
capital expenditure, obligated on or after the effective date of
this amendment, of five million dollars or more, not including 8,630
expenditures for equipment, staffing, or operational costs. For
purposes of division (R)(5)(a) of this section, a capital 8,632
expenditure is obligated:
(i) When a contract enforceable under Ohio law is entered 8,634
into for the construction, acquisition, lease, or financing of a 8,635
capital asset; 8,636
(ii) When the governing body of a hospital takes formal 8,638
action to commit its own funds for a construction project 8,639
undertaken by the hospital as its own contractor; 8,640
(iii) In the case of donated property, on the date the 8,642
gift is completed under applicable Ohio law. 8,643
(b) The renovation of a hospital obstetric or newborn care 8,645
unit or freestanding birthing center that involves a capital 8,647
expenditure of five million dollars or more, not including 8,648
195
expenditures for equipment, staffing, or operational costs. 8,649
(6) Any change in the health care services, bed capacity, 8,651
or site, or any other failure to conduct the reviewable activity 8,652
in substantial accordance with the approved application for which 8,653
a certificate of need was granted, if the change is made prior to 8,654
the date the activity for which the certificate was issued ceases 8,655
to be a reviewable activity; 8,656
(7) Any of the following changes in perinatal bed capacity 8,658
or pediatric intensive care bed capacity: 8,659
(a) An increase in bed capacity; 8,661
(b) A change in service or service-level designation of 8,664
newborn care beds or obstetric beds in a hospital or freestanding 8,665
birthing center, other than a change of service that is provided
within the service-level designation of newborn care or obstetric 8,666
beds as registered by the department of health; 8,667
(c) A relocation of perinatal or pediatric intensive care 8,670
beds from one physical facility or site to another, excluding the 8,671
relocation of beds within a hospital or freestanding birthing 8,672
center or the relocation of beds among buildings of a hospital or 8,674
freestanding birthing center at the same site. 8,675
(8) The expenditure of more than one hundred ten per cent 8,677
of the maximum expenditure specified in a certificate of need; 8,678
(9) Any transfer of a certificate of need issued prior to 8,680
April 20, 1995, from the person to whom it was issued to another 8,682
person before the project that constitutes a reviewable activity 8,683
is completed, any agreement that contemplates the transfer of a 8,684
certificate of need issued prior to that date upon completion of 8,686
the project, and any transfer of the controlling interest in an 8,687
entity that holds a certificate of need issued prior to that
date. However, the transfer of a certificate of need issued 8,688
prior to that date or agreement to transfer such a certificate of 8,690
need from the person to whom the certificate of need was issued 8,691
to an affiliated or related person does not constitute a 8,692
reviewable transfer of a certificate of need for the purposes of 8,693
196
this division, unless the transfer results in a change in the 8,694
person that holds the ultimate controlling interest in the 8,695
certificate of need.
(10)(a) The acquisition by any person of any of the 8,697
following medical equipment, regardless of the amount of 8,699
operating costs or capital expenditure:
(i) A cobalt radiation therapy unit; 8,701
(ii) A linear accelerator; 8,703
(iii) A gamma knife unit. 8,705
(b) The acquisition by any person of medical equipment 8,707
with a cost of two million dollars or more. The cost of 8,708
acquiring medical equipment includes the sum of the following: 8,709
(i) The greater of its fair market value or the cost of 8,711
its lease or purchase; 8,712
(ii) The cost of installation and any other activities 8,714
essential to the acquisition of the equipment and its placement 8,715
into service.
(11) The addition of another cardiac catheterization 8,718
laboratory to an existing cardiac catheterization service. 8,719
(S) Except as provided in division (T) of this section, 8,722
"reviewable activity" also means any of the following activities, 8,724
none of which are subject to a termination date:
(1) The establishment, development, or construction of a 8,726
new long-term care facility; 8,727
(2) The replacement of an existing long-term care 8,729
facility; 8,730
(3) The renovation of a long-term care facility that 8,732
involves a capital expenditure of two million dollars or more, 8,733
not including expenditures for equipment, staffing, or 8,734
operational costs; 8,735
(4) Any of the following changes in long-term care bed 8,737
capacity: 8,738
(a) An increase in bed capacity; 8,740
(b) A relocation of beds from one physical facility or 8,743
197
site to another, excluding the relocation of beds within a 8,744
long-term care facility or among buildings of a long-term care 8,745
facility at the same site;
(c) A recategorization of hospital beds registered under 8,748
section 3701.07 of the Revised Code from another registration 8,750
category to skilled nursing beds or long-term care beds. 8,751
(5) Any change in the health services, bed capacity, or 8,753
site, or any other failure to conduct the reviewable activity in 8,754
substantial accordance with the approved application for which a 8,755
certificate of need concerning long-term care beds was granted, 8,756
if the change is made within five years after the implementation 8,757
of the reviewable activity for which the certificate was granted; 8,759
(6) The expenditure of more than one hundred ten per cent 8,761
of the maximum expenditure specified in a certificate of need 8,762
concerning long-term care beds; 8,763
(7) Any transfer of a certificate of need that concerns 8,765
long-term care beds and was issued prior to April 20, 1995, from 8,767
the person to whom it was issued to another person before the 8,768
project that constitutes a reviewable activity is completed, any 8,769
agreement that contemplates the transfer of such a certificate of 8,770
need upon completion of the project, and any transfer of the 8,771
controlling interest in an entity that holds such a certificate 8,772
of need. However, the transfer of a certificate of need that 8,773
concerns long-term care beds and was issued prior to April 20, 8,775
1995, or agreement to transfer such a certificate of need from 8,776
the person to whom the certificate was issued to an affiliated or 8,777
related person does not constitute a reviewable transfer of a 8,778
certificate of need for purposes of this division, unless the 8,779
transfer results in a change in the person that holds the 8,780
ultimate controlling interest in the certificate of need. 8,781
(T) "Reviewable activity" does not include any of the 8,783
following activities: 8,784
(1) Acquisition of computer hardware or software; 8,786
(2) Acquisition of a telephone system; 8,788
198
(3) Construction or acquisition of parking facilities; 8,790
(4) Correction of cited deficiencies that are in violation 8,792
of federal, state, or local fire, building, or safety laws and 8,793
rules and that constitute an imminent threat to public health or 8,794
safety; 8,795
(5) Acquisition of an existing health care facility that 8,797
does not involve a change in the number of the beds, by service, 8,798
or in the number or type of health services; 8,799
(6) Correction of cited deficiencies identified by 8,801
accreditation surveys of the joint commission on accreditation of 8,802
healthcare organizations or of the American osteopathic 8,803
association; 8,804
(7) Acquisition of medical equipment to replace the same 8,806
or similar equipment for which a certificate of need has been 8,807
issued if the replaced equipment is removed from service; 8,808
(8) Mergers, consolidations, or other corporate 8,810
reorganizations of health care facilities that do not involve a 8,811
change in the number of beds, by service, or in the number or 8,812
type of health services; 8,813
(9) Construction, repair, or renovation of bathroom 8,815
facilities; 8,816
(10) Construction of laundry facilities, waste disposal 8,818
facilities, dietary department projects, heating and air 8,819
conditioning projects, administrative offices, and portions of 8,820
medical office buildings used exclusively for physician services; 8,821
(11) Acquisition of medical equipment to conduct research 8,823
required by the United States food and drug administration or 8,824
clinical trials sponsored by the national institute of health. 8,825
Use of medical equipment that was acquired without a certificate 8,826
of need under division (T)(11) of this section and for which 8,828
premarket approval has been granted by the United States food and 8,829
drug administration to provide services for which patients or 8,830
reimbursement entities will be charged shall be a reviewable 8,831
activity. 8,832
199
(12) Removal of asbestos from a health care facility. 8,834
Only that portion of a project that meets the requirements 8,836
of division (T) of this section is not a reviewable activity. 8,838
(U) "Small rural hospital" means a hospital that is 8,840
located within a rural area, has fewer than one hundred beds, and 8,842
to which fewer than four thousand persons were admitted during 8,843
the most recent calendar year.
(V) "Children's hospital" means any of the following: 8,845
(1) A hospital registered under section 3701.07 of the 8,847
Revised Code that provides general pediatric medical and surgical 8,848
care, and in which at least seventy-five per cent of annual 8,849
inpatient discharges for the preceding two calendar years were 8,850
individuals less than eighteen years of age; 8,851
(2) A distinct portion of a hospital registered under 8,853
section 3701.07 of the Revised Code that provides general 8,854
pediatric medical and surgical care, has a total of at least one 8,855
hundred fifty registered pediatric special care and pediatric 8,856
acute care beds, and in which at least seventy-five per cent of 8,857
annual inpatient discharges for the preceding two calendar years 8,858
were individuals less than eighteen years of age; 8,859
(3) A distinct portion of a hospital, if the hospital is 8,861
registered under section 3701.07 of the Revised Code as a 8,862
children's hospital and the children's hospital meets all the 8,863
requirements of division (V)(1) of this section. 8,864
(W) "Long-term care facility" means any of the following: 8,866
(1) A nursing home licensed under section 3721.02 of the 8,868
Revised Code or by a political subdivision certified under 8,869
section 3721.09 of the Revised Code; 8,870
(2) The portion of any facility, including a county home 8,872
or county nursing home, that is certified as a skilled nursing 8,873
facility or a nursing facility under Title XVIII or XIX of the 8,874
"Social Security Act";
(3) The portion of any hospital that contains beds 8,876
registered under section 3701.07 of the Revised Code as skilled 8,877
200
nursing beds or long-term care beds. 8,878
(X) "Long-term care bed" means a bed in a long-term care 8,880
facility.
(Y) "Perinatal bed" means a bed in a hospital that is 8,882
registered under section 3701.07 of the Revised Code as a newborn 8,883
care bed or obstetric bed, or a bed in a freestanding birthing 8,884
center.
(Z) "Freestanding birthing center" means any facility in 8,886
which deliveries routinely occur, regardless of whether the 8,888
facility is located on the campus of another health care
facility, and which is not licensed under Chapter 3711. of the 8,890
Revised Code as a level one, two, or three maternity unit or a 8,892
limited maternity unit.
(AA)(1) "Reviewability ruling" means a ruling issued by 8,894
the director of health under division (A) of section 3702.52 of 8,895
the Revised Code as to whether a particular proposed project is 8,896
or is not a reviewable activity. 8,897
(2) "Nonreviewability ruling" means a ruling issued under 8,899
that division that a particular proposed project is not a 8,900
reviewable activity. 8,901
(BB)(1) "Metropolitan statistical area" means an area of 8,904
this state designated a metropolitan statistical area or primary 8,905
metropolitan statistical area in United States office of 8,907
management and budget bulletin No. 93-17, June 30, 1993, and its 8,909
attachments. 8,910
(2) "Rural area" means any area of this state not located 8,912
within a metropolitan statistical area. 8,913
Sec. 3702.62. (A) Any action pursuant to section 140.03, 8,922
140.04, 140.05, 307.091, 313.21, 339.01, 339.021, 339.03, 339.06, 8,923
339.08, 339.09, 339.12, 339.14, 339.21, 339.231, 339.24, 339.31, 8,924
339.36, 339.39, 513.05, 513.07, 513.08, 513.081, 513.12, 513.15, 8,925
513.17, 513.171, 749.02, 749.14, 749.16, 749.20, 749.25, 749.28, 8,926
749.35, 1742.06 1751.06, or 3707.29 of the Revised Code shall be 8,927
taken in accordance with sections 3702.51 to 3702.61 of the 8,928
201
Revised Code.
(B) A nursing home certified as an intermediate care 8,930
facility for the mentally retarded under Title XIX of the "Social 8,931
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, 8,932
that is required to apply for licensure as a residential facility 8,933
under section 5123.19 of the Revised Code is not, with respect to 8,934
the portion of the home certified as an intermediate care
facility for the mentally retarded, subject to sections 3702.51 8,935
to 3702.61 of the Revised Code. 8,936
Sec. 3709.16. The board of health of a city or general 8,945
health district shall determine the duties and fix the salaries 8,946
of its employees. 8,947
No member of the board shall be appointed as health officer 8,949
or ward physician. 8,950
The board of health of any health district may procure and 8,952
pay all or any part of the cost of group life, hospitalization, 8,953
surgical, major medical, sickness and accident insurance, or a 8,954
combination of any of the foregoing types of insurance or 8,955
coverage, for the health commissioner, the employees of the 8,956
health district, and their immediate dependents, from the funds 8,957
or budgets from which said health commissioner or employees are 8,958
compensated for services, issued by an insurance company or 8,959
nonprofit medical care A HEALTH INSURING corporation duly 8,960
authorized to do business in this state. 8,961
Notwithstanding section 3917.01 of the Revised Code, the 8,963
board of health of any health district may purchase group life 8,964
insurance authorized by this section by reason of payment of 8,965
premiums therefor by the board from its funds, and such group 8,966
life insurance may be issued and purchased if otherwise 8,967
consistent with sections 3917.01 to 3917.06 of the Revised Code. 8,968
Sec. 3729.12. Not later than a date specified by the 8,978
director of health, the Ohio health care data center shall make 8,979
its first submission of a report containing the health care 8,980
information specified in this section to the governor, the 8,981
202
speaker of the house of representatives, the president of the 8,982
senate, and the chairpersons of the standing committees of the 8,983
house of representatives and the senate that have primary 8,984
responsibility for the consideration of health legislation. Each 8,985
year thereafter, the data center shall submit a report not later 8,986
than the thirty-first day of December. The report shall contain, 8,987
to the extent possible with the data collected under sections 8,988
3729.15 to 3729.45 of the Revised Code, an analysis of all of the 8,989
following:
(A) The one hundred high priority diagnoses and one 8,991
hundred high priority medical procedures that account for eighty 8,992
per cent of public and private health care costs in this state, 8,993
and diagnoses and medical procedures for which a disproportionate 8,994
share of public and private expenditures are consumed relative to 8,995
the total number of diseases diagnosed and medical procedures 8,996
performed; 8,997
(B) The relationship between: 8,999
(1) Health care costs, access, outcomes, continuity of 9,001
care, and professional practice patterns for selected diseases 9,002
and procedures; 9,003
(2) An individual's source of payment, age, geographic 9,005
location, sex, race, and income. 9,006
(C) The differences in administrative expenses for 9,008
delivery of health care in the public sector versus the private 9,009
sector; 9,010
(D)(1) Compared to previous years when appropriate data 9,012
were collected, the increase in expenditures that has occurred in 9,013
the public health care programs in each of the following 9,014
categories: 9,015
(a) Long-term care facilities; 9,017
(b) Hospital inpatient services; 9,019
(c) Hospital outpatient services; 9,021
(d) Home-based health care; 9,023
(e) Physicians' services; 9,025
203
(f) Allied health services; 9,027
(g) Pharmaceuticals; 9,029
(h) Durable medical equipment and medical and surgical 9,031
products; 9,032
(i) Mental health services; 9,034
(j) Other health services selected by the director of 9,036
health. 9,037
(2) The factors that have contributed to the expenditure 9,039
increases in each of the categories specified by division (D)(1) 9,040
of this section. 9,041
(E) The extent to which physicians and other health care 9,043
providers selected by the director participate in public versus 9,044
private health care programs, and changes in this participation 9,045
from previous years when appropriate data were collected; 9,046
(F) The distribution of emergency medical services among 9,048
the population of this state, and the relationship between: 9,049
(1) Access to emergency medical services; 9,051
(2) An individual's source of payment, age, geographic 9,053
location, sex, race, and income. 9,054
(G) The number of residents of this state who are 9,056
uninsured or underinsured with respect to health care, the 9,057
distribution of this population by county, the demographic 9,058
characteristics, including employment status, of this population, 9,059
and the changes in those demographic characteristics from 9,060
previous years when appropriate data were collected; 9,061
(H) The percentage of individuals who seek or register for 9,063
health care services that: 9,064
(1) Are diagnosed or treated; 9,066
(2) Are denied services; 9,068
(3) Receive primary care services from emergency 9,070
facilities. 9,071
(I) The differences between primary care case managed 9,073
systems and other managed health care reimbursement systems in 9,074
health care costs and outcomes for one hundred high priority 9,075
204
diseases or procedures selected by the director, access to health 9,076
care, and professional practice patterns and variations, and the 9,077
factors that contribute to those differences; 9,078
(J) The relationship between: 9,080
(1) Long-term care facility admission, transfer, and 9,082
length-of-stay; 9,083
(2) An individual's source of payment, age, geographic 9,085
location, sex, race, and income. 9,086
(K) The percentage of hospitals' uncompensated care, 9,088
including uncompensated care provided by group practices as 9,089
defined in section 4731.65 of the Revised Code that have one 9,090
hundred members or more, that is attributable to each of the 9,092
following:
(1) Charity care; 9,094
(2) Courtesy care; 9,096
(3) Contractual allowances; 9,098
(4) The medical assistance program; 9,100
(5) The medicare program; 9,102
(6) Bad debts. 9,104
(L) The relationship between the number and type of 9,106
pharmaceutical prescriptions and each of the following: 9,107
(1) An individual's source of payment, age, geographic 9,109
location, and sex; 9,110
(2) Use of a therapeutic formulary by disease category. 9,112
(M) The extent to which physicians and other health care 9,114
providers selected by the director provide primary care services 9,115
to indigent individuals and the type of primary care services 9,116
provided; 9,117
(N) Public or private provider reimbursement strategies 9,119
that have been effective in containing health care costs; 9,120
(O) The effectiveness of quality improvement programs 9,122
introduced by health care organizations, including health 9,123
maintenance organizations INSURING CORPORATIONS and independent 9,124
practice associations, or health care plans in improving the 9,125
205
general quality of health care in this state; 9,126
(P) The comparison of health care costs, access, outcomes, 9,128
continuity of care, and professional practice patterns in this 9,129
state with other states and countries; 9,130
(Q) State and local statutes, ordinances, or rules that 9,132
may contribute to health care cost increases and suggested 9,133
changes in the regulatory framework to reduce costs without 9,134
adversely affecting quality or access; 9,135
(R) The increase in health care costs that can be 9,137
attributed to increases in malpractice insurance premiums and 9,138
increases in the practice of defensive medicine; 9,139
(S) The total number of visits by medical assistance 9,141
program recipients and medicare beneficiaries to clinics versus 9,142
primary care health care practitioner offices in this state, 9,143
categorized by type of clinic or primary care practitioner and 9,144
diagnosis; 9,145
(T) Variations in treatment, costs, and medical outcome of 9,147
a range of diagnoses selected by the director according to 9,148
practitioner specialty versus primary care case management with 9,149
global fees and comparison of individuals' source of payment, 9,150
age, geographic location, sex, race, and income; 9,151
(U) The major components of the cost of long-term care 9,153
facilities and the variations in the costs of the components 9,154
according to diagnosis, the resident's level of functioning, 9,155
facility size and geographic location, and source of payment; 9,156
(V) Factors that account for increases in the utilization 9,158
of long-term care facilities in comparison with home and 9,159
community outpatient care; 9,160
(W) The effect of health care utilization and costs on the 9,162
general health of residents of this state and the effect of 9,163
behaviorial BEHAVIORAL risk factors, including tobacco use, 9,164
alcohol and substance abuse, lack of exercise, being overweight, 9,166
and other factors selected by the director; 9,167
(X) The effect of utilization of preventive health care 9,169
206
services on health care costs and outcomes, categorized by age, 9,170
occupation, and type of health care coverage; 9,171
(Y) The number of individuals in each county who received 9,173
services the previous calendar year from a public health care 9,174
program administered in whole or in part by the department of 9,175
mental retardation and developmental disabilities or a county 9,176
board of mental retardation and developmental disabilities, 9,177
compared to the number of individuals in each county who applied 9,178
and were found eligible for those services that year but did not 9,179
receive them; 9,180
(Z) The number of individuals in each county that received 9,182
services the previous calendar year from a public health care 9,183
program administered in whole or in part by the department of 9,184
mental health, a community mental health board, or a board of 9,185
alcohol, drug abuse, and mental health services, compared to the 9,186
number of individuals in each county who applied and were found 9,187
eligible for those services that year but did not receive them. 9,188
The report must comply with section 3729.46 of the Revised 9,190
Code. 9,191
Sec. 3901.04. (A) As used in this section: 9,200
(1) "Laws of this state relating to insurance" include but 9,202
are not limited to Chapters 1736., 1737., 1738., 1739. 9,203
notwithstanding section 1739.02, 1740., and 1742. CHAPTER 1751. 9,205
notwithstanding section 1742.30 1751.08, Title XXXIX, sections 9,206
5725.18 to 5725.25, and Chapter 5729. of the Revised Code. 9,207
(2) "Person" has the meaning defined in division (A) of 9,209
section 3901.19 of the Revised Code. 9,210
(B) Whenever it appears to the superintendent of 9,212
insurance, from his THE SUPERINTENDENT'S files, upon complaint or 9,214
otherwise, that any person has engaged in, is engaged in, or is
about to engage in any act or practice declared to be illegal or 9,215
prohibited by the laws of this state relating to insurance, or 9,216
defined as unfair or deceptive by such laws, or when the 9,217
superintendent believes it to be in the best interest of the 9,218
207
public and necessary for the protection of the people in this 9,219
state, the superintendent or anyone designated by the 9,220
superintendent under his THE SUPERINTENDENT'S official seal may 9,221
do any one or more of the following:
(1) Require any person to file with the superintendent, on 9,223
a form that is appropriate for review by the superintendent, an 9,224
original or additional statement or report in writing, under oath 9,225
or otherwise, as to any facts or circumstances concerning the 9,226
person's conduct of the business of insurance within this state 9,227
and as to any other information that the superintendent considers 9,228
to be material or relevant to such business; 9,229
(2) Administer oaths, summon and compel by order or 9,231
subpoena the attendance of witnesses to testify in relation to 9,232
any matter which, by the laws of this state relating to 9,233
insurance, is the subject of inquiry and investigation, and 9,234
require the production of any book, paper, or document pertaining 9,235
to such matter. A subpoena, notice, or order under this section 9,236
may be served by certified mail, return receipt requested. If 9,237
the subpoena, notice, or order is returned because of inability 9,238
to deliver, or if no return is received within thirty days of the 9,239
date of mailing, the subpoena, notice, or order may be served by 9,240
ordinary mail. If no return of ordinary mail is received within 9,241
thirty days after the date of mailing, service shall be deemed to 9,242
have been made. If the subpoena, notice, or order is returned 9,243
because of inability to deliver, the superintendent may designate 9,244
a person or persons to effect either personal or residence 9,245
service upon the witness. Service of any subpoena, notice, or 9,246
order and return may also be made in any manner authorized under 9,247
the Rules of Civil Procedure. Such service shall be made by an 9,248
employee of the department designated by the superintendent, a 9,249
sheriff, a deputy sheriff, an attorney, or any person authorized 9,250
by the Rules of Civil Procedure to serve process. 9,251
In the case of disobedience of any notice, order, or 9,253
subpoena served on a person or the refusal of a witness to 9,254
208
testify to a matter regarding which he THE PERSON may lawfully be 9,256
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 9,257
obedience by attachment proceedings for contempt, as in the case 9,258
of disobedience of the requirements of a subpoena issued from 9,259
such court, or a refusal to testify therein. Witnesses shall 9,260
receive the fees and mileage allowed by section 2335.06 of the 9,261
Revised Code. All such fees, upon the presentation of proper 9,262
vouchers approved by the superintendent, shall be paid out of the 9,263
appropriation for the contingent fund of the department of 9,264
insurance. The fees and mileage of witnesses not summoned by the 9,265
superintendent or his THE SUPERINTENDENT'S designee shall not be 9,266
paid by the state. 9,267
(3) In a case in which there is no administrative 9,269
procedure available to the superintendent to resolve a matter at 9,270
issue, request the attorney general to commence an action for a 9,271
declaratory judgment under Chapter 2721. of the Revised Code with 9,272
respect to the matter. 9,273
(4) Initiate criminal proceedings by presenting evidence 9,275
of the commission of any criminal offense established under the 9,276
laws of this state relating to insurance to the prosecuting 9,277
attorney of any county in which the offense may be prosecuted. At 9,279
the request of the prosecuting attorney, the attorney general may 9,280
assist in the prosecution of the violation with all the rights, 9,281
privileges, and powers conferred by law on prosecuting attorneys 9,282
including, but not limited to, the power to appear before grand 9,283
juries and to interrogate witnesses before grand juries. 9,284
Sec. 3901.041. The superintendent of insurance shall 9,293
adopt, amend, and rescind rules and make adjudications, necessary 9,294
to discharge his THE SUPERINTENDENT'S duties and exercise his THE 9,295
SUPERINTENDENT'S powers, including, but not limited to, his THE 9,296
SUPERINTENDENT'S duties and powers under Chapters 1737., 1738., 9,297
and 1740. CHAPTER 1751. and Title XXXIX of the Revised Code, 9,299
subject to sections 119.01 to 119.13 CHAPTER 119. of the Revised 9,300
209
Code.
Sec. 3901.043. The superintendent of insurance may adopt 9,309
rules in accordance with Chapter 119. of the Revised Code to 9,310
establish reasonable fees for any service or transaction 9,311
performed by the department of insurance pursuant to section 9,312
1738.04, 1742.03 1751.03, 3901.321, 3901.341, 3907.09, 3907.10, 9,313
3907.11, 3907.12, 3911.011, 3913.31, 3915.14, 3917.06, 3918.07,
3923.02, 3935.04, 3937.03, 3953.28, 3957.12, or 3957.13 of the 9,314
Revised Code or any provision in sections 3913.01 to 3913.23 or 9,315
in Chapter 3905. of the Revised Code, if no fee is otherwise 9,316
provided under Title XVII or XXXIX of the Revised Code for such 9,317
service or transaction. Any fee collected pursuant to those 9,318
rules shall be paid into the state treasury to the credit of the 9,319
department of insurance operating fund.
Sec. 3901.071. All moneys collected by the superintendent 9,328
of insurance for expenses incurred by him THE SUPERINTENDENT in 9,329
conducting examinations pursuant to the Revised Code of the 9,330
financial affairs of any insurance company doing business in this 9,331
state, for which the insurance company examined is required to 9,332
pay the costs, shall be paid to the superintendent. The 9,333
superintendent shall deposit the money in the state treasury to 9,334
the credit of the superintendent's examination fund, which is 9,335
hereby established. Any funds expended or obligated therefrom by 9,336
the superintendent shall be expended or obligated solely for 9,337
defrayment of the costs of examinations of the financial affairs 9,338
of insurance companies made by the superintendent pursuant to the 9,339
Revised Code. For purposes of this section, "insurance company" 9,340
means any domestic or foreign stock company, risk retention 9,341
group, mutual company, mutual protective association, fraternal 9,342
benefit society, reciprocal or inter-insurance exchange, 9,343
nonprofit medical care corporation, AND health care INSURING 9,345
corporation, and nonprofit dental care corporation, regardless of 9,346
the type of coverage written, benefits provided, or guarantees 9,347
made by each.
210
Sec. 3901.16. Any association, company, or corporation, 9,356
INCLUDING A HEALTH INSURING CORPORATION, which violates any law 9,357
relating to the superintendent of insurance, ANY PROVISION OF 9,359
CHAPTER 1751. OF THE REVISED CODE, or any insurance law of this
state, for the violation of which no forfeiture or penalty is 9,360
elsewhere provided in the Revised Code, shall forfeit and pay not 9,361
less than one thousand nor more than ten thousand dollars, to be 9,362
recovered by an action in the name of the state and on collection 9,363
to be paid to the superintendent, who shall pay such sum into the 9,364
state treasury.
Sec. 3901.19. As used in sections 3901.19 to 3901.26 of 9,373
the Revised Code: 9,374
(A) "Person" means any individual, corporation, 9,376
association, partnership, reciprocal exchange, inter-insurer, 9,377
fraternal benefit society, title guarantee and trust company, 9,378
prepaid dental plan organization, medical care corporation, 9,379
health care INSURING corporation, dental care corporation, health 9,381
maintenance organization incorporated under Chapter 1735., 1736.,
1737., 1738., 1740., or 1742. of the Revised Code, and any other 9,382
legal entity. 9,383
(B) "Residents" includes any individual, partnership, or 9,385
corporation. 9,386
(C) "Maternity benefits" means those benefits calculated 9,388
to indemnify the insured for hospital and medical expenses fairly 9,389
and reasonably associated with a pregnancy and childbirth. 9,390
(D) "Insurance" includes, but is not limited to, any 9,392
policy or contract offered, issued, sold, or marketed by an 9,393
insurer, corporation, association, organization, or entity 9,394
regulated by the superintendent of insurance or doing business in 9,395
this state. Nothing in any other section of the Revised Code 9,396
shall be construed to exclude single premium deferred annuities 9,397
from the regulation of the superintendent under sections 3901.19 9,398
to 3901.26 of the Revised Code. 9,399
Sec. 3901.31. (A) Every person who is directly or 9,408
211
indirectly the beneficial owner of more than ten per cent of any 9,409
class of any equity security of a domestic stock insurance 9,410
company which is not a wholly owned subsidiary of an insurance 9,411
holding company system or who is a director or officer of such 9,412
company, shall file with the superintendent of insurance within 9,413
ten days after he THE PERSON becomes such beneficial owner, 9,414
director, or officer, a statement in such form as the 9,416
superintendent of insurance may prescribe, of the amount of all 9,417
equity securities of such company of which he THE PERSON is the 9,418
beneficial owner, and within ten days after the close of each 9,420
calendar month thereafter, if there has been a change in such 9,421
ownership during such month, shall file with the superintendent 9,422
of insurance a statement, in such form as the superintendent of 9,423
insurance may prescribe, indicating his THE PERSON'S ownership at 9,424
the close of the calendar month and such changes in his THE 9,425
PERSON'S ownership as have occurred during such calendar month. 9,426
(B) For the purpose of preventing the unfair use of 9,428
information which may have been obtained by such beneficial 9,429
owner, director, or officer by reason of his THE BENEFICIAL 9,430
OWNER'S, DIRECTOR'S, OR OFFICER'S relationship to such company, 9,431
any profit realized by him THE BENEFICIAL OWNER, DIRECTOR, OR 9,432
OFFICER from any purchase and sale, or any sale and purchase, of 9,433
any equity security of such company within any period of less 9,435
than six months, unless such security was acquired in good faith 9,436
in connection with a debt previously contracted, shall inure to 9,437
and be recoverable by the company, irrespective of any intention 9,438
on the part of such beneficial owner, director, or officer in 9,439
entering into such transaction of holding the security purchased 9,440
or of not repurchasing the security sold for a period exceeding 9,441
six months. Suit to recover such profit may be instituted at law 9,442
or in equity in any court of competent jurisdiction by the 9,443
company, or by the owner of any security of the company in the 9,444
name and in behalf of the company if the company fails or refuses 9,445
to bring such suit within sixty days after request or fails 9,446
212
diligently to prosecute the same thereafter; but no such suit 9,447
shall be brought more than two years after the date such profit 9,448
was realized. Division (B) of this section shall not be 9,449
construed to cover any transaction where such beneficial owner 9,450
was not such both at the time of purchase and sale, or the sale 9,451
and purchase, of the security involved, or any transaction or 9,452
transactions which the superintendent of insurance by rules may 9,453
exempt as not comprehended within the purpose of division (B) of 9,454
this section.
(C) No such beneficial owner, director, or officer, 9,456
directly or indirectly, shall sell any equity security of such 9,457
company if the person selling the security or his THE PERSON'S 9,458
principal does not own the security sold, or if owning the 9,459
security, does not deliver it against such sale within twenty 9,460
days thereafter, or does not within five days after such sale 9,461
deposit it in the mails or other usual channels of 9,462
transportation; but no person shall be deemed to have violated 9,463
division (C) of this section if he THE PERSON proves that 9,464
notwithstanding the exercise of good faith he THE PERSON was 9,465
unable to make such delivery or deposit within such time, or that 9,466
to do so would cause undue inconvenience or expense.
(D) A domestic insurance company having at least fifty 9,468
shareholders or any other person soliciting proxies with respect 9,469
to such domestic insurance company shall not solicit voting 9,470
proxies from any shareholder or other person except upon a proxy 9,471
statement and pursuant to a notice of meeting, which statement 9,472
and notice have been submitted to the superintendent of insurance 9,473
at least ten days prior to being mailed to the intended 9,474
recipients. Such proxy statement and notice of meeting shall 9,475
make such disclosures pertinent to the business to be carried on 9,476
at the meeting or meetings with respect to which such proxies are 9,477
solicited and such notices are given as the superintendent by 9,478
rule requires. The superintendent shall retain such proxy 9,479
material for examination by any interested party for at least one 9,480
213
year. 9,481
(E) Division (B) of this section does not apply to any 9,483
purchase and sale, or sale and purchase, and division (C) of this 9,484
section does not apply to any sale, of an equity security of a 9,485
domestic stock insurance company not then or theretofore held by 9,486
him in an investment account, by a dealer in the ordinary course 9,487
of his THE DEALER'S business and incident to the establishment or 9,489
maintenance by him THE DEALER of a primary or secondary market 9,490
for such security. The superintendent of insurance may, by such 9,491
rules as he THE SUPERINTENDENT considers necessary or appropriate 9,492
in the public interest, describe and define the terms and 9,494
conditions with respect to securities held in an investment 9,495
account and transactions made in the ordinary course of business 9,496
and incident to the establishment or maintenance of a primary or 9,497
secondary market.
(F) Divisions (A), (B), and (C) of this section do not 9,499
apply to foreign or domestic arbitrage transactions unless made 9,500
in contravention of such rules as the superintendent of insurance 9,501
may adopt in order to carry out the purposes of this section. 9,502
(G) "Equity security" when used in this section means any 9,504
stock or similar security; or any security convertible, with or 9,505
without consideration, into such a security, or carrying any 9,506
warrant or right to subscribe to or purchase such a security; or 9,507
any such warrant or right; or any other security which the 9,508
superintendent of insurance determines to be of similar nature 9,509
and considers necessary or appropriate, by such rules as he THE 9,510
SUPERINTENDENT may prescribe in the public interest or for the 9,511
protection of investors, to treat as an equity security. 9,512
(H) The superintendent of insurance may adopt, amend, and 9,514
rescind rules, pursuant to Chapter 119. of the Revised Code, 9,515
which will enable him THE SUPERINTENDENT to carry out the duties 9,517
imposed upon him by this section.
(I) THIS SECTION APPLIES TO HEALTH INSURING CORPORATIONS 9,519
IN THE SAME MANNER IN WHICH THIS SECTION APPLIES TO DOMESTIC 9,520
214
STOCK INSURANCE COMPANIES. 9,521
Sec. 3901.32. As used in sections 3901.32 to 3901.37 of 9,530
the Revised Code: 9,531
(A) "Affiliate of" or "affiliated with" a specific person 9,533
means a person that, directly or indirectly, through one or more 9,534
intermediaries, controls, is controlled by, or is under common 9,535
control with, the person specified. 9,536
(B) "Control," including "controlling," "controlled by," 9,538
and "under common control with," means the possession, direct or 9,539
indirect, of the power to direct or cause the direction of the 9,540
management and policies of a person, whether through the 9,541
ownership of voting securities, by contract other than a 9,542
commercial contract for goods or nonmanagement services, or 9,543
otherwise, unless the power is the result of an official position 9,544
with or corporate office held by the person. Control shall be 9,545
presumed to exist if any person, directly or indirectly, owns, 9,546
controls, holds with the power to vote, or holds proxies 9,547
representing, ten per cent or more of the voting securities of 9,548
any other person. This presumption may be rebutted by a showing 9,549
made in the manner provided in division (J) of section 3901.33 of 9,551
the Revised Code that control does not exist in fact. The 9,552
superintendent of insurance may determine, after furnishing all 9,553
persons in interest notice and opportunity to be heard and making 9,554
specific findings of fact to support such determination, that 9,555
control exists in fact, notwithstanding the absence of a 9,556
presumption to that effect. 9,557
(C) "Insurance holding company system" means two or more 9,559
affiliated persons, one or more of which is an insurer. 9,560
(D) "Insurer" means any person engaged in the business of 9,562
insurance, guaranty, or membership, an inter-insurance exchange, 9,563
a mutual or fraternal benefit society, a prepaid dental plan 9,564
organization, a health maintenance organization, a medical care, 9,565
OR A health care, or dental care INSURING corporation, excepting 9,567
any agency, authority, or instrumentality of the United States,
215
its possessions and territories, the Commonwealth of Puerto Rico, 9,568
the District of Columbia, or a state or political subdivision of 9,569
a state. 9,570
(E) "Person" means an individual, a corporation, a 9,572
partnership, an association, a joint stock company, a trust, an 9,573
unincorporated organization, any similar entity, or any 9,574
combination of the foregoing acting in concert. 9,575
(F) "Subsidiary" of a specified person is an affiliate 9,577
controlled by such person, directly or indirectly, through one or 9,578
more intermediaries. 9,579
(G) "Voting security" includes any security convertible 9,581
into or evidencing a right to acquire a voting security. 9,582
Sec. 3901.38. (A) As used in this section: 9,591
(1) "Beneficiary" means any policyholder, subscriber, 9,593
member, employee, or other person who is eligible for benefits 9,594
under a benefits contract. 9,595
(2) "Benefits contract" means a sickness and accident 9,597
insurance policy providing hospital, surgical, or medical expense 9,598
coverage, OR A health maintenance organization INSURING 9,599
CORPORATION contract, preferred provider organization contract, 9,601
or other policy or agreement under which a third-party payer 9,602
agrees to reimburse for covered health care or dental services 9,603
rendered to beneficiaries, up to the limits and exclusions 9,604
contained in the benefits contract.
(3) "Completed claim" means a proof of loss or a claim for 9,606
payment for health care services which has been submitted to the 9,607
appropriate claims processing office of the third-party payer 9,608
accompanied by sufficient documentation for the third-party payer 9,609
to determine proof of loss and reasonably required by the 9,610
third-party payer to accept or reject the claim. 9,611
(4) "Hospital" has the same meaning set forth in section 9,613
3727.01 of the Revised Code. 9,614
(5) "Proof of loss" means a claim for payment for health 9,616
care services which has been submitted to the appropriate claims 9,617
216
processing office of the third-party payer accompanied by 9,618
sufficient documentation for the third-party payer to determine 9,619
benefits payable under the benefits contract and reasonably 9,620
required by the third-party payer to accept or reject the claim. 9,621
(6) "Provider" means a hospital, nursing home, physician, 9,623
podiatrist, dentist, pharmacist, chiropractor, or other licensed 9,624
health care provider entitled to reimbursement by a third-party 9,625
payer for services rendered to a beneficiary under a benefits 9,626
contract. 9,627
(7) "Reimburse" means indemnify, make payment, or 9,629
otherwise accept responsibility for payment for health care 9,630
services rendered to a beneficiary, or arrange for the provision 9,631
of health care services to a beneficiary. 9,632
(8) "Third-party payer" means any of the following: 9,634
(a) An insurance company; 9,636
(b) A health maintenance organization INSURING 9,638
CORPORATION;
(c) A preferred provider organization; 9,640
(d) A labor organization; 9,642
(e) An employer; 9,644
(f) A prepaid dental plan organization AN INTERMEDIARY 9,646
ORGANIZATION, AS DEFINED IN SECTION 1751.01 OF THE REVISED CODE, 9,647
THAT IS NOT A HEALTH DELIVERY NETWORK CONTRACTING SOLELY WITH 9,648
SELF-INSURED EMPLOYERS;
(g) An administrator subject to sections 3959.01 to 9,650
3959.16 of the Revised Code; 9,651
(h) A HEALTH DELIVERY NETWORK, AS DEFINED IN SECTION 9,653
1751.01 OF THE REVISED CODE; 9,654
(i) Any other person that is obligated pursuant to a 9,656
benefits contract to reimburse for covered health care services 9,657
rendered to beneficiaries under such contract. 9,658
(B)(1) Except as provided in division (B)(2) of this 9,660
section, within twenty-four days of the receipt of a completed 9,661
claim from a provider or a beneficiary for reimbursement for 9,662
217
health care services rendered by the provider to a beneficiary, a 9,663
third-party payer shall, in accordance with division (D) of this 9,664
section, make payment of any amount due on such claim. 9,665
(2) A third-party payer and a provider may, in negotiating 9,667
a reimbursement contract, agree to any time period by which a 9,668
third-party payer shall, subject to division (D) of this section, 9,669
make payment of any amount due on a completed claim. Nothing in 9,670
this division shall be construed as limiting in any manner the 9,671
application of the requirements of this section to any benefits 9,672
or reimbursement contract. 9,673
(3) Any provider or beneficiary aggrieved with respect to 9,675
any act of a third-party payer that such provider or beneficiary 9,676
believes to be a violation of division (B)(1) or (2) of this 9,677
section may file a written complaint with the superintendent of 9,678
insurance. If a series of such complaints is received by the 9,679
superintendent with respect to a particular third-party payer and 9,680
if, after investigation, the superintendent finds that such 9,681
third-party payer has engaged in a series of such violations 9,682
which, taken together, constitute a consistent pattern or a 9,683
practice of such third-party payer to violate division (B)(1) or 9,684
(2) of this section, the superintendent shall issue an order 9,685
requiring such third-party payer to cease and desist from 9,686
engaging in such violations and to pay a late payment penalty as 9,687
specified in divisions (B)(4) and (5) of this section with 9,688
respect to the claims the superintendent finds were not timely 9,689
paid. In the order, the superintendent shall specify the reasons 9,690
for his THE SUPERINTENDENT'S finding and order and state that a 9,691
hearing conducted pursuant to Chapter 119. of the Revised Code 9,693
shall be held within fifteen days after requested in writing by 9,694
the third-party payer. The provisions of this division (B)(3) of 9,695
this section are in addition to, and not in lieu of, such other 9,696
remedies as providers and beneficiaries may otherwise have by 9,697
law.
(4)(a) The late payment penalty shall be computed based 9,699
218
upon the number of days that have elapsed between the date 9,700
payment is due in accordance with division (B)(1) or (2) of this 9,701
section and the date payment is actually sent. 9,702
(b) The interest rate for determining the amount of the 9,704
late payment penalty shall be the rate agreed to by the provider 9,705
and the third-party payer or the rate specified by and determined 9,706
in accordance with division (A) of section 1343.01 of the Revised 9,707
Code. 9,708
(5) A provider and a third-party payer may enter into a 9,710
contractual agreement in which the timing of payments by the 9,711
third-party payer is not directly related to the receipt of a 9,712
completed claim. Such contractual arrangement may include 9,713
periodic interim payment arrangements, capitation payment 9,714
arrangements, or other payment arrangements acceptable to the 9,715
provider and the third-party payer. Except as agreed to under 9,716
such contract, this section does not apply to such payment 9,717
arrangements. 9,718
(6) Any late payment penalty due and payable by a 9,720
third-party payer in accordance with this section shall not be 9,721
used to reduce benefits or payments otherwise payable under a 9,722
benefits contract. 9,723
(C) No third-party payer shall refuse to process or pay 9,725
within the time period required under division (B)(1) or (2) of 9,726
this section a completed claim submitted by a provider on the 9,727
ground the beneficiary has not been discharged from the hospital 9,728
or the treatment has not been completed, if the submitted claim 9,729
covers services actually rendered and charges actually incurred 9,730
over at least a thirty-day period. 9,731
(D)(1) Nothwithstanding NOTWITHSTANDING section 1742.10 or 9,733
division (I)(2) of section 3923.04 of the Revised Code, a 9,734
reimbursement contract entered into or renewed on or after the 9,735
effective date of this section JUNE 29, 1988, between a 9,736
third-party payer and a hospital shall provide that reimbursement 9,737
for any service provided by a hospital pursuant to a 9,738
219
reimbursement contract and covered under a benefits contract 9,739
shall be made directly to the hospital. 9,740
(2) If the third-party payer and the hospital have not 9,742
entered into a contract regarding the provision and reimbursement 9,743
for covered services, the third-party payer shall accept and 9,744
honor a completed and validly executed assignment of benefits 9,745
with a hospital by a beneficiary, except when the third-party 9,746
payer has notified the hospital in writing of the conditions 9,747
under which the third-party payer will not accept and honor an 9,748
assignment of benefits. Such notice shall be made annually. 9,749
(3) A third-party payer may not refuse to accept and honor 9,751
a validly executed assignment of benefits with a hospital 9,752
pursuant to division (D)(2) of this section for medically 9,753
necessary hospital services provided on an emergency basis. 9,754
(E) A series of violations which taken together, 9,756
constitute a consistent pattern or a practice of violation of any 9,757
of the provisions of this section is an unfair and deceptive act 9,758
pursuant to sections 3901.19 to 3901.23 of the Revised Code and 9,759
is subject to proceedings pursuant to those sections. 9,760
Sec. 3901.40. No insurance company, medical care 9,769
corporation, health care INSURING corporation, OR self-insurance 9,771
plan, or dental care corporation authorized to do business in 9,773
this state shall include or provide in its policies or subscriber
agreements for benefit payments or reimbursement for services in 9,774
any hospital which is not certified or accredited as provided in 9,775
division (A) of section 3727.02 of the Revised Code. No hospital 9,776
located in this state shall charge any insurance company, medical 9,777
care corporation, health care INSURING corporation, dental care 9,779
corporation, federal, state, or local government agency, or
person for any services rendered unless the hospital is certified 9,781
or accredited as provided in division (A) of section 3727.02 of 9,782
the Revised Code. "Hospital" as used in this section means only 9,783
those institutions included within the definition of that term 9,784
contained in section 3727.01 of the Revised Code, and the 9,785
220
prohibitions in this section do not apply to facilities excluded
from that definition. 9,786
Sec. 3901.41. (A) An insurance company licensed to 9,795
transact business in this state, OR A HEALTH INSURING CORPORATION 9,797
HOLDING A CERTIFICATE OF AUTHORITY UNDER CHAPTER 1751. OF THE 9,798
REVISED CODE, shall notify the superintendent of insurance and 9,799
deliver a copy of any order or judgment to the superintendent 9,800
within thirty days of the happening in another state of any one 9,801
or more of the following:
(1) Suspension or revocation of its right to transact 9,803
business; 9,804
(2) Receipt of an order to show cause why its license 9,806
should not be suspended or revoked; 9,807
(3) Imposition of a penalty on it for any violation of the 9,809
insurance laws of such other state. 9,810
(B) Whenever the superintendent finds that an insurance 9,812
company OR A HEALTH INSURING CORPORATION has failed to notify the 9,813
superintendent and to deliver a copy of any order or judgment to 9,815
him THE SUPERINTENDENT pursuant to division (A) of this section, 9,816
he THE SUPERINTENDENT may order a hearing to be held not less 9,817
than thirty days after the service of notice, to require it to 9,818
show cause why an order should not be made by the superintendent, 9,819
as a result of the violation of division (A) of this section, 9,820
directing the company OR CORPORATION to suspend any transaction 9,821
of business in this state or levying a penalty against the 9,823
company in an amount not to exceed five hundred dollars. All 9,824
such hearings shall be conducted, and may be appealed, in 9,825
accordance with sections 119.01 to 119.13 CHAPTER 119. of the 9,826
Revised Code. 9,827
Sec. 3901.48. (A) The original work papers of a certified 9,836
public accountant performing an audit of an insurance company OR 9,838
HEALTH INSURING CORPORATION doing business in this state that is
required by rule or by any section of the Revised Code to file an 9,840
audited financial report with the superintendent of insurance 9,841
221
shall remain the property of the certified public accountant. 9,842
Any copies of these work papers voluntarily given to the 9,843
superintendent shall be the property of the superintendent. The 9,844
original work papers or any copies of them, whether in possession 9,845
of the certified public accountant or the department of 9,846
insurance, are confidential and are not a public record as 9,847
defined in section 149.43 of the Revised Code. The original work 9,848
papers and any copies of them are not subject to subpoena and 9,849
shall not be made public by the superintendent or any other 9,850
person. However, the original work papers and any copies of them 9,851
may be released by the superintendent to the insurance regulatory 9,852
authority of any other state if that authority agrees to maintain 9,853
the confidentiality of the work papers or copies and if the work 9,854
papers and copies are not public records under the laws of that 9,855
state. 9,856
(B) The work papers of the superintendent or of the person 9,858
appointed by him THE SUPERINTENDENT, resulting from the conduct 9,859
of an examination made pursuant to section 3901.07 of the Revised 9,861
Code, are confidential and are not a public record as defined in 9,862
section 149.43 of the Revised Code. The original work papers and 9,863
any copies of them are not subject to subpoena and shall not be 9,864
made public by the superintendent or any other person. However, 9,865
the original work papers and any copies of them may be released 9,866
by the superintendent to the insurance regulatory authority of 9,867
any other state if that authority agrees to maintain the 9,868
confidentiality of the work papers or copies and if the work 9,869
papers and copies are not public records under the laws of that 9,870
state. 9,871
(C) The work papers of the superintendent or of any person 9,873
appointed by the superintendent, resulting from the conduct of a 9,874
performance regulation examination made pursuant to authority 9,875
granted under section 3901.011 of the Revised Code, are 9,876
confidential and are not a public record as defined in section 9,877
149.43 of the Revised Code. The original work papers and any 9,878
222
copies of them are not subject to subpoena and shall not be made 9,879
public by the superintendent or any other person. However, the 9,880
original work papers and any copies of them may be released by 9,881
the superintendent to the insurance regulatory authority of any 9,882
other state if that authority agrees to maintain the 9,883
confidentiality of the work papers or copies and if the work 9,884
papers and copies are not public records under the laws of that 9,885
state.
Sec. 3901.72. Any person may advance to a domestic 9,895
insurance company or a health maintenance organization INSURING 9,896
CORPORATION any sum of money necessary for the purpose of the 9,898
insurance company's or health maintenance organization's INSURING 9,899
CORPORATION'S business, or to enable the insurance company or 9,901
health maintenance organization INSURING CORPORATION to comply 9,902
with any law, or as a cash guarantee fund. Such money, and 9,903
interest agreed upon, not exceeding ten per cent per annum or the 9,904
total of four hundred basis points plus the rate on United States 9,905
treasury notes or bonds closest in maturity to the final 9,906
repayment date of the money so advanced, whichever is greater, 9,907
shall not be a liability or claim against the insurance company 9,908
or health maintenance organization INSURING CORPORATION, or any 9,909
of its assets, except as provided in this section, and shall be 9,911
repaid only out of the surplus earnings of such insurance company 9,912
or health maintenance organization INSURING CORPORATION. Except 9,913
as ordered by the superintendent of insurance, no part of the 9,915
principal or interest thereof shall be repaid until the surplus 9,916
of the insurance company or health maintenance organization 9,917
INSURING CORPORATION remaining after such repayment is equal in 9,918
amount to the principal of the money so advanced. Such 9,919
advancement and repayment shall be subject to the approval of the 9,920
superintendent, provided that this section shall not affect the 9,921
power to borrow money which any such insurance company or health 9,922
maintenance organization INSURING CORPORATION possesses under 9,923
other laws. No commission or promotion expenses shall be paid by 9,925
223
the insurance company or health maintenance organization INSURING 9,926
CORPORATION, in connection with the advance of any such money to 9,928
the insurance company or health maintenance organization INSURING 9,929
CORPORATION, and the amount of any such unpaid advance shall be 9,931
reported in each annual statement.
Sec. 3902.01. (A) The purpose of sections 3902.01 to 9,940
3902.08 of the Revised Code is to establish minimum standards for 9,941
language used in policies and certificates of life insurance and 9,942
annuities, credit life insurance and credit disability insurance, 9,943
and sickness and accident insurance, and subscriber POLICIES OR 9,944
certificates of medical care corporations, health care INSURING 9,945
corporations, dental care corporations, and health maintenance 9,946
organizations, delivered or issued for deliver DELIVERY in this 9,948
state, to facilitate ease of reading by insureds and subscribers. 9,950
(B) Sections 3902.01 to 3902.08 of the Revised Code are 9,952
not intended to increase the risk assumed by insurance companies 9,953
or other entities subject to sections 3902.01 to 3902.08 of the 9,954
Revised Code or to supersede their obligation to comply with the 9,955
substance of other applicable insurance laws. Sections 3902.01 9,956
to 3902.08 of the Revised Code are not intended to impede
flexibility and innovation in the development of policy forms or 9,957
content, or to lead to the standardization of policy forms or 9,958
content.
Sec. 3902.02. As used in sections 3902.01 to 3902.08 of 9,967
the Revised Code: 9,968
(A) "Policy" or "policy form" means any policy, contract, 9,970
plan or agreement of life insurance and annuities, credit life 9,971
insurance and credit disability insurance, and sickness and 9,972
accident insurance, and subscriber POLICIES, CONTRACTS, 9,973
certificates, AND AGREEMENTS of medical care corporations, health 9,975
care INSURING corporations, dental care corporations, and health 9,977
maintenance organizations, delivered or issued for delivery in 9,978
this state by any company subject to sections 3902.01 to 3902.08 9,979
of the Revised Code; any certificate, contract or policy issued 9,980
224
by a fraternal benefit society; any certificate issued pursuant 9,981
to a group insurance policy delivered or issued for delivery in 9,982
this state; and any evidence of coverage issued by a health 9,983
maintenance organization INSURING CORPORATION.
(B) "Company" or "insurer" means any entity authorized to 9,985
do the business of life insurance and annuities, sickness and 9,986
accident insurance, credit life insurance, or credit disability 9,987
insurance; a fraternal benefit society; AND a medical care 9,988
corporation; a health care INSURING corporation; a dental care 9,990
corporation; and a health maintenance organization. 9,991
Sec. 3902.11. As used in sections 3902.11 to 3902.14 of 10,000
the Revised Code: 10,001
(A) "Beneficiary" has the same meaning as in division 10,003
(A)(1) of section 3901.38 of the Revised Code. 10,004
(B) "Plan of health coverage" means any of the following 10,006
if the policy, contract, or agreement contains a coordination of 10,007
benefits provision: 10,008
(1) An individual or group sickness and accident insurance 10,010
policy or an individual or group contract of a health maintenance 10,011
organization, which policy or contract provides for hospital, 10,012
dental, surgical, or medical services; 10,013
(2) Any individual or group contract that provides dental 10,015
benefits OF A HEALTH INSURING CORPORATION, WHICH CONTRACT 10,016
PROVIDES FOR HOSPITAL, DENTAL, SURGICAL, OR MEDICAL SERVICES; 10,017
(3) Any other individual or group policy or agreement 10,019
under which a third-party payer provides for hospital, dental, 10,020
surgical, or medical services; 10,021
(4) An individual or group contract of a health care 10,023
corporation. 10,024
(C) "Provider" has the same meaning as in division (A)(6) 10,026
of section 3901.38 of the Revised Code. 10,027
(D) "Third-party payer" has the same meaning as in 10,029
division (A)(8) of section 3901.38 of the Revised Code, and 10,030
includes any health care corporation. 10,031
225
Sec. 3902.13. (A) A plan of health coverage determines 10,040
its order of benefits using the first of the following that 10,041
applies: 10,042
(1) A plan that does not coordinate with other plans is 10,044
always the primary plan. 10,045
(2) The benefits of the plan that covers a person as an 10,047
employee, member, insured, or subscriber, other than a dependent, 10,048
is the primary plan. The plan that covers the person as a 10,049
dependent is the secondary plan. 10,050
(3) When more than one plan covers the same child as a 10,052
dependent of different parents who are not divorced or separated, 10,053
the primary plan is the plan of the parent whose birthday falls 10,054
earlier in the year. The secondary plan is the plan of the 10,055
parent whose birthday falls later in the year. If both parents 10,056
have the same birthday, the benefits of the plan that covered the 10,057
parent the longer is the primary plan. The plan that covered the 10,058
parent the shorter time is the secondary plan. If the other 10,059
plan's provision for coordination of benefits does not include 10,060
the rule contained in this division because it is not subject to 10,061
regulation under this division, but instead has a rule based on 10,062
the gender of the parent, and if, as a result, the plans do not 10,063
agree on the order of benefits, the rule of the other plan will 10,064
determine the order of benefits. 10,065
(4)(a) Except as provided in division (A)(4)(b) of this 10,067
section, if more than one plan covers a person as a dependent 10,068
child of divorced or separated parents, benefits for the child 10,069
are determined in the following order: 10,070
(i) The plan of the parent who is the residential parent 10,072
and legal custodian of the child; 10,073
(ii) The plan of the spouse of the parent who is the 10,075
residential parent and legal custodian of the child; 10,076
(iii) The plan of the parent who is not the residential 10,078
parent and legal custodian of the child. 10,079
(b) If the specific terms of a court decree state that one 10,081
226
parent is responsible for the health care expenses of the child, 10,082
the plan of that parent is the primary plan. A parent 10,083
responsible for the health care pursuant to a court decree must 10,084
notify the insurer or health maintenance organization INSURING 10,085
CORPORATION of the terms of the decree. 10,087
(5) The primary plan is the plan that covers a person as 10,089
an employee who is neither laid off or retired, or that 10,090
employee's dependent. The secondary plan is the plan that covers 10,091
that person as a laid-off or retired employee, or that employee's 10,092
dependent. 10,093
(6) If none of the rules in divisions (A)(1), (2), (3), 10,095
(4), and (5) of this section determines the order of benefits, 10,096
the primary plan is the plan that covered an employee, member, 10,097
insured, or subscriber longer. The secondary plan is the plan 10,098
that covered that person the shorter time. 10,099
(B) When a plan of health coverage is determined to be a 10,101
secondary plan it acts to provide benefits in excess of those 10,102
provided by the primary plan. 10,103
(C) The secondary plan shall not be required to make 10,105
payment in an amount which exceeds the amount it would have paid 10,106
if it were the primary plan, but in no event, when combined with 10,107
the amount paid by the primary plan, shall payments by the 10,108
secondary plan exceed one hundred per cent of expenses allowable 10,109
under the provisions of the applicable policies and contracts. 10,110
(D) A third-party payer may require a beneficiary to file 10,112
a claim with the primary plan before it determines the amount of 10,113
its payment obligation, if any, with regard to that claim. 10,114
(E) Nothing in this section shall be construed to require 10,116
a plan to make a payment until it determines whether it is the 10,117
primary plan or the secondary plan and what benefits are payable 10,118
under the primary plan. 10,119
(F) A plan may obtain any facts and information necessary 10,121
to apply the provisions of this section, or supply this 10,122
information to any other third-party payer or provider, or any 10,123
227
agent of such third-party payer or provider, without the consent 10,124
of the beneficiary. Each person claiming benefits under the plan 10,125
shall provide any information necessary to apply the provisions 10,126
of this section. 10,127
(G) If the amount of payments made by any plan is more 10,129
than should have been paid, the plan may recover the excess from 10,130
whichever party received the excess payment. 10,131
(H) No third-party payer shall administer a plan of health 10,133
coverage delivered, issued for delivery, or renewed on or after 10,134
June 29, 1988, unless such plan complies with this section. 10,135
(I)(1) A third-party payer that is subject to this section 10,137
and has reason to believe payment has been made by another 10,138
third-party payer for the same service may request from that 10,139
third-party payer, and shall be provided by the third-party 10,140
payer, such data as necessary to determine whether duplicate 10,141
payment has been made. 10,142
(2) A third-party payer that meets the criteria of a 10,144
secondary payer in accordance with this section may seek 10,145
repayment of any duplicate payment that may have been made from 10,146
the person to whom it made payment. If the person who received 10,147
the duplicate payment is a provider, absent a finding of a court 10,148
of competent jurisdiction that the provider has engaged in civil 10,149
or criminal fraudulent activities, the request for the return of 10,150
any duplicate payment shall be made within three years after the 10,151
close of the provider's fiscal year in which the duplicate 10,152
payment has been made. 10,153
(J) Nothing in this section shall be construed to affect 10,155
the prohibition of section 3923.37 of the Revised Code. 10,156
(K)(1) No third-party payer shall knowingly fail to comply 10,158
with the order of benefits as set forth in division (A) of this 10,159
section. 10,160
(2) No primary plan shall direct or encourage an insured 10,162
to use the benefits of a secondary plan that results in a 10,163
reduction of payment by such primary plan. 10,164
228
(L) Whoever violates division (K) of this section is 10,166
deemed to have engaged in an unfair and deceptive insurance act 10,167
or practice under sections 3901.19 to 3901.26 of the Revised 10,168
Code, and is subject to proceedings pursuant to those sections. 10,169
Sec. 3904.01. As used in sections 3904.01 to 3904.22 of 10,178
the Revised Code: 10,179
(A)(1) "Adverse underwriting decision" means any of the 10,181
following actions with respect to insurance transactions 10,182
involving life, health, or disability insurance coverage that is 10,183
individually underwritten: 10,184
(a) A declination of insurance coverage; 10,186
(b) A termination of insurance coverage; 10,188
(c) Failure of an agent to apply for insurance coverage 10,190
with a specific insurance institution that the agent represents 10,191
and that is requested by an applicant; 10,192
(d) An offer to insure at higher than standard rates. 10,194
(2) Notwithstanding division (A)(1) of this section, none 10,196
of the following actions is an adverse underwriting decision, but 10,197
the insurance institution or agent responsible for their 10,198
occurrence shall nevertheless provide the applicant or 10,199
policyholder with the specific reason or reasons for their 10,200
occurrence: 10,201
(a) The termination of an individual policy form on a 10,203
class or statewide basis; 10,204
(b) A declination of insurance coverage solely because the 10,206
coverage is not available on a class or statewide basis; 10,207
(c) The rescission of a policy. 10,209
(B) "Affiliate" or "affiliated" means a person that 10,211
directly, or indirectly through one or more intermediaries, 10,212
controls, is controlled by, or is under common control with 10,213
another person. 10,214
(C) "Agent" means a person licensed under Chapter 3905. of 10,216
the Revised Code to negotiate or solicit applications for a 10,217
policy or contract of life, health, or disability insurance. 10,218
229
(D) "Applicant" means any person that seeks to contract 10,220
for life, health, or disability insurance coverage other than a 10,221
person seeking group insurance that is not individually 10,222
underwritten. 10,223
(E) "Consumer report" means any written, oral, or other 10,225
communication of information bearing on a natural person's credit 10,226
worthiness, credit standing, credit capacity, character, general 10,227
reputation, personal characteristics, or mode of living that is 10,228
used or expected to be used in connection with a life, health, or 10,229
disability insurance transaction. 10,230
(F) "Consumer reporting agency" means any person that does 10,232
all of the following: 10,233
(1) Regularly engages, in whole or in part, in the 10,235
practice of assembling or preparing consumer reports for a 10,236
monetary fee; 10,237
(2) Obtains information primarily from sources other than 10,239
insurance institutions; 10,240
(3) Furnishes consumer reports to other persons. 10,242
(G) "Control," including the terms "controlled by" or 10,244
"under common control with," means the possession, direct or 10,245
indirect, of the power to direct or cause the direction of the 10,246
management and policies of a person, whether through the 10,247
ownership of voting securities, by contract other than a 10,248
commercial contract for goods or nonmanagement services, or 10,249
otherwise, unless the power is the result of an official position 10,250
with or corporate office held by the person. 10,251
(H) "Declination of insurance coverage" means a denial, in 10,253
whole or in part, by an insurance institution or agent of 10,254
requested insurance coverage. 10,255
(I) "Individual" means any natural person who in 10,257
connection with life, health, or disability insurance: 10,258
(1) Is a past, present, or proposed principal insured or 10,260
certificate holder; 10,261
(2) Is a past, present, or proposed policy owner; 10,263
230
(3) Is a past or present applicant; 10,265
(4) Is a past or present claimant; 10,267
(5) Derived, derives, or is proposed to derive insurance 10,269
coverage under an insurance policy or certificate subject to 10,270
sections 3904.01 to 3904.22 of the Revised Code. 10,271
(J) "Institutional source" means any person or 10,273
governmental entity that provides information about an individual 10,274
to an agent, insurance institution, or insurance support 10,275
organization, other than any of the following: 10,276
(1) An agent; 10,278
(2) The individual who is the subject of the information; 10,280
(3) A natural person acting in a personal capacity rather 10,282
than in a business or professional capacity. 10,283
(K) "Insurance institution" means any corporation, 10,285
association, partnership, fraternal benefit society, or other 10,286
person engaged in the business of life, health, or disability 10,287
insurance, including health maintenance organizations, prepaid 10,288
dental plan organizations, medical care corporations, health care 10,289
INSURING corporations, and dental care corporations. "Insurance 10,291
institution" does not include agents or insurance support 10,292
organizations. 10,293
(L)(1) "Insurance support organization" means any person 10,295
that regularly engages, in whole or in part, in the practice of 10,296
assembling or collecting information about natural persons for 10,297
the primary purpose of providing the information to an insurance 10,298
institution or agent for insurance transactions, including both 10,299
of the following: 10,300
(a) The furnishing of consumer reports or investigative 10,302
consumer reports to an insurance institution or agent for use in 10,303
connection with an insurance transaction; 10,304
(b) The collection of personal information from insurance 10,306
institutions, agents, or other insurance support organizations 10,307
for the purpose of detecting or preventing fraud, material 10,308
misrepresentation, or material nondisclosure in connection with 10,309
231
insurance underwriting or insurance claim activity. 10,310
(2) Notwithstanding division (L)(1) of this section, 10,312
agents, government institutions, insurance institutions, medical 10,313
care institutions, and medical professionals are not "insurance 10,314
support organizations" for purposes of sections 3904.01 to 10,315
3904.22 of the Revised Code. 10,316
(M) "Insurance transaction" means any transaction 10,318
involving life, health, or disability insurance primarily for 10,319
personal, family, or household needs rather than business or 10,320
professional needs and entailing either the determination of an 10,321
individual's eligibility for a life, health, or disability 10,322
insurance coverage, benefit, or payment, or the servicing of a 10,323
life, health, or disability insurance application, policy, 10,324
contract, or certificate. 10,325
(N) "Investigative consumer report" means a consumer 10,327
report or portion thereof in which information about a natural 10,328
person's character, general reputation, personal characteristics, 10,329
or mode of living is obtained through personal interviews with 10,330
the person's neighbors, friends, associates, acquaintances, or 10,331
others who may have knowledge concerning such items of 10,332
information. 10,333
(O) "Medical care institution" means any facility or 10,335
institution that is licensed to provide health care services to 10,336
natural persons, including home-health agencies, hospitals, 10,337
medical clinics, public health agencies, rehabilitation agencies, 10,338
and skilled nursing facilities. 10,339
(P) "Medical professional" means any person licensed or 10,341
certified to provide health care services to natural persons, 10,342
including a chiropractor, clinical dietician, clinical 10,343
psychologist, dentist, nurse, occupational therapist, 10,344
optometrist, pharmacist, physical therapist, physician, 10,345
podiatrist, psychiatric social worker, and speech therapist. 10,346
(Q) "Medical record information" means personal 10,348
information that relates to an individual's physical or mental 10,349
232
condition, medical history, or medical treatment and that is 10,350
obtained from a medical professional or medical care institution, 10,351
from the individual, or from the individual's spouse, parent, or 10,352
legal guardian. 10,353
(R) "Personal information" means any individually 10,355
identifiable information gathered in connection with an insurance 10,356
transaction from which judgments can be made about an 10,357
individual's character, habits, avocations, finances, occupation, 10,358
general reputation, credit, health, or any other personal 10,359
characteristics. "Personal information" includes an individual's 10,360
name and address and medical record information but does not 10,361
include privileged information. 10,362
(S) "Policyholder" means any person that is a present 10,364
owner of individual life, health, or disability insurance, or a 10,365
present certificate holder under group life, health, or 10,366
disability insurance that is individually underwritten. 10,367
(T) "Pretext interview" means an interview whereby a 10,369
person, in an attempt to obtain information about a natural 10,370
person, performs one or more of the following acts: 10,371
(1) Pretends to be someone he THE INTERVIEWER is not; 10,373
(2) Pretends to represent a person he THE INTERVIEWER is 10,375
not in fact representing; 10,377
(3) Misrepresents the true purpose of the interview; 10,379
(4) Refuses to identify himself SELF upon request. 10,381
(U) "Privileged information" means any individually 10,383
identifiable information that relates to a claim for life, 10,384
health, or disability insurance benefits or a civil or criminal 10,385
proceeding involving an individual, and that is collected in 10,386
connection with, or in reasonable anticipation of, a claim for 10,387
life, health, or disability insurance benefits or civil or 10,388
criminal proceeding involving an individual. However, 10,389
information otherwise meeting the requirements of this division 10,390
shall nevertheless be considered personal information if it is 10,391
disclosed in violation of section 3904.13 of the Revised Code. 10,392
233
(V) "Termination of insurance coverage" or "termination of 10,394
an insurance policy" means either a cancellation or nonrenewal of 10,395
a life, health, or disability insurance policy, in whole or in 10,396
part, for any reason other than the failure to pay a premium as 10,397
required by the policy. 10,398
(W) "Unauthorized insurer" means an insurance institution 10,400
that has not been granted a certificate of authority by the 10,401
superintendent of insurance to transact the business of life, 10,402
health, or disability insurance in this state. 10,403
Sec. 3905.71. As used in sections 3905.71 to 3905.79 of 10,412
the Revised Code: 10,413
(A) "Actuary" means a person who is a member in good 10,415
standing of the American academy of actuaries. 10,416
(B) "Insurer" means any person licensed to do business in 10,418
this state under Chapter 1736., 1737., 1738., 1740., 1742., 1751. 10,420
or 1761. of the Revised Code or Title XXXIX of the Revised Code. 10,421
(C) "Laws of this state relating to insurance" has the 10,423
same meaning as in section 3901.04 of the Revised Code. 10,424
(D)(1) "Managing general agent" means any person that does 10,426
all of the following: 10,427
(a) Manages all or part of the insurance business of an 10,429
insurer, including the management of a separate division, 10,430
department, or underwriting office, or negotiates and binds 10,431
ceding reinsurance contracts on behalf of an insurer; 10,432
(b) Acts as an agent for the insurer, whether known as a 10,434
managing general agent, manager, or other similar term; 10,435
(c) With or without the authority of the insurer, 10,437
separately or together with affiliates, does both of the 10,438
following: 10,439
(i) Produces, directly or indirectly, and underwrites an 10,441
amount of gross direct written premium equal to or more than five 10,442
per cent of the policyholder surplus of the insurer as reported 10,443
in the last annual statement of the insurer in any one year; 10,444
(ii) Adjusts or pays claims, or negotiates reinsurance on 10,446
234
behalf of the insurer. 10,447
(2) "Managing general agent" does not include any of the 10,449
following: 10,450
(a) An employee of the insurer; 10,452
(b) A United States manager of the United States branch of 10,454
an alien insurer; 10,455
(c) An underwriting manager that, pursuant to contract, 10,457
manages all or a part of the insurance operations of the insurer, 10,458
is under common control with the insurer, subject to sections 10,459
3901.32 to 3901.37 of the Revised Code, and whose compensation is 10,460
not based on the volume of premiums written; 10,461
(d) The attorney authorized by and acting for the 10,463
subscribers of a reciprocal insurer or inter-insurance exchange 10,464
under powers of attorney; 10,465
(e) An administrator licensed pursuant to Chapter 3959. of 10,467
the Revised Code whose activities on behalf of an insurer are 10,468
limited to administrative services involving underwriting or the 10,469
payment of claims, and do not include the management of all or 10,470
part of the insurance business of the insurer. 10,471
(E) "Underwrite" or "underwriting" means the authority to 10,473
accept or reject risk on behalf of an insurer. 10,474
Sec. 3923.123. (A) As used in this section: 10,483
(1) "Association" means a voluntary unincorporated 10,485
association of insurers formed for the sole purpose of enabling 10,486
cooperative action to provide health coverage in accordance with 10,487
this section. 10,488
(2) "Insurer" includes any insurance company authorized to 10,490
do the business of sickness and accident insurance in this state, 10,491
medical care corporation organized under Chapter 1737. of the 10,492
Revised Code, AND ANY health care INSURING corporation organized 10,494
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 10,495
the Revised Code, dental care corporation organized under Chapter 10,497
1740. of the Revised Code, or hospital maintenance organization 10,498
organized under Chapter 1742. of the Revised Code.
235
(3) "Insured" means a person covered under a group policy 10,500
or contract issued pursuant to this section. 10,501
(4) "Qualified unemployed person" means one who became 10,503
unemployed while a resident of this state from employment or 10,504
self-employment and has since been continuously unemployed or is 10,505
employed only so that he THE PERSON does not have, or have a 10,506
right to purchase, group health coverage. An individual who is, 10,508
or who becomes, covered by medicare is not a qualified unemployed 10,509
person. A person eligible for coverage under this section, who 10,510
is also eligible for continuation of coverage under section 10,511
1737.30, 1738.26, 1742.34, 1751.53 or 3923.38 of the Revised 10,512
Code, may elect either coverage, but not both. A person who 10,514
elects continuation of coverage under any EITHER of such sections 10,515
may, upon the termination of the continuation of coverage, elect 10,517
any coverage available under this section. 10,518
(B) Any insurer may join with one or more other insurers, 10,520
in an association, to offer, sell, and issue to a policyholder or 10,521
subscriber selected by the association a policy or contract of 10,522
group health coverage, covering residents of this state who are 10,523
qualified unemployed persons and the spouses or dependents of 10,524
such residents. The coverage shall be offered, issued, and 10,525
administered in the name of the association. Membership in the 10,526
association shall be open to any insurer and each insurer which 10,527
participates shall be liable for a specified percentage of the 10,528
risks. The policy or contract may be executed on behalf of the 10,529
association by a duly authorized person. 10,530
(C) The persons eligible for coverage under the policy or 10,532
contract shall be all residents of this state who are qualified 10,533
unemployed persons and their spouses and dependents, subject to 10,534
reasonable underwriting restrictions to be set forth in the plan 10,535
of the association. The policy or contract may provide basic 10,536
hospital and surgical coverage, basic medical coverage, major 10,537
medical coverage, and any combination of these; provided that it 10,538
shall not be required as a condition for obtaining major medical 10,539
236
coverage that any basic coverage be taken. 10,540
(D) The association shall file with the superintendent of 10,542
insurance any policy, contract, certificate, or other evidence of 10,543
coverage, application, or other forms pertaining to such 10,544
insurance together with the premium rates to be charged therefor. 10,545
The superintendent may approve, disapprove, and withdraw approval 10,546
of the forms in accordance with section 3923.02 of the Revised 10,547
Code, or the premium rates if by reasonable assumptions such 10,548
rates are excessive in relation to the benefits provided. In 10,549
determining whether such rates by reasonable assumptions are 10,550
excessive in relation to the benefits provided, the 10,551
superintendent shall give due consideration to past and 10,552
prospective claim experience, within and outside this state, and 10,553
to fluctuations in such claim experience, to a reasonable risk 10,554
charge, to contribution to surplus and contingency funds, to past 10,555
and prospective expenses, both within and outside this state, and 10,556
to all other relevant factors within and outside this state, 10,557
including any differing operating methods of the insurers joining 10,558
in the issuance of the policy or contract. In reviewing the 10,559
forms the superintendent shall not be bound by the requirements 10,560
of sections 3923.04 to 3923.07 of the Revised Code with respect 10,561
to standard provisions to be included in sickness and accident 10,562
policies or forms. 10,563
(E) The association may enroll eligible persons for 10,565
coverage under the policy or contract through any person licensed 10,566
by, or authorized under the law of, this state to sell the 10,567
policies or contracts, or to enroll persons in the health plans, 10,568
of any of the insurers participating in the association. 10,569
(F) The association shall file annually with the 10,571
superintendent on such date and in such form as he THE 10,572
SUPERINTENDENT may prescribe, a financial summary of its 10,574
operations.
(G) The association may sue and be sued in its associate 10,576
name and for such purposes only shall be treated as a domestic 10,577
237
corporation. Service of process against such association made 10,578
upon a managing agent, any member thereof, or any agent 10,579
authorized by appointment to receive service of process, shall 10,580
have the same force and effect as if such service had been made 10,581
upon all members of the association. 10,582
(H) Under any policy issued as provided in this section, 10,584
the policyholder, or such person as the policyholder shall 10,585
designate, shall alone be a member of each domestic mutual 10,586
insurance company joining in the issue of the policy and shall be 10,587
entitled to one vote by virtue of such policy at the meetings of 10,588
each such mutual insurance company. Notice of the annual 10,589
meetings of each such mutual insurance company may be given by 10,590
written notice to the policyholder or as otherwise prescribed in 10,591
said policy. 10,592
Sec. 3923.30. Every person, the state and any of its 10,601
instrumentalities, any county, township, school district, or 10,602
other political subdivisions and any of its instrumentalities, 10,603
and any municipal corporation and any of its instrumentalities, 10,604
which provides payment for health care benefits for any of its 10,605
employees resident in this state, which benefits are not provided 10,606
by contract with an insurer qualified to provide sickness and 10,607
accident insurance, or a health maintenance organization INSURING 10,608
CORPORATION, shall include the following benefits in its plan of 10,610
health care benefits commencing on or after January 1, 1979: 10,611
(A) If such plan of health care benefits provides payment 10,613
for the treatment of mental or nervous disorders, then such plan 10,614
shall provide benefits for services on an outpatient basis for 10,615
each eligible employee and dependent for mental or emotional 10,616
disorders, or for evaluations, that are at least equal to the 10,617
following: 10,618
(1) Payments not less than five hundred fifty dollars in a 10,620
twelve-month period, for services legally performed by or under 10,621
the clinical supervision of a licensed physician or a licensed 10,622
psychologist, whether performed in an office, in a hospital, or 10,623
238
in a community mental health facility so long as the hospital or 10,624
community mental health facility is approved by the joint 10,625
commission on accreditation of hospitals or certified by the 10,626
department of mental health as being in compliance with standards 10,627
established under division (I) of section 5119.01 of the Revised 10,628
Code; 10,629
(2) Such benefit shall be subject to reasonable 10,631
limitations, and may be subject to reasonable deductibles and 10,632
co-insurance costs. 10,633
(3) In order to qualify for participation under this 10,635
division, every facility specified in this division shall have in 10,636
effect a plan for utilization review and a plan for peer review 10,637
and every person specified in this division shall have in effect 10,638
a plan for peer review. Such plans shall have the purpose of 10,639
ensuring high quality patient care and effective and efficient 10,640
utilization of available health facilities and services. 10,641
(4) Such payment for benefits shall not be greater than 10,643
usual, customary, and reasonable. 10,644
(5) For purposes of this division, "community mental 10,646
health facility" means a facility as defined in section 3923.28 10,647
of the Revised Code. 10,648
(6)(a) Services performed under the clinical supervision 10,650
of a licensed physician or licensed psychologist, in order to be 10,651
reimbursable under the coverage required in division (A) of this 10,652
section, shall meet both of the following requirements: 10,653
(i) The services shall be performed in accordance with a 10,655
treatment plan that describes the expected duration, frequency, 10,656
and type of services to be performed; 10,657
(ii) The plan shall be reviewed and approved by a licensed 10,659
physician or licensed psychologist every three months. 10,660
(b) Payment of benefits for services reimbursable under 10,662
division (A)(6)(a) of the section shall not be restricted to 10,663
services described in the treatment plan or conditioned upon 10,664
standards of a licensed physician or licensed psychologist, which 10,665
239
at least equal the requirements of division (A)(6)(a) of this 10,666
section. 10,667
(B) Payment for benefits for alcoholism treatment for 10,669
outpatient, inpatient, and intermediate primary care for each 10,670
eligible employee and dependent that are at least equal to the 10,671
following: 10,672
(1) Payments not less than five hundred fifty dollars in a 10,674
twelve-month period for services legally performed by or under 10,675
the clinical supervision of a licensed physician or licensed 10,676
psychologist, whether performed in an office, or in a hospital or 10,677
a community mental health facility or alcoholism treatment 10,678
facility so long as the hospital, community mental health 10,679
facility, or alcoholism treatment facility is approved by the 10,680
joint commission on accreditation of hospitals or certified by 10,681
the department of health; 10,682
(2) The benefits provided under this division shall be 10,684
subject to reasonable limitations and may be subject to 10,685
reasonable deductibles and co-insurance costs. 10,686
(3) A licensed physician or licensed psychologist shall 10,688
every three months certify a patient's need for continued 10,689
services performed by such facilities. 10,690
(4) In order to qualify for participation under this 10,692
division, every facility specified in this division shall have in 10,693
effect a plan for utilization review and a plan for peer review 10,694
and every person specified in this division shall have in effect 10,695
a plan for peer review. Such plans shall have the purpose of 10,696
ensuring high quality patient care and efficient utilization of 10,697
available health facilities and services. Such person or 10,698
facilities shall also have in effect a program of rehabilitation 10,699
or a program of rehabilitation and detoxification. 10,700
(5) Nothing in this section shall be construed to require 10,702
reimbursement for benefits which is greater than usual, 10,703
customary, and reasonable. 10,704
Sec. 3923.301. Every person, the state and any of its 10,713
240
instrumentalities, any county, township, school district, or 10,714
other political subdivision and any of its instrumentalities, and 10,715
any municipal corporation and any of its instrumentalities that 10,717
provides payment for health care benefits for any of its
employees resident in this state, which benefits are not provided 10,718
by contract with an insurer qualified to provide sickness and 10,719
accident insurance or a health maintenance organization INSURING 10,720
CORPORATION, and THAT includes reimbursement for any service that 10,722
may be legally performed by a certified nurse-midwife who is 10,723
authorized under section 4723.42 of the Revised Code to practice 10,725
nurse-midwifery, shall not deny reimbursement to a certified 10,726
nurse-midwife performing the service if the service is performed 10,728
in collaboration with a licensed physician. The collaborating 10,731
physician shall be identified on the claim form.
The cost of collaboration with a certified nurse-midwife by 10,734
a licensed physician as required under section 4723.43 of the 10,735
Revised Code is a reimbursable expense. 10,736
The division of any reimbursement payment for services 10,738
performed by a certified nurse-midwife between the nurse-midwife 10,739
and the nurse-midwife's collaborating physician shall be 10,740
determined and mutually agreed upon by the certified 10,742
nurse-midwife and the physician. The division of fees shall not 10,743
be considered a violation of division (B)(17) of section 4731.22 10,744
of the Revised Code. In no case shall the total fees charged 10,745
exceed the fee the physician would have charged had the physician 10,746
provided the entire service.
Sec. 3923.33. As used in section 3923.33 and sections 10,756
3923.331 to 3923.339 of the Revised Code: 10,757
(A) "Applicant" means: 10,759
(1) In the case of an individual medicare supplement 10,761
policy, the person who seeks to contract for insurance benefits; 10,762
and 10,763
(2) In the case of a group medicare supplement policy, the 10,765
proposed certificate holder. 10,766
241
(B) "Certificate" means, for purposes of section 3923.33 10,768
and sections 3923.331 to 3923.339 of the Revised Code, any 10,769
certificate delivered or issued for delivery in this state under 10,770
a group medicare supplement policy. 10,771
(C) "Certificate form" means the form on which the 10,773
certificate is delivered or issued for delivery by the issuer. 10,774
(D) "Direct response insurance policy" means a medicare 10,776
supplement policy or certificate marketed without the direct 10,777
involvement of an insurance agent. 10,778
(E) "Issuer" includes insurance companies, fraternal 10,780
benefit societies, health maintenance organizations INSURING 10,781
CORPORATIONS, and any other entities delivering or issuing for 10,783
delivery in this state medicare supplement policies or 10,784
certificates.
(F) "Medicare" means the "Health Insurance for the Aged 10,786
Act," Title XVIII of the Social Security Amendments of 1965, 79 10,787
Stat. 291, 42 U.S.C.A. 1395, as then constituted or later 10,788
amended. 10,789
(G) "Medicare supplement policy" means a group or 10,791
individual policy of sickness and accident insurance or a 10,792
subscriber contract of health maintenance organizations INSURING 10,793
CORPORATIONS or any other issuers, other than a policy issued 10,795
pursuant to a contract under section 1876 of the "Social Security 10,796
Act," 49 Stat. 620 (1935), 42 U.S.C.A., 1395mm, as amended, or an 10,797
issued policy under any demonstration project specified in 42 10,798
U.S.C.A. 1395ss(g)(1), which is advertised, marketed, or designed 10,800
primarily as a supplement to reimbursements under medicare for 10,801
the hospital, medical, or surgical expenses of persons eligible 10,802
for medicare.
(H) "Policy form" means the form on which the policy is 10,804
delivered or issued for delivery by the issuer. 10,805
Sec. 3923.333. Medicare supplement policies shall return 10,814
to policyholders benefits that are reasonable in relation to the 10,815
premium charged. The superintendent of insurance shall issue 10,816
242
reasonable rules to establish minimum standards for loss ratios 10,817
of medicare supplement policies on the basis of incurred claims 10,818
experience, or incurred health care expenses where coverage is
provided by a health maintenance organization INSURING 10,819
CORPORATION on a service rather than reimbursement basis, and 10,821
earned premiums in accordance with accepted actuarial principles 10,822
and practices.
Sec. 3923.38. (A) As used in this section: 10,831
(1) "Group policy" includes any group sickness and 10,833
accident policy or contract delivered, issued for delivery, or 10,834
renewed in this state on or after June 28, 1984, and any private 10,835
or public employer self-insurance plan or other plan that 10,836
provides, or provides payment for, health care benefits for 10,837
employees resident in this state other than through an insurer, 10,838
OR health care INSURING corporation, or health maintenance 10,840
organization, to which both of the following apply: 10,842
(a) The policy insures employees for hospital, surgical, 10,844
or major medical insurance on an expense incurred or service 10,845
basis, other than for specified diseases or for accidental 10,846
injuries only. 10,847
(b) The policy is in effect and covers an eligible 10,849
employee at the time the employee's employment is terminated. 10,850
(2) "Eligible employee" includes only an employee to whom 10,852
all of the following apply: 10,853
(a) The employee has been continuously insured under a 10,855
group policy or under the policy and any prior similar group 10,856
coverage replaced by the policy, during the entire three-month 10,857
period preceding the termination of the employee's employment. 10,858
(b) The employee is entitled, at the time of the 10,860
termination of his THE EMPLOYEE'S employment, to unemployment 10,861
compensation benefits under Chapter 4141. of the Revised Code. 10,863
(c) The employee is not, and does not become, covered by 10,865
or eligible for coverage by medicare under Title XVIII of the 10,866
Social Security Act, as amended. 10,867
243
(d) The employee is not, and does not become, covered by 10,869
or eligible for coverage by any other insured or uninsured 10,870
arrangement that provides hospital, surgical, or medical coverage 10,871
for individuals in a group and under which the person was not 10,872
covered immediately prior to such termination. A person eligible 10,873
for continuation of coverage under this section, who is also 10,874
eligible for coverage under section 3923.123 of the Revised Code, 10,875
may elect either coverage, but not both. A person who elects 10,876
continuation of coverage may elect any coverage available under 10,877
section 3923.123 of the Revised Code upon the termination of the 10,878
continuation of coverage. 10,879
(3) "Group rate" means, in the case of an employer 10,881
self-insurance or other health benefits plan, the average monthly 10,882
cost per employee, over a period of at least twelve months, of 10,883
the operation of the plan that would represent a group insurance 10,884
rate if the same coverage had been provided under a group 10,885
sickness and accident insurance policy. 10,886
(B) A group policy shall provide that any eligible 10,888
employee may continue the employee's hospital, surgical, and 10,889
medical insurance under the policy, for the employee and the 10,890
employee's eligible dependents, for a period of six months after 10,891
the date that the insurance coverage would otherwise terminate by 10,892
reason of the termination of his THE EMPLOYEE'S employment. Each 10,894
certificate of coverage, or other notice of coverage, issued to 10,895
employees under the policy shall include a notice of the 10,896
employee's privilege of continuation. 10,897
(C) All of the following apply to the continuation of 10,899
coverage required under division (B) of this section: 10,900
(1) Continuation need not include dental, vision care, 10,902
prescription drug benefits, or any other benefits provided under 10,903
the policy in addition to its hospital, surgical, or major 10,904
medical benefits. 10,905
(2) The employer shall notify the employee of the right of 10,907
continuation at the time the employer notifies the employee of 10,908
244
the termination of employment. The notice shall inform the 10,909
employee of the amount of contribution required by the employer 10,910
under division (C)(4) of this section. 10,911
(3) The employee shall file a written election of 10,913
continuation with the employer and pay the employer the first 10,914
contribution required under division (C)(4) of this section. The 10,915
request and payment must be received by the employer no later 10,916
than the earlier of any of the following dates: 10,917
(a) Thirty-one days after the date on which the employee's 10,919
coverage would otherwise terminate; 10,920
(b) Ten days after the date on which the employee's 10,922
coverage would otherwise terminate, if the employer has notified 10,923
the employee of the right of continuation prior to such date; 10,924
(c) Ten days after the employer notifies the employee of 10,926
the right of continuation, if the notice is given after the date 10,927
on which the employee's coverage would otherwise terminate. 10,928
(4) The employee must pay to the employer, on a monthly 10,930
basis, in advance, the amount of contribution required by the 10,931
employer. The amount required shall not exceed the group rate 10,932
for the insurance being continued under the policy on the due 10,933
date of each payment. 10,934
(5) The employee's privilege to continue coverage and the 10,936
coverage under any continuation ceases if any of the following 10,937
occurs: 10,938
(a) The employee ceases to be an eligible employee under 10,940
division (A)(2)(c) or (d) of this section; 10,941
(b) A period of six months expires after the date that the 10,943
employee's insurance under the policy would otherwise have 10,944
terminated because of the termination of employment; 10,945
(c) The employee fails to make a timely payment of a 10,947
required contribution, in which event the coverage shall cease at 10,948
the end of the coverage for which contributions were made; 10,949
(d) The policy is terminated, or the employer terminates 10,951
participation under the policy, unless the employer replaces the 10,952
245
coverage by similar coverage under another group policy or other 10,953
group health arrangement. 10,954
If the employer replaces the policy with similar group 10,956
health coverage, all of the following apply: 10,957
(i) The member shall be covered under the replacement 10,959
coverage, for the balance of the period that he THE MEMBER would 10,960
have remained covered under the terminated coverage if it had not 10,962
been terminated. 10,963
(ii) The minimum level of benefits under the replacement 10,965
coverage shall be the applicable level of benefits of the policy 10,966
replaced reduced by any benefits payable under the policy 10,967
replaced. 10,968
(iii) The policy replaced shall continue to provide 10,970
benefits to the extent of its accrued liabilities and extensions 10,971
of benefits as if the replacement had not occurred. 10,972
(D) This section does not apply to an employer's 10,974
self-insurance plan if federal law supersedes, preempts, 10,975
prohibits, or otherwise precludes its application to such plans. 10,976
Sec. 3923.382. (A) As used in this section: 10,985
(1) "Eligible person" means any person who, at the time a 10,987
reservist is called or ordered to active duty, is covered under a 10,988
group plan and is either of the following: 10,989
(a) An employee who is a reservist called or ordered to 10,991
active duty; 10,992
(b) The spouse or a dependent child of an employee 10,994
described in division (A)(1)(a) of this section. 10,995
(2) "Group plan" includes any private or public employer 10,997
self-insurance plan that satisfies all of the following: 10,998
(a) The plan is established or modified in this state on 11,000
or after the effective date of this section APRIL 17, 1991. 11,002
(b) The plan provides, or provides payment for, health 11,004
benefits for employees resident in this state other than through 11,005
an insurer, OR health maintenance organization, health care 11,007
INSURING corporation, or medical care corporation. 11,008
246
(c) The plan is in effect and covers an eligible person at 11,010
the time a reservist is called or ordered to active duty. 11,011
(3) "Group rate" means the average monthly cost per 11,013
employee, over a period of at least twelve months of the 11,014
operation of a group plan, that would represent a group insurance 11,015
rate if the same coverage had been provided under a group 11,016
sickness and accident insurance policy. 11,017
(4) "Reservist" means a member of a reserve component of 11,019
the armed forces of the United States. "Reservist" includes a 11,020
member of the Ohio national guard and the Ohio air national 11,021
guard. 11,022
(B) Every group plan shall provide that any eligible 11,024
person may continue the coverage under the plan for a period of 11,025
eighteen months after the date on which the coverage would 11,026
otherwise terminate because the reservist is called or ordered to 11,027
active duty. 11,028
(C)(1) An eligible person may extend the eighteen-month 11,030
period of continuation of coverage to a thirty-six-month period 11,031
of continuation of coverage, if any of the following occurs 11,032
during the eighteen-month period: 11,033
(a) The death of the reservist; 11,035
(b) The divorce or separation of a reservist from the 11,037
reservist's spouse; 11,038
(c) The cessation of dependency of a child pursuant to the 11,040
terms of the plan. 11,041
(2) The thirty-six-month period of continuation of 11,043
coverage is deemed to begin on the date on which the coverage 11,044
would otherwise terminate because the reservist is called or 11,045
ordered to active duty. 11,046
(3) The employer may begin the thirty-six-month period on 11,048
the date of any occurrence described in division (C)(1) of this 11,049
section. 11,050
(D) All of the following apply to any continuation of 11,052
coverage, or the extension of any continuation of coverage, 11,053
247
provided under division (B) or (C) of this section: 11,054
(1) The continuation of coverage shall provide the same 11,056
benefits as those provided to any similarly situated eligible 11,057
person who is covered under the same group plan and an employee 11,058
who has not been called or ordered to active duty. 11,059
(2) An employer shall notify each employee of the right of 11,061
continuation of coverage at the time of employment. At the time 11,062
the reservist is called or ordered to active duty, the employer 11,063
shall notify each eligible person of the requirements for the 11,064
continuation of coverage. 11,065
(3) Each certificate or other evidence of coverage issued 11,067
by an employer to an employee under the group plan shall include 11,068
a notice of the eligible person's right of continuation of 11,069
coverage. 11,070
(4) An eligible person shall file a written election of 11,072
continuation of coverage with the employer and pay the employer 11,073
the first contribution required under division (D)(5) of this 11,074
section. The written election and payment must be received by 11,075
the employer no later than thirty-one days after the date on 11,076
which the eligible person's coverage would otherwise terminate. 11,077
If the employer notifies the eligible person of the right of 11,078
continuation of coverage after the date on which the eligible 11,079
person's coverage would otherwise terminate, the written election 11,080
and payment must be received by the employer no later than 11,081
thirty-one days after the date of the notification. 11,082
(5)(a) Except as provided in division (D)(5)(b) of this 11,084
section, the eligible person shall pay to the employer, on a 11,085
monthly basis and in advance, the amount of contribution required 11,086
by the employer. The amount shall not exceed one hundred two per 11,087
cent of the group rate for the coverage being continued under the 11,088
group plan on the due date of each payment. 11,089
(b) The employer may pay a portion or all of the eligible 11,091
person's contribution. 11,092
(E) The eligible person's right to any continuation of 11,094
248
coverage, or the extension of any continuation of coverage, 11,095
provided under division (B) or (C) of this section ceases on the 11,096
date on which any of the following occurs: 11,097
(1) The eligible person, whether as an employee or 11,099
otherwise, enrolls in another group plan or other group health 11,100
plan or arrangement that does not contain any exclusion or 11,101
limitation with respect to any preexisting condition of that 11,102
eligible person. For purposes of division (E)(1) of this 11,103
section, a group plan or other group health plan or arrangement 11,104
does not include the civilian health and medical program of the 11,105
uniformed services as defined in Public Law 99-661, 100 Stat. 11,106
3898 (1986), 10 U.S.C.A. 1072. 11,107
(2) The period of either eighteen months provided under 11,109
division (B) of this section or thirty-six months provided under 11,110
division (C) of this section expires. 11,111
(3) The eligible person fails to make a timely payment of 11,113
a required contribution, in which case the coverage ceases at the 11,114
end of the period of coverage for which contributions were made. 11,115
(4) The group plan, or participation under the group plan, 11,117
is terminated, unless the employer, in accordance with division 11,118
(F) of this section, replaces the coverage with similar coverage 11,119
under another group plan or other group health plan or 11,120
arrangement. 11,121
(F) If the employer replaces the group plan with similar 11,123
coverage as described in division (E)(4) of this section, both of 11,124
the following apply: 11,125
(1) The eligible person is covered under the replacement 11,127
coverage for the balance of the period that he THE PERSON would 11,128
have remained covered under the terminated coverage if it had not 11,130
been terminated. 11,131
(2) The level of benefits under the replacement coverage 11,133
is the same as the level of benefits provided to any similarly 11,134
situated eligible person who is covered under the group plan and 11,135
an employee who has not been called or ordered to active duty. 11,136
249
(G) Upon the reservist's release from active duty and his 11,138
THE RESERVIST'S return to employment for the employer by whom he 11,140
THE RESERVIST was employed at the time he THE RESERVIST was 11,142
called or ordered to active duty, both of the following apply: 11,144
(1) Every eligible person is entitled, without any waiting 11,146
period, to coverage under the employer's group plan that is in 11,147
effect at the time of the reservist's return to employment. 11,148
(2) Every eligible person is entitled to all benefits 11,150
under the group plan described in division (G)(1) of this section 11,151
from the date of the original coverage under the plan. 11,152
(H)(1) No employer shall fail to provide for a 11,154
continuation of coverage, or an extension of a continuation of 11,155
coverage, in a group plan as required by and in accordance with 11,156
the terms and conditions set forth under this section. 11,157
(2) No employer shall fail to issue a certificate or other 11,159
evidence of coverage in compliance with division (D)(3) of this 11,160
section. 11,161
(3) No employer shall fail to provide an employee or 11,163
eligible person with notice of the right to a continuation of 11,164
coverage under a group plan in accordance with division (D)(2) of 11,165
this section. 11,166
(I) Whoever violates division (H)(1), (2), or (3) of this 11,168
section is deemed to have engaged in an unfair and deceptive act 11,169
or practice in the business of insurance under sections 3901.19 11,170
to 3901.26 of the Revised Code. 11,171
(J) This section does not apply to a group plan under 11,173
either of the following circumstances: 11,174
(1) The group plan is subject to section 5923.051 of the 11,176
Revised Code. 11,177
(2) The application of this section is superseded, 11,179
preempted, prohibited, or otherwise precluded by federal law. 11,180
Sec. 3923.41. As used in sections 3923.41 to 3923.48 of 11,189
the Revised Code: 11,190
(A) "Long-term care insurance" means any insurance policy 11,192
250
or rider advertised, marketed, offered, or designed to provide 11,193
coverage for not less than one year for each covered person on an 11,194
expense incurred, indemnity, prepaid, or other basis, for one or 11,195
more necessary or medically necessary diagnostic, preventive, 11,196
therapeutic, rehabilitative, maintenance, or personal care 11,197
services, provided in a setting other than an acute care unit of 11,198
a hospital. "Long-term care insurance" includes group and 11,199
individual annuities and life insurance policies or riders that 11,200
provide directly or supplement long-term care benefits, and 11,201
policies or riders that provide for payment of benefits based on 11,202
cognitive impairment or the loss of functional capacity. 11,203
"Long-term care insurance" includes group and individual policies 11,204
or riders whether issued by insurers, fraternal benefit 11,205
societies, OR health and medical care INSURING corporations, 11,207
prepaid health plans, or health maintenance organizations. 11,208
"Long-term care insurance" does not include any insurance policy 11,209
that is offered primarily to provide basic medicare supplement 11,210
coverage, basic hospital expense coverage, basic medical-surgical 11,211
expense coverage, hospital confinement indemnity coverage, major 11,212
medical expense coverage, disability income protection coverage, 11,213
accident only coverage, specified disease or specified accident 11,214
coverage, or limited benefit health coverage. 11,215
With regard to life insurance, "long-term care insurance" 11,217
does not include life insurance policies that accelerate the 11,218
death benefits specifically for one or more of the qualifying 11,219
events of terminal illness, medical conditions requiring 11,220
extraordinary medical intervention, or permanent institutional 11,221
confinement; that provide the option of a lump sum payment for 11,222
those benefits; and in which neither the benefits nor the 11,223
eligibility for the benefits is conditioned upon the receipt of 11,224
long-term care. 11,225
Notwithstanding any other provision contained in sections 11,227
3923.41 to 3923.48 of the Revised Code, any product advertised, 11,228
marketed, or offered as long-term care insurance shall be subject 11,229
251
to sections 3923.41 to 3923.48 of the Revised Code. 11,230
(B) "Applicant" means either of the following: 11,232
(1) In the case of an individual long-term care insurance 11,234
policy, the person who seeks to contract for benefits; 11,235
(2) In the case of a group long-term care insurance 11,237
policy, the proposed certificate holder. 11,238
(C) "Certificate" means any certificate issued under a 11,240
group long-term care insurance policy that has been delivered, 11,241
issued for delivery, or used in or outside this state. 11,242
(D) "Group long-term care insurance" means a form of 11,244
long-term care insurance covering any group of two or more 11,245
employees, members, or other persons, with or without one or more 11,246
of their dependents and members of their immediate families. Such 11,248
insurance may be offered to groups without regard to the purpose 11,249
or type of group or the occupation of the employees, members, and 11,250
other persons insured under the policy.
(E) "Policy" means any policy, contract, rider, or 11,252
endorsement delivered, issued for delivery, or used in or outside 11,253
this state by an insurer, fraternal benefit society, OR health or 11,254
medical care INSURING corporation, prepaid health plan, or health 11,256
maintenance organization. 11,257
Sec. 3923.51. (A) As used in this section, "official 11,266
poverty line" means the poverty line as defined by the United 11,267
States office of management and budget and revised by the 11,268
secretary of health and human services under 95 Stat. 511, 42 11,269
U.S.C.A. 9902, as amended. 11,270
(B) Every insurer that is authorized to write sickness and 11,272
accident insurance in this state may offer group contracts of 11,273
sickness and accident insurance to any charitable foundation that 11,274
is certified as exempt from taxation under section 501(c)(3) of 11,275
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 11,276
1, as amended, and that has the sole purpose of issuing 11,277
certificates of coverage under these contracts to persons under 11,278
the age of nineteen who are members of families that have incomes 11,279
252
that are no greater than three hundred per cent of the official 11,280
poverty line. 11,281
(C) Contracts offered pursuant to division (B) of this 11,283
section are not subject to any of the following: 11,284
(1) Sections 3923.122, 3923.24, and 3923.29 of the Revised 11,286
Code; 11,287
(2) Any other sickness and accident insurance coverage 11,289
required under this chapter on the effective date of this section 11,291
AUGUST 3, 1989. Any requirement of sickness and accident 11,292
insurance coverage enacted after that date applies to this 11,293
section only if the subsequent enactment specifically refers to 11,294
this section.
(3) Chapter 1742. 1751. of the Revised Code. 11,296
Sec. 3923.54. (A) As used in this section, "screening 11,305
mammography" means a radiologic examination utilized to detect 11,306
unsuspected breast cancer at an early stage in asymptomatic women 11,307
and includes the x-ray examination of the breast using equipment 11,308
that is dedicated specifically for mammography including, but not 11,309
limited to, the x-ray tube, filter, compression device, screens, 11,310
film, and cassettes, and that has an average radiation exposure 11,311
delivery of less than one rad mid-breast. "Screening 11,312
mammography" includes two views for each breast. The term also 11,314
includes the professional interpretation of the film. 11,315
"Screening mammography" does not include diagnostic 11,317
mammography.
(B) Each employer in this state that provides, in whole or 11,319
in part, health care benefits for its employees under a policy of 11,320
sickness and accident insurance issued in accordance with Chapter 11,321
3923. of the Revised Code shall also provide to its employees 11,322
benefits for the expenses of both of the following: 11,323
(1) Screening mammography to detect the presence of breast 11,325
cancer in adult women; 11,326
(2) Cytologic screening for the presence of cervical 11,328
cancer. 11,329
253
(C) An employer may comply with division (B) of this 11,331
section in any of the following ways: 11,332
(1) By providing the benefits under a health maintenance 11,334
organization INSURING CORPORATION contract issued in accordance 11,335
with Chapter 1742. 1751. of the Revised Code or a policy of 11,337
sickness and accident insurance issued in accordance with Chapter 11,338
3923. of the Revised Code;
(2) By reimbursing the employee for the direct health care 11,340
provider charges associated with receipt of the covered service; 11,341
(3) By making any other arrangement that provides the 11,343
benefits described in division (B) of this section. 11,344
(D) The benefits provided under division (B)(1) of this 11,346
section shall cover expenses in accordance with all of the 11,347
following: 11,348
(1) If a woman is at least thirty-five years of age but 11,350
under forty years of age, one screening mammography; 11,351
(2) If a woman is at least forty years of age but under 11,353
fifty years of age, either of the following: 11,354
(a) One screening mammography every two years; 11,356
(b) If a licensed physician has determined that the woman 11,358
has risk factors to breast cancer, one screening mammography 11,359
every year. 11,360
(3) If a woman is at least fifty years of age but under 11,362
sixty-five years of age, one screening mammography every year. 11,363
(E)(1) The benefits provided under division (B)(1) of this 11,365
section need not exceed eighty-five dollars per year. 11,366
(2) The benefit paid in accordance with division (E)(1) of 11,368
this section shall constitute full payment. No institutional or 11,369
professional health care provider shall seek or receive 11,370
compensation in excess of the payment made in accordance with 11,371
division (E)(1) of this section, except for approved deductibles 11,372
and copayments. 11,373
(F) The benefits provided under division (B)(1) of this 11,375
section shall be provided only for screening mammographies that 11,376
254
are performed in a facility or mobile mammography screening unit 11,377
that is accredited under the American college of radiology 11,379
mammography accreditation program or in a hospital as defined in 11,380
section 3727.01 of the Revised Code.
(G) The benefits provided under division (B)(2) of this 11,382
section shall be provided only for cytologic screenings that are 11,383
processed and interpreted in a laboratory certified by the 11,384
college of American pathologists or in a hospital as defined in 11,385
section 3727.01 of the Revised Code. 11,386
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 11,395
of the Revised Code: 11,396
(1) "Case characteristics," "eligible employee," "health 11,398
benefit plan," "late enrollee," "MEWA," and "pre-existing 11,399
conditions provision" have the same meanings as in section 11,400
3924.01 of the Revised Code. 11,401
(2) "Insurer" means any sickness and accident insurance 11,403
company authorized to issue health benefit plans in this state, 11,404
or MEWA authorized to issue insured health benefit plans in this 11,405
state. "Insurer" does not include any health maintenance 11,406
organization INSURING CORPORATION that is owned or operated by an 11,407
insurer. 11,408
(3) "Small employer" means any person, firm, corporation, 11,410
or partnership actively engaged in business whose total employed 11,411
work force, on at least fifty per cent of its working days during 11,412
the preceding year, consisted of at least two unrelated eligible 11,413
employees but no more than twenty-five eligible employees, the 11,414
majority of whom were employed within this state. In determining 11,415
the number of eligible employees, companies that are affiliated 11,416
companies or that are eligible to file a combined tax return for 11,417
purposes of state taxation shall be considered one employer. In 11,418
determining whether the members of an association are small 11,419
employers, each member of the association shall be considered as 11,420
a separate person, firm, corporation, or partnership. 11,421
(4) "Small employer group" means any group consisting of 11,423
255
all of the eligible employees of a small employer, except those 11,424
employees who are covered, or are eligible for coverage, under 11,425
any other private or public health benefits arrangement, 11,426
including the medicare program established under Title XVIII of 11,427
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 11,428
as amended, or any other act of congress or law of this or any 11,429
other state of the United States that provides benefits 11,430
comparable to the benefits provided under this section. 11,431
(B) Beginning in January of each year, insurers shall 11,433
accept applicants for open enrollment coverage, as set forth in 11,434
divisions (B)(1) and (2) of this section, in the order in which 11,435
they apply for coverage and subject to the limitation set forth 11,436
in division (G) of this section: 11,437
(1) Insurers in the business of issuing health benefit 11,439
plans to small employer groups shall accept small employer groups 11,440
for which coverage is not otherwise available and for whom 11,441
coverage had not been terminated by the employer or by an insurer 11,442
or, health maintenance organization, OR HEALTH INSURING 11,444
CORPORATION during the preceding twelve-month period; 11,447
(2) Insurers in the business of issuing individual 11,449
policies of sickness and accident insurance as contemplated by 11,450
section 3923.021 of the Revised Code, except individual policies 11,451
issued pursuant to section 3923.122 of the Revised Code, shall 11,452
either accept individuals pursuant to the open enrollment 11,453
requirements of section 3941.53 of the Revised Code, if subject 11,454
to that section, or accept for coverage pursuant to this section 11,456
individuals to whom both of the following conditions apply: 11,457
(a) The individual is not applying for coverage as an 11,459
employee of an employer, as a member of an association, or as a 11,460
member of any other group. 11,461
(b) The individual is not covered, and is not eligible for 11,463
coverage, under any other private or public health benefits 11,464
arrangement, including the medicare program established under 11,465
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 11,466
256
U.S.C.A. 301, as amended, or any other act of congress or law of 11,467
this or any other state of the United States that provides 11,468
benefits comparable to the benefits provided under this section, 11,469
any medicare supplement policy, or any conversion or continuation 11,470
of coverage policy under state or federal law. 11,471
(C) An insurer shall offer to any individual or small 11,473
employer group accepted under this section the small employer 11,474
health care plan established by the board of directors of the 11,475
Ohio small employer health reinsurance program under division (A) 11,476
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 11,477
plan in benefit plan design and scope of covered services. 11,478
An insurer may offer other health benefit plans in addition 11,480
to, but not in lieu of, the plan required to be offered under 11,481
this division. These additional health benefit plans shall 11,482
provide, at a minimum, the coverage provided by the small 11,483
employer health care plan or any health benefit plan that is 11,484
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 11,485
For purposes of this division, the superintendent of 11,487
insurance shall determine whether a health benefit plan is 11,488
substantially similar to the small employer health care plan in 11,489
benefit plan design and scope of covered services. 11,490
(D) Health benefit plans issued under this section may 11,492
establish pre-existing conditions provisions that exclude or 11,493
limit coverage for a period of up to twelve months following the 11,494
individual's effective date of coverage and that may relate only 11,495
to conditions during the six months immediately preceding the 11,496
effective date of coverage. However, an insurer may exclude a 11,497
late enrollee for a period of up to eighteen months following the 11,498
individual's date of application for coverage. 11,499
(E) Premiums charged to groups or individuals under this 11,501
section may not exceed an amount that is two and one-half times 11,502
the highest rate charged any other group with similar case 11,503
257
characteristics or any other individual to which the insurer is 11,504
currently accepting new business, and for which similar 11,505
copayments and deductibles are applied. 11,506
(F) In offering health benefit plans under this section, 11,508
an insurer may require the purchase of health benefit plans that 11,509
condition the reimbursement of health services upon the use of a 11,510
specific network of providers. 11,511
(G)(1) In no event shall an insurer be required to accept 11,513
annually under this section either individuals or small employer 11,514
groups that, in the aggregate, would cause the insurer to have a 11,515
total number of new insureds that is more than one-half per cent 11,516
of its total number of insured individuals in this state per 11,517
year, as contemplated by section 3923.021 of the Revised Code, 11,518
and small group certificate holders of health benefit plans in 11,519
this state per year, calculated as of the immediately preceding 11,521
thirty-first day of December and excluding the insurer's medicare 11,522
supplement policies and conversion or continuation of coverage 11,524
policies under state or federal law and any policies described in 11,525
division (N) of this section. If an insurer is subject to, and 11,527
elects to operate under, the individual open enrollment 11,528
requirements of section 3941.53 of the Revised Code, in no event 11,529
shall the insurer be required to accept annually under this 11,530
section small employer groups that would cause the insurer to 11,531
have a total number of new insureds that is more than one-half 11,532
per cent of its total number of small group certificate holders 11,533
calculated as set forth in division (G)(1) of this section. 11,534
(2) An officer of the insurer shall certify to the 11,536
department of insurance when it has met the enrollment limit set 11,537
forth in division (G)(1) of this section. Upon providing such 11,538
certification, the insurer shall be relieved of its open 11,539
enrollment requirement under this section for the remainder of 11,540
the calendar year. 11,541
(H) An insurer shall not be required to accept under this 11,543
section applicants who, at the time of enrollment, are confined 11,544
258
to a health care facility because of chronic illness, permanent 11,545
injury, or other infirmity that would cause economic impairment 11,546
to the insurer if the applicants were accepted, or to make the 11,547
effective date of benefits for individuals or groups accepted 11,548
under this section earlier than ninety days after the date of 11,549
acceptance. 11,550
(I) The requirements of this section do not apply to any 11,552
insurer that is currently in a state of supervision, insolvency, 11,553
or liquidation. If an insurer demonstrates to the satisfaction 11,554
of the superintendent that the requirements of this section would 11,556
place the insurer in a state of supervision, insolvency, or 11,557
liquidation, the superintendent may waive or modify the 11,558
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 11,560
a period of not more than one year. At the expiration of such 11,561
time, a new showing of need for a waiver or modification by the 11,562
insurer shall be made before a new waiver or modification is 11,563
issued or imposed.
(J) No hospital, health care facility, or health care 11,565
practitioner, and no person who employs any health care 11,566
practitioner, shall balance bill any individual or dependent of 11,567
an individual or any eligible employee or dependent of an 11,568
employee for any health care supplies or services provided to the 11,569
individual or dependent or the eligible employee or dependent, 11,570
who is insured under a policy or enrolled under a health benefit 11,572
plan issued under this section. The hospital, health care 11,573
facility, or health care practitioner, or any person that employs 11,574
the health care practitioner, shall accept payments made to it by 11,575
the insurer under the terms of the policy or contract insuring or 11,577
covering such individual as payment in full for such health care 11,578
supplies or services. 11,579
As used in this division, "hospital" has the same meaning 11,581
as in section 3727.01 of the Revised Code; "health care 11,582
practitioner" has the same meaning as in section 4769.01 of the 11,583
259
Revised Code; and "balance bill" means charging or collecting an 11,584
amount in excess of the amount reimbursable or payable under the 11,585
policy or health care service contract issued to an individual or 11,586
group under this section for such health care supply or service. 11,587
"Balance bill" does not include charging for or collecting 11,588
copayments or deductibles required by the policy or contract. 11,589
(K) An insurer shall pay an agent a commission in the 11,591
amount of five per cent of the premium charged for initial 11,592
placement or for otherwise securing the issuance of a policy or 11,593
contract issued to an individual or small employer group under 11,594
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 11,595
adopt, in accordance with Chapter 119. of the Revised Code, such 11,596
rules as are necessary to enforce this division. 11,597
(L) Except as otherwise provided in this section, sections 11,599
3924.01 to 3924.06 of the Revised Code apply to all health 11,600
benefit plans issued under this section. 11,601
(M) Individuals accepted for coverage under this section 11,603
may be issued contracts and certificates subject to the 11,604
requirements of section 3923.12 of the Revised Code. The 11,605
coverage issued to such individuals is not subject to the 11,606
requirements of section 3923.021 of the Revised Code. 11,607
(N) This section does not apply to any policy that 11,609
provides coverage for specific diseases or accidents only, or to 11,611
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 11,613
than six months, or other policy that offers only supplemental 11,614
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 11,623
the Revised Code: 11,624
(A) "Actuarial certification" means a written statement 11,626
prepared by a member of the American academy of actuaries, or by 11,627
any other person acceptable to the superintendent of insurance, 11,628
that states that, based upon the person's examination, a carrier 11,629
260
offering health benefit plans to small employers is in compliance 11,630
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 11,631
certification" shall include a review of the appropriate records 11,632
of, and the actuarial assumptions and methods used by, the 11,633
carrier relative to establishing premium rates for the health 11,634
benefit plans. 11,635
(B) "Adjusted average market premium price" means the 11,637
average market premium price as determined by the board of 11,639
directors of the Ohio small employer health reinsurance program 11,640
either on the basis of the arithmetic mean of all carriers' 11,641
premium rates for an SEHC plan sold to groups with similar case 11,642
characteristics by all carriers selling SEHC plans in the state, 11,644
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 11,646
plan that is issued by a carrier and that covers at least two but 11,647
no more than fifty employees of a small employer, the lowest 11,649
premium rate for a new or existing business prescribed by the 11,650
carrier for the same or similar coverage under a plan or 11,651
arrangement covering any small employer with similar case 11,652
characteristics.
(D) "Carrier" means any sickness and accident insurance 11,654
company or health maintenance organization INSURING CORPORATION 11,655
authorized to issue health benefit plans in this state or a MEWA. 11,657
A sickness and accident insurance company that owns or operates a 11,659
health maintenance organization INSURING CORPORATION, either as a 11,660
separate corporation or as a line of business, shall be 11,662
considered as a separate carrier from that health maintenance 11,663
organization INSURING CORPORATION for purposes of sections 11,665
3924.01 to 3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 11,667
employer, the geographic area in which the employees work; the 11,668
age and sex of the individual employees and their dependents; the 11,669
appropriate industry classification as determined by the carrier; 11,670
the number of employees and dependents; and such other objective 11,671
261
criteria as may be established by the carrier. "Case 11,672
characteristics" does not include claims experience, health 11,673
status, or duration of coverage from the date of issue. 11,674
(F) "Dependent" means the spouse or child of an eligible 11,676
employee, subject to applicable terms of the health benefits plan 11,677
covering the employee. 11,678
(G) "Eligible employee" means an employee who works a 11,680
normal work week of twenty-five or more hours. "Eligible 11,681
employee" does not include a temporary or substitute employee, or 11,683
a seasonal employee who works only part of the calendar year on 11,684
the basis of natural or suitable times or circumstances. 11,685
(H) "Financially impaired" means a program member that, 11,687
after April 14, 1993, is not insolvent but is determined by the 11,690
superintendent to be potentially unable to fulfill its 11,691
contractual obligations, or is placed under an order of 11,692
rehabilitation or conservation by a court of competent 11,693
jurisdiction or under an order of supervision by the 11,694
superintendent.
(I) "Health benefit plan" means any hospital or medical 11,696
expense policy or certificate or any health plan provided by a 11,698
carrier, that is delivered, issued for delivery, renewed, or used 11,700
in this state on or after the date occurring six months after the 11,701
effective date of this amendment NOVEMBER 24, 1995. "Health 11,702
benefit plan" does not include policies covering only accident, 11,704
credit, dental, disability income, long-term care, hospital 11,705
indemnity, medicare supplement, specified disease, or vision 11,706
care; coverage under a one-time-limited-duration policy of no 11,707
longer than six months; coverage issued by a health care 11,708
corporation; coverage issued by a prepaid dental plan 11,710
organization solely or in conjunction with a carrier; coverage 11,711
issued as a supplement to liability insurance; insurance arising 11,712
out of a workers' compensation or similar law; automobile 11,713
medical-payment insurance; or insurance under which benefits are 11,714
payable with or without regard to fault and which is statutorily 11,715
262
required to be contained in any liability insurance policy or 11,716
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 11,718
period immediately following any service waiting period 11,719
established by an employer. 11,720
(K) "Late enrollee" means an eligible employee or 11,722
dependent who requests enrollment in a small employer's health 11,723
benefit plan following the initial enrollment period provided 11,724
under the terms of the first plan for which the employee or 11,725
dependent was eligible through the small employer, unless any of 11,726
the following apply: 11,727
(1) The individual: 11,729
(a) Was covered under another health benefit plan at the 11,732
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 11,734
coverage under another health benefit plan was the reason for 11,737
declining enrollment;
(c) Has lost coverage under another health benefit plan as 11,740
a result of the termination of employment, a reduction of hours 11,741
worked per week, the termination of the other plan's coverage, 11,742
death of a spouse, or divorce; and 11,743
(d) Requests enrollment within thirty days after the 11,745
termination of coverage under another health benefit plan. 11,746
(2) The individual is employed by an employer who offers 11,748
multiple health benefit plans and the individual elects a 11,749
different health benefit plan during an open enrollment period. 11,750
(3) A court has ordered coverage to be provided for a 11,752
spouse or minor child under a covered employee's plan and a 11,753
request for enrollment is made within thirty days after issuance 11,754
of the court order. 11,755
(L) "MEWA" means any "multiple employer welfare 11,757
arrangement" as defined in section 3 of the "Federal Employee 11,758
Retirement Income Security Act of 1974," 88 Stat. 832, 29 11,759
U.S.C.A. 1001, as amended, except for any arrangement which is 11,760
263
fully insured as defined in division (b)(6)(D) of section 514 of 11,761
that act. 11,762
(M) "Midpoint rate" means, for small employers with 11,764
similar case characteristics and plan designs and as determined 11,765
by the applicable carrier for a rating period, the arithmetic 11,766
average of the applicable base premium rate and the corresponding 11,767
highest premium rate. 11,768
(N) "Pre-existing conditions provision" means a policy 11,770
provision that excludes or limits coverage for charges or 11,771
expenses incurred during a specified period following the 11,772
insured's effective date of coverage as to a condition which, 11,773
during a specified period immediately preceding the effective 11,774
date of coverage, had manifested itself in such a manner as would 11,775
cause an ordinarily prudent person to seek medical advice, 11,776
diagnosis, care, or treatment or for which medical advice, 11,777
diagnosis, care, or treatment was recommended or received, or a 11,778
pregnancy existing on the effective date of coverage. 11,779
(O) "Service waiting period" means the period of time 11,781
after employment begins before an eligible employee may enroll in 11,782
any applicable health benefit plan offered by the small employer. 11,783
(P)(1) "Small employer" means any person, firm, 11,786
corporation, partnership, or association actively engaged in 11,787
business whose total employed work force consisted of, on at 11,788
least fifty per cent of its working days during the preceding 11,789
year, at least two but no more than fifty eligible employees, the 11,790
majority of whom were employed within the state. 11,791
(2) In determining the number of eligible employees for 11,793
purposes of division (P)(1) of this section, companies which are 11,794
affiliated companies or which are eligible to file a combined tax 11,795
return for purposes of state taxation shall be considered one 11,796
employer. Except as otherwise specifically provided, provisions 11,797
of sections 3924.01 to 3924.14 of the Revised Code that apply to 11,798
a small employer that has a health benefit plan shall continue to 11,799
apply until the plan anniversary following the date the employer 11,800
264
no longer meets the requirements of this division. 11,801
(Q) "SEHC plan" means an Ohio small employer health care 11,804
plan, which is a health benefit plan for small employers
established by the board in accordance with section 3924.10 of 11,805
the Revised Code. 11,806
Sec. 3924.02. (A) An individual or group health benefit 11,815
plan is subject to sections 3924.01 to 3924.14 of the Revised 11,816
Code if it provides health care benefits covering at least two 11,818
but no more than fifty employees of a small employer, and if it 11,819
meets either of the following conditions: 11,820
(1) Any portion of the premium or benefits is paid by a 11,822
small employer, or any covered individual is reimbursed, whether 11,823
through wage adjustments or otherwise, by a small employer for 11,824
any portion of the premium. 11,825
(2) The health benefit plan is treated by the employer or 11,827
any of the covered individuals as part of a plan or program for 11,828
purposes of section 106 or 162 of the "Internal Revenue Code of 11,829
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 11,830
(B) Notwithstanding division (A) of this section, 11,832
divisions (G) to (J) of section 3924.03 of the Revised Code and 11,834
section 3924.04 of the Revised Code do not apply to health 11,835
benefit policies that are not sold to owners of small businesses 11,836
as an employment benefit plan. Such policies shall clearly state 11,837
that they are not being sold as an employment benefit plan and 11,838
that the owner of the business is not responsible, either 11,839
directly or indirectly, for paying the premium or benefits. 11,840
(C) Every health benefit plan offered or delivered by a 11,842
carrier, other than a health maintenance organization INSURING 11,843
CORPORATION, to a small employer is subject to sections 3923.23, 11,845
3923.231, 3923.232, 3923.233, and 3923.234 of the Revised Code 11,846
and any other provision of the Revised Code that requires the 11,847
reimbursement, utilization, or consideration of a specific 11,848
category of a licensed or certified health care practitioner. 11,849
(D) Except as expressly provided in sections 3924.01 to 11,851
265
3924.14 of the Revised Code, no health benefit plan offered to a 11,852
small employer is subject to any of the following: 11,853
(1) Any law that would inhibit any carrier from 11,855
contracting with providers or groups of providers with respect to 11,856
health care services or benefits; 11,857
(2) Any law that would impose any restriction on the 11,859
ability to negotiate with providers regarding the level or method 11,860
of reimbursing care or services provided under the health benefit 11,861
plan; 11,862
(3) Any law that would require any carrier to either 11,864
include a specific provider or class of provider when contracting 11,865
for health care services or benefits, or to exclude any class of 11,866
provider that is generally authorized by statute to provide such 11,867
care. 11,868
Sec. 3924.08. (A) The board of directors of the Ohio 11,877
small employer health reinsurance program shall consist of nine 11,878
appointed members who shall serve staggered terms as determined 11,879
by the initial board for its members and by the plan of operation 11,880
of the program for members of subsequent boards. Within thirty 11,881
days after April 14, 1993, the members of the board shall be 11,882
appointed, as follows: 11,883
(1) The chairperson of the senate committee having 11,885
jurisdiction over insurance shall appoint the following members: 11,886
(a) Two member carriers that are small employer carriers; 11,888
(b) One member carrier that is a health maintenance 11,890
organization INSURING CORPORATION predominantly in the small 11,891
employer market; 11,892
(c) One representative of providers of health care. 11,894
(2) The chairperson of the committee in the house of 11,896
representatives having jurisdiction over insurance shall appoint 11,897
the following members: 11,898
(a) One member carrier that is a small employer carrier; 11,900
(b) One member carrier whose principal health insurance 11,902
business is in the large employer market; 11,903
266
(c) One representative of an employer with fifty or fewer 11,905
employees; 11,906
(d) One representative of consumers in this state. 11,908
(3) The superintendent shall appoint a representative of a 11,910
member carrier operating in the small employer market who is a 11,911
fellow of the society of actuaries. 11,912
The superintendent, a member of the house of 11,914
representatives appointed by the speaker of the house of 11,915
representatives, and a member of the senate appointed by the 11,916
president of the senate, shall be ex-officio members of the 11,917
board. The membership of all boards subsequent to the initial 11,918
board shall reflect the distribution described in division (A) of 11,920
this section.
The chairperson of the initial board and each subsequent 11,922
board shall represent a small employer member carrier and shall 11,923
be elected by a majority of the voting members of the board. 11,924
Each chairperson shall serve for the maximum duration established 11,925
in the plan of operation. 11,926
(B) Within one hundred eighty days after the appointment 11,928
of the initial board, the board shall establish a plan of 11,929
operation and, thereafter, any amendments to the plan that are 11,930
necessary or suitable, to assure the fair, reasonable, and 11,931
equitable administration of the program. The board shall, 11,932
immediately upon adoption, provide to the superintendent copies 11,933
of the plan of operation and all subsequent amendments to it. 11,934
(C) The plan of operation shall establish rules, 11,936
conditions, and procedures for all of the following: 11,937
(1) The handling and accounting of assets and moneys of 11,939
the program and for an annual fiscal reporting to the 11,940
superintendent; 11,941
(2) Filling vacancies on the board; 11,943
(3) Selecting an administering insurer, which shall be a 11,945
carrier as defined in section 3924.01 of the Revised Code, and 11,946
setting forth the powers and duties of the administering insurer; 11,947
267
(4) Reinsuring risks in accordance with sections 3924.07 11,949
to 3924.14 of the Revised Code; 11,950
(5) Collecting assessments subject to section 3924.13 of 11,952
the Revised Code from all members to provide for claims reinsured 11,953
by the program and for administrative expenses incurred or 11,954
estimated to be incurred during the period for which the 11,955
assessment is made; 11,956
(6) Providing protection for carriers from the financial 11,958
risk associated with small employers that present poor credit 11,959
risks; 11,960
(7) Establishing standards for the coverage of small 11,962
employers that have a high turnover of employees; 11,963
(8) Establishing an appeals process for carriers to seek 11,965
relief when a carrier has experienced an unfair share of 11,966
administrative and credit risks; 11,967
(9) Establishing the adjusted average market premium 11,969
prices for use by the SEHC plan for groups of two to twenty-five 11,970
employees and for groups of twenty-six to fifty employees that 11,971
are offered in the state; 11,972
(10) Establishing participation standards at issue and 11,974
renewal for reinsured cases; 11,975
(11) Reinsuring risks and collecting assessments in 11,977
accordance with division (G) of section 3924.11 of the Revised 11,978
Code; 11,979
(12) Any additional matters as determined by the board. 11,981
Sec. 3924.10. (A) The board of directors of the Ohio 11,990
small employer health reinsurance program shall design the SEHC 11,991
plan which, when offered by a carrier, is eligible for 11,992
reinsurance under the program. The board shall establish the 11,993
form and level of coverage to be made available by carriers in 11,994
their SEHC plan. In designing the plan the board shall also 11,996
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 11,997
of coverage established by the board shall specify which 11,998
268
components of a health benefit plan offered by a small employer 11,999
carrier may be reinsured. The SEHC plan is subject to division 12,001
(C) of section 3924.02 of the Revised Code and to the provisions 12,002
in Chapters 1742. 1751., 3923., and any other chapter of the 12,004
Revised Code that require coverage or the offer of coverage of a 12,005
health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 12,008
eighty days after its appointment. The plan may include cost 12,009
containment features including any of the following:
(1) Utilization review of health care services, including 12,011
review of the medical necessity of hospital and physician 12,012
services; 12,013
(2) Case management benefit alternatives; 12,015
(3) Selective contracting with hospitals, physicians, and 12,017
other health care providers; 12,018
(4) Reasonable benefit differentials applicable to 12,020
participating and nonparticipating providers; 12,021
(5) Employee assistance program options that provide 12,023
preventive and early intervention mental health and substance 12,024
abuse services; 12,025
(6) Other provisions for the cost-effective management of 12,027
the plan. 12,028
(C) An SEHC plan established for use by health maintenance 12,031
organizations INSURING CORPORATIONS shall be consistent with the 12,032
basic method of operation of such organizations CORPORATIONS. 12,033
(D) Each carrier shall certify to the superintendent of 12,035
insurance, in the form and manner prescribed by the 12,036
superintendent, that the SEHC plan filed by the carrier is in 12,038
substantial compliance with the provisions of the board SEHC 12,039
plan. Upon receipt by the superintendent of the certification, 12,040
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 12,042
date that the program becomes operational and as a condition of 12,043
transacting business in this state, renew coverage provided to 12,044
269
any individual or group under its SEHC plan. 12,045
(F) A carrier shall not be required to renew coverage 12,047
where the superintendent finds that renewal of coverage would 12,048
place the carrier in a financially impaired condition. The 12,049
superintendent shall determine when the carrier is no longer 12,050
financially impaired and is, therefore, subject to the guaranteed 12,051
renewability requirements. 12,052
Sec. 3924.12. (A) Except as provided in division (B) of 12,061
this section, premium rates charged for coverage reinsured by the 12,062
Ohio small employer health reinsurance program shall be 12,063
established as follows: 12,064
(1) For whole group reinsurance coverage, one and one-half 12,066
times the adjusted average market premium price established by 12,067
the program for that classification or group with similar 12,068
characteristics and coverage, with respect to the eligible 12,069
employees of a small employer and their dependents, all of whose 12,070
coverage is reinsured with the program, minus a ceding expense 12,071
factor determined by the board of directors of the program; 12,072
(2) For individual reinsurance coverage, five times the 12,074
adjusted average market premium price established by the program 12,075
for an individual in that classification or group with similar 12,076
characteristics and coverage, with respect to an eligible 12,077
employee or his THE EMPLOYEE'S dependents, minus a ceding expense 12,079
factor determined by the board. 12,080
(B) Premium rates charged for reinsurance by the program 12,082
to a health maintenance organization INSURING CORPORATION that is 12,084
approved by the secretary of health and human services as a 12,085
federally qualified health maintenance organization pursuant to 12,086
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 12,087
as amended, and as such is subject to requirements that limit the 12,088
amount of risk that may be ceded to the program, may be modified 12,089
to reflect the portion of risk that may be ceded to the program. 12,090
Sec. 3924.13. (A) Following the close of each calendar 12,099
year, the administering insurer of the Ohio small employer health 12,100
270
reinsurance program shall determine the net premiums, the program 12,101
expenses for administration, and the incurred losses, if any, for 12,102
the year, taking into account investment income and other 12,103
appropriate gains and losses. For purposes of this section, 12,104
health benefit plan premiums earned by MEWAs shall be established 12,105
by adding paid claim losses and administrative expenses of the 12,106
MEWA. Health benefit plan premiums and benefits paid by a 12,108
carrier that are less than an amount determined by the board of 12,109
directors of the program to justify the cost of collection shall 12,110
not be considered for purposes of determining assessments. For 12,111
purposes of this division, "net premiums" means health benefit 12,112
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 12,114
assessments of carriers in accordance with this division. 12,115
Assessments shall be apportioned by the board among all carriers 12,116
participating in the program in proportion to their respective 12,117
shares of the total premiums, net of reinsurance premiums paid 12,118
for coverage under this program earned in the state from health 12,119
benefit plans covering small employers that are issued by 12,120
participating members during the calendar year coinciding with or 12,121
ending during the fiscal year of the program, or on any other 12,122
equitable basis reflecting coverage of small employers as may be 12,123
provided in the plan of operation. An assessment shall be made 12,124
pursuant to this division against a health maintenance 12,125
organization INSURING CORPORATION that is approved by the 12,126
secretary of health and human services as a federally qualified 12,128
health maintenance organization pursuant to the "Social Security 12,129
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, subject 12,130
to an assessment adjustment formula adopted by the board for such 12,131
health maintenance organizations INSURING CORPORATIONS that 12,132
recognizes the restrictions imposed on the organizations ENTITIES 12,134
by federal law. The adjustment formula shall be adopted by the 12,136
board prior to the first anniversary of the program's operation. 12,137
In no event shall the assessment made pursuant to this division 12,138
271
exceed, on an annual basis, one per cent of the carrier's Ohio 12,140
small employer group premium as reported on its most recent 12,141
annual statement filed with the superintendent of insurance. If 12,142
an excess is actuarially projected, the superintendent may take 12,143
any action necessary to lower the assessment to the maximum level 12,144
of one per cent.
(C) If assessments exceed actual losses and administrative 12,146
expenses of the program, the excess shall be held at interest and 12,147
used by the board to offset future losses or to reduce program 12,148
premiums. As used in this division, "future losses" includes 12,149
reserves for incurred but not reported claims. 12,150
(D) Each carrier's proportion of participation in the 12,152
program shall be determined annually by the board based on annual 12,154
statements and other reports deemed necessary by the board and 12,155
filed by the carrier with the board. MEWAs shall report to the 12,156
board claims payments made and administrative expenses incurred 12,157
in this state on an annual basis on a form prescribed by the 12,158
superintendent.
(E) Provision shall be made in the plan of operation for 12,160
the imposition of an interest penalty for late payment of 12,161
assessments. 12,162
(F) A carrier may seek from the superintendent a 12,164
deferment, in whole or in part, from any assessment issued by the 12,165
board. The superintendent may defer, in whole or in part, the 12,166
assessment of a carrier if, in the opinion of the superintendent, 12,167
payment of the assessment would endanger the carrier's ability to 12,168
fulfill its contractual obligations. 12,169
(G) In the event an assessment against a carrier is 12,171
deferred in whole or in part, the amount by which the assessment 12,172
is deferred may be assessed against the other carriers in a 12,173
manner consistent with the basis for assessments set forth in 12,174
this section. In such event, the other carriers assessed shall 12,175
have a claim in the amount of the assessment against the carrier 12,176
receiving the deferment. The carrier receiving the deferment 12,177
272
shall remain liable to the program for the amount deferred. The 12,178
superintendent may attach appropriate conditions to any 12,179
deferment. 12,180
Sec. 3924.41. (A) As used in sections 3924.41 and 3924.42 12,189
of the Revised Code, "health insurer" means any sickness and 12,190
accident insurer, health maintenance organization, preferred 12,191
provider organization, OR health care INSURING corporation, 12,193
medical care corporation, dental care corporation, or prepaid 12,194
dental plan organization. "Health insurer" also includes any 12,195
group health plan as defined in section 607 of the federal 12,196
"Employee Retirement Income Security Act of 1974," 88 Stat. 832, 12,197
29 U.S.C.A. 1167. 12,198
(B) Notwithstanding any other provision of the Revised 12,200
Code, no health insurer shall take into consideration the 12,201
availability of, or eligibility for, medical assistance in this 12,202
state under Chapter 5111. of the Revised Code or in any other 12,203
state pursuant to Title XIX of the "Social Security Act," 49 12,204
Stat. 620 (1935), 42 U.S.C.A. 301, as amended, when determining 12,205
an individual's eligibility for coverage or when making payments 12,206
to or on behalf of an enrollee, subscriber, policyholder, or 12,207
certificate holder. 12,208
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 12,217
the Revised Code: 12,218
(A) "Account holder" means the natural person who opens a 12,221
medical savings account or on whose behalf a medical savings 12,222
account is opened.
(B) "Eligible medical expense" means any expense for a 12,225
service rendered by a licensed health care provider or a 12,226
christian science CHRISTIAN SCIENCE practitioner, or for an 12,227
article, device, or drug prescribed by a licensed health care 12,228
provider or provided by a christian science CHRISTIAN SCIENCE 12,230
practitioner, when intended for use in the mitigation, treatment, 12,232
or prevention of disease; or premiums paid for comprehensive 12,233
sickness and accident insurance, coverage under a health care 12,234
273
plan of a health maintenance organization INSURING CORPORATION 12,235
organized under Chapter 1742. 1751. of the Revised Code, 12,237
long-term care insurance as defined in section 3923.41 of the
Revised Code, Medicare supplemental coverage as defined in 12,238
section 3923.33 of the Revised Code, or payments made pursuant to 12,240
cost sharing agreements under comprehensive sickness and accident 12,241
plans. An "eligible medical expense" does not include expenses 12,242
otherwise paid or reimbursed, including medical expenses paid or 12,243
reimbursed under an automobile or motor vehicle insurance policy, 12,244
a workers' compensation insurance policy or plan, or an
employer-sponsored health coverage policy, plan, or contract. 12,245
(C) "Qualified dependent" means a child of an account 12,248
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 12,251
twenty-three years of age and a full-time student at an
accredited college or university; 12,252
(2) The child is not self-sufficient due to physical or 12,254
mental disorders or impairments; 12,255
(3) The child is legally entitled to the provision of 12,257
proper or necessary subsistence, education, medical care, or 12,258
other care necessary for the child's health, guidance, or 12,259
well-being and is not otherwise emancipated, self-supporting, 12,260
married, or a member of the armed forces of the United States. 12,262
Sec. 3924.62. (A) A medical savings account may be opened 12,271
by or on behalf of any natural person, to pay the person's 12,272
eligible medical expenses and the eligible medical expenses of 12,273
that person's spouse or qualified dependent. A medical savings 12,274
account may be opened by or on behalf of a person only if that 12,276
person participates in a sickness or accident insurance plan, a 12,277
plan offered by a health maintenance organization INSURING
CORPORATION organized under Chapter 1742. 1751. of the Revised 12,279
Code, or a self-funded, employer-sponsored health benefit plan
established pursuant to the "Employee Retirement Income Security 12,280
Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. While 12,281
274
the medical savings account is open, the account holder shall 12,282
continue to participate in such a plan.
(B) A person who refuses to participate in a policy, plan, 12,285
or contract of health coverage that is funded by the person's 12,286
employer, and who receives additional monetary compensation by 12,287
virtue of refusing that coverage, may not open a medical savings 12,288
account unless the medical savings account also is sponsored by 12,289
the person's employer. 12,290
Sec. 3924.64. (A) At the time a medical savings account 12,300
is opened, an administrator for the account shall be designated. 12,301
If an employer opens an account for an employee, the employer may 12,302
designate the administrator. If an account is opened by any 12,303
person other than an employer, or if an employer chooses not to 12,304
designate an administrator for an account opened for an employee, 12,305
the account holder shall designate the administrator. The 12,306
administrator shall manage the account in a fiduciary capacity 12,307
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 12,310
of the following:
(1) A federally or state-chartered bank, savings and loan 12,313
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 12,315
(3) An insurer authorized under Title XXXIX of the Revised 12,318
Code to engage in the business of sickness and accident 12,319
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 12,322
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 12,325
Revised Code;
(6) A certified public accountant; 12,327
(7) An employer that administers an employee benefit plan 12,330
subject to regulation under the "Employee Retirement Income 12,331
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 12,333
amended, or that maintains medical savings accounts for its 12,334
275
employees;
(8) Health maintenance organizations INSURING CORPORATIONS 12,336
organized under Chapter 1742. 1751. of the Revised Code. 12,337
(C) Each administrator shall send to the account holder, 12,340
at least annually, a statement setting forth the balance 12,341
remaining in the account holder's account and detailing the 12,342
activity in the account since the last statement was issued. 12,343
Upon an administrator's receipt of a written request from an 12,344
account holder for a current statement, the administrator shall 12,345
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 12,348
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 12,349
account holder, the account holder's spouse, or qualified 12,350
dependents, the administrator shall reimburse the account holder 12,351
for, or shall pay for, the eligible medical expense with funds 12,352
from the account holder's account, if sufficient funds are 12,353
available in the account holder's account. If there are not 12,354
sufficient funds in the account to fully reimburse the account 12,355
holder or pay the expenses, the administrator shall reimburse the 12,357
account holder or pay the expenses using whatever funds are in 12,358
the account. The reimbursement or payment shall be made within 12,359
thirty days of the administrator's receipt of the documentation. 12,360
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 12,361
expense does not count toward meeting the deductible or other 12,362
obligation for the receipt of benefits that is required by the 12,363
insurer or other third-party payer providing health coverage to 12,364
the account holder. The administrator shall keep a record of the 12,365
amounts disbursed from the account for documented eligible 12,366
medical expenses and of the dates on which the expenses were 12,367
incurred. This record shall be made available to any sickness 12,368
and accident insurer or other third-party payer providing health 12,369
coverage to the account holder, for use by the insurer or 12,370
276
third-party payer in determining whether the account holder has 12,371
met the deductible or other obligation required for the receipt 12,372
of benefits from the insurer or third-party payer. 12,373
(E) When an account is opened, the administrator shall 12,376
give written notice to the account holder of the date of the last 12,377
business day of the administrator's business year. 12,378
Sec. 3924.73. (A) As used in this section: 12,387
(1) "Health care insurer" means any person legally engaged 12,389
in the business of providing sickness and accident insurance 12,390
contracts in this state, a health maintenance organization 12,391
INSURING CORPORATION organized under Chapter 1742. 1751. of the 12,392
Revised Code, or any legal entity that is self-insured and 12,393
provides health care benefits to its employees or members. 12,394
(2) "Small employer" has the same meaning as in division 12,396
(P) of section 3924.01 of the Revised Code. 12,397
(B)(1) Subject to division (B)(2) of this section, nothing 12,400
in sections 3924.61 to 3924.74 of the Revised Code shall be 12,401
construed to limit the rights, privileges, or protections of 12,402
employees or small employers under sections 3924.01 to 3924.14 of 12,403
the Revised Code. 12,404
(2) If any account holder enrolls or applies to enroll in 12,406
a policy or contract offered by a health care insurer providing 12,407
sickness and accident coverage that is more comprehensive than, 12,408
and has a deductible amount that is less than, the coverage and 12,409
deductible amount of the policy under which the account holder 12,410
currently is enrolled, the health care insurer to which the 12,411
account holder applies may subject the account holder to the same 12,413
medical review, waiting periods, and underwriting requirements to 12,414
which the health care insurer generally subjects other enrollees 12,415
or applicants, unless the account holder enrolls or applies to 12,416
enroll during a designated period of open enrollment. 12,417
Sec. 3929.77. The joint underwriting association shall be 12,426
governed by a board of governors consisting of nine members seven 12,427
of whom shall be selected from the members of the joint 12,428
277
underwriting association and appointed by the superintendent of 12,429
insurance. Five members shall be selected from insurers and
corporations domiciled in this state. Two members shall be 12,430
selected from insurers and corporations domiciled outside this 12,431
state. One member shall be an insurance agent licensed and 12,432
writing insurance in this state. One member shall represent the 12,433
interests of consumers and shall neither be a member of, or 12,434
associated with, a health care provider or profession nor
associated with an insurance company or an association organized 12,435
A HEALTH INSURING CORPORATION HOLDING A CERTIFICATE OF AUTHORITY 12,436
under Chapter 1737., 1738., or 1740. 1751. of the Revised Code. 12,437
The directors of the stabilization reserve fund shall serve as ex 12,439
officio members of the board of governors.
Sec. 3956.01. As used in this chapter: 12,448
(A) "Account" means either of the two accounts created 12,450
under section 3956.06 of the Revised Code. 12,451
(B) "Contractual obligation" means any obligation under a 12,453
policy, contract, or certificate under a group policy or 12,454
contract, or portion of the policy or contract, for which 12,455
coverage is provided under section 3956.04 of the Revised Code. 12,456
(C) "Covered policy or contract" means any policy, 12,458
contract, or group certificate within the scope of section 12,459
3956.04 of the Revised Code. 12,460
(D) "Impaired insurer" means a member insurer that, after 12,462
the effective date of this section NOVEMBER 20, 1989, is not an 12,464
insolvent insurer, and to which either of the following applies: 12,465
(1) The insurer is considered by the superintendent to be 12,467
potentially unable to fulfill its contractual obligations; 12,468
(2) The insurer is placed under an order of rehabilitation 12,470
or conservation by a court of competent jurisdiction. 12,471
(E) "Insolvent insurer" means a member insurer that, after 12,473
the effective date of this section NOVEMBER 20, 1989, is placed 12,475
under an order of liquidation by a court of competent 12,476
jurisdiction with a finding of insolvency. 12,477
278
(F)(1) "Member insurer" means any insurer that holds a 12,479
certificate of authority or is licensed to transact in this state 12,480
any kind of insurance for which coverage is provided under 12,481
section 3956.04 of the Revised Code, and includes any insurer 12,482
whose certificate of authority or license in this state may have 12,483
been suspended, revoked, not renewed, or voluntarily withdrawn 12,484
after the effective date of this section NOVEMBER 20, 1989. 12,486
(2) "Member insurer" does not include any of the 12,488
following: 12,489
(a) A medical care corporation; 12,491
(b) A health care corporation; 12,493
(c) A dental care corporation; 12,495
(d) A prepaid dental plan; 12,497
(e) A health maintenance organization INSURING 12,500
CORPORATION;
(f) A preferred provider organization; 12,502
(g)(b) A fraternal benefit society; 12,504
(h)(c) A self-insurance or joint self-insurance pool or 12,506
plan of the state or any political subdivision of the state; 12,507
(i)(d) A mutual protective association; 12,509
(j)(e) An insurance exchange; 12,511
(k)(f) Any person who qualifies as a "member insurer" 12,513
under section 3955.01 of the Revised Code and who does not 12,515
receive premiums on covered policies or contracts;
(l)(g) Any entity similar to any of those described in 12,517
divisions (F)(2)(a) to (k)(f) of this section. 12,518
(3) "Member insurer" includes any insurer that operates 12,520
any of the entities described in division (F)(2) of this section 12,521
as a line of business, and not as a separate, affiliated legal 12,522
entity, and otherwise qualifies as a member insurer. 12,523
(G) "Premiums" means amounts received on covered policies 12,525
or contracts, less premiums, considerations, and deposits 12,526
returned on the policies or contracts, and less dividends and 12,527
experience credits on the policies and contracts. "Premiums" 12,528
279
does not include either of the following: 12,529
(1) Any amounts in excess of one million dollars received 12,531
on any unallocated annuity contract not issued under a 12,532
governmental retirement plan established under Section 401, 12,533
403(b), or 457 of the "Internal Revenue Code of 1986," 100 Stat. 12,534
2085, 26 U.S.C.A. 1, as amended; 12,535
(2) Any amounts received for any policies or contracts or 12,537
for the portions of any policies or contracts for which coverage 12,538
is not provided under section 3956.04 of the Revised Code. 12,539
Division (G)(2) of this section shall not be construed to require 12,540
the exclusion, from assessable premiums, of premiums paid for 12,541
coverages in excess of the interest limitations specified in 12,542
division (B)(2)(c) of section 3956.04 of the Revised Code or of 12,543
premiums paid for coverages in excess of the limitations with 12,544
respect to any one individual, any one participant, or any one 12,545
contract holder specified in division (C)(2) of section 3956.04 12,546
of the Revised Code. 12,547
(H) "Resident" means any person who resides in this state 12,549
at the time a member insurer is determined to be an impaired or 12,550
insolvent insurer and to whom a contractual obligation is owed. 12,551
A person may be a resident of only one state, which, in the case 12,552
of a person other than a natural person, shall be its principal 12,553
place of business. 12,554
(I) "Subaccount" means any of the three subaccounts 12,556
created under division (A) of section 3956.06 of the Revised 12,557
Code. 12,558
(J) "Supplemental contract" means any agreement entered 12,560
into for the distribution of policy or contract proceeds. 12,561
(K) "Unallocated annuity contract" means any annuity 12,563
contract or group annuity certificate that is not issued to and 12,564
owned by an individual, except to the extent of any annuity 12,565
benefits guaranteed to an individual by an insurer under that 12,566
contract or certificate. 12,567
Sec. 3959.01. (A) "Administration fees" means any amount 12,576
280
charged a covered person for services rendered. "Administration 12,577
fees" includes commissions earned or paid by any person relative 12,578
to services performed by an administrator. 12,579
(B) "Administrator" means any person who adjusts or 12,581
settles claims on, residents of this state in connection with 12,582
life, dental, health, or disability insurance or self-insurance 12,583
programs. "Administrator" does not include any of the following: 12,584
(1) An insurance agent or solicitor licensed in this state 12,586
whose activities are limited exclusively to the sale of insurance 12,587
and who does not provide any administrative services; 12,588
(2) Any person who administers or operates the workers' 12,590
compensation program of a self-insuring employer under Chapter 12,591
4123. of the Revised Code; 12,592
(3) Any person who administers pension plans for the 12,594
benefit of the person's own members or employees or administers 12,596
pension plans for the benefit of the members or employees of any 12,597
other person; 12,598
(4) Any person that administers an insured plan or a 12,600
self-insured plan that provides life, dental, health, or 12,601
disability benefits exclusively for the person's own members or 12,602
employees; 12,603
(5) Any medical care corporation organized under Chapter 12,605
1737. of the Revised Code, prepaid dental plan organization 12,606
organized under Chapter 1736. of the Revised Code, health care 12,607
INSURING corporation organized HOLDING A CERTIFICATE OF AUTHORITY 12,609
under Chapter 1738. 1751. of the Revised Code, dental care 12,611
corporation organized under Chapter 1740. of the Revised Code, 12,612
health maintenance organization organized under Chapter 1742. of 12,613
the Revised Code, or an insurance company that is authorized to 12,614
write life or sickness and accident insurance in this state. 12,615
(C) "Aggregate excess insurance" means that type of 12,617
coverage whereby the insurer agrees to reimburse the insured 12,618
employer or trust for all benefits or claims paid during an 12,619
agreement period on behalf of all covered persons under the plan 12,620
281
or trust which exceed a stated deductible amount and subject to a 12,621
stated maximum. 12,622
(D) "Contributions" means any amount collected from a 12,624
covered person to fund the self-insured portion of any plan in 12,625
accordance with the plan's provisions, summary plan descriptions, 12,626
and contracts of insurance. 12,627
(E) "Fiduciary" has the meaning set forth in section 12,629
1002(21)(A) of the "Employee Retirement Income Security Act of 12,630
1974," 88 Stat. 829, 29 U.S.C. 1001, as amended. 12,631
(F) "Fiscal year" means the twelve-month accounting period 12,633
commencing on the date the plan is established and ending twelve 12,634
months following that date, and each corresponding twelve-month 12,635
accounting period thereafter as provided for in the summary plan 12,636
description. 12,637
(G) "Plan" means any arrangement in written form for the 12,639
payment of life, dental, health, or disability benefits to 12,640
covered persons defined by the summary plan description. 12,641
(H) "Plan sponsor" means the person who establishes the 12,643
plan. 12,644
(I) "Self-insurance program" means a program whereby an 12,646
employer provides a plan of benefits for its employees without 12,647
involving an intermediate insurance carrier to assume risk or pay 12,648
claims. "Self-insurance program" includes but is not limited to 12,649
employer programs that pay claims up to a prearranged limit 12,650
beyond which they purchase insurance coverage to protect against 12,651
unpredictable or catastrophic losses. 12,652
(J) "Specific excess insurance" means that type of 12,654
coverage whereby the insurer agrees to reimburse the insured 12,655
employer or trust for all benefits or claims paid during an 12,656
agreement period on behalf of a covered person in excess of a 12,657
stated deductible amount and subject to a stated maximum. 12,658
(K) "Summary plan description" means the written document 12,660
adopted by the plan sponsor which outlines the plan of benefits, 12,661
conditions, limitations, exclusions, and other pertinent details 12,662
282
relative to the benefits provided to covered persons thereunder. 12,663
Sec. 3999.32. (A) As used in this section: 12,673
(1) "Certificate holder" means any person whose employment 12,675
or retirement status is the basis of eligibility for coverage 12,676
under a group policy of sickness and accident insurance or for 12,677
enrollment under a group contract of a prepaid dental plan 12,678
organization, medical care corporation, health care INSURING 12,679
corporation, dental care corporation, or health maintenance 12,681
organization.
(2) "Health insurer" means any sickness and accident 12,683
insurer, prepaid dental plan organization, medical care 12,684
corporation, OR health care INSURING corporation, dental care, 12,686
corporation, or health maintenance organization. 12,687
(B) Each person to whom a group policy or contract of 12,689
sickness and accident insurance or other health care coverage has 12,690
been delivered or issued for delivery in this state by a health 12,691
insurer shall make a reasonable effort to notify every 12,692
certificate holder, or his CERTIFICATE HOLDER'S designee, who is 12,694
covered under that policy or contract whenever the person fails 12,695
to make a required premium payment or contribution on behalf of 12,696
the certificate holder and that failure results in the 12,697
termination of coverage. The person shall mail or present the 12,698
notice to the certificate holder or his CERTIFICATE HOLDER'S 12,699
designee no later than five days after the date on which the 12,701
person receives the notice from the health insurer as required 12,702
under division (D) of this section. If a person other than the 12,703
policyholder or contract holder is obligated to make the required 12,704
premium payment or contribution on behalf of the certificate 12,705
holder, that person shall mail or present the notice as required 12,706
by this section.
(C) The notice required by division (B) of this section 12,708
shall be in writing and shall clearly state that the person 12,709
failed to make the required premium payment or contribution, the 12,710
reasons for the failure, and the effect of the failure on the 12,711
283
coverage of the certificate holder under the policy or contract. 12,712
(D) If a person described in division (B) of this section 12,714
fails to make a required premium payment or contribution on 12,715
behalf of a certificate holder and that failure results in the 12,716
termination of the coverage, the health insurer providing the 12,717
coverage shall notify the person in writing of that person's 12,718
duties as described in divisions (B) and (C) of this section. If 12,719
a person other than the policyholder or contract holder if IS 12,720
obligated to make the required premium payment or contribution on 12,721
behalf of the certificate holder, the insurer shall notify the 12,722
person in writing of that person's duties as described in 12,723
divisions (B) and (C) of this section. 12,724
(E) A certificate holder may designate any person to 12,726
receive on his THE CERTIFICATE HOLDER'S behalf the notice 12,727
required by division (B) of this section. The certificate holder 12,729
shall furnish the name and address of the person so designated to 12,730
the person to whom the group policy or contract has been 12,731
delivered or issued for delivery. 12,732
(F) No person shall knowingly fail to comply with division 12,734
(B) or (C) of this section. 12,735
Sec. 3999.36. (A) As used in this section and sections 12,745
3999.37 and 3999.38 of the Revised Code: 12,746
(1) "Insurer" means any person that is authorized to 12,748
engage in the business of insurance in this state under title 12,750
TITLE XXXIX of the Revised Code;, any prepaid dental plan 12,751
organization, medical care corporation, health care INSURING 12,752
corporation, dental care corporation, or health maintenance 12,754
organization; or any other person engaging either directly or 12,755
indirectly in this state in the business of insurance or entering 12,756
into contracts substantially amounting to insurance under section 12,757
3905.42 of the Revised Code. 12,758
(2) "Impaired" or "impairment" means a financial situation 12,760
in which the insurer's assets are less than the sum of the 12,761
insurer's minimum required capital, minimum required surplus, and 12,762
284
all liabilities, as determined in accordance with the 12,763
requirements for the preparation and filing of the insurer's 12,764
annual financial statement. 12,765
(3) "Chief executive officer" means the person, 12,767
irrespective of his THE PERSON'S title, designated by the board 12,768
of directors or trustees of an insurer as the person charged with 12,770
the responsibility of administering and implementing the 12,771
insurer's policies and procedures. 12,772
(B) Whenever a chief executive officer of an insurer knows 12,774
or has reason to know that the insurer is impaired, he THE CHIEF 12,775
EXECUTIVE OFFICER shall provide written notice of the impairment 12,777
to the superintendent of insurance and to each member of the 12,778
board of directors or trustees of the insurer. The chief 12,779
executive officer shall provide the notice as soon as reasonably 12,780
possible, but no later than thirty days after he THE CHIEF 12,781
EXECUTIVE OFFICER knows or has reason to know of the impairment. 12,783
No chief executive officer shall fail to provide notice in 12,784
compliance with this division.
(C) The notice received by the superintendent under 12,786
division (B) of this section is not a public record under section 12,787
149.43 of the Revised Code. 12,788
Sec. 4582.041. (A) Any port authority created under 12,797
section 4582.02 of the Revised Code may procure and pay all or 12,798
any part of the cost of group hospitalization, surgical, major 12,799
medical, sickness and accident insurance, or group life 12,800
insurance, or a combination of any of the foregoing types of 12,801
insurance or coverage for full-time employees and their immediate 12,802
dependents, whether issued by an insurance company or a medical 12,803
care corporation, duly authorized to do business in this state. 12,804
(B) Any port authority also may procure and pay all or any 12,806
part of the cost of a plan of group hospitalization, surgical, or 12,807
major medical insurance with a health care INSURING corporation 12,808
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,810
1751. of the Revised Code, provided that each full-time employee 12,812
285
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,814
insurance company or medical care corporation as provided in 12,815
division (A) of this section and such a plan offered by a health 12,816
care INSURING corporation under this division, on the condition 12,817
that the full-time employee shall pay any amount by which the 12,819
cost of the plan offered in this division exceeds the cost of the 12,820
plan offered under division (A) of this section; and 12,821
(2) Change from one of the two plans to the other at a 12,823
time each year as determined by the port authority. 12,824
Sec. 4582.29. (A) Any port authority created under 12,833
section 4582.22 of the Revised Code may procure and pay all or 12,834
any part of the cost of group hospitalization, surgical, major 12,835
medical, sickness and accident insurance, or group life 12,836
insurance, or a combination of any of the foregoing types of 12,837
insurance or coverage for full-time employees and their immediate 12,838
dependents, whether issued by an insurance company or a medical 12,839
care corporation, duly authorized to do business in this state. 12,840
(B) Any port authority also may procure and pay all or any 12,842
part of the cost of a plan of group hospitalization, surgical, or 12,843
major medical insurance with a health care INSURING corporation 12,844
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,846
1751. of the Revised Code, provided that each full-time employee 12,848
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,850
insurance company, hospital service association, or medical care 12,851
corporation as provided in division (A) of this section and a 12,852
plan offered by a health care INSURING corporation under this 12,853
division, on the condition that the full-time employee shall pay 12,855
any amount by which the cost of the plan offered in this division 12,856
exceeds the cost of the plan offered under division (A) of this 12,857
section; and
(2) Change from one of the two plans to the other at a 12,859
time each year as determined by the port authority. 12,860
286
Sec. 4715.02. The governor, with the advice and consent of 12,869
the senate, shall appoint a state dental board consisting of 12,870
seven persons, five of whom shall be graduates of a reputable 12,871
dental college, a citizen CITIZENS of the United States, and 12,872
shall have been in the legal and reputable practice of dentistry 12,873
in the state at least five years next preceding his THEIR 12,874
appointment; one of whom shall be a graduate of a reputable 12,875
school of dental hygiene, a citizen of the United States, and 12,876
shall have been in the legal and reputable practice of dental 12,877
hygiene in the state at least five years next preceding his THE 12,878
PERSON'S appointment; and one of whom shall be a member of the 12,880
public at large who is not associated with or financially 12,881
interested in the practice of dentistry. Terms of office shall 12,882
be for five years, commencing on the seventh day of April and 12,883
ending on the sixth day of April, except that upon expiration of 12,884
the term ending April 25, 1978, the new term which succeeds it 12,885
shall commence on April 26, 1978 and end on April 6, 1983; upon 12,886
expiration of the term ending July 23, 1974, the new term which 12,887
succeeds it shall commence on July 24, 1974 and end on April 6, 12,888
1979; and upon expiration of the term ending June 24, 1975, the 12,889
new term which succeeds it shall commence on June 25, 1975 and 12,890
end on April 6, 1980. Each member shall hold office from the 12,891
date of his THE MEMBER'S appointment until the end of the term 12,893
for which he THE MEMBER was appointed. Any member appointed to 12,895
fill a vacancy occurring prior to the expiration of the term for 12,896
which his THE MEMBER'S predecessor was appointed shall hold 12,898
office for the remainder of such term. Any member shall continue 12,899
in office subsequent to the expiration date of his THE MEMBER'S 12,900
term until his THE MEMBER'S successor takes office, or until a 12,901
period of sixty days has elapsed, whichever occurs first. No 12,903
person so appointed shall serve to exceed two terms. The Ohio 12,904
dental association may submit to the governor the names of five 12,905
nominees for each position to be filled by a dentist and from the 12,906
names so submitted or from others, at his THE GOVERNOR'S 12,907
287
discretion, the governor shall make such appointments; provided 12,909
that all such appointees shall possess the required 12,910
qualifications. The Ohio dental hygienists association, inc. 12,911
may submit to the governor the names of five nominees for each 12,912
position to be filled by a dental hygienist and from the names so 12,913
submitted or from others, at his THE GOVERNOR'S discretion, the 12,915
governor shall make such appointments; provided that all such
appointees shall possess the required qualifications. No person 12,916
shall be appointed to the state dental board who is employed by 12,917
or practices in a partnership, association, or corporation 12,918
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1740. 12,920
1751. of the Revised Code with a person who is a member of the 12,921
board.
Sec. 4719.01. (A) As used in sections 4719.01 to 4719.18 12,930
of the Revised Code: 12,931
(1) "Affiliate" means a business entity that is owned by, 12,933
operated by, controlled by, or under common control with another 12,934
business entity.
(2) "Communication" means a written or oral notification 12,936
or advertisement that meets both of the following criteria, as 12,937
applicable:
(a) The notification or advertisement is transmitted by or 12,939
on behalf of the seller of goods or services and by or through 12,940
any printed, audio, video, cinematic, telephonic, or electronic 12,941
means.
(b) In the case of a notification or advertisement other 12,943
than by telephone, either of the following conditions is met: 12,944
(i) The notification or advertisement is followed by a 12,946
telephone call from a telephone solicitor or salesperson. 12,947
(ii) The notification or advertisement invites a response 12,949
by telephone, and, during the course of that response, a 12,950
telephone solicitor or salesperson attempts to make or makes a 12,951
sale of goods or services. As used in division (A)(2)(b)(ii) of 12,952
this section, "invites a response by telephone" excludes the mere 12,953
288
listing or inclusion of a telephone number in a notification or 12,954
advertisement.
(3) "Gift, award, or prize" means anything of value that 12,957
is offered or purportedly offered, or given or purportedly given 12,958
by chance, at no cost to the receiver and with no obligation to 12,959
purchase goods or services. As used in this division, "chance"
includes a situation in which a person is guaranteed to receive 12,961
an item and, at the time of the offer or purported offer, the 12,962
telephone solicitor does not identify the specific item that the
person will receive. 12,963
(4) "Goods or services" means any real property or any 12,966
tangible or intangible personal property, or services of any kind 12,967
provided or offered to a person. "Goods or services" includes,
but is not limited to, advertising; labor performed for the 12,968
benefit of a person; personal property intended to be attached to 12,969
or installed in any real property, regardless of whether it is so 12,970
attached or installed; timeshare estates or licenses; and 12,971
extended service contracts.
(5) "Purchaser" means a person that is solicited to become 12,974
or does become financially obligated as a result of a telephone 12,975
solicitation.
(6) "Salesperson" means an individual who is employed, 12,977
appointed, or authorized by a telephone solicitor to make 12,979
telephone solicitations but does not mean any of the following:
(a) An individual who comes within one of the exemptions 12,981
in division (B) of this section; 12,982
(b) An individual employed, appointed, or authorized by a 12,984
person who comes within one of the exemptions in division (B) of 12,985
this section; 12,986
(c) An individual under a written contract with a person 12,988
who comes within one of the exemptions in division (B) of this 12,989
section, if liability for all transactions with purchasers is 12,990
assumed by the person so exempted. 12,991
(7) "Telephone solicitation" means a communication to a 12,993
289
person that meets both of the following criteria: 12,994
(a) The communication is initiated by or on behalf of a 12,996
telephone solicitor or by a salesperson. 12,997
(b) The communication either represents a price or the 12,999
quality or availability of goods or services or is used to induce 13,000
the person to purchase goods or services, including, but not 13,001
limited to, inducement through the offering of a gift, award, or 13,002
prize.
(8) "Telephone solicitor" means a person that engages in 13,004
telephone solicitation directly or through one or more 13,005
salespersons either from a location in this state or from a 13,006
location outside this state to persons in this state. "Telephone 13,007
solicitor" includes, but is not limited to, any such person that 13,008
is an owner, operator, officer, or director of, partner in, or 13,009
other individual engaged in the management activities of, a 13,010
business.
(B) A telephone solicitor is exempt from the provisions of 13,013
sections 4719.02 to 4719.18 and section 4719.99 of the Revised
Code if the telephone solicitor is any one of the following: 13,014
(1) A person engaging in a telephone solicitation that is 13,016
a one-time or infrequent transaction not done in the course of a 13,017
pattern of repeated transactions of a like nature; 13,018
(2) A person engaged in telephone solicitation solely for 13,020
religious or political purposes; a charitable organization, 13,021
fund-raising counsel, or professional solicitor in compliance 13,022
with the registration and reporting requirements of Chapter 1716. 13,023
of the Revised Code; or any person or other entity exempt under 13,024
section 1716.03 of the Revised Code from filing a registration 13,025
statement under section 1716.02 of the Revised Code; 13,027
(3) A person, making a telephone solicitation involving a 13,029
home solicitation sale as defined in section 1345.21 of the 13,030
Revised Code, that makes the sales presentation and completes the 13,031
sale at a later, face-to-face meeting between the seller and the 13,033
purchaser rather than during the telephone solicitation. 13,034
290
However, if the person, following the telephone solicitation, 13,035
causes another person to collect the payment of any money, this 13,036
exemption does not apply.
(4) A licensed securities, commodities, or investment 13,038
broker, dealer, investment advisor, or associated person when 13,039
making a telephone solicitation within the scope of the person's 13,040
license. As used in division (B)(4) of this section, "licensed 13,041
securities, commodities, or investment broker, dealer, investment 13,042
advisor, or associated person" means a person subject to 13,043
licensure or registration as such by the securities and exchange 13,044
commission; the National Association of Securities Dealers or 13,045
other self-regulatory organization, as defined by 15 U.S.C.A. 13,046
78c; by the division of securities under Chapter 1707. Revised 13,047
Code; or by an official or agency of any other state of the 13,048
United States.
(5)(a) A person primarily engaged in soliciting the sale 13,050
of a newspaper of general circulation; 13,051
(b) As used in division (B)(5)(a) of this section, 13,053
"newspaper of general circulation" includes, but is not limited 13,054
to, both of the following:
(i) A newspaper that is a daily law journal designated as 13,056
an official publisher of court calendars pursuant to section 13,057
2701.09 of the Revised Code;
(ii) A newspaper or publication that has at least 13,059
twenty-five per cent editorial, non-advertising content, 13,060
exclusive of inserts, measured relative to total publication 13,061
space, and an audited circulation to at least fifty per cent of 13,062
the households in the newspaper's retail trade zone as defined by
the audit. 13,063
(6)(a) An issuer, or its subsidiary, that has a class of 13,065
securities to which all of the following apply: 13,066
(i) The class of securities is subject to section 12 of 13,068
the "Securities Exchange Act of 1934," 15 U.S.C.A. 78l, and is 13,069
registered or is exempt from registration under 15 U.S.C.A. 13,071
291
78l(g)(2)(A), (B), (C), (E), (F), (G), or (H);
(ii) The class of securities is listed on the New York 13,074
stock exchange, the American stock exchange, or the NASDAQ 13,075
national market system;
(iii) The class of securities is a reported security as 13,077
defined in 17 C.F.R. 240.11Aa3-1(a)(4). 13,078
(b) An issuer, or its subsidiary, that formerly had a 13,080
class of securities that met the criteria set forth in division 13,081
(B)(6)(a) of this section if the issuer, or its subsidiary, has a 13,083
net worth in excess of one hundred million dollars, files or its 13,084
parent files with the securities and exchange commission an 13,085
S.E.C. form 10-K, and has continued in substantially the same 13,086
business since it had a class of securities that met the criteria
in division (B)(6)(a) of this section. As used in division 13,087
(B)(6)(b) of this section, "issuer" and "subsidiary" include the 13,088
successor to an issuer or subsidiary. 13,090
(7) A person soliciting a transaction regulated by the 13,092
commodity futures trading commission, if the person is registered 13,093
or temporarily registered for that activity with the commission 13,094
under 7 U.S.C.A. 1 et. seq. and the registration or temporary 13,095
registration has not expired or been suspended or revoked; 13,096
(8) A person soliciting the sale of any book, record, 13,098
audio tape, compact disc, or video, if the person allows the 13,099
purchaser to review the merchandise for at least seven days and 13,101
provides a full refund within thirty days to a purchaser who 13,102
returns the merchandise or if the person solicits the sale on 13,103
behalf of a membership club operating in compliance with 13,104
regulations adopted by the federal trade commission in 16 C.F.R. 13,105
425;
(9) A supervised financial institution or its subsidiary. 13,107
As used in division (B)(9) of this section, "supervised financial 13,109
institution" means a bank, trust company, savings and loan 13,110
association, savings bank, credit union, industrial loan company,
consumer finance lender, commercial finance lender, or 13,111
292
institution described in section 2(c)(2)(F) of the "Bank Holding 13,112
Company Act of 1956," 12 U.S.C.A. 1841(c)(2)(F), as amended, 13,113
supervised by an official or agency of the United States, this 13,114
state, or any other state of the United States; or a licensee or 13,115
registrant under sections 1321.01 to 1321.19, 1321.51 to 1321.60, 13,116
or 1321.71 to 1321.83 of the Revised Code. 13,117
(10)(a) An insurance company, association, or other 13,119
organization that is licensed or authorized to conduct business 13,120
in this state by the superintendent of insurance pursuant to 13,121
Title XXXIX of the Revised Code or Chapter 1736., 1737., 1738., 13,122
1739., 1740., or 1742. 1751. of the Revised Code, when soliciting 13,123
within the scope of its license or authorization. 13,124
(b) A licensed insurance broker, agent, or solicitor when 13,127
soliciting within the scope of the person's license. As used in 13,128
division (B)(10)(b) of this section, "licensed insurance broker, 13,129
agent, or solicitor" means any person licensed as an insurance 13,130
broker, agent, or solicitor by the superintendent of insurance 13,131
pursuant to Title XXXIX of the Revised Code.
(11) A person soliciting the sale of services provided by 13,133
a cable television system operating under authority of a 13,134
governmental franchise or permit; 13,135
(12) A person soliciting a business-to-business sale under 13,137
which any of the following conditions are met: 13,138
(a) The telephone solicitor has been operating 13,140
continuously for at least three years under the same business 13,141
name under which it solicits purchasers, and at least fifty-one 13,142
per cent of its gross dollar volume of sales consists of repeat 13,143
sales to existing customers to whom it has made sales under the 13,144
same business name.
(b) The purchaser business intends to resell the goods 13,147
purchased.
(c) The purchaser business intends to use the goods or 13,150
services purchased in a recycling, reuse, manufacturing, or
remanufacturing process. 13,151
293
(d) The telephone solicitor is a publisher of a periodical 13,153
or of magazineS distributed as controlled circulation 13,154
publicationS as defined in division (CC) of section 5739.01 of 13,155
the Revised Code and is soliciting sales of advertising, 13,156
subscriptions, reprints, lists, information databases, conference 13,157
participation or sponsorships, trade shows or media products 13,158
related to the periodical or magazine, or other publishing
services provided by the controlled circulation publication. 13,159
(13) A person that, not less often than once each year, 13,161
publishes and delivers to potential purchasers a catalog that 13,162
complies with both of the following: 13,163
(a) It includes all of the following: 13,165
(i) The business address of the seller; 13,167
(ii) A written description or illustration of each good or 13,170
service offered for sale;
(iii) A clear and conspicuous disclosure of the sale price 13,172
of each good or service; shipping, handling, and other charges; 13,174
and return policy;
(b) One of the following applies: 13,176
(i) The catalog includes at least twenty-four pages of 13,178
written material and illustrations, is distributed in more than 13,179
one state, and has an annual postage-paid mail circulation of not 13,180
less than two hundred fifty thousand households; 13,181
(ii) The catalog includes at least ten pages of written 13,183
material or an equivalent amount of material in electronic form 13,184
on the internet or an on-line computer service, the person does 13,185
not solicit customers by telephone but solely receives telephone 13,186
calls made in response to the catalog, and during the calls the 13,188
person takes orders but does not engage in further solicitation
of the purchaser. As used in division (B)(13)(b)(ii) of this 13,189
section, "further solicitation" does not include providing the 13,190
purchaser with information about, or attempting to sell, any 13,191
other item in the catalog that prompted the purchaser's call or 13,192
in a substantially similar catalog issued by the seller. 13,193
294
(14) A political subdivision or instrumentality of the 13,195
United States, this state, or any state of the United States; 13,197
(15) A college or university or any other public or 13,199
private institution of higher education in this state; 13,200
(16) A public utility, as defined in section 4905.02 of 13,202
the Revised Code, that is subject to regulation by the public 13,203
utilities commission, or its affiliate; 13,204
(17) A travel agency or tour promoter that is registered 13,206
in compliance with section 1333.96 of the Revised Code when 13,207
soliciting within the scope of the agency's or promoter's 13,208
registration;
(18) A person that solicits sales through a television 13,210
program or advertisement that is presented in the same market 13,211
area no fewer than twenty days per month or offers for sale no 13,212
fewer than ten distinct items of goods or services; and offers to 13,213
the purchaser an unconditional right to return any good or 13,214
service purchased within a period of at least seven days and to 13,215
receive a full refund within thirty days after the purchaser
returns the good or cancels the service; 13,216
(19)(a) A person that, for at least one year, has been 13,218
operating a retail business under the same name as that used in 13,219
connection with telephone solicitation and both of the following 13,220
occur on a continuing basis: 13,221
(i) The person either displays goods and offers them for 13,223
retail sale at the person's business premises or offers services 13,224
for sale and provides them at the person's business premises. 13,225
(ii) At least fifty-one per cent of the person's gross 13,228
dollar volume of retail sales involves purchases of goods or
services at the person's business premises. 13,229
(b) An affiliate of a person that meets the requirements 13,231
in division (B)(19)(a) of this section if the affiliate meets all 13,233
of the following requirements:
(i) The affiliate has operated a retail business for a 13,235
period of less than one year; 13,236
295
(ii) The affiliate either displays goods and offers them 13,238
for retail sale at the affiliate's business premises or offers 13,239
services for sale and provides them at the affiliate's business 13,240
premises;
(iii) At least fifty-one per cent of the affiliate's gross 13,242
dollar volume of retail sales involves purchases of goods or 13,243
services at the affiliate's business premises. 13,244
(c) A person that, for a period of less than one year, has 13,246
been operating a retail business in this state under the same 13,247
name as that used in connection with telephone solicitation, as 13,248
long as all of the following requirements are met: 13,249
(i) The person either displays goods and offers them for 13,251
retail sale at the person's business premises or offers services 13,252
for sale and provides them at the person's business premises; 13,253
(ii) The goods or services that are the subject of 13,255
telephone solicitation are sold at the person's business 13,256
premises, and at least sixty-five per cent of the person's gross 13,257
dollar volume of retail sales involves purchases of goods or 13,258
services at the person's business premises;
(iii) The person conducts all telephone solicitation 13,260
activities according to sections 310.3, 310.4, and 310.5 of the 13,261
telemarketing sales rule adopted by the federal trade commission 13,262
in 16 C.F.R. part 310.
(20) A person who performs telephone solicitation sales 13,264
services on behalf of other persons and to whom one of the 13,265
following applies:
(a) The person has operated under the same ownership, 13,267
control, and business name for at least five years, and the 13,268
person receives at least seventy-five per cent of its gross 13,269
revenues from written telephone solicitation contracts with 13,270
persons who come within one of the exemptions in division (B) of
this section. 13,271
(b) The person is an affiliate of one or more exempt 13,273
persons and makes telephone solicitations on behalf of only the 13,274
296
exempt persons of which it is an affiliate. 13,275
(c) The person makes telephone solicitations on behalf of 13,277
only exempt persons, the person and each exempt person on whose 13,278
behalf telephone solicitations are made have entered into a 13,279
written contract that specifies the manner in which the telephone 13,280
solicitations are to be conducted and that at a minimum requires 13,281
compliance with the telemarketing sales rule adopted by the
federal trade commission in 16 C.F.R. part 310, and the person 13,283
conducts the telephone solicitations in the manner specified in 13,284
the written contract.
(d) The person performs telephone solicitation for 13,286
religious or political purposes, a charitable organization, a 13,287
fund-raising council, or a professional solicitor in compliance 13,288
with the registration and reporting requirements of Chapter 1716. 13,289
of the Revised Code; and meets all of the following requirements: 13,290
(i) The person has operated under the same ownership, 13,292
control, and business name for at least five years, and the 13,293
person receives at least fifty-one per cent of its gross revenues 13,294
from written telephone solicitation contracts with persons who 13,295
come within the exemption in division (B)(2) of this section; 13,296
(ii) The person does not conduct a prize promotion or 13,298
offer the sale of an investment opportunity; and 13,299
(iii) The person conducts all telephone solicitation 13,301
activities according to sections 310.3, 310.4, and 310.5 of the 13,302
telemarketing sales rules adopted by the federal trade commission 13,303
in 16 C.F.R. part 310. 13,304
(21) A person that is a licensed real estate salesperson 13,306
or broker under Chapter 4735. of the Revised Code when soliciting 13,307
within the scope of the person's license; 13,308
(22) A publisher that solicits the sale of the publisher's 13,310
periodical or magazine of general, paid circulation, or a person 13,311
that solicits a sale of that nature on behalf of a publisher 13,312
under a written agreement directly between the publisher and the 13,313
person. As used in division (B)(22) of this section, "periodical 13,314
297
or magazine of general, paid circulation" excludes a periodical 13,315
or magazine circulated only as part of a membership package or 13,316
given as a free gift or prize from the publisher or person. 13,317
(23) A person that solicits the sale of food, as defined 13,319
in section 3715.01 of the Revised Code, or the sale of products 13,320
of horticulture, as defined in section 5739.01 of the Revised 13,321
Code, if the person does not intend the solicitation to result 13,322
in, or the solicitation actually does not result in, a sale that 13,323
costs the purchaser an amount greater than five hundred dollars.
(24) A funeral director licensed pursuant to Chapter 4717. 13,325
of the Revised Code when soliciting within the scope of that 13,326
license, if both of the following apply: 13,327
(a) The solicitation and sale are conducted in compliance 13,329
with 16 C.F.R. part 453, as adopted by the federal trade 13,330
commission, and with sections 1107.33 and 1345.21 to 1345.28 of 13,331
the Revised Code;
(b) The person provides to the purchaser of any preneed 13,333
funeral contract a notice that clearly and conspicuously sets 13,334
forth the cancellation rights specified in division (G) of 13,335
section 1107.33 of the Revised Code, and retains a copy of the 13,336
that notice signed by the purchaser.
(25) A person, or affiliate thereof, licensed to sell or 13,338
issue Ohio instruments designated as travelers checks pursuant to 13,339
sections 1315.01 to 1315.11 of the Revised Code. 13,340
(26) A person that solicits sales from its previous 13,342
purchasers and meets all of the following requirements: 13,343
(a) The solicitation is made under the same business name 13,345
that was previously used to sell goods or services to the 13,346
purchaser;
(b) The person has, for a period of not less than three 13,348
years, operated a business under the same business name as that 13,349
used in connection with telephone solicitation; 13,350
(c) The person does not conduct a prize promotion or offer 13,352
the sale of an investment opportunity; 13,353
298
(d) The person conducts all telephone solicitation 13,355
activities according to sections 310.3, 310.4, and 310.5 of the 13,356
telemarketing sales rules adopted by the federal trade commission 13,357
in 16 C.F.R. part 310;
(e) Neither the person nor any of its principals has been 13,359
convicted of, pleaded guilty to, or has entered a plea of no 13,360
contest for a felony or a theft offense as defined in sections 13,361
2901.02 and 2913.01 of the Revised Code or similar law of another 13,362
state or of the United States;
(f) Neither the person nor any of its principals has had 13,364
entered against them an injunction or a final judgment or order, 13,365
including an agreed judgment or order, an assurance of voluntary 13,366
compliance, or any similar instrument, in any civil or 13,367
administrative action involving engaging in a pattern of corrupt 13,368
practices, fraud, theft, embezzlement, fraudulent conversion, or 13,369
misappropriation of property; the use of any untrue, deceptive,
or misleading representation; or the use of any unfair, unlawful, 13,370
deceptive, or unconscionable trade act or practice. 13,371
(27) An institution defined as a home health agency in 13,373
section 3701.88 of the Revised Code, that conducts all telephone 13,374
solicitation activities according to sections 310.3, 310.4, and 13,375
310.5 of the telemarketing sales rules adopted by the federal 13,376
trade commission in 16 C.F.R. part 310, and engages in telephone 13,377
solicitation only within the scope of the institution's 13,378
certification, accreditation, contract with the department of
aging, or status as a home health agency; and that meets one of 13,379
the following requirements: 13,380
(a) The institution is certified as a provider of home 13,382
health services under Title XVIII of the Social Security Act, 49 13,384
Stat. 620, 42 U.S.C. 301, as amended; and is registered with the 13,385
department of health pursuant to division (B) of section 3701.88 13,386
of the Revised Code; 13,387
(b) The institution is accredited by either the joint 13,389
commission on accreditation of health care organizations or the 13,390
299
community health accreditation program; 13,391
(c) The institution is providing PASSPORT services under 13,394
the direction of the Ohio department of aging under section
173.40 of the Revised Code; 13,395
(d) An affiliate of an institution that meets the 13,397
requirements of division (B)(27)(a), (b), or (c) of this section 13,399
when offering for sale substantially the same goods and services 13,400
as those that are offered by the institution that meets the
requirements of division (B)(27)(a), (b), or (c) of this section. 13,402
(28) A person licensed to provide a hospice care program 13,404
by the department of health pursuant to section 3712.04 of the 13,405
Revised Code when conducting telephone solicitations within the 13,406
scope of the person's license and according to sections 310.3, 13,407
310.4, and 310.5 of the telemarketing sales rules adopted by the 13,408
federal trade commission in 16 C.F.R. part 310.
Sec. 4729.381. No licensed pharmacist shall be liable for 13,417
civil damages or in any criminal prosecution arising from the 13,418
dispensing of a drug based upon a formulary established by a 13,419
practitioner in a hospital, health maintenance organization 13,420
INSURING CORPORATION, or long-term care facility and requiring 13,421
the pharmacist to dispense the particular drug. 13,422
Sec. 4731.67. Section 4731.66 of the Revised Code does not 13,431
apply to any of the following referrals by the holder of a 13,432
certificate under this chapter: 13,433
(A) Referrals for physicians' services that are performed 13,435
by or under the personal supervision of a physician in the same 13,436
group practice as the referring physician; 13,437
(B) Referrals for clinical laboratory services by a 13,439
certificate holder specializing in the practice of pathology if 13,440
those services are provided by or under the supervision of the 13,441
pathologist pursuant to a consultation requested by another 13,442
physician; 13,443
(C) Referrals for in-office ancillary services to which 13,445
all of the following apply: 13,446
300
(1) The services are furnished by the referring physician, 13,448
a physician in the same group practice as the referring 13,449
physician, or individuals who are employed by the referring 13,450
physician or the group practice and who are supervised by the 13,451
referring physician or a physician in the group practice, and are 13,452
furnished either: 13,453
(a) In a building in which the referring physician, or 13,455
another physician in the same group practice as the referring 13,456
physician, furnishes physicians' services unrelated to the 13,457
furnishing of designated health services; 13,458
(b) In another building used by the referring physician's 13,460
group practice for the centralized provision of the group's 13,461
designated health services. 13,462
(2) The services are billed by the physician performing or 13,464
supervising the services, the physician's group practice, or an 13,465
entity wholly owned by the group practice. 13,466
(3) The physician's ownership or investment interest in 13,468
the services described in this division meets any other 13,469
requirements that the state medical board applies in rules 13,470
adopted under section 4731.70 of the Revised Code. 13,471
(D) "Referrals for in-office ancillary services if the 13,473
third-party payer is aware of and has agreed in writing to 13,474
reimburse the services notwithstanding the financial arrangement 13,475
between the physician and the provider of such ancillary 13,476
services. 13,477
(E) Referrals for services furnished by a health 13,479
maintenance organization INSURING CORPORATION to an enrollee of 13,480
the organization CORPORATION; 13,481
(F) Referrals to a hospital for designated health 13,484
services, if all of the following apply:
(1) The financial arrangement between the referring 13,486
physician or immediate family member and the hospital consists of 13,487
an ownership or investment interest described in division (A)(1) 13,488
of section 4731.66 of the Revised Code and not a compensation 13,489
301
arrangement described in division (A)(2) of that section. 13,490
(2) The referring physician is authorized to perform 13,492
services at the hospital. 13,493
(3) The ownership or investment interest is in the 13,495
hospital itself and not merely in a subdivision of the hospital. 13,496
(G) Referrals to a hospital with which the certificate 13,498
holder's or immediate family member's financial relationship does 13,499
not relate to the provision of designated health services; 13,501
(H) Referrals to a laboratory located in a rural area as 13,503
defined in section 1886(d)(2)(D) of the "Social Security Act," 49 13,504
Stat. 620 (1935), 42 U.S.C.A. 1395ww(d)(2)(D), as amended, if the 13,505
financial relationship consists of an ownership or investment 13,506
interest described in division (A)(1) of section 4731.66 of the 13,507
Revised Code, and not a compensation arrangement described in 13,508
division (A)(2) of that section; 13,509
(I) Any other referrals in which the financial 13,511
relationship between the certificate holder or immediate family 13,512
member and the person furnishing services has been specified in 13,513
rules adopted by the state medical board under section 4731.70 of 13,514
the Revised Code. 13,515
Sec. 5111.02. (A) Under the medical assistance program: 13,524
(1) Reimbursement by the department of human services to a 13,526
medical provider for any medical service rendered under the 13,527
program shall not exceed the authorized reimbursement level for 13,528
the same service under the medicare program established under 13,529
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 13,530
U.S.C.A. 301, as amended. 13,531
(2) Reimbursement for freestanding medical laboratory 13,533
charges shall not exceed the customary and usual fee for 13,534
laboratory profiles. 13,535
(3) The department may deduct from payments for services 13,537
rendered by a medicaid provider under the medical assistance 13,538
program any amounts the provider owes the state as the result of 13,539
incorrect medical assistance payments the department has made to 13,540
302
the provider. 13,541
(4) The department may conduct final fiscal audits in 13,543
accordance with the applicable requirements set forth in federal 13,544
laws and regulations and determine any amounts the provider may 13,545
owe the state. When conducting final fiscal audits, the 13,546
department shall consider generally accepted auditing standards, 13,547
which include the use of statistical sampling. 13,548
(5) To the maximum extent that federal laws and 13,550
regulations permit the implementation of such a policy, the 13,551
department may institute a copayment program for all services 13,552
provided under the medical assistance program. The program shall 13,553
be administered in accordance with the applicable requirements 13,554
set forth in federal laws and regulations. 13,555
(6) The number of days of inpatient hospital care for 13,557
which reimbursement is made on behalf of a recipient of medical 13,558
assistance to a hospital that is not paid under a 13,559
diagnostic-related-group prospective payment system shall not 13,560
exceed thirty days during a period beginning on the day of the 13,561
recipient's admission to the hospital and ending sixty days after 13,562
the termination of that hospital stay, except that the department 13,563
may make exceptions to this limitation. The limitation does not 13,564
apply to children participating in the program for medically 13,565
handicapped children established under section 3701.023 of the 13,566
Revised Code. 13,567
(B) The director of human services may adopt, amend, or 13,569
rescind rules under Chapter 119. of the Revised Code establishing 13,570
the amount, duration, and scope of medical services to be 13,571
included in the medical assistance program. Such rules shall 13,572
establish the conditions under which services are covered and 13,573
reimbursed, the method of reimbursement applicable to each 13,574
covered service, and the amount of reimbursement or, in lieu of 13,575
such amounts, methods by which such amounts are to be determined 13,576
for each covered service. Any rules that pertain to nursing 13,577
facilities or intermediate care facilities for the mentally 13,578
303
retarded shall be consistent with sections 5111.20 to 5111.33 of 13,579
the Revised Code. 13,580
(C) No health maintenance organization INSURING 13,582
CORPORATION that has a contract to provide health care services 13,584
to recipients of medical assistance shall restrict the 13,585
availability to its enrollees of any prescription drugs included 13,586
in the Ohio medicaid drug formulary as established under rules of 13,587
the department.
(D) The division of any reimbursement between a 13,589
collaborating physician or podiatrist and a clinical nurse 13,590
specialist, certified nurse-midwife, or certified nurse 13,591
practitioner for services performed by the nurse shall be 13,592
determined and agreed on by the nurse and collaborating physician 13,593
or podiatrist. In no case shall reimbursement exceed the payment
that the physician or podiatrist would have received had the 13,594
physician or podiatrist provided the entire service. 13,596
Sec. 5111.17. (A) As used in this section, 13,605
"community-based clinic" means a clinic that provides prenatal, 13,606
family planning, well child, or primary care services and is 13,607
funded in whole or in part by the state or federal government. 13,608
(B) On receipt of a waiver from the United States 13,610
department of health and human services of any federal 13,611
requirement that would otherwise be violated, the department of 13,612
human services shall establish in Franklin, Hamilton, and Lucas 13,613
counties a managed care system under which designated recipients 13,614
of medical assistance are required to obtain medical services 13,615
from providers designated by the department. The department may 13,616
stagger implementation of the managed care system, but the system 13,617
shall be implemented in at least one county not later than 13,618
January 1, 1995, and in all three counties not later than July 1, 13,619
1996.
(B)(C) The department, by rule adopted under this section, 13,621
may require any recipients in any other county to receive all or 13,622
some of their care through managed care organizations that 13,623
304
contract with the department and are paid by the department 13,624
pursuant to a capitation or other risk-based methodology 13,625
prescribed in the rules, and to receive their care only from 13,626
providers designated by the organizations.
(C)(D) In accordance with rules adopted under division 13,629
(E)(G) of this section, the department may issue requests for 13,630
proposals from managed care organizations interested in 13,631
contracting with the department to provide managed care to
participating medical assistance recipients. 13,632
(E) A health maintenance organization INSURING CORPORATION 13,635
under contract with the department under this section may enter 13,637
into an agreement with any community-based clinic for the 13,638
provision of medical services to medical assistance recipients
participating in the managed care system if the clinic is willing 13,639
to accept the terms, conditions, and payment procedures 13,640
established by the health maintenance organization INSURING 13,641
CORPORATION.
(D)(F) For the purpose of determining the amount the 13,643
department pays hospitals under section 5112.08 of the Revised 13,645
Code and the amount of disproportionate share hospital payments 13,646
paid by the medicare program established under Title XVIII of the 13,647
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 13,648
amended, each managed care organization under contract with the 13,649
department to provide managed care to participating medical
assistance recipients shall keep detailed records for each 13,650
hospital with which it contracts about the cost to the hospital 13,651
of providing the care, payments made by the organization to the 13,652
hospital for the care, utilization of hospital services by 13,653
medical assistance recipients participating in managed care, and
other utilization data required by the department. 13,654
(E)(G) The department shall adopt rules in accordance with 13,656
Chapter 119. of the Revised Code to implement this section. The 13,658
rules shall include all of the following: 13,659
(1) A monthly capitation or other risk-based payment rate 13,661
305
system for managed care organizations under contract to provide 13,662
managed care to participating medical assistance recipients; 13,664
(2) The method by which the department will issue requests 13,666
for proposals from managed care organizations interested in 13,667
providing managed care to participating medical assistance 13,668
recipients, including all of the following: 13,669
(a) Public notice of the department's intent to issue a 13,671
request for proposals within a county; 13,672
(b) The process for managed care organizations to submit 13,674
letters of interest;
(c) The procurement, selection, and implementation 13,676
timetable within each county; 13,677
(d) The time by which the department will furnish 13,679
interested managed care organizations with demographic, cost, and 13,680
utilization data about medical assistance recipients required or 13,681
permitted to enroll in a managed care organization in a county. 13,682
(3) Performance standards of managed care organizations 13,684
under contract with the department governing all of the 13,685
following:
(a) Scope of coverage and benefits; 13,687
(b) Quality assurance performance indicators for services 13,689
including prenatal care, immunizations, screenings that are part 13,690
of the early and periodic screening, diagnostic, and treatment 13,691
program, and any other service specified by the department; 13,692
(c) Service delivery system capacity; 13,694
(d) Reporting requirements; 13,696
(e) Grievance and complaint procedures; 13,698
(f) Enrollment and disenrollment procedures; 13,700
(g) Stop-loss arrangements; 13,702
(h) Marketing; 13,704
(i) Consumer and provider advisory councils; 13,706
(j) Any other requirement established by the department. 13,708
(4) A review process for any managed care organization 13,710
that has submitted a proposal to have the department reconsider 13,711
306
the denial of a contract under this section or termination of a 13,712
contract entered into under this section;
(5) Any other procedures or requirements the department 13,714
considers necessary to implement managed care. 13,715
Sec. 5111.171. On receipt of a waiver from the United 13,724
States department of health and human services of any federal 13,725
requirement that would be violated by implementation of this 13,726
section, the department shall establish a case management system 13,727
to ensure that recipients of medical assistance under this 13,728
chapter whose medical treatment and care is exceptionally 13,729
expensive receive medical services in a cost-effective manner. 13,730
Recipients identified by the department as being subject to this 13,731
division shall comply with the requirements of the case 13,732
management system as a condition of continued eligibility for 13,733
medical assistance. The department shall reimburse a hospital 13,734
under the medical assistance program for emergency services 13,735
covered by the medical assistance program provided to a medical 13,736
assistance recipient pursuant to section 1867 of the "Social 13,737
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 1395dd, as 13,738
amended, regardless of whether the hospital is participating in 13,739
the case management system. 13,740
A hospital's participation in the case management system 13,742
does not prevent its participation in the hospital care assurance 13,743
program established by sections 5112.01 to 5112.21 of the Revised 13,744
Code unless the hospital is operated by a health maintenance 13,745
organization INSURING CORPORATION. 13,746
Sec. 5111.19. The department of human services shall adopt 13,755
rules governing the calculation and payment of graduate medical 13,756
education costs associated with services rendered to recipients 13,757
of the medical assistance program after June 30, 1994. The rules 13,758
shall provide for reimbursement of graduate medical education 13,759
costs associated with services rendered to medical assistance 13,760
recipients, including recipients enrolled in health maintenance 13,761
organizations INSURING CORPORATIONS, that the department 13,762
307
determines are allowable and reasonable. 13,764
If the department requires a health maintenance 13,766
organization INSURING CORPORATION to pay a provider for graduate 13,767
medical education costs associated with the delivery of services 13,769
to medical assistance recipients enrolled in the organization 13,770
CORPORATION, the department shall include in its payment to the 13,772
organization CORPORATION an amount sufficient for the 13,774
organization CORPORATION to pay such costs. If the department 13,776
does not include in its payments to the organization HEALTH 13,777
INSURING CORPORATION amounts for graduate medical education costs 13,778
of providers, all of the following apply: 13,779
(A) The department shall pay the provider for graduate 13,781
medical education costs associated with the delivery of services 13,782
to medical assistance recipients enrolled in the organization 13,783
CORPORATION; 13,784
(B) No provider shall seek reimbursement from the 13,786
organization CORPORATION for such costs; 13,787
(C) The organization CORPORATION is not required to pay 13,789
providers for such costs. 13,791
Sec. 5111.74. (A) Not later than July 1, 1995, the 13,800
department of human services shall establish a fair share 13,801
demonstration project in Butler county for two years. The 13,802
demonstration project shall be administered by the Butler county 13,803
health care management board created under division (B) of this 13,804
section. In establishing the project, the department shall enter 13,805
into an agreement with the board, which shall provide that 13,806
medical assistance services be given to designated medical 13,807
assistance recipients who elect or are required by the department 13,808
to receive their services from or through the board or at least 13,809
one other managed care arrangement designated and approved by the 13,810
department.
The demonstration project shall demonstrate the viability 13,812
of delivering health care services to Butler county medical 13,813
assistance recipients through a cooperative health care 13,814
308
purchasing plan involving the organization of a managed care 13,815
network by physicians practicing medicine in Butler county and 13,816
hospitals located there. The demonstration project shall 13,817
restructure the medical assistance delivery system to improve the 13,818
delivery of cost effective, quality health care with an emphasis 13,819
on primary and preventive care, and shall prevent cost shifting 13,820
to the private sector. The demonstration project shall 13,821
demonstrate all of the following: 13,822
(1) A cost savings through prevention, the use of 13,824
appropriate levels of care, reduced administrative costs, and 13,825
utilization of the demonstration project through primary provider 13,826
reimbursement policies that encourage the delivery of primary and 13,827
preventive care; 13,828
(2) The effectiveness of local collaboration and autonomy 13,830
in managing medical assistance expenditures in Butler county; 13,831
(3) Improved access to quality health care for Butler 13,833
county's medical assistance recipients, while containing health 13,834
care costs. 13,835
The department shall make a grant of two hundred fifty 13,837
thousand dollars to the board on its establishment for operating 13,838
and project expenses. These funds shall be transferred from the 13,839
department's medical assistance account. 13,840
(B)(1) There is hereby created the Butler county health 13,842
care management board to administer the fair share demonstration 13,843
project in that county. The board shall consist of the county 13,844
director of human services and the following members: 13,845
(a) One representative of each hospital system located in 13,847
Butler county, selected by the hospital; 13,848
(b) Two physicians who specialize in pediatrics; two 13,850
family practice physicians; a physician who specializes in 13,851
obstetrics; an emergency department physician; a primary care 13,852
physician; a physician who is a medical specialist; a physician 13,853
who is a surgical specialist; a psychiatrist; and one physician 13,854
selected at large. The physicians shall be selected by the 13,855
309
county medical society or a similar organization of physicians in 13,856
the county. 13,857
(c) A chiropractor selected by an association of 13,859
chiropractors in the county; 13,860
(d) A licensed registered nurse who is an advanced 13,862
practice nurse selected by an organization of nurses in the 13,863
county; 13,864
(e) A dentist selected by an organization of dentists in 13,866
the county; 13,867
(f) An optometrist selected by an organization of 13,869
optometrists in the county; 13,870
(g) A psychologist selected by an organization of 13,872
psychologists in the county; 13,873
(h) A representative of child and family health services 13,875
clinics selected by the child health service consortium of Butler 13,876
county; 13,877
(i) A podiatrist selected by an organization of 13,879
podiatrists in the county. 13,880
(2) All members of the board shall be selected on the 13,882
basis of their experience with the delivery of health care 13,883
services to medical assistance recipients. If more than one 13,884
physician is to be selected from a specialty area, the order of 13,885
preference for determining board membership shall first be those 13,886
physicians that have significant experience in providing health 13,887
care services to medical assistance recipients. 13,888
(3) Each member of the board shall serve for the duration 13,890
of the demonstration project. In the event of a vacancy on the 13,891
board, a member shall be selected in the same manner as the 13,892
member he replaces REPLACED. Members shall not be compensated, 13,894
but may be reimbursed by the board for their actual and necessary 13,895
expenses. A majority of the members constitutes a quorum, and 13,896
the board may take official action only by affirmative vote of a 13,897
quorum.
(4) Not later than thirty days after July 1, 1993, the 13,899
310
representatives of the hospital systems in Butler county shall 13,901
select a temporary chairman CHAIRPERSON, who shall convene the 13,903
board not later than ninety days after July 1, 1993. Once
convened, the board shall elect a chairman CHAIRPERSON by a 13,905
majority vote from among its members, and all further meetings 13,907
shall be convened by the chairman CHAIRPERSON. The board may 13,909
elect officers and shall establish rules and procedures for its 13,910
governance and a schedule of meetings. The board may establish 13,911
an executive committee and such other subcommittees as it 13,912
determines necessary to act on behalf of the board. The county 13,913
department shall provide the board with any clerical,
professional, or technical assistance it requests. 13,914
(C) The Butler county health care management board shall 13,916
develop and implement a plan for the fair share demonstration 13,917
project. The board shall establish educational and case 13,918
management programs as it determines necessary to facilitate 13,919
access to and encourage appropriate utilization of essential 13,920
preventive medicine and primary care services. The board shall 13,921
have limited immunity from antitrust actions in developing and 13,922
implementing the project. The board shall apply for a 13,923
certificate of authority to establish and operate a health 13,924
maintenance organization INSURING CORPORATION under Chapter 1742. 13,926
1751. of the Revised Code. On application of the board, the 13,927
superintendent of insurance shall issue a certificate of 13,928
authority to the board for a two-year period, notwithstanding the 13,929
fact that the board may not meet the requirements of Chapter 13,930
1742. 1751. of the Revised Code. The certificate of authority 13,932
shall be void if the agreement with the department is not 13,933
executed. The superintendent shall retain powers and duties 13,934
under Chapter 3903. of the Revised Code with regard to the Butler 13,935
county health care management board and the demonstration 13,936
project.
The board may do any of the following: 13,938
(1) Enter into contracts with any person organized to do 13,940
311
business in this state on behalf of the board; 13,941
(2) Accept and spend donations, grants, and other funds 13,943
received by the board; 13,944
(3) Employ personnel and professionals that may be needed 13,946
to assess the feasibility and to develop the demonstration 13,947
project; 13,948
(4) Establish provider agreements in Butler county that 13,950
will organize a managed health care delivery system for medical 13,951
assistance recipients and will establish provider reimbursement 13,952
policies to encourage the delivery of primary health care 13,953
services; 13,954
(5) Monitor the quality of health care delivered to 13,956
medical assistance recipients in Butler county; 13,957
(6) Establish provider agreements with physicians and 13,959
other health care practitioners that set forth the terms, 13,960
conditions, and payment procedures for the provision of health 13,961
care services to medical assistance recipients. Any provider 13,962
willing to accept such terms and conditions shall be eligible for 13,963
participation in the project. 13,964
(7) Establish, in cooperation with the county medical 13,966
society, voluntary participation guidelines for the project for 13,967
physicians in Butler county to ensure that they provide health 13,968
care services to their fair share of medical assistance 13,969
recipients in the county. Such guidelines shall be communicated 13,970
to all medical providers providing services in Butler county. 13,971
(8) Require that all medical assistance recipients, other 13,973
than those described in division (A)(2) of section 5111.01 of the 13,974
Revised Code, who elect or are required by the department to 13,975
receive their medical assistance services through the board 13,976
choose a physician who is participating in the demonstration 13,978
project to provide all health care services to the recipient, and 13,979
adopt standards for changing physicians, including disenrollment 13,980
as provided by federal law;
(9) So long as it is consistent with federal law, 13,982
312
establish a co-pay system for the following: 13,983
(a) Provision of medical services under the demonstration 13,985
project; 13,986
(b) Inappropriate utilization of medical services; 13,988
(c) Over-utilization of medical services; 13,990
(d) Failure of a medical assistance recipient to appear 13,992
for a scheduled medical appointment. 13,993
(10) Enter into agreements with the board of nursing 13,995
authorizing advanced practice nurses, certified nurse 13,997
practitioners, clinical nurse specialists, and certified 13,998
nurse-midwives in Butler county to have prescription powers and 14,000
perform primary care services in collaboration with or under the
supervision of a physician or podiatrist in accordance with 14,002
division (D) of this section; 14,004
(11) Enter into agreements with the state medical board 14,006
authorizing physician assistants in Butler county to have 14,007
prescription powers and perform primary care services under the 14,008
general supervision and authority of a physician in accordance 14,009
with division (D) of this section.
(12) Assign medical assistance recipients, other than 14,011
those described in division (A)(2) of section 5111.01 of the 14,012
Revised Code, who elect or are required by the department to 14,013
receive their medical assistance services through the board, to 14,014
providers who have entered into provider agreements with the 14,016
board.
(D) The Butler county health care management board shall 14,018
pass a resolution by a majority vote establishing the terms and 14,019
conditions under which the scope of practice of advanced practice 14,020
nurses, certified nurse practitioners, clinical nurse 14,021
specialists, certified nurse-midwives, and physician assistants 14,022
in Butler county may be expanded. The expansion of practice for 14,024
advanced practice nurses shall comply with section 4723.56 of the 14,025
Revised Code. The expansion of practice for certified nurse 14,027
practitioners, clinical nurse specialists, and certified
313
nurse-midwives shall comply with Chapter 4723. of the Revised 14,028
Code. The expansion of practice for physician assistants shall 14,030
comply with sections 4730.06 and 4730.07 of the Revised Code. 14,031
The resolution shall be sent to the board of nursing and the Ohio 14,032
state medical board with a request that the scope of practice of 14,033
the practitioners be amended in accordance with the resolution. 14,034
On receipt of the resolution and request, the board of nursing 14,035
and the Ohio state medical board shall, without amendment, adopt 14,036
rules establishing the terms and conditions for expansion of the 14,037
scope of practice of advanced practice nurses, certified nurse 14,038
practitioners, clinical nurse specialists, certified 14,039
nurse-midwives, and physician assistants in Butler county in 14,041
accordance with the resolution. Such rules shall apply only to 14,042
such practitioners performing their duties in Butler county in 14,043
conjunction with and in accordance with the fair share 14,044
demonstration project.
(E) The department of human services may negotiate and 14,046
enter into an agreement with the board establishing a 14,047
comprehensive capitated fee for purposes of delivering health 14,048
care services to persons receiving benefits under Chapter 5107. 14,049
and section 5111.013 of the Revised Code, if the department 14,050
obtains a waiver from the secretary of the United States 14,051
department of health and human services of any federal regulation 14,052
that would prohibit or restrict the use of federal funds. The 14,053
department may include those persons described in division (A)(2) 14,054
of section 5111.01 of the Revised Code in the project as it 14,055
considers necessary. The capitated fee shall be based on 14,056
historic and expected utilization of the medical assistance 14,057
program by the Butler county medical assistance population, 14,058
adjusted by the current inflation rate, and shall be sufficient 14,059
to ensure that all Butler county primary care physicians 14,060
participating in the demonstration project are reimbursed for 14,061
office visits at a rate of not less than thirty dollars per 14,062
patient during the first year of the project, and not less than 14,063
314
thirty-five dollars per patient for the second year of the 14,064
project. Any savings of state funds the department of human 14,065
services receives as the result of the demonstration project 14,066
shall be distributed as follows: 14,067
(1) One-third of the savings to Butler county for 14,069
children's health programs; 14,070
(2) One-third of the savings to the department of human 14,072
services; 14,073
(3) One-third of the savings to providers participating in 14,075
the demonstration project. 14,076
(F) All provider agreements or any contracts entered into 14,078
or negotiated by the board shall be exempt from any contract 14,079
provision contained in a contract between medical providers and 14,080
health insurers or indemnity insurers licensed to do business in 14,081
this state that provides for a lower payment for the services. 14,083
(G) The Butler county health care management board shall, 14,085
at the end of each year of the demonstration project, issue a 14,086
report listing every medical provider practicing in Butler 14,087
county, the degree to which such provider has participated in the 14,088
demonstration project, and the extent to which such provider has 14,089
met the voluntary guidelines adopted by the board under division 14,090
(C)(7) of this section. 14,091
(H) The department of human services shall apply for any 14,093
federal waiver needed to implement the Butler county fair share 14,094
demonstration project. 14,095
Sec. 5115.10. (A) The disability assistance medical 14,104
assistance program shall consist of a system of managed primary 14,105
care. Until July 1, 1992, the program shall also include limited 14,106
hospital services, except that if prior to that date hospitals 14,107
are required by section 5112.17 of the Revised Code to provide 14,108
medical services without charge to persons specified in that 14,109
section, the program shall cease to include hospital services at 14,110
the time the requirement of section 5112.17 of the Revised Code 14,111
takes effect. 14,112
315
The state department of human services may require 14,114
disability assistance medical assistance recipients to enroll in 14,115
health maintenance organizations, preferred provider 14,117
organizations, INSURING CORPORATIONS or other managed care 14,118
programs, or may limit the number or type of health care 14,120
providers from which a recipient may receive services. 14,121
The state department shall adopt rules governing the 14,123
disability assistance medical assistance program established 14,124
under this division. The rules shall specify all of the 14,125
following: 14,126
(1) Services that will be provided under the system of 14,128
managed primary care; 14,129
(2) Hospital services that will be provided during the 14,131
period that hospital services are provided under the program; 14,132
(3) The maximum authorized amount, scope, duration, or 14,134
limit of payment for services. 14,135
(B) The director of human services shall designate medical 14,137
services providers for the disability assistance medical 14,138
assistance program. The first such designation shall be made not 14,139
later than September 30, 1991. Services under the program shall 14,140
be provided only by providers designated by the director. The 14,141
director may require that, as a condition of being designated a 14,142
disability assistance medical assistance provider, a provider 14,143
enter into a provider agreement with the state department. 14,144
(C) As long as the disability assistance medical 14,146
assistance program continues to include hospital services, the 14,147
state department or a county director of human services may, 14,148
pursuant to rules adopted by the state department under this 14,149
section, approve an application for disability assistance medical 14,150
assistance for emergency inpatient hospital services when care 14,151
has been given to a person who had not completed a sworn 14,152
application for disability assistance at the time the care was 14,153
rendered, if all of the following apply: 14,154
(1) The person files an application for disability 14,156
316
assistance within sixty days after being discharged from the 14,157
hospital or, if the conditions of division (D) of this section 14,158
are met, while in the hospital; 14,159
(2) The person met all eligibility requirements for 14,161
disability assistance at the time the care was rendered; 14,162
(3) The care given to the person was a medical service 14,164
within the scope of disability assistance medical assistance as 14,165
established under rules adopted by the department of human 14,166
services. 14,167
(D) If a person files an application for disability 14,169
assistance medical assistance for emergency inpatient hospital 14,170
services while in the hospital, a face-to-face interview shall be 14,171
conducted with the applicant while he THE APPLICANT is in the 14,172
hospital to determine whether he THE APPLICANT is eligible for 14,174
the assistance. If the hospital agrees to reimburse the county 14,176
department of human services for all actual costs incurred by the 14,177
department in conducting the interview, the interview shall be 14,178
conducted by an employee of the county department. If, at the 14,179
request of the hospital, the county department designates an 14,180
employee of the hospital to conduct the interview, the interview 14,181
shall be conducted by the hospital employee. 14,182
(E) The state department of human services may assume 14,184
responsibility for peer review of expenditures for disability 14,185
assistance medical assistance. 14,186
Sec. 5119.01. The director of mental health is the chief 14,199
executive and administrative officer of the department of mental 14,200
health. The director may establish procedures for the governance 14,201
of the department, conduct of its employees and officers, 14,202
performance of its business, and custody, use, and preservation 14,203
of departmental records, papers, books, documents, and property. 14,204
Whenever the Revised Code imposes a duty upon or requires an 14,205
action of the department or any of its institutions, the director 14,206
shall perform the action or duty in the name of the department, 14,207
except that the medical director appointed pursuant to section 14,208
317
5119.07 of the Revised Code shall be responsible for decisions 14,209
relating to medical diagnosis, treatment, rehabilitation, quality 14,210
assurance, and the clinical aspects of the following: licensure 14,211
of hospitals and residential facilities, research, community 14,212
mental health plans, and delivery of mental health services. 14,213
The director shall: 14,215
(A) Adopt rules for the proper execution of the powers and 14,217
duties of the department with respect to the institutions under 14,218
its control, and require the performance of additional duties by 14,219
the officers of the institutions as necessary to fully meet the 14,220
requirements, intents, and purposes of this chapter. In case of 14,221
an apparent conflict between the powers conferred upon any 14,222
managing officer and those conferred by such sections upon the 14,223
department, the presumption shall be conclusive in favor of the 14,224
department. 14,225
(B) Adopt rules for the nonpartisan management of the 14,227
institutions under the department's control. An officer or 14,228
employee of the department or any officer or employee of any 14,230
institution under its control who, by solicitation or otherwise, 14,231
exerts influence directly or indirectly to induce any other 14,232
officer or employee of the department or any of its institutions 14,233
to adopt the exerting officer's or employee's political views or 14,234
to favor any particular person, issue, or candidate for office 14,236
shall be removed from the exerting officer's or employee's office 14,237
or position, by the department in case of an officer or employee, 14,238
and by the governor in case of the director. 14,239
(C) Appoint such employees, including the medical 14,241
director, as are necessary for the efficient conduct of the 14,242
department, and prescribe their titles and duties; 14,243
(D) Prescribe the forms of affidavits, applications, 14,245
medical certificates, orders of hospitalization and release, and 14,246
all other forms, reports, and records that are required in the 14,247
hospitalization or admission and release of all persons to the 14,248
institutions under the control of the department, or are 14,249
318
otherwise required under this chapter or Chapter 5122. of the 14,250
Revised Code; 14,251
(E) Contract with hospitals licensed by the department 14,253
under section 5119.20 of the Revised Code for the care and 14,254
treatment of mentally ill patients, or with persons, 14,255
organizations, or agencies for the custody, supervision, care, or 14,256
treatment of mentally ill persons receiving services elsewhere 14,257
than within the enclosure of a hospital operated under section 14,258
5119.02 of the Revised Code; 14,259
(F) Exercise the powers and perform the duties relating to 14,261
community mental health facilities and services that are assigned 14,262
to the director under this chapter and Chapter 340. of the 14,263
Revised Code; 14,264
(G) Adopt rules under Chapter 119. of the Revised Code for 14,266
the establishment of minimum standards, including standards for 14,267
use of seclusion and restraint, of mental health services that 14,268
are not inconsistent with nationally recognized applicable 14,269
standards and that facilitate participation in federal assistance 14,270
programs; 14,271
(H) Develop and implement clinical evaluation and 14,273
monitoring of services that are operated by the department; 14,274
(I) At the director's discretion, adopt rules establishing 14,276
standards for the adequacy of services provided by community 14,278
mental health facilities, and certify the compliance of such 14,279
facilities with the standards for the purpose of authorizing 14,280
their participation in the health care plans of medical care 14,281
corporations under Chapter 1737., health care INSURING 14,282
corporations under Chapter 1738., 1751. and sickness and accident 14,284
insurance policies issued under Chapter 3923. of the Revised 14,285
Code;
(J) Adopt rules establishing standards for the performance 14,287
of evaluations by a forensic center or other psychiatric program 14,288
or facility of the mental condition of defendants ordered by the 14,289
court under section 2919.271, or 2945.371 of the Revised Code, 14,291
319
and for the treatment of defendants who have been found 14,292
incompetent to stand trial and ordered by the court under section 14,293
2945.38, 2945.39, 2945.401, or 2945.402 of the Revised Code to
receive treatment in facilities; 14,294
(K) On behalf of the department, have the authority and 14,296
responsibility for entering into contracts and other agreements; 14,297
(L) Prepare and publish regularly a state mental health 14,299
plan that describes the department's philosophy, current 14,300
activities, and long-term and short-term goals and activities. 14,301
(M) Adopt rules in accordance with Chapter 119. of the 14,303
Revised Code specifying the supplemental services that may be 14,304
provided through a trust authorized by section 1339.51 of the 14,305
Revised Code; 14,306
(N) Adopt rules in accordance with Chapter 119. of the 14,308
Revised Code establishing standards for the maintenance and 14,309
distribution to a beneficiary of assets of a trust authorized by 14,310
section 1339.51 of the Revised Code; 14,311
(O) As used in division (I) of this section: 14,313
(1) "Community mental health facility" means a facility 14,315
that provides community mental health services and is included in 14,317
the community mental health plan for the alcohol, drug addiction, 14,318
and mental health service district in which it is located. 14,319
(2) "Community mental health service" means services, 14,321
other than inpatient services, provided by a community mental 14,322
health facility. 14,323
Sec. 5119.202. No third-party payer shall directly or 14,333
indirectly reimburse, nor shall any person be obligated to pay 14,334
any hospital for psychiatric services for which a license is 14,335
required under section 5119.20 of the Revised Code unless the 14,336
hospital is licensed by the department of mental health.
As used in this section, "third-party payer" means a 14,338
medical care corporation licensed under Chapter 1737. of the 14,340
Revised Code, a health care INSURING corporation licensed under 14,342
Chapter 1738. 1751. of the Revised Code, an insurance company 14,343
320
that issues sickness and accident insurance in conformity with 14,344
Chapter 3923. of the Revised Code, a state-financed health 14,345
insurance program under Chapter 3701., 4123., or 5101. of the 14,346
Revised Code, or any self-insurance plan.
Sec. 5505.28. (A) The state highway patrol retirement 14,355
board may enter into an agreement with insurance companies, 14,356
medical or health care INSURING corporations, health maintenance 14,358
organizations, or government agencies authorized to do business 14,359
in the state for issuance of a policy or contract of health, 14,360
medical, hospital, or surgical benefits, or any combination 14,361
thereof, for those persons receiving pensions and subscribing to 14,363
the plan. Notwithstanding any other provision of this chapter, 14,364
the policy or contract may also include coverage for any eligible 14,365
individual's spouse and dependent children and for any of the 14,367
individual's sponsored dependents as the board considers 14,368
appropriate.
If all or any portion of the policy or contract premium is 14,370
to be paid by any individual receiving a service, disability, or 14,372
survivor pension or benefit, the individual shall, by written 14,374
authorization, instruct the board to deduct from the individual's 14,376
pension or benefit the premium agreed to be paid by the 14,377
individual to the company, corporation, or agency. 14,379
The board may contract for coverage on the basis of part or 14,382
all of the cost of the coverage to be paid from appropriate funds 14,383
of the state highway patrol retirement system. The cost paid 14,384
from the funds of the system shall be included in the employer's 14,386
contribution rate as provided by section 5505.15 of the Revised 14,387
Code.
(B) If the board provides health, medical, hospital, or 14,389
surgical benefits through any means other than a health 14,390
maintenance organization INSURING CORPORATION, it shall offer to 14,391
each individual eligible for the benefits the alternative of 14,394
receiving benefits through enrollment in a health maintenance 14,396
organization INSURING CORPORATION, if all of the following apply: 14,398
321
(1) The health maintenance organization INSURING 14,400
CORPORATION provides HEALTH CARE services in the geographical 14,402
area in which the individual lives; 14,403
(2) The eligible individual was receiving health care 14,405
benefits through a health maintenance organization OR A HEALTH 14,407
INSURING CORPORATION before retirement; 14,408
(3) The rate and coverage provided by the health 14,410
maintenance organization INSURING CORPORATION to eligible 14,411
individuals is comparable to that currently provided by the board 14,414
under division (A) of this section. If the rate or coverage 14,415
provided by the health maintenance organization INSURING 14,416
CORPORATION is not comparable to that currently provided by the 14,418
board under division (A) of this section, the board may deduct 14,419
the additional cost from the eligible individual's monthly 14,421
benefit.
The health maintenance organization INSURING CORPORATION 14,423
shall accept as an enrollee any eligible individual who requests 14,425
enrollment.
The board shall permit each eligible individual to change 14,427
from one plan to another at least once a year at a time 14,429
determined by the board. 14,430
(C) The board shall, beginning the month following receipt 14,432
of satisfactory evidence of the payment for coverage, pay monthly 14,433
to each recipient of a pension under the state highway patrol 14,435
retirement system who is eligible for medical insurance coverage 14,436
under part B of "The Social Security Amendments of 1965," 79 14,437
Stat. 301, 42 U.S.C.A. 1395j, as amended, the lesser of an 14,438
amount equal to the basic premium for such coverage or an amount 14,440
equal to the basic premium for such coverage in effect on January 14,442
1, 1994.
(D) The board shall establish by rule requirements for the 14,444
coordination of any coverage, payment, or benefit provided under 14,446
this section with any similar coverage, payment, or benefit made 14,447
available to the same individual by the public employees 14,448
322
retirement system, police and firemen's disability and pension 14,449
fund, state teachers retirement system, or school employees 14,450
retirement system. 14,451
(E) The board shall make all other necessary rules 14,453
pursuant to the purpose and intent of this section. 14,454
Sec. 5505.33. (A) As used in this section: 14,463
(1) "Long-term care insurance" has the same meaning as in 14,465
section 3923.41 of the Revised Code. 14,466
(2) "Retirement systems" has the same meaning as in 14,468
division (A) of section 145.581 of the Revised Code. 14,469
(B) The state highway patrol retirement board shall 14,471
establish a program under which members of the retirement system, 14,472
employers on behalf of members, and persons receiving service or 14,473
disability pensions or survivor benefits are permitted to 14,474
participate in contracts for long-term care insurance. 14,475
Participation may include dependents and family members. If a 14,476
participant in a contract for long-term care insurance leaves his 14,477
employment, he THE PERSON and his THE PERSON'S dependents and 14,479
family members may, at their election, continue to participate in 14,480
a program established under this section in the same manner as if 14,481
he THE PERSON had not left his employment, except that no part of 14,483
the cost of the insurance shall be paid by his THE PERSON'S 14,484
former employer. Such program may be established independently 14,486
or jointly with one or more of the retirement systems. 14,487
(C) The board may enter into an agreement with insurance 14,489
companies, medical or health care INSURING corporations, health 14,491
maintenance organizations, or government agencies authorized to 14,492
do business in the state for issuance of a long-term care 14,493
insurance policy or contract. However, prior to entering into 14,494
such an agreement with an insurance company, medical or health 14,495
care INSURING corporation, or health maintenance organization, 14,497
the board shall request the superintendent of insurance to 14,498
certify the financial condition of the company, OR corporation, 14,499
or organization. The board shall not enter into the agreement 14,501
323
if, according to that certification, the company, OR corporation, 14,502
or organization is insolvent, is determined by the superintendent 14,504
to be potentially unable to fulfill its contractual obligations, 14,505
or is placed under an order of rehabilitation or conservation by 14,506
a court of competent jurisdiction or under an order of 14,507
supervision by the superintendent. 14,508
(D) The board shall adopt rules in accordance with section 14,510
111.15 of the Revised Code governing the program. The rules 14,511
shall establish methods of payment for participation under this 14,512
section, which may include establishment of a payroll deduction 14,513
plan under section 5505.203 of the Revised Code, deduction of the 14,514
full premium charged from a person's service or disability 14,515
pension or survivor benefit, or any other method of payment 14,516
considered appropriate by the board. If the program is 14,517
established jointly with one or more of the other retirement 14,518
systems, the rules also shall establish the terms and conditions 14,519
of such joint participation. 14,520
Sec. 5923.051. Notwithstanding any collective bargaining 14,529
agreement or other agreement or law to the contrary, the state 14,530
and any agency, authority, commission, or board thereof, shall, 14,531
at the request of any person employed by the entity who is called 14,532
to active duty as specified in division (B) of section 5923.05 of 14,533
the Revised Code, or at the request of the spouse or dependent of 14,534
that person, continue or reactivate the health, medical, 14,535
hospital, dental, vision, and surgical benefits coverage, whether 14,536
provided by an insurance company, medical care corporation, 14,537
health care INSURING corporation, health maintenance 14,538
organization, or other health plan or entity, of that person for 14,540
the duration of the time the person is on active duty as 14,541
described in that division. The person or the spouse or 14,542
dependent thereof who requests the continuation or reactivation 14,543
of the coverage and the employing state or agency, authority, 14,544
commission, or board thereof, each are liable for payment of the 14,545
same costs for the coverage as if the person were not on a leave 14,546
324
of absence.
Section 2. That existing sections 101.271, 124.81, 124.82, 14,548
124.822, 124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 14,549
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 14,550
1319.12, 1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 14,551
1901.312, 2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 14,552
3307.74, 3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 14,553
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 14,554
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 14,555
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 14,556
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 14,557
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 14,558
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 14,559
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 14,561
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 14,562
4719.01, 4729.381, 4731.67, 5111.02, 5111.17, 5111.171, 5111.19,
5111.74, 5115.10, 5119.01, 5119.202, 5505.28, 5505.33, and 14,564
5923.051 and sections 1736.01, 1736.02, 1736.03, 1736.04,
1736.05, 1736.06, 1736.07, 1736.08, 1736.09, 1736.10, 1736.11, 14,565
1736.12, 1736.13, 1736.14, 1736.15, 1736.16, 1736.17, 1736.18, 14,566
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 1736.24, 1736.25, 14,567
1736.26, 1736.27, 1736.28, 1737.01, 1737.02, 1737.03, 1737.04, 14,568
1737.05, 1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 1737.11, 14,569
1737.12, 1737.13, 1737.14, 1737.15, 1737.16, 1737.17, 1737.18, 14,570
1737.19, 1737.20, 1737.21, 1737.22, 1737.23, 1737.24, 1737.25, 14,571
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 1737.301, 1737.31, 14,572
1737.32, 1737.99, 1738.01, 1738.02, 1738.03, 1738.04, 1738.05, 14,573
1738.06, 1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 1738.12, 14,574
1738.13, 1738.14, 1738.15, 1738.16, 1738.17, 1738.18, 1738.19, 14,575
1738.20, 1738.21, 1738.22, 1738.23, 1738.24, 1738.25, 1738.26, 14,576
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 1738.99, 1740.01, 14,577
1740.02, 1740.03, 1740.04, 1740.05, 1740.06, 1740.07, 1740.08, 14,578
1740.09, 1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 1740.15, 14,579
1740.16, 1740.17, 1740.18, 1740.19, 1740.20, 1740.21, 1740.22, 14,580
325
1740.23, 1740.24, 1740.25, 1740.26, 1740.99, 1742.01, 1742.02, 14,581
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 1742.08, 1742.09, 14,582
1742.10, 1742.11, 1742.12, 1742.13, 1742.131, 1742.14, 1742.141, 14,583
1742.15, 1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 1742.19, 14,584
1742.20, 1742.21, 1742.22, 1742.23, 1742.24, 1742.25, 1742.26, 14,585
1742.27, 1742.28, 1742.29, 1742.30, 1742.301, 1742.31, 1742.32, 14,586
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 1742.37, 1742.38, 14,587
1742.39, 1742.40, 1742.41, 1742.42, 1742.43, 1742.44, and 1742.45 14,588
of the Revised Code are hereby repealed. 14,589
Section 3. (A) The certificate of authority of every 14,591
prepaid dental plan organization, health care corporation, dental 14,592
care corporation, and health maintenance organization licensed to 14,594
operate under Chapter 1736., 1738., 1740., or 1742. of the 14,596
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 14,599
Chapter 1751. of the Revised Code. All assets and liabilities of 14,600
the prepaid dental plan organization, health care corporation, 14,601
dental care corporation, or health maintenance organization, 14,602
including all obligations under subscriber contracts delivered, 14,603
issued for delivery, or renewed prior to the effective date of 14,604
this section, shall be assumed by the successor entity. Except 14,605
as otherwise provided in division (B) of this section, such 14,606
entity shall, no later than January 1, 1998, comply with Chapter 14,607
1751. of the Revised Code. 14,608
(B)(1) Each entity described in division (A) of this 14,610
section shall do both of the following: 14,611
(a) Comply with sections 1751.19 and 1751.26 of the 14,614
Revised Code no later than six months after the effective date of
this section. 14,615
(b) Comply with section 1751.28 of the Revised Code by 14,618
making annual deposits with the Superintendent of Insurance, no 14,619
later than the first day of January of each year, for up to three 14,620
years, beginning the first day of January immediately following 14,621
the effective date of this section. 14,622
326
(2) Every contract delivered, issued for delivery, or 14,624
renewed by an entity described in division (A) of this section 14,625
prior to the effective date of this section shall comply with 14,626
section 1751.13 of the Revised Code no later than the contract's 14,628
first renewal date after the first day of January immediately 14,629
following the effective date of this section. 14,631
(3) Every contract delivered, issued for delivery, or 14,634
renewed by an entity described in division (A) of this section 14,635
prior to the effective date of this section shall comply with 14,636
section 1751.31 of the Revised Code no later than three months 14,637
after the effective date of this section. 14,638
(4) An entity described in division (A) of this section 14,640
may comply with section 1751.27 of the Revised Code by making 14,641
annual deposits with the Superintendent of Insurance, not later 14,642
than the first day of January of each year, for up to three years 14,643
beginning the first day of January immediately following the 14,644
effective date of this section. An equal amount shall be 14,645
deposited each year until the total amount required under section 14,646
1751.27 of the Revised Code has been deposited. 14,647
Section 4. On and after the effective date of this 14,649
section, the Department of Insurance shall no longer accept new 14,650
applications for certificates of authority to operate under 14,651
Chapter 1736., 1737., 1738., 1740., or 1742. of the Revised Code, 14,652
and shall not issue any such certificates of authority. Any such 14,653
application received by the Department of Insurance that is 14,654
pending on the effective date of this section shall be considered 14,655
an application for a certificate of authority to operate under 14,656
Chapter 1751. of the Revised Code, and the review period for that 14,657
application shall begin to run on the effective date of this 14,658
section.
Section 5. The member of the Board of Directors of the 14,660
Ohio Small Employer Health Reinsurance Program who, on the 14,661
effective date of this section, is serving pursuant to section 14,662
3924.08 of the Revised Code as the member carrier that is a 14,663
327
health maintenance organization predominantly in the small 14,664
employer market, shall continue in office until the end of the 14,665
term for which the member was appointed. Thereafter, that 14,666
appointment shall be filled by a member carrier that is a health 14,667
insuring corporation predominantly in the small employer market. 14,668
Section 6. Section 1751.64 of the Revised Code is hereby 14,670
repealed, effective February 9, 2004. The repeal of that section 14,672
shall apply only to contracts that are delivered, issued for 14,673
delivery, or renewed in this state on or after that date.
Section 7. Every provision for mandated health benefits, 14,675
as defined in section 3901.71 of the Revised Code, that is 14,676
contained in Chapter 1751. of the Revised Code, shall be applied 14,678
to every policy, contract, certificate, or agreement of a health 14,679
insuring corporation on the effective date of the section in 14,680
which the provision is contained, notwithstanding section 3901.71 14,681
of the Revised Code.
Section 8. Section 5119.01 of the Revised Code is 14,683
presented in this act as a composite of the section as amended by 14,684
both Sub. H.B. 670 and Am. Sub. S.B. 285 of the 121st General 14,685
Assembly, with the new language of neither of the acts shown in 14,687
capital letters. This is in recognition of the principle stated 14,688
in division (B) of section 1.52 of the Revised Code that such 14,689
amendments are to be harmonized where not substantively 14,690
irreconcilable and constitutes a legislative finding that such is 14,691
the resulting version in effect prior to the effective date of 14,692
this act.