As Passed by the Senate 1
122nd General Assembly 4
Regular Session Sub. S. B. No. 67 5
1997-1998 6
SENATORS GILLMOR-ZALESKI-HOWARD-OELSLAGER-WATTS-LATELL- 8
RAY-LATTA-DRAKE 9
11
A B I L L
To amend sections 101.271, 124.81, 124.82, 124.822, 13
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 14
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 15
742.45, 742.53, 1319.12, 1337.16, 1545.071, 16
1731.01, 1731.06, 1739.05, 1901.111, 1901.312,
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 17
3113.217, 3307.74, 3307.741, 3309.69, 3309.691, 18
3313.202, 3375.40, 3381.14, 3501.141, 3701.24, 19
3701.76, 3702.51, 3702.62, 3709.16, 3729.12,
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 20
3901.19, 3901.31, 3901.32, 3901.38, 3901.40, 22
3901.41, 3901.48, 3901.72, 3902.01, 3902.02,
3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 23
3923.30, 3923.301, 3923.33, 3923.333, 3923.38, 25
3923.382, 3923.41, 3923.51, 3923.54, 3923.58,
3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 27
3924.13, 3924.41, 3924.61, 3924.62, 3924.64,
3924.73, 3929.77, 3956.01, 3959.01, 3999.32, 28
3999.36, 4582.041, 4582.29, 4715.02, 4719.01, 29
4729.381, 4731.67, 5111.02, 5111.17, 5111.171,
5111.19, 5111.74, 5115.10, 5119.01, 5119.202, 31
5505.28, 5505.33, and 5923.051; to enact sections 32
1751.01 to 1751.08, 1751.11 to 1751.21, 1751.25 33
to 1751.28, 1751.31 to 1751.36, 1751.38, 1751.40,
1751.42, 1751.44 to 1751.48, 1751.51 to 1751.56, 34
1751.59 to 1751.67, 1751.70, and 1751.71; and to 36
repeal sections 1736.01, 1736.02, 1736.03,
2
1736.04, 1736.05, 1736.06, 1736.07, 1736.08, 38
1736.09, 1736.10, 1736.11, 1736.12, 1736.13, 39
1736.14, 1736.15, 1736.16, 1736.17, 1736.18,
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 40
1736.24, 1736.25, 1736.26, 1736.27, 1736.28, 42
1737.01, 1737.02, 1737.03, 1737.04, 1737.05,
1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 43
1737.11, 1737.12, 1737.13, 1737.14, 1737.15, 45
1737.16, 1737.17, 1737.18, 1737.19, 1737.20, 46
1737.21, 1737.22, 1737.23, 1737.24, 1737.25,
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 47
1737.301, 1737.31, 1737.32, 1737.99, 1738.01, 49
1738.02, 1738.03, 1738.04, 1738.05, 1738.06,
1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 50
1738.12, 1738.13, 1738.14, 1738.15, 1738.16, 52
1738.17, 1738.18, 1738.19, 1738.20, 1738.21, 53
1738.22, 1738.23, 1738.24, 1738.25, 1738.26,
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 54
1738.99, 1740.01, 1740.02, 1740.03, 1740.04, 56
1740.05, 1740.06, 1740.07, 1740.08, 1740.09,
1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 57
1740.15, 1740.16, 1740.17, 1740.18, 1740.19, 59
1740.20, 1740.21, 1740.22, 1740.23, 1740.24, 60
1740.25, 1740.26, 1740.99, 1742.01, 1742.02,
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 61
1742.08, 1742.09, 1742.10, 1742.11, 1742.12, 62
1742.13, 1742.131, 1742.14, 1742.141, 1742.15,
1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 63
1742.19, 1742.20, 1742.21, 1742.22, 1742.23, 64
1742.24, 1742.25, 1742.26, 1742.27, 1742.28, 65
1742.29, 1742.30, 1742.301, 1742.31, 1742.32,
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 66
1742.37, 1742.38, 1742.39, 1742.40, 1742.41, 67
1742.42, 1742.43, 1742.44, and 1742.45 of the
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Revised Code to provide for the establishment, 68
operation, and regulation of health insuring 69
corporations; to repeal the laws governing
prepaid dental plan organizations, medical care 70
corporations, health care corporations, dental 71
care corporations, and health maintenance 72
organizations; and to eliminate certain
provisions of this act on and after February 9, 74
2004, by repealing section 1751.64 of the Revised
Code on that date. 75
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 77
Section 1. That sections 101.271, 124.81, 124.82, 124.822, 79
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 305.171, 80
306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 1319.12, 81
1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 1901.312, 82
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 3307.74, 83
3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 84
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 85
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 86
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 87
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 88
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 89
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 90
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 92
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 93
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 95
5923.051 be amended and sections 1751.01, 1751.02, 1751.03, 96
1751.04, 1751.05, 1751.06, 1751.07, 1751.08, 1751.11, 1751.12, 97
1751.13, 1751.14, 1751.15, 1751.16, 1751.17, 1751.18, 1751.19, 98
1751.20, 1751.21, 1751.25, 1751.26, 1751.27, 1751.28, 1751.31, 100
1751.32, 1751.33, 1751.34, 1751.35, 1751.36, 1751.38, 1751.40, 101
1751.42, 1751.44, 1751.45, 1751.46, 1751.47, 1751.48, 1751.51, 102
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1751.52, 1751.53, 1751.54, 1751.55, 1751.56, 1751.59, 1751.60, 103
1751.61, 1751.62, 1751.63, 1751.64, 1751.65, 1751.66, 1751.67, 104
1751.70, and 1751.71 of the Revised Code be enacted to read as 106
follows:
Sec. 101.271. (A) As used in this section, "medical 115
insurance premium" means any premium payment made under a 116
contract with an insurance company, nonprofit health plan, health 117
care INSURING corporation, health maintenance organization, or 119
any combination of such organizations, pursuant to section 124.82 120
of the Revised Code. 121
(B) After the general election in each even-numbered year, 123
the clerk of the senate, with the assistance of the department of 124
administrative services, shall estimate the cost of the medical 125
insurance premiums that will be necessary to provide coverage, on 126
the same basis as for a similarly situated state employee, for 127
each person who is elected to a term as senator at such election, 128
or appointed to fill the unexpired portion of any such term, and 129
any of his THE SENATOR'S dependents qualified for coverage at the 131
time he THE SENATOR assumes office. Using this estimate, the 132
clerk shall determine a fixed amount to be paid by the state in 133
equal monthly installments on behalf of the senator each year of 134
his THE SENATOR'S term as a medical insurance premium, but in no 135
event in an amount to exceed the total premium required in any 137
month by the contract of the state by the carrier. Any amount 138
not paid in such a case shall be placed in reserve and applied 139
against any subsequent month's premium up to the full amount 140
thereof until the entire amount has been paid along with the 141
original estimate for each month. This fixed amount shall be 142
such that, as nearly as can be predicted, the sum of the monthly 143
premiums paid for the senator during his THE SENATOR'S term shall 145
equal the total amount of medical insurance premiums that will be 146
paid for such an employee, as required by section 124.82 of the 147
Revised Code, during that term. The senator shall pay the 148
difference between the amount so fixed and the total premium 149
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required by the contract of the state with the carrier.
(C) After the general election in each even-numbered year, 151
the executive secretary of the house of representatives, with the 152
assistance of the department of administrative services, shall 153
estimate the cost of the medical insurance premiums that will be 154
necessary to provide coverage, on the same basis as for a 155
similarly situated state employee, for each person who is elected 156
to a term as representative at such election, or appointed to 157
fill the unexpired portion of any such term, and any of his THE 158
REPRESENTATIVE'S dependents qualified for coverage at the time he 159
THE REPRESENTATIVE assumes office. Using this estimate, the 160
executive secretary shall determine a fixed amount to be paid by 161
the state in equal monthly installments on behalf of the 163
representative each year of his THE REPRESENTATIVE'S term as a 165
medical insurance premium, but in no event in an amount to exceed 166
the total premium required in any month by the contract of the 167
state with the carrier. Any amount not paid in such a case shall 168
be placed in reserve and applied against any subsequent month's 169
premium up to the full amount thereof until the entire reserve 170
has been paid along with the original estimate for each month. 171
This fixed amount shall be such that, as nearly as can be 172
predicted, the sum of the monthly premiums paid for the
representative during his THE REPRESENTATIVE'S term shall equal 173
the total amount of medical insurance premiums that will be paid 175
for such an employee, as required by section 124.82 of the 176
Revised Code, during that term. The representative shall pay the 177
difference between the amount so fixed and the total premium 178
required by the contract of the state with the carrier. 179
Sec. 124.81. (A) Except as provided in division (E) of 188
this section, the department of administrative services in 189
consultation with the superintendent of insurance shall negotiate 190
with and, in accordance with the competitive selection procedures 191
of Chapter 125. of the Revised Code, contract with one or more 192
insurance companies authorized to do business in this state, for 193
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the issuance of one of the following: 194
(1) A policy of group life insurance covering all state 196
employees who are paid directly by warrant of the state auditor, 197
including elected state officials; 198
(2) A combined policy, or coordinated policies of one or 200
more insurance companies, medical care corporations, health care 201
corporations, dental care corporations, or health maintenance 202
INSURING corporations in combination with one or more insurance 203
companies providing group life and health, medical, hospital, 205
dental, or surgical insurance, or any combination thereof, 206
covering all such employees; 207
(3) A policy that may include, but is not limited to, 209
hospitalization, surgical, major medical, dental, vision, and 210
medical care, disability, hearing aids, prescription drugs, group 211
life, life, sickness, and accident insurance, group legal 212
services, or a combination of the above benefits for some or all 213
of the employees paid in accordance with section 124.152 of the 214
Revised Code and for some or all of the employees listed in 215
divisions (B)(2) and (4) of section 124.14 of the Revised Code, 216
and their immediate dependents. 217
(B) If a state employee uses all accumulated sick leave 220
and then goes on an extended medical disability, the policyholder 221
shall continue at no cost to the employee the coverage of the 222
group life insurance for such employee for the period of such 223
extended leave, but not beyond three years.
(C) If a state employee insured under a group life 226
insurance policy as provided in division (A) of this section is 227
laid off pursuant to section 124.32 of the Revised Code, such
employee by request to the policyholder, made no later than the 228
effective date of the layoff, may elect to continue the 229
employee's group life insurance for the one-year period through 230
which the employee may be considered to be on laid-off status by 231
paying the policyholder through payroll deduction or otherwise 233
twelve times the monthly premium computed at the existing average 234
7
rate for the group life case for the amount of the employee's 235
insurance thereunder at the time of the employee's layoff. The 237
policyholder shall pay the premiums to the insurance company at 239
the time of the next regular monthly premium payment for the 240
actively insured employees and furnish the company appropriate 241
data as to such laid-off employees. At the time an employee 242
receives written notice of a layoff, the policyholder shall also 243
give such employee written notice of the opportunity to continue 244
group life insurance in accordance with this division. When such 246
laid-off employee is reinstated for active work before the end of 247
the one-year period, the employee shall be reclassified as 249
insured again as an active employee under the group and 250
appropriate refunds for the number of full months of unearned 251
premium payment shall be made by the policyholder.
(D) This section does not affect the conversion rights of 253
an insured employee when the employee's group insurance 254
terminates under the policy. 255
(E) Notwithstanding division (A) of this section, the 257
department may provide benefits equivalent to those that may be 258
paid under a policy issued by an insurance company, or the 259
department may, to comply with a collectively bargained contract, 260
enter into an agreement with a jointly administered trust fund 261
which receives contributions pursuant to a collective bargaining 262
agreement entered into between this state, or any of its 263
political subdivisions, and any collective bargaining 264
representative of the employees of this state or any political 265
subdivision for the purpose of providing for self-insurance of 266
all risk in the provision of fringe benefits similar to those 267
that may be paid pursuant to division (A) of this section, and 268
the jointly administered trust fund may provide through the 269
self-insurance method specific fringe benefits as authorized by 270
the rules of the board of trustees of the jointly administered 271
trust fund. Amounts from the fund may be used to pay direct and 272
indirect costs that are attributable to consultants or a 273
8
third-party administrator and that are necessary to administer 274
this section. Benefits provided under this section include, but 275
are not limited to, hospitalization, surgical care, major medical 276
care, disability, dental care, vision care, medical care, hearing 277
aids, prescription drugs, group life insurance, sickness and 278
accident insurance, group legal services, or a combination of the 279
above benefits, for the employees and their immediate dependents. 280
(F) Notwithstanding any other provision of the Revised 282
Code, any public employer, including the state, and any of its 283
political subdivisions, including, but not limited to, any 284
county, county hospital, municipal corporation, township, park 285
district, school district, state institution of higher education, 286
public or special district, state agency, authority, commission, 287
or board, or any other branch of public employment, and any 288
collective bargaining representative of employees of the state or 289
any political subdivision may agree in a collective bargaining 290
agreement that any mutually agreed fringe benefit including, but 291
not limited to, hospitalization, surgical care, major medical 292
care, disability, dental care, vision care, medical care, hearing 293
aids, prescription drugs, group life insurance, sickness and 294
accident insurance, group legal services, or a combination 295
thereof, for employees and their dependents be provided through a 296
mutually agreed upon contribution to a jointly administered trust 297
fund. Amounts from the fund may be used to pay direct and 298
indirect costs that are attributable to consultants or a 299
third-party administrator and that are necessary to administer 300
this section. The amount, type, and structure of fringe benefits 302
provided under this division is subject to the determination of 303
the board of trustees of the jointly administered trust fund. 304
Notwithstanding any other provision of the Revised Code, 305
competitive bidding does not apply to the purchase of fringe 306
benefits for employees under this division through a jointly 307
administered trust fund. 308
Sec. 124.82. (A) Except as provided in division (D) of 317
9
this section, the department of administrative services, in 318
consultation with the superintendent of insurance, shall, in 319
accordance with competitive selection procedures of Chapter 125. 320
of the Revised Code, contract with an insurance company or a 322
nonprofit health plan in combination with an insurance company, 323
authorized to do business in this state, for the issuance of a 324
policy or contract of health, medical, hospital, dental, or 325
surgical benefits, or any combination thereof, covering state 326
employees who are paid directly by warrant of the auditor of 327
state, including elected state officials. The department may 328
fulfill its obligation under this division by exercising its 329
authority under division (A)(2) of section 124.81 of the Revised 330
Code.
(B) The department may, in addition, in consultation with 332
the superintendent of insurance, negotiate and contract with 333
health care INSURING corporations organized HOLDING A CERTIFICATE 335
OF AUTHORITY under Chapter 1738. 1751. of the Revised Code, in 336
their APPROVED service areas only, for issuance of any policy or 337
policies or contract or contracts of health, medical, hospital, 338
dental, or surgical benefits, or any combination thereof, or with 339
health maintenance organizations organized under Chapter 1742. of 340
the Revised Code, in their service areas only, for issuance of a 341
contract or contracts of health care services, covering state 342
employees who are paid directly by warrant of the auditor of 343
state, including elected state officials. Except for health care 344
corporation and health maintenance organization plans INSURING 345
CORPORATIONS, no more than one insurance carrier or nonprofit 346
health plan, shall be contracted with to provide the same plan of 348
benefits, provided that:
(1) The amount of the premium or cost for such coverage 350
contributed by the state, for an individual or for an individual 351
and his THE INDIVIDUAL'S family, does not exceed that same amount 353
of the premium or cost contributed by the state under division 354
(A) of this section; 355
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(2) The employee be permitted to exercise his THE option 357
as to which plan he THE EMPLOYEE will select under division (A) 358
or (B) of this section, at a set time each year, which time shall 360
be determined by the department; 361
(3) The health care INSURING corporations or the health 363
maintenance organizations do not refuse to accept the employee, 364
or the employee and his THE EMPLOYEE'S family, if he THE EMPLOYEE 366
exercises the option to select care provided by the corporations 367
or organizations;
(4) The employee may choose participation in only one of 369
the plans sponsored by the department; 370
(5) The director of health examines and certifies to the 372
department that the quality and adequacy of care rendered by the 373
health care INSURING corporations or the health maintenance 374
organizations meet at least the standards of care provided by 375
hospitals and physicians in that employee's community, who would 376
be providing such care as would be covered by a contract awarded 377
under division (A) of this section. 378
(C) All or any portion of the cost, premium, or charge for 380
the coverage in divisions (A) and (B) of this section may be paid 381
in such manner or combination of manners as the department 382
determines and may include the proration of health care costs, 383
premiums, or charges for part-time employees. 384
(D) Notwithstanding division (A) of this section, the 386
department may provide benefits equivalent to those that may be 387
paid under a policy or contract issued by an insurance company or 388
a nonprofit health plan pursuant to division (A) of this section. 389
(E) This section does not prohibit the state office of 391
collective bargaining from entering into an agreement with an 392
employee representative for the purposes of providing fringe 393
benefits including, but not limited to, hospitalization, surgical 394
care, major medical care, disability, dental care, vision care, 395
medical care, hearing aids, prescription drugs, group life 396
insurance, sickness and accident insurance, group legal services 397
11
or other benefits, or any combination thereof, to employees paid 398
directly by warrant of the auditor of state through a jointly 399
administered trust fund. The employer's contribution for the 400
cost of the benefit care shall be mutually agreed to in the 401
collectively bargained agreement. The amount, type, and 402
structure of fringe benefits provided under this division is 403
subject to the determination of the board of trustees of the 404
jointly administered trust fund. Notwithstanding any other 405
provision of the Revised Code, competitive bidding does not apply 406
to the purchase of fringe benefits for employees under this 407
division when such benefits are provided through a jointly 408
administered trust fund. 409
Sec. 124.822. (A) The department of administrative 419
services shall require, as a condition of entering into a 420
contract with a health maintenance organization INSURING 421
CORPORATION that desires to provide health care services to state 423
employees, including elected public officials, who are paid 424
directly by warrant of the auditor of state and who reside within 425
its APPROVED service area, that the health maintenance 426
organization INSURING CORPORATION enroll at least five hundred of 427
such eligible state employees, or at least five per cent of such 428
eligible state employees, whichever is less. 429
(B) Division (A) of this section applies only to contracts 431
that are entered into or renewed on or after the effective date 432
of this section JULY 16, 1991. 433
Sec. 124.84. (A) The department of administrative 442
services, in consultation with the superintendent of insurance 443
and subject to division (D) of this section, shall negotiate and 444
contract with, one or more insurance companies, medical or health 446
care INSURING corporations, or health maintenance organizations 448
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 450
state employees who are paid directly by warrant of the auditor 451
of state, including elected state officials. Any policy 452
12
purchased under this division shall be negotiated and entered 453
into in accordance with the competitive selection procedures 454
specified in Chapter 125. of the Revised Code. As used in this 455
section, "long-term care insurance" has the same meaning as in 456
section 3923.41 of the Revised Code. 457
(B) Any elected state official or state employee paid 459
directly by warrant of the auditor of state may elect to 460
participate in any long-term care insurance policy purchased 461
under division (A) of this section and any official or employee 462
who does so shall be responsible for paying the entire premium 463
charged, which shall be deducted from the official's or 464
employee's salary or wage and be remitted by the auditor of state 466
directly to the insurance company, medical or health care 467
INSURING corporation, or health maintenance organization. 468
Participation in the policy may include the dependents and family 469
members of the elected state official or state employee. 470
If a participant in a long-term care insurance policy 472
leaves employment, the participant and the participant's 474
dependents and family members may, at their election, continue to 475
participate in a policy established under this section in the 476
same manner as if the participant had not left employment. 477
(C) Any long-term care insurance policy purchased under 479
this section or section 124.841 or 145.581 of the Revised Code 480
shall provide for all of the following with respect to the 481
premiums charged for the policy: 482
(1) They shall be set at the entry age of the official or 484
employee when first covered by the policy and shall not increase 485
except as a class during coverage under the policy. 486
(2) They shall be based on the class of all officials or 488
employees covered by the policy. 489
(3) They shall continue, pursuant to section 145.581 of 491
the Revised Code, after the retirement of the official or 492
employee who is covered under the policy, at the rate in effect 493
on the date of the official's or employee's retirement. 494
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(D) Prior to entering into a contract with an insurance 496
company, medical or health care INSURING corporation, or health 498
maintenance organization for the purchase of a long-term care
insurance policy under this section, the department shall request 499
the superintendent of insurance to certify the financial 500
condition of the company, OR corporation, or organization. The 502
department shall not enter into the contract if, according to 503
that certification, the company, OR corporation, or organization 505
is insolvent, is determined by the superintendent to be
potentially unable to fulfill its contractual obligations, or is 507
placed under an order of rehabilitation or conservation by a 508
court of competent jurisdiction or under an order of supervision 509
by the superintendent. 510
(E) The department shall adopt rules in accordance with 512
section 111.15 of the Revised Code governing long-term care 513
insurance purchased under this section. The rules shall 514
establish methods of payment for participation under this 515
section, which may include establishment of a payroll deduction 516
plan. 517
Sec. 124.841. (A) As used in this section: 526
(1) "Long-term care insurance" has the same meaning as in 528
section 3923.41 of the Revised Code. 529
(2) "Political subdivision" has the same meaning as in 531
section 9.833 of the Revised Code. 532
(B) Any political subdivision may negotiate with and may 534
contract with, one or more insurance companies, medical or health 536
care INSURING corporations, or health maintenance organizations 537
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 538
elected officials and employees of the political subdivision. 540
The contract may be entered into without competitive bidding. 541
Any elected official or employee of a political subdivision may 542
elect to participate in any long-term care insurance policy that 543
the political subdivision purchases under this division and any 544
14
official or employee who does so shall be responsible for paying 545
the entire premium charged, which shall be deducted from his THE 546
OFFICIAL'S OR EMPLOYEE'S salary or wage and be remitted directly 547
to the insurance company, medical or health care INSURING 548
corporation, or health maintenance organization. 549
(C) Any long-term care insurance policy entered into under 551
this section is subject to division (C) of section 124.84 of the 552
Revised Code. 553
Sec. 124.92. If the superintendent of insurance has 562
approved all or a portion of a service area expansion of a health 563
maintenance organization INSURING CORPORATION into an additional 564
county or counties, the department of administrative services 565
shall authorize the organization CORPORATION, at the next open 566
enrollment period conducted by the department, to participate in 567
the open enrollment for state employees who reside in the 568
expanded service area, if both of the following apply:
(A) The open enrollment is conducted in accordance with 570
section 1742.12 1751.15 of the Revised Code; 571
(B) Prior to the expansion of the service area, fewer than 573
two health maintenance organizations INSURING CORPORATIONS were 574
available to state employees in the county or counties into which 576
the organization CORPORATION expanded.
Sec. 124.93. (A) As used in this section, "physician" 585
means any person who holds a valid certificate to practice 586
medicine and surgery or osteopathic medicine and surgery issued 587
under Chapter 4731. of the Revised Code. 588
(B) No health maintenace organization INSURING CORPORATION 590
that, on or after the effective date of this section JULY 1, 593
1993, enters into or renews a contract with the department of 594
administrative services under section 124.82 of the Revised Code 595
shall, because of a physician's race, color, religion, sex, 596
national origin, handicap, age, or ancestry, refuse to contract 597
with that physician for the provision of health care services 598
under that section. 599
15
Any health maintenance organization INSURING CORPORATION 601
that violates this division is deemed to have engaged in an 602
unlawful discriminatory practice as defined in section 4112.02 of 603
the Revised Code and is subject to Chapter 4112. of the Revised 604
Code.
(C) Each health maintenance organization INSURING 606
CORPORATION that, on or after the efective date of this section 608
JULY 1, 1993, enters into or renews a contract with the 610
department of administrative services under section 124.82 of the 611
Revised Code and that refuses to contract with a physician for 612
the provision of health care services under that section shall 613
provide that physician with a written notice that clearly 614
explains the reason or reasons for the refusal. The notice shall 615
be sent to the physician by regular mail within thirty days after 616
the refusal.
Any health maintenance organization INSURING CORPORATION 618
that fails to provide notice in compliance with this division is 619
deemed to have engaged in an unfair and deceptive act or practice 620
in the business of insurance as defined in section 3901.21 of the 621
Revised Code and is subject to sections 3901.19 to 3901.26 of the 622
Revised Code.
Sec. 145.58. (A) As used in this section, "ineligible 631
individual" means all of the following: 632
(1) A former member receiving benefits pursuant to section 634
145.32, 145.33, 145.331, 145.34, or 145.46 of the Revised Code 635
for whom eligibility is established more than five years after 636
June 13, 1981, and who, at the time of establishing eligibility, 637
has accrued less than ten years' service credit, exclusive of 638
credit obtained pursuant to section 145.297 or 145.298 of the 639
Revised Code, credit obtained after January 29, 1981, pursuant to 640
section 145.293 or 145.301 of the Revised Code, and credit 641
obtained after May 4, 1992, pursuant to section 145.28 of the 642
Revised Code; 643
(2) The spouse of the former member; 645
16
(3) The beneficiary of the former member receiving 647
benefits pursuant to section 145.46 of the Revised Code. 648
(B) The public employees retirement board may enter into 650
agreements with insurance companies, medical or health care 651
INSURING corporations, health maintenance organizations, or 653
government agencies authorized to do business in the state for 654
issuance of a policy or contract of health, medical, hospital, or 655
surgical benefits, or any combination thereof, for those 656
individuals receiving age and service retirement or a disability 658
or survivor benefit subscribing to the plan, or for PERS 659
retirants employed under section 145.38 of the Revised Code, for 660
coverage of benefits in accordance with division (D)(4)(b) of 661
section 145.38 of the Revised Code. Notwithstanding any other 662
provision of this chapter, the policy or contract may also 663
include coverage for any eligible individual's spouse and 664
dependent children and for any of the individual's sponsored 665
dependents as the board determines appropriate. If all or any 667
portion of the policy or contract premium is to be paid by any 668
individual receiving age and service retirement or a disability 669
or survivor benefit, the individual shall, by written 670
authorization, instruct the board to deduct the premium agreed to 672
be paid by the individual to the company, corporation, or agency. 674
The board may contract for coverage on the basis of part or 677
all of the cost of the coverage to be paid from appropriate funds 678
of the public employees retirement system. The cost paid from 679
the funds of the system shall be included in the employer's 681
contribution rate provided by sections 145.48 and 145.51 of the 682
Revised Code. The board may by rule provide coverage to 683
ineligible individuals if the coverage is provided at no cost to 684
the retirement system. The board shall not pay or reimburse the 685
cost for coverage under this section or section 145.325 of the 686
Revised Code for any ineligible individual.
The board may provide for self-insurance of risk or level 688
of risk as set forth in the contract with the companies, 689
17
corporations, or agencies, and may provide through the 690
self-insurance method specific benefits as authorized by rules of 691
the board. 692
(C) If the board provides health, medical, hospital, or 694
surgical benefits through any means other than a health 695
maintenance organization INSURING CORPORATION, it shall offer to 696
each individual eligible for the benefits the alternative of 699
receiving benefits through enrollment in a health maintenance 701
organization INSURING CORPORATION, if all of the following apply: 703
(1) The health maintenance organization INSURING 705
CORPORATION provides services in the geographical area in which 707
the individual lives; 708
(2) The eligible individual was receiving health care 710
benefits through a health maintenance organization OR A HEALTH 712
INSURING CORPORATION before retirement; 713
(3) The rate and coverage provided by the health 715
maintenance organization INSURING CORPORATION to eligible 716
individuals is comparable to that currently provided by the board 719
under division (B) of this section. If the rate or coverage 720
provided by the health maintenance organization INSURING 721
CORPORATION is not comparable to that currently provided by the 723
board under division (B) of this section, the board may deduct 724
the additional cost from the eligible individual's monthly 725
benefit.
The health maintenance organization INSURING CORPORATION 727
shall accept as an enrollee any eligible individual who requests 729
enrollment.
The board shall permit each eligible individual to change 731
from one plan to another at least once a year at a time 733
determined by the board. 734
(D) The board shall, beginning the month following receipt 736
of satisfactory evidence of the payment for coverage, pay monthly 737
to each recipient of service retirement, or a disability or 738
survivor benefit under the public employees retirement system who 739
18
is eligible for medical insurance coverage under part B of Title 740
XVIII of "The Social Security Act," 79 Stat. 301 (1965), 42 741
U.S.C.A. 1395j, as amended, an amount equal to the basic premium 742
for such coverage, except that the board shall make no such 744
payment to any ineligible individual.
(E) The board shall establish by rule requirements for the 746
coordination of any coverage, payment, or benefit provided under 748
this section or section 145.325 of the Revised Code with any 749
similar coverage, payment, or benefit made available to the same 750
individual by the police and firemen's disability and pension
fund, state teachers retirement system, school employees 751
retirement system, or state highway patrol retirement system. 752
(F) The board shall make all other necessary rules 756
pursuant to the purpose and intent of this section. 757
Sec. 145.581. (A) As used in this section: 766
(1) "Long-term care insurance" has the same meaning as in 768
section 3923.41 of the Revised Code. 769
(2) "Retirement systems" means the public employees 771
retirement system, the police and firemen's disability and 773
pension fund, the state teachers retirement system, the school 774
employees retirement system, and the state highway patrol 775
retirement system. 776
(B) The public employees retirement board shall establish 778
a long-term care insurance program consisting of the programs 779
authorized by divisions (C) and (D) of this section. Such 780
program may be established independently or jointly with one or 781
more of the other retirement systems. If the program is 782
established jointly, the board shall adopt rules in accordance 783
with section 111.15 of the Revised Code to establish the terms 784
and conditions of such joint participation. 785
(C) The board shall establish a program under which it 787
makes long-term care insurance available to any person who 788
participated in a policy of long-term care insurance for which 789
the state or a political subdivision contracted under section 790
19
124.84 or 124.841 of the Revised Code and is the recipient of a 791
pension, benefit, or allowance from the system. To implement the 792
program under this division, the board, subject to division (E) 793
of this section, may enter into an agreement with the insurance 794
company, medical or health care INSURING corporation, health 796
maintenance organization, or government agency that provided the
insurance. The board shall, under any such agreement, deduct the 797
full premium charged from the person's benefit, pension, or 798
allowance notwithstanding any employer agreement to the contrary. 799
Any long-term care insurance policy entered into under this 801
division is subject to division (C) of section 124.84 of the 802
Revised Code. 803
(D)(1) The board, subject to division (E) of this section, 805
shall establish a program under which a recipient of a pension, 806
benefit, or allowance from the system who is not eligible for 807
such insurance under division (C) of this section may participate 808
in a contract for long-term care insurance. Participation may 809
include the recipient's dependents and family members. 810
(2) The board shall adopt rules in accordance with section 812
111.15 of the Revised Code governing the program. The rules 813
shall establish methods of payment for participation under this 814
section, which may include deduction of the full premium charged 815
from a recipient's pension, benefit, or allowance, or any other 816
method of payment considered appropriate by the board. 817
(E) Prior to entering into any agreement or contract with 819
an insurance company, medical or health care INSURING 821
corporation, or health maintenance organization for the purchase
of, or participation in, a long-term care insurance policy under 822
this section, the board shall request the superintendent of 823
insurance to certify the financial condition of the company, OR 824
corporation, or organization. The board shall not enter into the 825
agreement or contract if, according to that certification, the 827
company, OR corporation, or organization is insolvent, is 828
determined by the superintendent to be potentially unable to 829
20
fulfill its contractual obligations, or is placed under an order 830
of rehabilitation or conservation by a court of competent 831
jurisdiction or under an order of supervision by the 832
superintendent. 833
Sec. 305.171. (A) The board of county commissioners of 842
any county may contract for, purchase, or otherwise procure and 843
pay all or any part of the cost of group insurance policies that 844
may provide benefits including, but not limited to, 845
hospitalization, surgical care, major medical care, disability, 846
dental care, eye care, medical care, hearing aids, or 847
prescription drugs, and that may provide sickness and accident 848
insurance, group legal services, or group life insurance, or a 849
combination of any of the foregoing types of insurance or 850
coverage for county officers and employees and their immediate 851
dependents from the funds or budgets from which the officers or 852
employees are compensated for services, issued by an insurance 853
company, a medical care corporation organized under Chapter 1737. 854
of the Revised Code, or a dental care corporation organized under 855
Chapter 1740. of the Revised Code. 856
(B) The board also may negotiate and contract for any plan 858
or plans of group insurance or health care services with health 859
care INSURING corporations organized HOLDING A CERTIFICATE OF 861
AUTHORITY under Chapter 1738. 1751. of the Revised Code and 862
health maintenance organizations organized under Chapter 1742. of 863
the Revised Code, provided that each officer or employee shall be 864
permitted to do both of the following:
(1) Exercise an option between a plan offered by an 866
insurance company, medical care corporation, or dental care 867
corporation, and such plan or plans offered by health care 868
INSURING corporations or health maintenance organizations under 869
this division, on the condition that the officer or employee 870
shall pay any amount by which the cost of the plan chosen by such 871
officer or employee pursuant to this division exceeds the cost of 872
the plan offered under division (A) of this section; 873
21
(2) Change from one of the plans to another at a time each 875
year as determined by the board. 876
(C) Section 307.86 of the Revised Code does not apply to 878
the purchase of benefits for county officers or employees under 879
divisions (A) and (B) of this section when those benefits are 880
provided through a jointly administered health and welfare trust 881
fund in which the county or contracting authority and a 882
collective bargaining representative of the county employees or 883
contracting authority agree to participate. 884
(D) The board of trustees of a jointly administered trust 886
fund that receives contributions pursuant to collective 887
bargaining agreements entered into between the board of county 888
commissioners of any county and a collective bargaining 889
representative of the employees of the county may provide for 890
self-insurance of all risk in the provision of fringe benefits, 891
and may provide through the self-insurance method specific fringe 892
benefits as authorized by the rules of the board of trustees of 893
the jointly administered trust fund. The fringe benefits may 894
include, but are not limited to, hospitalization, surgical care, 895
major medical care, disability, dental care, vision care, medical 896
care, hearing aids, prescription drugs, group life insurance, 897
sickness and accident insurance, group legal services, or a 898
combination of any of the foregoing types of insurance or 899
coverage, for employees and their dependents. 900
(E) The board of county commissioners may provide the 902
benefits described in divisions (A) to (D) of this section 903
through an individual self-insurance program or a joint 904
self-insurance program as provided in section 9.833 of the 905
Revised Code. 906
(F) When a board of county commissioners offers health 908
benefits authorized under this section to an officer or employee 909
of the county, the board may offer the benefits through a 910
cafeteria plan meeting the requirements of section 125 of the 911
"Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 125, 912
22
as amended, and, as part of that plan, may offer the officer or
employee the option of receiving a cash payment in any form 913
permissible under such cafeteria plans. A cash payment made to 914
an officer or employee under this division shall not exceed 915
twenty-five per cent of the cost of premiums or payments that 916
otherwise would be paid by the board for benefits for the officer 917
or employee under a policy or plan.
(G) The board of county commissioners may establish a 919
policy authorizing any county appointing authority to make a cash 920
payment to any officer or employee in lieu of providing a benefit 921
authorized under this section if the officer or employee elects 922
to take the cash payment instead of the offered benefit. A cash 923
payment made to an officer or employee under this division shall
not exceed twenty-five per cent of the cost of premiums or 924
payments that otherwise would be paid by the board for benefits 925
for the officer or employee under an offered policy or plan. 926
(H) No cash payment in lieu of a health benefit shall be 928
made to a county officer or employee under division (F) or (G) of 929
this section unless the officer or employee signs a statement 930
affirming that he THE OFFICER OR EMPLOYEE is covered under 931
another health insurance or health care policy, contract, or 932
plan, and setting forth the name of the employer, if any, that 933
sponsors the coverage, the name of the carrier that provides the
coverage, and the identifying number of the policy, contract, or 934
plan.
(I)(1) As used in this division: 936
(a) "County-operated municipal court" and "legislative 938
authority" have the same meanings as in section 1901.03 of the 939
Revised Code. 940
(b) "Health care coverage" has the same meaning as in 942
section 1901.111 of the Revised Code. 943
(2) The legislative authority of a county-operated 945
municipal court, after consultation with the judges, or the clerk 946
and deputy clerks, of the municipal court, shall negotiate and 947
23
contract for, purchase, or otherwise procure, and pay the costs, 948
premiums, or charges for, group health care coverage for the 949
judges, and group health care coverage for the clerk and deputy 950
clerks, in accordance with section 1901.111 or 1901.312 of the 951
Revised Code. 952
Sec. 306.48. A regional transit authority may procure and 961
pay all or any part of the cost of group hospitalization, 962
surgical, major medical, or sickness and accident insurance or a 963
combination of any of the foregoing for the officers and 964
employees of the regional transit authority and their immediate
dependents, whether issued by an insurance company, or nonprofit 965
medical care A HEALTH INSURING corporation duly authorized to do 966
business in this state. 967
Sec. 307.86. Anything to be purchased, leased, leased with 976
an option or agreement to purchase, or constructed, including, 977
but not limited to, any product, structure, construction, 978
reconstruction, improvement, maintenance, repair, or service, 979
except the services of an accountant, architect, attorney at law, 980
physician, professional engineer, construction project manager, 981
consultant, surveyor, or appraiser by or on behalf of the county 982
or contracting authority, as defined in section 307.92 of the 983
Revised Code, at a cost in excess of fifteen thousand dollars, 984
except as otherwise provided in division (D) of section 713.23 985
and in sections 125.04, 307.022, 307.041, 307.861, 339.05, 986
340.03, 340.033, 4115.31 to 4115.35, 5119.16, 5513.01, 5543.19, 987
5713.01, and 6137.05 of the Revised Code, shall be obtained 988
through competitive bidding. However, competitive bidding is not 989
required when: 990
(A) The board of county commissioners, by a unanimous vote 992
of its members, makes a determination that a real and present 993
emergency exists and such determination and the reasons therefor 994
are entered in the minutes of the proceedings of the board, when: 995
(1) The estimated cost is less than fifty thousand 997
dollars; or 998
24
(2) There is actual physical disaster to structures, radio 1,000
communications equipment, or computers. 1,001
Whenever a contract of purchase, lease, or construction is 1,003
exempted from competitive bidding under division (A)(1) of this 1,004
section because the estimated cost is less than fifty thousand 1,005
dollars, but the estimated cost is fifteen thousand dollars or 1,006
more, the county or contracting authority shall solicit informal 1,007
estimates from no fewer than three persons who could perform the 1,008
contract, before awarding the contract. With regard to each such 1,009
contract, the county or contracting authority shall maintain a 1,010
record of such estimates, including the name of each person from 1,011
whom an estimate is solicited, for no less than one year after 1,012
the contract is awarded. 1,013
(B) The purchase consists of supplies or a replacement or 1,015
supplemental part or parts for a product or equipment owned or 1,016
leased by the county and the only source of supply for such 1,017
supplies, part, or parts is limited to a single supplier. 1,018
(C) The purchase is from the federal government, state, 1,020
another county or contracting authority thereof, a board of 1,021
education, township, or municipal corporation. 1,022
(D) Public social services are purchased for provision by 1,024
the county department of human services under section 329.04 of 1,025
the Revised Code or program services, such as direct and 1,026
ancillary client services, child day-care, case management 1,027
services, residential services, and family resource services, are 1,028
purchased for provision by a county board of mental retardation 1,029
and developmental disabilities under section 5126.05 of the 1,030
Revised Code. 1,031
(E) The purchase consists of human and social services by 1,033
the board of county commissioners from nonprofit corporations or 1,034
associations under programs which are funded entirely by the 1,035
federal government. 1,036
(F) The purchase consists of any form of an insurance 1,038
policy or contract authorized to be issued under Title XXXIX of 1,039
25
the Revised Code or any form of health care contract or plan 1,040
authorized to be issued under Chapter 1736., 1737., 1740., or 1,041
1742. 1751. of the Revised Code, or any combination of such 1,042
policies, contracts, or plans that the contracting authority is 1,043
authorized to purchase, and the contracting authority does all of 1,044
the following: 1,045
(1) Determines that compliance with the requirements of 1,047
this section would increase, rather than decrease, the cost of 1,048
such purchase; 1,049
(2) Employs a competent consultant to assist the 1,051
contracting authority in procuring appropriate coverages at the 1,052
best and lowest prices; 1,053
(3) Requests issuers of such policies, contracts, or plans 1,055
to submit proposals to the contracting authority, in a form 1,056
prescribed by the contracting authority, setting forth the 1,057
coverage and cost of such policies, contracts, or plans as the 1,058
contracting authority desires to purchase; 1,059
(4) Negotiates with such issuers for the purpose of 1,061
purchasing such policies, contracts, or plans at the best and 1,062
lowest price reasonably possible. 1,063
(G) The purchase consists of computer hardware, software, 1,065
or consulting services that are necessary to implement a 1,066
computerized case management automation project administered by 1,067
the Ohio prosecuting attorneys association and funded by a grant 1,068
from the federal government. 1,069
(H) Child day-care services are purchased for provision to 1,071
county employees. 1,072
(I)(1) Property, including land, buildings, and other real 1,074
property, is leased for offices, storage, parking, or other 1,075
purposes and all of the following apply: 1,076
(a) The contracting authority is authorized by the Revised 1,078
Code to lease the property; 1,079
(b) The contracting authority develops requests for 1,081
proposals for leasing the property, specifying the criteria that 1,082
26
will be considered prior to leasing the property, including the 1,083
desired size and geographic location of the property; 1,084
(c) The contracting authority receives responses from 1,086
prospective lessors with property meeting the criteria specified 1,087
in the requests for proposals by giving notice in a manner 1,088
substantially similar to the procedures established for giving 1,089
notice under section 307.87 of the Revised Code; 1,090
(d) The contracting authority negotiates with the 1,092
prospective lessors to obtain a lease at the best and lowest 1,093
price reasonably possible considering the fair market value of 1,094
the property and any relocation and operational costs that may be 1,095
incurred during the period the lease is in effect. 1,097
(2) The contracting authority may use the services of a 1,099
real estate appraiser to obtain advice, consultations, or other 1,100
recommendations regarding the lease of property under this 1,101
division. 1,102
Any issuer of policies, contracts, or plans listed in 1,104
division (F) of this section and any prospective lessor under 1,105
division (I) of this section may have his THE ISSUER'S OR 1,106
PROSPECTIVE LESSOR'S name and address, or the name and address of 1,108
an agent, placed on a special notification list to be kept by the 1,109
contracting authority, by sending the contracting authority such 1,110
name and address. The contracting authority shall send notice to 1,111
all persons listed on the special notification list. Notices 1,112
shall state the deadline and place for submitting proposals. The 1,113
contracting authority shall mail the notices at least six weeks 1,114
prior to the deadline set by the contracting authority for 1,115
submitting such proposals. Every five years the contracting 1,116
authority may review this list and remove any person from the 1,117
list after mailing the person notification of such action. 1,118
Any contracting authority that negotiates a contract under 1,120
division (F) of this section shall request proposals and 1,121
renegotiate with issuers in accordance with that division at 1,122
least every three years from the date of the signing of such a 1,123
27
contract. 1,124
Any consultant employed pursuant to division (F) of this 1,126
section and any real estate appraiser employed pursuant to 1,127
division (I) of this section shall disclose any fees or 1,128
compensation received from any source in connection with that 1,129
employment.
Sec. 339.16. A board of trustees of any county hospital, 1,138
or of any county or district tuberculosis hospital, may contract 1,139
for, purchase, or otherwise procure on behalf of any or all of 1,140
its employees or such employees and their immediate dependents 1,141
the following types of fringe benefits: 1,142
(A) Group or individual insurance contracts which may 1,144
include life, sickness, accident, disability, annuities, 1,145
endowment, health, medical expense, hospital, dental, surgical 1,146
and related coverage or any combination thereof; 1,147
(B) Group or individual contracts with medical care 1,149
corporations, health care INSURING corporations, dental care 1,151
corporations, or other providers of professional services, care, 1,152
or benefits duly authorized to do business in this state.
A board of trustees of any county hospital, or of any 1,154
county or district tuberculosis hospital, may contract for, 1,155
purchase, or otherwise procure insurance contracts which provide 1,156
protection for the trustees and employees against liability, 1,157
including professional liability, provided that this section or 1,158
any insurance contract issued pursuant to this section shall not 1,159
be construed as a waiver of or in any manner affect the immunity 1,160
of the hospital or county. 1,161
All or any portion of the cost, premium, fees, or charges 1,163
therefor may be paid in such manner or combination of manners as 1,164
the board of trustees may determine, including direct payment by 1,165
the employee, and, if authorized in writing by the employee, by 1,166
the board of trustees with moneys made available by deduction 1,167
from or reduction in salary or wages or by the foregoing of a 1,168
salary or wage increase. 1,169
28
Notwithstanding sections 3917.01 and 3917.06 of the Revised 1,171
Code, the board of trustees may purchase group life insurance 1,172
authorized by this section by reason of payment of premiums 1,173
therefor by the board of trustees from its funds, and such group 1,174
life insurance may be issued and purchased if otherwise 1,175
consistent with sections 3917.01 to 3917.06 of the Revised Code. 1,176
Sec. 351.08. (A) A convention facilities authority may 1,185
procure and pay any or all of the cost of group hospitalization, 1,186
surgical, major medical, sickness and accident insurance, or 1,187
group life insurance, or a combination of any of the foregoing 1,188
types of insurance or coverage for full-time employees and their 1,189
dependents, whether issued by an insurance company or a medical 1,190
care corporation, duly authorized to do business in this state. 1,191
(B) A convention facilities authority also may procure and 1,193
pay any or all of the cost of a plan of group hospitalization, 1,194
surgical, or major medical insurance with a health care INSURING 1,195
corporation with a certificate of authority or license issued 1,196
under Chapter 1738. 1751. of the Revised Code, provided that each 1,198
full-time employee shall be permitted to:
(1) Exercise an option between a plan offered by an 1,200
insurance company or medical care corporation as provided in 1,201
division (A) of this section and a plan offered by a health care 1,202
INSURING corporation under this division, on the condition that 1,203
the full-time employee shall pay the amount by which the cost of 1,204
the plan offered in this division exceeds the cost of the plan 1,205
offered under division (A) of this section; and 1,206
(2) Change from one of the two plans to the other at a 1,208
time each year as determined by the convention facilities 1,209
authority. 1,210
Sec. 505.60. (A) The board of township trustees of any 1,219
township may procure and pay all or any part of the cost of 1,220
insurance policies that may provide benefits for hospitalization, 1,221
surgical care, major medical care, disability, dental care, eye 1,222
care, medical care, hearing aids, prescription drugs, or sickness 1,223
29
and accident insurance, or a combination of any of the foregoing 1,224
types of insurance for township officers and employees. If the 1,225
board so procures any such insurance policies, the board shall 1,226
provide uniform coverage under these policies for township 1,227
officers and full-time township employees and their immediate 1,228
dependents and may provide coverage under these policies for 1,229
part-time township employees and their immediate dependents, from 1,230
the funds or budgets from which the officers or employees are 1,231
compensated for services, whether such policies are TO BE issued 1,233
by an insurance company, a medical care corporation organized
under Chapter 1737. of the Revised Code, or a dental care 1,234
corporation organized under Chapter 1740. of the Revised Code 1,235
duly authorized to do business in this state. Any township 1,236
officer or employee may refuse to accept the insurance coverage 1,237
without affecting the availability of such insurance coverage to 1,238
other township officers and employees. 1,239
The board may also contract for group insurance or health 1,241
care services with health care INSURING corporations organized 1,243
HOLDING CERTIFICATES OF AUTHORITY under Chapter 1738. 1751. of 1,244
the Revised Code and health maintenance organizations organized 1,245
under Chapter 1742. of the Revised Code for township officers and 1,246
employees. If the board so contracts, it shall provide uniform 1,247
coverage under any such contracts for township officers and 1,248
full-time township employees and their immediate dependents and 1,249
may provide coverage under such contracts for part-time township 1,250
employees and their immediate dependents, provided that each 1,251
officer and employee so covered is permitted to: 1,252
(1) Choose between a plan offered by an insurance company, 1,254
medical care corporation, or dental care corporation and a plan 1,255
offered by a health care INSURING corporation or health 1,256
maintenance organization, and provided further that the officer 1,257
or employee pays any amount by which the cost of the plan chosen 1,259
by him exceeds the cost of the plan offered by the board under 1,260
this section; 1,261
30
(2) Change his THE choice MADE under division (A) of this 1,264
section at a time each year as determined in advance by the 1,265
board.
An addition of a class or change of definition of coverage 1,267
to the plan offered by the board may be made at any time that it 1,268
is determined by the board to be in the best interest of the 1,269
township. If the total cost to the township of the revised plan 1,270
for any trustee's coverage does not exceed that cost under the 1,271
plan in effect during the prior policy year, the revision of the 1,272
plan does not cause an increase in that trustee's compensation. 1,273
The board may provide the benefits authorized under this 1,275
section, without competitive bidding, by contributing to a health 1,276
and welfare trust fund administered through or in conjunction 1,277
with a collective bargaining representative of the township 1,278
employees. 1,279
The board may also provide the benefits described in this 1,281
section through an individual self-insurance program or a joint 1,282
self-insurance program as provided in section 9.833 of the 1,283
Revised Code. 1,284
(B) A board of township trustees may procure and pay all 1,286
or any part of the cost of group life insurance to insure the 1,287
lives of officers and full-time employees of the township. The 1,288
amount of group life insurance coverage provided by the board to 1,289
insure the lives of officers of the township shall not exceed 1,290
fifty thousand dollars per officer. 1,291
(C) If a board of township trustees fails to pay one or 1,293
more premiums for a policy, contract, or plan of insurance or 1,294
health care services authorized by division (A) of this section 1,295
and the failure causes a lapse, cancellation, or other 1,296
termination of coverage under the policy, contract, or plan, it 1,297
may reimburse a township officer or employee for, or pay on 1,298
behalf of the officer or employee, any expenses incurred that 1,299
would have been covered under the policy, contract, or plan. 1,300
(D) As used in this section, "part-time township employee" 1,302
31
means a township employee who is hired with the expectation that 1,303
the employee will work not more than one thousand five hundred 1,304
hours in any year. 1,305
Sec. 742.45. (A) The board of trustees of the police and 1,314
firemen's disability and pension fund may enter into an agreement 1,316
with insurance companies, medical or health care INSURING 1,317
corporations, health maintenance organizations, or government 1,319
agencies authorized to do business in the state for issuance of a 1,320
policy or contract of health, medical, hospital, or surgical 1,321
benefits, or any combination thereof, for those individuals 1,322
receiving service or disability pensions or survivor benefits 1,324
subscribing to the plan. Notwithstanding any other provision of 1,325
this chapter, the policy or contract may also include coverage 1,326
for any eligible individual's spouse and dependent children and 1,327
for any of the eligible individual's sponsored dependents as the 1,329
board considers appropriate. 1,330
If all or any portion of the policy or contract premium is 1,332
to be paid by any individual receiving a service, disability, or 1,334
survivor pension or benefit, the individual shall, by written 1,336
authorization, instruct the board to deduct from the individual's 1,338
benefit the premium agreed to be paid by the individual to the 1,339
company, corporation, or agency. 1,341
The board may contract for coverage on the basis of part or 1,344
all of the cost of the coverage to be paid from appropriate funds 1,345
of the police and firemen's disability and pension fund. The 1,346
cost paid from the funds of the police and firemen's disability 1,347
and pension fund shall be included in the employer's contribution 1,348
rates provided by sections 742.33 and 742.34 of the Revised Code. 1,350
The board may provide for self-insurance of risk or level 1,352
of risk as set forth in the contract with the companies, 1,353
corporations, or agencies, and may provide through the 1,354
self-insurance method specific benefits as authorized by the 1,355
rules of the board. 1,356
(B) If the board provides health, medical, hospital, or 1,358
32
surgical benefits through any means other than a health 1,359
maintenance organization INSURING CORPORATION, it shall offer to 1,360
each individual eligible for the benefits the alternative of 1,363
receiving benefits through enrollment in a health maintenance 1,364
organization INSURING CORPORATION, if all of the following apply: 1,366
(1) The health maintenance organization INSURING 1,368
CORPORATION provides HEALTH CARE services in the geographical 1,370
area in which the individual lives; 1,371
(2) The eligible individual was receiving health care 1,373
benefits through a health maintenance organization OR A HEALTH 1,375
INSURING CORPORATION before retirement; 1,376
(3) The rate and coverage provided by the health 1,378
maintenance organization INSURING CORPORATION to eligible 1,379
individuals is comparable to that currently provided by the board 1,382
under division (A) of this section. If the rate or coverage 1,383
provided by the health maintenance organization INSURING 1,384
CORPORATION is not comparable to that currently provided by the 1,386
board under division (A) of this section, the board may deduct 1,387
the additional cost from the eligible individual's monthly 1,388
benefit.
The health maintenance organization INSURING CORPORATION 1,390
shall accept as an enrollee any eligible individual who requests 1,392
enrollment.
The board shall permit each eligible individual to change 1,394
from one plan to another at least once a year at a time 1,396
determined by the board. 1,397
(C) The board shall, beginning the month following receipt 1,399
of satisfactory evidence of the payment for coverage, pay monthly 1,400
to each recipient of service, disability, or survivor benefits 1,402
under the police and firemen's disability and pension fund who is 1,403
eligible for medical insurance coverage under part B of "The 1,404
Social Security Amendments of 1965," 79 Stat. 301, 42 U.S.C.A. 1,405
1395j, as amended, an amount equal to the basic premiums for such 1,406
coverage.
33
(D) The board shall establish by rule requirements for the 1,408
coordination of any coverage, payment, or benefit provided under 1,409
this section with any similar coverage, payment, or benefit made 1,410
available to the same individual by the public employees 1,412
retirement system, state teachers retirement system, school
employees retirement system, or state highway patrol retirement 1,413
system.
(E) The board shall make all other necessary rules 1,415
pursuant to the purpose and intent of this section. 1,416
Sec. 742.53. (A) As used in this section: 1,425
(1) "Long-term care insurance" has the same meaning as in 1,427
section 3923.41 of the Revised Code. 1,428
(2) "Retirement systems" has the same meaning as in 1,430
division (A) of section 145.581 of the Revised Code. 1,431
(B) The board of trustees of the police and firemen's 1,433
disability and pension fund shall establish a program under which 1,434
members of the fund, employers on behalf of members, and persons 1,435
receiving service or disability pensions or survivor benefits are 1,436
permitted to participate in contracts for long-term care 1,437
insurance. Participation may include dependents and family 1,438
members. If a participant in a contract for long-term care 1,439
insurance leaves his employment, he THE PARTICIPANT and his THE 1,441
PARTICIPANT'S dependents and family members may, at their 1,442
election, continue to participate in a program established under 1,443
this section in the same manner as if he THE PARTICIPANT had not 1,444
left his employment, except that no part of the cost of the 1,446
insurance shall be paid by his THE PARTICIPANT'S former employer. 1,447
Such program may be established independently or jointly 1,449
with one or more of the other retirement systems. 1,450
(C) The fund may enter into an agreement with insurance 1,452
companies, medical or health care INSURING corporations, health 1,454
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 1,455
insurance policy or contract. However, prior to entering into 1,456
34
such an agreement with an insurance company, medical or health 1,457
care INSURING corporation, or health maintenance organization, 1,459
the fund shall request the superintendent of insurance to certify 1,460
the financial condition of the company, OR corporation, or 1,461
organization. The fund shall not enter into the agreement if, 1,462
according to that certification, the company, OR corporation, or 1,463
organization is insolvent, is determined by the superintendent to 1,465
be potentially unable to fulfill its contractual obligations, or 1,466
is placed under an order of rehabilitation or conservation by a 1,467
court of competent jurisdiction or under an order of supervision 1,468
by the superintendent. 1,469
(D) The board shall adopt rules in accordance with section 1,471
111.15 of the Revised Code governing the program. The rules 1,472
shall establish methods of payment for participation under this 1,473
section, which may include establishment of a payroll deduction 1,474
plan under section 742.56 of the Revised Code, deduction of the 1,475
full premium charged from a person's service or disability 1,476
pension or survivor benefit, or any other method of payment 1,477
considered appropriate by the board. If the program is 1,478
established jointly with one or more of the other retirement 1,479
systems, the rules also shall establish the terms and conditions 1,480
of such joint participation. 1,481
Sec. 1319.12. (A)(1) As used in this section, "collection 1,491
agency" means any person who, for compensation, contingent or 1,492
otherwise, or for other valuable consideration, offers services 1,493
to collect an alleged debt asserted to be owed to another. 1,494
(2) "Collection agency" does not mean a person whose 1,496
collection activities are confined to and directly related to the 1,498
operation of another business, including, but not limited to, the 1,499
following:
(a) Any bank, including the trust department of a bank, 1,502
trust company, savings and loan association, savings bank, credit 1,503
union, or fiduciary as defined in section 1339.03 of the Revised 1,505
Code, except those that own or operate a collection agency; 1,507
35
(b) Any real estate broker, real estate salesperson, 1,510
limited real estate broker, or limited real estate salesperson, 1,511
as these persons are defined in section 4735.01 of the Revised 1,512
Code;
(c) Any retail seller collecting its own accounts; 1,515
(d) Any insurance company authorized to do business in 1,517
this state under Title XXXIX of the Revised Code or a health 1,518
maintenance organization INSURING CORPORATION authorized to 1,519
operate in this state under Chapter 1742. 1751. of the Revised 1,520
Code;
(e) Any public officer or judicial officer acting under 1,522
order of a court;
(f) Any licensee as defined either in section 1321.01 or 1,524
1321.71 of the Revised Code, or any registrant as defined in 1,525
section 1321.51 of the Revised Code; 1,526
(g) Any public utility. 1,528
(B) A collection agency with a place of business in this 1,531
state may take assignment of another person's accounts, bills, or 1,533
other evidences of indebtedness in its own name for the purpose 1,534
of billing, collecting, or filing suit in its own name as the 1,535
real party in interest.
(C) No collection agency shall commence litigation for the 1,538
collection of an assigned account, bill, or other evidence of 1,539
indebtedness unless it has taken the assignment in accordance 1,540
with all of the following requirements: 1,541
(1) The assignment was voluntary, properly executed, and 1,543
acknowledged by the person transferring title to the collection 1,544
agency. 1,545
(2) The collection agency did not require the assignment 1,547
as a condition to listing the account, bill, or other evidence of 1,549
indebtedness with the collection agency for collection.
(3) The assignment was manifested by a written agreement 1,551
separate from and in addition to any document intended for the 1,552
purpose of listing the account, bill, or other evidence of 1,553
36
indebtedness with the collection agency. The written agreement 1,554
must state the effective date of the assignment and the 1,555
consideration paid or given, if any, for the assignment, and must 1,557
expressly authorize the collection agency to refer the assigned 1,558
account, bill, or other evidence of indebtedness to an attorney 1,559
admitted to the practice of law in this state for the
commencement of litigation. The written agreement must also 1,560
disclose that the collection agency may, for purposes of filing 1,561
an action, consolidate the assigned account, bill, or other 1,562
evidence of indebtedness with those of other creditors against an 1,563
individual debtor or co-debtors.
(4) Upon the effective date of the assignment to the 1,565
collection agency, the creditor's account maintained by the 1,566
collection agency in connection with the assigned account, bill, 1,567
or other evidence of indebtedness was canceled. 1,568
(D) A collection agency shall commence litigation for the 1,571
collection of an assigned account, bill, or other evidence of 1,572
indebtedness in a court of competent jurisdiction located in the 1,573
county in which the debtor resides, or in the case of co-debtors, 1,574
a county in which at least one of the co-debtors resides. 1,575
(E) No collection agency shall commence any litigation 1,578
authorized by this section unless the agency appears by an 1,579
attorney admitted to the practice of law in this state. 1,580
(F) This section does not affect the powers and duties of 1,582
any person described in division (A)(2) of this section. 1,583
(G) Nothing in this section relieves a collection agency 1,585
from complying with the "Fair Debt Collection Practices Act," 91 1,586
Stat. 874 (1977), 15 U.S.C. 1692, as amended, or deprives any 1,587
debtor of the right to assert defenses as provided in section 1,588
1317.031 of the Revised Code and 16 C.F.R. 433, as amended. 1,589
(H) For purposes of filing an action, a collection agency 1,592
that has taken an assignment or assignments pursuant to this 1,593
section may consolidate the assigned accounts, bills, or other 1,594
evidences of indebtedness of one or more creditors against an 1,595
37
individual debtor or co-debtors. Each separate assigned account, 1,596
bill, or evidence of indebtedness must be separately identified 1,597
and pled in any consolidated action authorized by this section. 1,598
If a debtor or co-debtor raises a good faith dispute concerning 1,599
any account, bill, or other evidence of indebtedness, the court 1,600
shall separate each disputed account, bill, or other evidence of 1,601
indebtedness from the action and hear the disputed account, bill, 1,603
or other evidence of indebtedness on its own merits in a separate 1,604
action. The court shall charge the filing fee of the separate 1,605
action to the losing party.
Sec. 1337.16. (A) No physician, health care facility, 1,614
other health care provider, person authorized to engage in the 1,615
business of insurance in this state under Title XXXIX of the 1,616
Revised Code, medical care corporation, health care INSURING 1,618
corporation, health maintenance organization, other health care 1,619
plan, or legal entity that is self-insured and provides benefits 1,620
to its employees or members shall require an individual to create 1,621
or refrain from creating a durable power of attorney for health 1,622
care, or shall require an individual to revoke or refrain from 1,623
revoking a durable power of attorney for health care, as a 1,624
condition of being admitted to a health care facility, being 1,625
provided health care, being insured, or being the recipient of 1,626
benefits. 1,627
(B)(1) Subject to division (B)(2) of this section, an 1,629
attending physician of a principal or a health care facility in 1,630
which a principal is confined may refuse to comply or allow 1,631
compliance with the instructions of an attorney in fact under a 1,632
durable power of attorney for health care on the basis of a 1,633
matter of conscience or on another basis. An employee or agent 1,634
of an attending physician of a principal or of a health care 1,635
facility in which a principal is confined may refuse to comply 1,636
with the instructions of an attorney in fact under a durable 1,637
power of attorney for health care on the basis of a matter of 1,638
conscience. 1,639
38
(2)(a) An attending physician of a principal who, or 1,641
health care facility in which a principal is confined that, is 1,642
not willing or not able to comply or allow compliance with the 1,643
instructions of an attorney in fact under a durable power of 1,644
attorney for health care to use or continue, or to withhold or 1,645
withdraw, health care that were given under division (A) of 1,646
section 1337.13 of the Revised Code, or with any probate court 1,647
reevaluation order issued pursuant to division (D)(6) of this 1,648
section, shall not prevent or attempt to prevent, or unreasonably 1,649
delay or attempt to unreasonably delay, the transfer of the 1,650
principal to the care of a physician who, or a health care 1,651
facility that, is willing and able to so comply or allow 1,652
compliance. 1,653
(b) If the instruction of an attorney in fact under a 1,655
durable power of attorney for health care that is given under 1,656
division (A) of section 1337.13 of the Revised Code is to use or 1,657
continue life-sustaining treatment in connection with a principal 1,658
who is in a terminal condition or in a permanently unconscious 1,659
state, the attending physician of the principal who, or the 1,660
health care facility in which the principal is confined that, is 1,661
not willing or not able to comply or allow compliance with that 1,662
instruction shall use or continue the life-sustaining treatment 1,663
or cause it to be used or continued until a transfer as described 1,664
in division (B)(2)(a) of this section is made. 1,665
(C) Sections 1337.11 to 1337.17 of the Revised Code and a 1,667
durable power of attorney for health care created under section 1,668
1337.12 of the Revised Code do not affect or limit the authority 1,669
of a physician or a health care facility to provide or not to 1,670
provide health care to a person in accordance with reasonable 1,671
medical standards applicable in an emergency situation. 1,672
(D)(1) If the attending physician of a principal and one 1,674
other physician who examines the principal determine that he THE 1,675
PRINCIPAL is in a terminal condition or in a permanently 1,677
unconscious state, if the attending physician additionally 1,678
39
determines that the principal has lost the capacity to make 1,679
informed health care decisions for himself THE PRINCIPAL and that 1,680
there is no reasonable possibility that the principal will regain 1,682
the capacity to make informed health care decisions for himself 1,683
THE PRINCIPAL, and if the attorney in fact under the principal's 1,685
durable power of attorney for health care makes a health care 1,686
decision pertaining to the use or continuation, or the 1,687
withholding or withdrawal, of life-sustaining treatment, the 1,688
attending physician shall do all of the following: 1,689
(a) Record the determinations and health care decision in 1,691
the principal's medical record; 1,692
(b) Make a good faith effort, and use reasonable 1,694
diligence, to notify the appropriate individual or individuals, 1,695
in accordance with the following descending order of priority, of 1,696
the determinations and health care decision: 1,697
(i) If any, the guardian of the principal. This division 1,699
does not permit or require the appointment of a guardian for the 1,700
principal. 1,701
(ii) The principal's spouse; 1,703
(iii) The principal's adult children who are available 1,705
within a reasonable period of time for consultation with the 1,706
principal's attending physician; 1,707
(iv) The principal's parents; 1,709
(v) An adult sibling of the principal or, if there is more 1,711
than one adult sibling, a majority of the principal's adult 1,712
siblings who are available within a reasonable period of time for 1,713
such consultation. 1,714
(c) Record in the principal's medical record the names of 1,715
the individual or individuals notified pursuant to division 1,716
(D)(1)(b) of this section and the manner of notification; 1,717
(d) Afford time for the individual or individuals notified 1,719
pursuant to division (D)(1)(b) of this section to object in the 1,720
manner described in division (D)(3)(a) of this section. 1,721
(2)(a) If, despite making a good faith effort, and despite 1,723
40
using reasonable diligence, to notify the appropriate individual 1,724
or individuals described in division (D)(1)(b) of this section, 1,725
the attending physician cannot notify the individual or 1,726
individuals of the determinations and health care decision 1,727
because the individual or individuals are deceased, cannot be 1,728
located, or cannot be notified for some other reason, the 1,729
requirements of divisions (D)(1)(b), (c), and (d) of this section 1,730
and, except as provided in division (D)(3)(b) of this section, 1,731
the provisions of divisions (D)(3) to (6) of this section shall 1,732
not apply in connection with the principal. However, the 1,733
attending physician shall record in the principal's medical 1,734
record information pertaining to the reason for the failure to 1,735
provide the requisite notices and information pertaining to the 1,736
nature of the good faith effort and reasonable diligence used. 1,737
(b) The requirements of divisions (D)(1)(b), (c), and (d) 1,739
of this section and, except as provided in division (D)(3)(b) of 1,740
this section, the provisions of divisions (D)(3) to (6) of this 1,741
section shall not apply in connection with the principal if only 1,742
one individual would have to be notified pursuant to division 1,743
(D)(1)(b) of this section and that individual is the attorney in 1,744
fact under the durable power of attorney for health care. 1,745
However, the attending physician of the principal shall record in 1,746
the principal's medical record information indicating that no 1,747
notice was given pursuant to division (D)(1)(b) of this section 1,748
because of the provisions of division (D)(2)(b) of this section. 1,749
(3)(a) Within forty-eight hours after receipt of a notice 1,751
pursuant to division (D)(1) of this section, any individual so 1,752
notified shall advise the attending physician of the principal 1,753
whether he THE INDIVIDUAL objects on a basis specified in 1,754
division (D)(4)(c) of this section. If an objection as described 1,756
in that division is communicated to the attending physician, 1,757
then, within two business days after the communication, the 1,758
individual shall file a complaint as described in division (D)(4) 1,759
of this section in the probate court of the county in which the 1,760
41
principal is located. If the individual fails to so file a 1,761
complaint, his THE INDIVIDUAL'S objections as described in 1,763
division (D)(4)(c) of this section shall be considered to be 1,764
void.
(b) Within forty-eight hours after the priority individual 1,766
or any member of a priority class of individuals receives a 1,767
notice pursuant to division (D)(1) of this section or within 1,768
forty-eight hours after information pertaining to an unnotified 1,769
priority individual or unnotified priority class of individuals 1,770
is recorded in a principal's medical record pursuant to division 1,771
(D)(2)(a) or (b) of this section, the individual or a majority of 1,772
the individuals in the next class of individuals that pertains to 1,773
the principal in the descending order of priority set forth in 1,774
divisions (D)(1)(b)(i) to (v) of this section shall advise the 1,775
attending physician of the principal whether he THE INDIVIDUAL or 1,777
they MAJORITY object on a basis specified in division (D)(4)(c) 1,778
of this section. If an objection as described in that division 1,779
is communicated to the attending physician, then, within two 1,780
business days after the communication, the objecting individual 1,781
or majority shall file a complaint as described in division 1,782
(D)(4) of this section in the probate court of the county in 1,783
which the principal is located. If the objecting individual or 1,784
majority fails to file a complaint, his or their THE objections 1,785
as described in division (D)(4)(c) of this section shall be 1,786
considered to be void.
(4) A complaint of an individual that is filed in 1,788
accordance with division (D)(3)(a) of this section or of an 1,789
individual or majority of individuals that is filed in accordance 1,790
with division (D)(3)(b) of this section shall satisfy all of the 1,791
following: 1,792
(a) Name any health care facility in which the principal 1,794
is confined; 1,795
(b) Name the principal, his THE PRINCIPAL'S attending 1,797
physician, and the consulting physician associated with the 1,799
42
determination that the principal is in a terminal condition or in 1,800
a permanently unconscious state; 1,801
(c) Indicate whether the plaintiff or plaintiffs object on 1,803
one or more of the following bases: 1,804
(i) To the attending physician's determination that the 1,806
principal has lost the capacity to make informed health care 1,807
decisions for himself THE PRINCIPAL; 1,808
(ii) To the attending physician's determination that there 1,810
is no reasonable possibility that the principal will regain the 1,811
capacity to make informed health care decisions for himself THE 1,812
PRINCIPAL; 1,813
(iii) That, in exercising his THE ATTORNEY IN FACT'S 1,815
authority, the attorney in fact is not acting consistently with 1,817
the desires of the principal or, if the desires of the principal 1,818
are unknown, in the best interest of the principal; 1,819
(iv) That the durable power of attorney for health care 1,821
has expired or otherwise is no longer effective; 1,822
(v) To the attending physician's and consulting 1,824
physician's determinations that the principal is in a terminal 1,825
condition or in a permanently unconscious state; 1,826
(vi) That the attorney in fact's health care decision 1,828
pertaining to the use or continuation, or the withholding or 1,829
withdrawal, of life-sustaining treatment is not authorized by the 1,830
durable power of attorney for health care or is prohibited under 1,831
section 1337.13 of the Revised Code; 1,832
(vii) That the durable power of attorney for health care 1,834
was executed when the principal was not of sound mind or was 1,835
under or subject to duress, fraud, or undue influence; 1,836
(viii) That the durable power of attorney for health care 1,838
otherwise does not substantially comply with section 1337.12 of 1,839
the Revised Code. 1,840
(d) Request the probate court to issue one or more of the 1,842
following types of orders: 1,843
(i) An order to the attending physician to reevaluate, in 1,845
43
light of the court proceedings, the determination that the 1,846
principal has lost the capacity to make informed health care 1,847
decisions for himself THE PRINCIPAL, the determination that the 1,848
principal is in a terminal condition or in a permanently 1,850
unconscious state, or the determination that there is no 1,851
reasonable possibility that the principal will regain the 1,852
capacity to make informed health care decisions for himself THE 1,853
PRINCIPAL;
(ii) An order to the attorney in fact to act consistently 1,855
with the desires of the principal or, if the desires of the 1,856
principal are unknown, in the best interest of the principal in 1,857
exercising his THE ATTORNEY IN FACT'S authority, or to make only 1,858
health care decisions pertaining to life-sustaining treatment 1,860
that are authorized by the durable power of attorney for health 1,861
care and that are not prohibited under section 1337.13 of the 1,862
Revised Code;
(iii) An order invalidating the durable power of attorney 1,864
for health care because it has expired or otherwise is no longer 1,865
effective, it was executed when the principal was not of sound 1,866
mind or was under or subject to duress, fraud, or undue 1,867
influence, or it otherwise does not substantially comply with 1,868
section 1337.12 of the Revised Code. 1,869
(e) Be accompanied by an affidavit of the plaintiff or 1,870
plaintiffs that includes averments relative to whether he THE 1,871
PLAINTIFF is an individual or they THE PLAINTIFFS are individuals 1,873
as described in division (D)(1)(b)(i), (ii), (iii), (iv), or (v) 1,875
of this section and to the factual basis for his THE PLAINTIFF'S 1,876
or their THE PLAINTIFFS' objections; 1,877
(f) Name any individuals who were notified by the 1,879
attending physician in accordance with division (D)(1)(b) of this 1,880
section and who are not joining in the complaint as plaintiffs; 1,881
(g) Name, in the caption of the complaint, as defendants 1,883
the attending physician of the principal, the attorney in fact 1,884
under the durable power of attorney for health care, the 1,885
44
consulting physician associated with the determination that the 1,886
principal is in a terminal condition or in a permanently 1,887
unconscious state, any health care facility in which the 1,888
principal is confined, and any individuals who were notified by 1,889
the attending physician in accordance with division (D)(1)(b) of 1,890
this section and who are not joining in the complaint as 1,891
plaintiffs. 1,892
(5) Notwithstanding any contrary provision of the Revised 1,894
Code or of the Rules of Civil Procedure, the state and persons 1,895
other than an objecting individual as described in division 1,896
(D)(3)(a) of this section, other than an objecting individual or 1,897
majority of individuals as described in division (D)(3)(b) of 1,898
this section, and other than persons described in division 1,899
(D)(4)(g) of this section are prohibited from commencing a civil 1,900
action under division (D) of this section and from joining or 1,901
being joined as parties to an action commenced under division (D) 1,902
of this section, including joining by way of intervention. 1,903
(6)(a) A probate court in which a complaint as described 1,905
in division (D)(4) of this section is filed within the period 1,906
specified in division (D)(3)(a) or (b) of this section shall 1,907
conduct a hearing on the complaint after a copy of it and a 1,908
notice of the hearing have been served upon the defendants. The 1,909
clerk of the probate court in which the complaint is filed shall 1,910
cause the complaint and the notice of the hearing to be so served 1,911
in accordance with the Rules of Civil Procedure, which service 1,912
shall be made, if possible, within three days after the filing of 1,913
the complaint. The hearing shall be conducted at the earliest 1,914
possible time, but no later than the third business day after 1,915
such service has been completed. Immediately following the 1,916
hearing, the court shall enter on its journal its determination 1,917
whether a requested order will be issued. 1,918
(b) If the health care decision of the attorney in fact 1,920
authorized the use or continuation of life-sustaining treatment 1,921
and if the plaintiff or plaintiffs requested a reevaluation order 1,922
45
to the attending physician of the principal or an order to the 1,923
attorney in fact as described in division (D)(4)(d)(i) or (ii) of 1,924
this section, the court shall issue the requested order only if 1,925
it finds that the plaintiff or plaintiffs have established a 1,926
factual basis for the objection or objections involved by clear 1,927
and convincing evidence and, if applicable, to a reasonable 1,928
degree of medical certainty and in accordance with reasonable 1,929
medical standards. 1,930
(c) If the health care decision of the attorney in fact 1,932
authorized the withholding or withdrawal of life-sustaining 1,933
treatment and if the plaintiff or plaintiffs requested a 1,934
reevaluation order to the attending physician of the principal or 1,935
an order to the attorney in fact as described in division 1,936
(D)(4)(d)(i) or (ii) of this section, the court shall issue the 1,937
requested order only if it finds that the plaintiff or plaintiffs 1,938
have established a factual basis for the objection or objections 1,939
involved by a preponderance of the evidence and, if applicable, 1,940
to a reasonable degree of medical certainty and in accordance 1,941
with reasonable medical standards. 1,942
(d) If the plaintiff or plaintiffs requested an 1,944
invalidation order as described in division (D)(4)(d)(iii) of 1,945
this section, the court shall issue the order only if it finds 1,946
that the plaintiff or plaintiffs have established a factual basis 1,947
for the objection or objections involved by clear and convincing 1,948
evidence. 1,949
(e) If the court issues a reevaluation order to the 1,951
principal's attending physician pursuant to division (D)(6)(b) or 1,952
(c) of this section, the attending physician shall make the 1,953
requisite reevaluation. If, after doing so, the attending 1,954
physician again determines that the principal has lost the 1,955
capacity to make informed health care decisions for himself THE 1,956
PRINCIPAL, that the principal is in a terminal condition or in a 1,958
permanently unconscious state, or that there is no reasonable 1,959
possibility that the principal will regain the capacity to make 1,960
46
informed health care decisions for himself THE PRINCIPAL, the 1,961
attending physician shall notify the court in writing of the 1,964
determination and comply with division (B)(2) of this section. 1,965
(E)(1) In connection with the provision of comfort care in 1,967
a manner consistent with divisions (C) and (E) of section 1337.13 1,968
of the Revised Code to a principal who is in a terminal condition 1,969
or in a permanently unconscious state, nothing in sections 1,970
1337.11 to 1337.17 of the Revised Code precludes the attending 1,971
physician of the principal who carries out the responsibility to
provide comfort care to the principal in good faith and while 1,972
acting within the scope of his THE ATTENDING PHYSICIAN'S 1,973
authority from prescribing, dispensing, administering, or causing 1,975
to be administered any particular medical procedure, treatment,
intervention, or other measure to the principal, including, but 1,976
not limited to, prescribing, dispensing, administering, or 1,977
causing to be administered by judicious titration or in another 1,978
manner any form of medication, for the purpose of diminishing his 1,979
THE PRINCIPAL'S pain or discomfort and not for the purpose of 1,981
postponing or causing his THE PRINCIPAL'S death, even though the 1,982
medical procedure, treatment, intervention, or other measure may 1,984
appear to hasten or increase the risk of the principal's death. 1,985
In connection with the provision of comfort care in a manner 1,986
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 1,987
a permanently unconscious state, nothing in sections 1337.11 to 1,988
1337.17 of the Revised Code precludes health care personnel 1,989
acting under the direction of the principal's attending physician 1,990
who carry out the responsibility to provide comfort care to the 1,991
principal in good faith and while acting within the scope of
their authority from dispensing, administering, or causing to be 1,992
administered any particular medical procedure, treatment, 1,993
intervention, or other measure to the principal, including, but 1,994
not limited to, dispensing, administering, or causing to be 1,995
administered by judicious titration or in another manner any form 1,996
47
of medication, for the purpose of diminishing his THE PRINCIPAL'S 1,997
pain or discomfort and not for the purpose of postponing or 1,998
causing his THE PRINCIPAL'S death, even though the medical 2,000
procedure, treatment, intervention, or other measure may appear
to hasten or increase the risk of the principal's death. 2,001
(2) If, at any time, a priority individual or any member 2,003
of a priority class of individuals under division (D)(1)(b) of 2,004
this section or if, at any time, the individual or a majority of 2,006
the individuals in the next class of individuals that pertains to 2,007
the principal in the descending order of priority set forth in 2,008
that division, believes in good faith that both of the following 2,009
circumstances apply, the priority individual, the member of the 2,011
priority class of individuals, or the individual or majority of 2,012
individuals in the next class of individuals that pertains to the 2,013
principal may commence an action in the probate court of the
county in which a principal who is in a terminal condition or 2,014
permanently unconscious state is located for the issuance of an 2,015
order mandating the use or continuation of comfort care in 2,016
connection with the principal in a manner that is consistent with 2,017
sections 1337.11 to 1337.17 of the Revised Code: 2,018
(a) Comfort care is not being used or continued in 2,020
connection with the principal. 2,021
(b) The withholding or withdrawal of the comfort care is 2,023
contrary to sections 1337.11 to 1337.17 of the Revised Code. 2,024
(F) Except as provided in divisions (D) and (E) of this 2,026
section in connection with principals who are in a terminal 2,027
condition or in a permanently unconscious state, sections 1337.11 2,028
to 1337.17 of the Revised Code do not authorize the commencement 2,029
of any civil action in a probate court or court of common pleas 2,031
for the purpose of obtaining an order relative to a health care 2,032
decision made by an attorney in fact under a durable power of 2,033
attorney for health care. 2,034
(G) A durable power of attorney for health care, or other 2,036
document, that is similar to a durable power of attorney for 2,037
48
health care authorized by sections 1337.11 to 1337.17 of the 2,038
Revised Code, that is or has been executed under the law of 2,039
another state prior to, on, or after October 10, 1991, and that 2,040
substantially complies with that law or with sections 1337.11 to 2,042
1337.17 of the Revised Code shall be considered to be valid for 2,043
purposes of those sections.
Sec. 1545.071. The board of park commissioners of any park 2,052
district may procure and pay all or any part of the cost of group 2,053
insurance policies that may provide benefits for hospitalization, 2,054
surgical care, major medical care, disability, dental care, eye 2,055
care, medical care, hearing aids, or prescription drugs, or 2,056
sickness and accident insurance or a combination of any of the 2,057
foregoing types of insurance or coverage for park district 2,058
officers and employees and their immediate dependents issued by 2,059
an insurance company, a medical care corporation organized under 2,060
Chapter 1737. of the Revised Code, or a dental care corporation 2,061
organized under Chapter 1740. of the Revised Code duly authorized 2,062
to do business in this state. 2,063
The board may procure and pay all or any part of the cost 2,065
of group life insurance to insure the lives of park district 2,066
employees. 2,067
The board also may contract for group insurance or health 2,069
care services with health care INSURING corporations organized 2,071
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 2,072
the Revised Code and health maintenance organizations organized 2,073
under Chapter 1742. of the Revised Code provided that each 2,074
officer or employee is permitted to:
(A) Choose between a plan offered by an insurance company, 2,076
medical care corporation, or dental care corporation and a plan 2,077
offered by a health care INSURING corporation or health 2,078
maintenance organization and provided further that the officer or 2,080
employee pays any amount by which the cost of the plan chosen by 2,081
him THE OFFICER OR EMPLOYEE exceeds the cost of the plan offered 2,082
by the board under this section; 2,084
49
(B) Change his THE choice MADE under division (A) of this 2,087
section at a time each year as determined in advance by the
board.
Any appointed member of the board of park commissioners and 2,089
the spouse and dependent children of the member may be covered, 2,090
at the option and expense of the member, as a noncompensated 2,091
employee of the park district under any benefit plan described in 2,092
division (A) of this section. The member shall pay to the park 2,093
district the amount certified to it by the benefit provider as 2,094
the provider's charge for the coverage the member has chosen 2,095
under division (A) of this section. Payments for coverage shall 2,096
be made, in advance, in a manner prescribed by the board. The 2,097
member's exercise of an option to be covered under this section 2,098
shall be in writing, announced at a regular public meeting of the 2,099
board, and recorded as a public record in the minutes of the 2,100
board. 2,101
The board may provide the benefits authorized in this 2,103
section by contributing to a health and welfare trust fund 2,104
administered through or in conjunction with a collective 2,105
bargaining representative of the park district employees. 2,106
The board may provide the benefits described in this 2,108
section through an individual self-insurance program or a joint 2,109
self-insurance program as provided in section 9.833 of the 2,110
Revised Code. 2,111
Sec. 1731.01. As used in this chapter: 2,120
(A) "Alliance" or "small employer health care alliance" 2,122
means an existing or newly created organization that has been 2,123
granted a certificate of authority by the superintendent of 2,124
insurance under section 1731.021 of the Revised Code and that is 2,125
either of the following: 2,126
(1) A chamber of commerce, trade association, professional 2,128
organization, or any other organization that has all of the 2,129
following characteristics: 2,130
(a) Is a nonprofit corporation or association; 2,132
50
(b) Has members that include or are exclusively small 2,134
employers; 2,135
(c) Sponsors or is part of a program to assist such small 2,137
employer members to obtain coverage for their employees under one 2,138
or more health benefit plans; 2,139
(d) Is not directly or indirectly controlled, through 2,141
voting membership, representation on its governing board, or 2,142
otherwise, by any insurance company, person, firm, or corporation 2,143
that sells insurance, any provider, or by persons who are 2,144
officers, trustees, or directors of such enterprises, or by any 2,145
combination of such enterprises or persons. 2,146
(2) A nonprofit corporation controlled by one or more 2,148
organizations described in division (A)(1) of this section. 2,149
(B) "Alliance program" or "alliance health care program" 2,151
means a program sponsored by a small employer health care 2,152
alliance that assists small employer members of such small 2,153
employer health care alliance or any other small employer health 2,154
care alliance to obtain coverage for their employees under one or 2,155
more health benefit plans, and that includes at least one 2,156
agreement between a small employer health care alliance and an 2,157
insurer that contains the insurer's agreement to offer and sell 2,158
one or more health benefit plans to such small employers and 2,159
contains all of the other features required under section 1731.04 2,160
of the Revised Code. 2,161
(C) "Eligible employees, retirees, their dependents, and 2,163
members of their families," as used together or separately, means 2,164
the active employees of a small employer, or retired former 2,165
employees of a small employer or predecessor firm or 2,166
organization, their dependents or members of their families, who 2,167
are eligible for coverage under the terms of the applicable 2,168
alliance program. 2,169
(D) "Enrolled small employer" or "enrolled employer" means 2,171
a small employer that has obtained coverage for its eligible 2,172
employees from an insurer under an alliance program. 2,173
51
(E) "Health benefit plan" means any hospital or medical 2,175
expense policy of insurance or A health care plan provided by an 2,176
insurer, including a health maintenance organization INSURING 2,177
CORPORATION plan and a preferred provider organization plan, 2,178
provided by or through an insurer, or any combination thereof. 2,180
"Health benefit plan" does not include any of the following: 2,181
(1) A policy covering only accident, credit, dental, 2,183
disability income, long-term care, hospital indemnity, medicare 2,184
supplement, specified disease, OR vision care, or coverage issued 2,185
by a health care corporation, except where any of the foregoing 2,186
is offered as an addition, indorsement, or rider to a health 2,187
benefit plan; 2,188
(2) Coverage issued as a supplement to liability 2,190
insurance, insurance arising out of a workers' compensation or 2,191
similar law, automobile medical-payment insurance, or insurance 2,192
under which benefits are payable with or without regard to fault 2,193
and which is statutorily required to be contained in any 2,194
liability insurance policy or equivalent self-insurance; 2,195
(3) COVERAGE ISSUED BY A HEALTH INSURING CORPORATION 2,197
AUTHORIZED TO OFFER SUPPLEMENTAL HEALTH CARE SERVICES ONLY. 2,198
(F) "Insurer" means an insurance company authorized to do 2,200
the business of sickness and accident insurance in this state or, 2,201
for the purposes of this chapter, a health maintenance 2,202
organization INSURING CORPORATION authorized to issue health 2,203
benefit CARE plans in this state. 2,204
(G) "Participants" or "beneficiaries" means those eligible 2,206
employees, retirees, their dependents, and members of their 2,207
families who are covered by health benefit plans provided by an 2,208
insurer to enrolled small employers under an alliance program. 2,209
(H) "Provider" means a hospital, urgent care facility, 2,211
nursing home, physician, podiatrist, dentist, pharmacist, 2,212
chiropractor, certified registered nurse anesthetist, dietitian, 2,213
health maintenance organization, or other health care provider 2,214
licensed by this state, or group of such health care providers. 2,215
52
(I) "Qualified alliance program" means an alliance program 2,217
under which health care benefits are provided to two thousand 2,218
five hundred or more participants. 2,219
(J) "Small employer," regardless of its definition in any 2,221
other chapter of the Revised Code, in this chapter means an 2,222
employer that employs no more than one hundred fifty full-time 2,223
employees, at least a majority of whom are employed at locations 2,224
within this state. 2,225
(1) For this purpose: 2,227
(a) Each entity that is controlled by, controls, or is 2,229
under common control with, one or more other entities shall, 2,230
together with such other entities, be considered to be a single 2,231
employer. 2,232
(b) "Full-time employee" means a person who normally works 2,234
at least twenty-five hours per week and at least forty weeks per 2,235
year for the employer. 2,236
(c) An employer will be treated as having one hundred 2,238
fifty or fewer full-time employees on any day if, during the 2,239
prior calendar year or any twelve consecutive months during the 2,240
twenty-four full months immediately preceding that day, the mean 2,241
number of full-time employees employed by the employer does not 2,242
exceed one hundred fifty. 2,243
(2) An employer that qualifies as a small employer for 2,245
purposes of becoming an enrolled small employer continues to be 2,246
treated as a small employer for purposes of this chapter until 2,247
such time as it fails to meet the conditions described in 2,248
division (J)(1) of this section for any period of thirty-six 2,249
consecutive months after first becoming an enrolled small 2,250
employer, unless earlier disqualified under the terms of the 2,251
alliance program. 2,252
Sec. 1731.06. (A) No health benefit plan offered or 2,261
provided by an insurer to a small employer under a qualified 2,262
alliance program is subject to any law that does any of the 2,263
following: 2,264
53
(1) Inhibits the insurer from selectively contracting with 2,266
providers or groups of providers with respect to health care 2,267
service or benefits; 2,268
(2) Imposes any restrictions on the ability of the insurer 2,270
to negotiate with providers regarding the level or method of 2,271
reimbursing for care or services; 2,272
(3) Requires the insurer either to include a specific 2,274
provider or class of providers, or to exclude any class of 2,275
providers that are generally authorized by law to provide such 2,276
care, in connection with health care services or benefits under 2,277
such health benefit plan; 2,278
(4) Limits the financial incentives that a health benefit 2,280
plan may require a beneficiary to pay when a nonplan provider is 2,281
used on a nonemergency basis; 2,282
(5) Prohibits utilization review of any or all treatments 2,284
and conditions; 2,285
(6) Requires the use of specified standards of health care 2,287
practice in such reviews or requires the disclosure of the 2,288
specific criteria used in such reviews; 2,289
(7) Requires payments to providers for the expenses of 2,291
responding to utilization review requests; 2,292
(8) Imposes liability for delays in performing such 2,294
review. 2,295
(B) Notwithstanding division (A) of this section, every 2,297
health benefit plan offered or provided by an insurer, other than 2,298
a health maintenance organization INSURING CORPORATION, to a 2,299
small employer under a qualified alliance program is subject to 2,301
sections 3923.23, 3923.231, 3923.232, 3923.233, and 3923.234 of 2,302
the Revised Code and any other provision of the Revised Code that 2,303
requires the reimbursement, utilization, or consideration of a 2,304
specific category of licensed or certified health care 2,305
practitioner.
Sec. 1739.05. (A) A multiple employer welfare arrangement 2,314
that is created pursuant to sections 1739.01 to 1739.22 of the 2,315
54
Revised Code and that operates a group self-insurance program may 2,316
be established only if any of the following applies: 2,317
(1) The arrangement has and maintains a minimum enrollment 2,319
of three hundred employees of two or more employers. 2,320
(2) The arrangement has and maintains a minimum enrollment 2,322
of three hundred self-employed individuals. 2,323
(3) The arrangement has and maintains a minimum enrollment 2,325
of three hundred employees or self-employed individuals in any 2,326
combination of divisions (A)(1) and (2) of this section. 2,327
(B) A multiple employer welfare arrangement that is 2,329
created pursuant to sections 1739.01 to 1739.22 of the Revised 2,330
Code and that operates a group self-insurance program shall 2,331
comply with all laws applicable to self-funded programs in this 2,332
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 2,333
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 2,334
3923.301, and 3923.38 of the Revised Code. 2,335
(C) A multiple employer welfare arrangement created 2,337
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,338
solicit enrollments only through agents or solicitors licensed 2,339
pursuant to Chapter 3905. of the Revised Code to sell or solicit 2,340
sickness and accident insurance. 2,341
(D) A multiple employer welfare arrangement created 2,343
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,344
provide benefits only to individuals who are members, employees 2,345
of members, or the dependents of members or employees, or are 2,346
eligible for continuation of coverage under section 1742.34 2,347
1751.53 or 3923.38 of the Revised Code or under Title X of the 2,348
"Consolidated Omnibus Budget Reconciliation Act of 1985," 100 2,349
Stat. 227, 29 U.S.C.A. 1161, as amended. 2,350
Sec. 1751.01. AS USED IN THIS CHAPTER: 2,352
(A) "BASIC HEALTH CARE SERVICES" MEANS THE FOLLOWING 2,355
SERVICES WHEN MEDICALLY NECESSARY: 2,356
(1) PHYSICIAN'S SERVICES, EXCEPT WHEN SUCH SERVICES ARE 2,358
SUPPLEMENTAL UNDER DIVISION (B) OF THIS SECTION; 2,360
55
(2) INPATIENT HOSPITAL SERVICES; 2,362
(3) OUTPATIENT MEDICAL SERVICES; 2,364
(4) EMERGENCY HEALTH SERVICES; 2,366
(5) URGENT CARE SERVICES; 2,368
(6) DIAGNOSTIC LABORATORY SERVICES AND DIAGNOSTIC AND 2,370
THERAPEUTIC RADIOLOGIC SERVICES; 2,371
(7) PREVENTIVE HEALTH CARE SERVICES, INCLUDING, BUT NOT 2,373
LIMITED TO, VOLUNTARY FAMILY PLANNING SERVICES, INFERTILITY 2,374
SERVICES, PERIODIC PHYSICAL EXAMINATIONS, PRENATAL OBSTETRICAL 2,375
CARE, AND WELL-CHILD CARE. 2,376
"BASIC HEALTH CARE SERVICES" DOES NOT INCLUDE EXPERIMENTAL 2,378
PROCEDURES. 2,379
A HEALTH INSURING CORPORATION SHALL NOT OFFER COVERAGE FOR 2,381
A HEALTH CARE SERVICE, DEFINED AS A BASIC HEALTH CARE SERVICE BY 2,382
THIS DIVISION, UNLESS IT OFFERS COVERAGE FOR ALL LISTED BASIC 2,383
HEALTH CARE SERVICES. HOWEVER, THIS REQUIREMENT DOES NOT APPLY 2,385
TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XVIII OF THE 2,386
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 2,388
AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR MEDICARE COST 2,389
CONTRACT, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN THE 2,390
FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 2,392
8905, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XIX 2,393
OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,395
301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR 2,396
MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER 2,397
CHAPTER 5111. OF THE REVISED CODE, OR TO THE COVERAGE OF 2,399
BENEFICIARIES UNDER ANY FEDERAL HEALTH CARE PROGRAM REGULATED BY 2,400
A FEDERAL REGULATORY BODY.
(B) "SUPPLEMENTAL HEALTH CARE SERVICES" MEANS ANY HEALTH 2,403
CARE SERVICES OTHER THAN BASIC HEALTH CARE SERVICES THAT A HEALTH 2,404
INSURING CORPORATION MAY OFFER, ALONE OR IN COMBINATION WITH 2,405
EITHER BASIC HEALTH CARE SERVICES OR OTHER SUPPLEMENTAL HEALTH 2,406
CARE SERVICES, AND INCLUDES:
(1) SERVICES OF FACILITIES FOR INTERMEDIATE OR LONG-TERM 2,408
56
CARE, OR BOTH; 2,409
(2) DENTAL CARE SERVICES; 2,411
(3) VISION CARE AND OPTOMETRIC SERVICES INCLUDING LENSES 2,413
AND FRAMES; 2,414
(4) PODIATRIC CARE OR FOOT CARE SERVICES; 2,416
(5) MENTAL HEALTH SERVICES INCLUDING PSYCHOLOGICAL 2,418
SERVICES; 2,419
(6) SHORT-TERM OUTPATIENT EVALUATIVE AND 2,421
CRISIS-INTERVENTION MENTAL HEALTH SERVICES; 2,422
(7) MEDICAL OR PSYCHOLOGICAL TREATMENT AND REFERRAL 2,424
SERVICES FOR ALCOHOL AND DRUG ABUSE OR ADDICTION; 2,425
(8) HOME HEALTH SERVICES; 2,427
(9) PRESCRIPTION DRUG SERVICES; 2,429
(10) NURSING SERVICES; 2,431
(11) SERVICES OF A DIETITIAN LICENSED UNDER CHAPTER 4759. 2,434
OF THE REVISED CODE;
(12) PHYSICAL THERAPY SERVICES; 2,436
(13) CHIROPRACTIC SERVICES; 2,438
(14) ANY OTHER CATEGORY OF SERVICES APPROVED BY THE 2,440
SUPERINTENDENT OF INSURANCE. 2,441
(C) "SPECIALTY HEALTH CARE SERVICES" MEANS ONE OF THE 2,443
SUPPLEMENTAL HEALTH CARE SERVICES LISTED IN DIVISION (B)(1) TO 2,445
(13) OF THIS SECTION, WHEN PROVIDED BY A HEALTH INSURING 2,446
CORPORATION ON AN OUTPATIENT-ONLY BASIS AND NOT IN COMBINATION 2,447
WITH OTHER SUPPLEMENTAL HEALTH CARE SERVICES.
(D) "CLOSED PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,450
REQUIRES ENROLLEES TO USE PARTICIPATING PROVIDERS, OF WHICH 2,451
PARTICIPATING PROVIDERS, AT LEAST ONE RECEIVES COMPENSATION FROM 2,452
A HEALTH INSURING CORPORATION FOR FURNISHING THOSE HEALTH CARE 2,453
SERVICES COVERED BY THE HEALTH CARE PLAN TO THE HEALTH CARE 2,454
PLAN'S ENROLLEES. 2,455
(E) "COMPENSATION" MEANS REMUNERATION FOR THE PROVISION OF 2,459
HEALTH CARE SERVICES, DETERMINED ON OTHER THAN A FEE-FOR-SERVICE 2,460
OR DISCOUNTED-FEE-FOR-SERVICE BASIS.
57
(F) "CONTRACTUAL PERIODIC PREPAYMENT" MEANS THE FORMULA 2,463
FOR DETERMINING THE PREMIUM RATE FOR ALL SUBSCRIBERS OF A HEALTH 2,464
INSURING CORPORATION. 2,465
(G) "CORPORATION" MEANS A CORPORATION FORMED UNDER CHAPTER 2,468
1701. OR 1702. OF THE REVISED CODE OR THE SIMILAR LAWS OF ANOTHER 2,470
STATE.
(H) "EMERGENCY HEALTH SERVICES" MEANS THOSE HEALTH CARE 2,473
SERVICES THAT MUST BE AVAILABLE ON A SEVEN-DAYS-PER-WEEK, 2,474
TWENTY-FOUR-HOURS-PER-DAY BASIS IN ORDER TO PREVENT JEOPARDY TO 2,475
AN ENROLLEE'S HEALTH STATUS THAT WOULD OCCUR IF SUCH SERVICES 2,476
WERE NOT RECEIVED AS SOON AS POSSIBLE, AND INCLUDES, WHERE 2,477
APPROPRIATE, PROVISIONS FOR TRANSPORTATION AND INDEMNITY PAYMENTS 2,478
OR SERVICE AGREEMENTS FOR OUT-OF-AREA COVERAGE. 2,479
(I) "ENROLLEE" MEANS ANY NATURAL PERSON WHO IS ENTITLED TO 2,482
RECEIVE HEALTH CARE BENEFITS PROVIDED BY A HEALTH INSURING 2,483
CORPORATION.
(J) "EVIDENCE OF COVERAGE" MEANS ANY CERTIFICATE, 2,486
AGREEMENT, POLICY, OR CONTRACT ISSUED TO A SUBSCRIBER THAT SETS 2,487
OUT THE COVERAGE AND OTHER RIGHTS TO WHICH SUCH PERSON IS 2,488
ENTITLED UNDER A HEALTH CARE PLAN. 2,489
(K) "HEALTH CARE FACILITY" MEANS ANY FACILITY, EXCEPT A 2,492
HEALTH CARE PRACTITIONER'S OFFICE, THAT PROVIDES PREVENTIVE, 2,493
DIAGNOSTIC, THERAPEUTIC, ACUTE CONVALESCENT, REHABILITATION, 2,494
MENTAL HEALTH, MENTAL RETARDATION, INTERMEDIATE CARE, OR SKILLED 2,495
NURSING SERVICES. 2,496
(L) "HEALTH CARE SERVICES" MEANS ANY SERVICES INVOLVED IN 2,499
OR INCIDENT TO THE FURNISHING OF PREVENTIVE, DIAGNOSTIC, 2,500
THERAPEUTIC, OR REHABILITATIVE CARE. 2,501
(M) "HEALTH DELIVERY NETWORK" MEANS ANY GROUP OF PROVIDERS 2,504
OR HEALTH CARE FACILITIES, OR BOTH, OR ANY REPRESENTATIVE 2,505
THEREOF, THAT HAVE ENTERED INTO AN AGREEMENT TO OFFER HEALTH CARE 2,507
SERVICES IN A PANEL RATHER THAN ON AN INDIVIDUAL BASIS. 2,508
(N) "HEALTH INSURING CORPORATION" MEANS A CORPORATION, AS 2,511
DEFINED IN DIVISION (G) OF THIS SECTION, THAT, PURSUANT TO A 2,512
58
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT, PAYS FOR, 2,513
REIMBURSES, OR PROVIDES, DELIVERS, ARRANGES FOR, OR OTHERWISE 2,514
MAKES AVAILABLE, BASIC HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH 2,515
CARE SERVICES, OR SPECIALTY HEALTH CARE SERVICES, OR A 2,516
COMBINATION OF BASIC HEALTH CARE SERVICES AND EITHER SUPPLEMENTAL 2,517
HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE SERVICES, THROUGH 2,519
EITHER AN OPEN PANEL PLAN OR A CLOSED PANEL PLAN, IN EXCHANGE FOR 2,520
A PREMIUM RATE.
"HEALTH INSURING CORPORATION" DOES NOT INCLUDE A LIMITED 2,523
LIABILITY COMPANY FORMED PURSUANT TO CHAPTER 1705. OF THE REVISED 2,525
CODE, A CORPORATION FORMED BY OR ON BEHALF OF A POLITICAL 2,527
SUBDIVISION OR A DEPARTMENT, OFFICE, OR INSTITUTION OF THE STATE, 2,528
OR A PUBLIC ENTITY FORMED BY OR ON BEHALF OF A BOARD OF COUNTY 2,529
COMMISSIONERS, A COUNTY BOARD OF MENTAL RETARDATION AND 2,530
DEVELOPMENTAL DISABILITIES, AN ALCOHOL AND DRUG ADDICTION 2,533
SERVICES BOARD, A BOARD OF ALCOHOL, DRUG ADDICTION, AND MENTAL 2,534
HEALTH SERVICES, OR A COMMUNITY MENTAL HEALTH BOARD, AS THOSE 2,535
TERMS ARE USED IN CHAPTERS 340. AND 5126. OF THE REVISED CODE. 2,536
EXCEPT AS PROVIDED BY DIVISION (D) OF SECTION 1751.02 OF THE 2,539
REVISED CODE, OR AS OTHERWISE PROVIDED BY LAW, NO BOARD, 2,542
COMMISSION, AGENCY, OR OTHER ENTITY UNDER THE CONTROL OF A 2,543
POLITICAL SUBDIVISION MAY ACCEPT INSURANCE RISK IN PROVIDING FOR 2,544
HEALTH CARE SERVICES. HOWEVER, NOTHING IN THIS DIVISION SHALL BE 2,545
CONSTRUED AS PROHIBITING SUCH ENTITIES FROM PURCHASING THE 2,546
SERVICES OF A HEALTH INSURING CORPORATION OR A THIRD-PARTY 2,547
ADMINISTRATOR LICENSED UNDER CHAPTER 3959. OF THE REVISED CODE. 2,549
(O) "INTERMEDIARY ORGANIZATION" MEANS A HEALTH DELIVERY 2,552
NETWORK OR OTHER ENTITY THAT CONTRACTS WITH LICENSED HEALTH 2,553
INSURING CORPORATIONS OR SELF-INSURED EMPLOYERS, OR BOTH, TO 2,554
PROVIDE HEALTH CARE SERVICES, AND THAT ENTERS INTO CONTRACTUAL 2,556
ARRANGEMENTS WITH OTHER ENTITIES FOR THE PROVISION OF HEALTH CARE 2,557
SERVICES FOR THE PURPOSE OF FULFILLING THE TERMS OF ITS CONTRACTS 2,558
WITH THE HEALTH INSURING CORPORATIONS AND SELF-INSURED EMPLOYERS. 2,559
(P) "INTERMEDIATE CARE" MEANS RESIDENTIAL CARE ABOVE THE 2,562
59
LEVEL OF ROOM AND BOARD FOR PATIENTS WHO REQUIRE PERSONAL 2,563
ASSISTANCE AND HEALTH-RELATED SERVICES, BUT WHO DO NOT REQUIRE 2,564
SKILLED NURSING CARE.
(Q) "MEDICAL RECORD" MEANS THE PERSONAL INFORMATION THAT 2,567
RELATES TO AN INDIVIDUAL'S PHYSICAL OR MENTAL CONDITION, MEDICAL 2,568
HISTORY, OR MEDICAL TREATMENT. 2,569
(R)(1)(a) "OPEN PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,571
PROVIDES INCENTIVES FOR ENROLLEES TO USE PARTICIPATING PROVIDERS, 2,573
WHICH PARTICIPATING PROVIDERS RECEIVE COMPENSATION FROM A HEALTH 2,574
INSURING CORPORATION FOR FURNISHING THOSE HEALTH CARE SERVICES 2,575
COVERED BY THE HEALTH CARE PLAN TO THE HEALTH CARE PLAN'S 2,576
ENROLLEES, AND THAT ALSO ALLOWS ENROLLEES TO USE PROVIDERS THAT 2,577
ARE NOT PARTICIPATING PROVIDERS IN EXCHANGE FOR A REDUCTION IN 2,578
BENEFITS.
(b) WITH RESPECT TO A HEALTH INSURING CORPORATION THAT, ON 2,581
THE EFFECTIVE DATE OF THIS SECTION, HOLDS A CERTIFICATE OF 2,582
AUTHORITY OR LICENSE TO OPERATE UNDER CHAPTER 1740. OF THE 2,584
REVISED CODE, "OPEN PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,585
REIMBURSES PROVIDERS ON A FEE-FOR-SERVICE OR 2,586
DISCOUNTED-FEE-FOR-SERVICE BASIS.
(2) NO HEALTH INSURING CORPORATION MAY OFFER AN OPEN PANEL 2,589
PLAN, UNLESS THE HEALTH INSURING CORPORATION IS ALSO LICENSED AS 2,590
AN INSURER UNDER TITLE XXXIX OF THE REVISED CODE, THE HEALTH 2,591
INSURING CORPORATION, ON THE EFFECTIVE DATE OF THIS SECTION, 2,592
HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO OPERATE UNDER 2,593
CHAPTER 1740. OF THE REVISED CODE, OR AN INSURER LICENSED UNDER 2,595
TITLE XXXIX OF THE REVISED CODE IS RESPONSIBLE FOR THE 2,596
OUT-OF-NETWORK RISK AS EVIDENCED BY BOTH AN EVIDENCE OF COVERAGE 2,597
FILING UNDER SECTION 1751.11 OF THE REVISED CODE AND A POLICY AND 2,598
CERTIFICATE FILING UNDER SECTION 3923.02 OF THE REVISED CODE. 2,600
(S) "PERSON" HAS THE SAME MEANING AS IN SECTION 1.59 OF 2,602
THE REVISED CODE, AND, UNLESS THE CONTEXT OTHERWISE REQUIRES, 2,603
INCLUDES ANY INSURANCE COMPANY HOLDING A CERTIFICATE OF AUTHORITY 2,604
UNDER TITLE XXXIX OF THE REVISED CODE, ANY SUBSIDIARY AND 2,606
60
AFFILIATE OF AN INSURANCE COMPANY, AND ANY GOVERNMENT AGENCY. 2,607
(T) "PREMIUM RATE" MEANS ANY SET FEE REGULARLY PAID BY A 2,610
SUBSCRIBER TO A HEALTH INSURING CORPORATION. A "PREMIUM RATE" 2,611
DOES NOT INCLUDE A ONE-TIME MEMBERSHIP FEE, AN ANNUAL
ADMINISTRATIVE FEE, OR A NOMINAL ACCESS FEE, PAID TO A MANAGED 2,612
HEALTH CARE SYSTEM UNDER WHICH THE RECIPIENT OF HEALTH CARE 2,613
SERVICES REMAINS SOLELY RESPONSIBLE FOR ANY CHARGES ACCESSED FOR 2,614
THOSE SERVICES BY THE PROVIDER OR HEALTH CARE FACILITY. 2,615
(U) "PRIMARY CARE PROVIDER" MEANS A PROVIDER THAT IS 2,618
DESIGNATED BY A HEALTH INSURING CORPORATION TO SUPERVISE, 2,619
COORDINATE, OR PROVIDE INITIAL CARE OR CONTINUING CARE TO AN 2,620
ENROLLEE, AND THAT MAY BE REQUIRED BY THE HEALTH INSURING 2,621
CORPORATION TO INITIATE A REFERRAL FOR SPECIALTY CARE AND TO 2,622
MAINTAIN SUPERVISION OF THE HEALTH CARE SERVICES RENDERED TO THE 2,623
ENROLLEE.
(V) "PROVIDER" MEANS ANY NATURAL PERSON OR PARTNERSHIP OF 2,626
NATURAL PERSONS WHO ARE LICENSED, CERTIFIED, ACCREDITED, OR 2,627
OTHERWISE AUTHORIZED IN THIS STATE TO FURNISH HEALTH CARE 2,628
SERVICES, OR ANY PROFESSIONAL ASSOCIATION ORGANIZED UNDER CHAPTER 2,629
1785. OF THE REVISED CODE, PROVIDED THAT NOTHING IN THIS CHAPTER 2,631
OR OTHER PROVISIONS OF LAW SHALL BE CONSTRUED TO PRECLUDE A 2,632
HEALTH INSURING CORPORATION, HEALTH CARE PRACTITIONER, OR 2,633
ORGANIZED HEALTH CARE GROUP ASSOCIATED WITH A HEALTH INSURING 2,634
CORPORATION FROM EMPLOYING NURSE PRACTITIONERS, DIETITIANS, 2,635
PHYSICIANS' ASSISTANTS, DENTAL ASSISTANTS, DENTAL HYGIENISTS, 2,636
OPTOMETRIC TECHNICIANS, OR OTHER ALLIED HEALTH PERSONNEL WHO ARE 2,637
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THIS 2,638
STATE TO FURNISH HEALTH CARE SERVICES.
(W) "PROVIDER SPONSORED ORGANIZATION" MEANS A CORPORATION, 2,641
AS DEFINED IN DIVISION (G) OF THIS SECTION, THAT IS AT LEAST 2,642
EIGHTY PER CENT OWNED OR CONTROLLED BY ONE OR MORE HOSPITALS, AS 2,644
DEFINED IN SECTION 3727.01 OF THE REVISED CODE, OR ONE OR MORE 2,645
PHYSICIANS LICENSED TO PRACTICE MEDICINE OR SURGERY OR 2,646
OSTEOPATHIC MEDICINE AND SURGERY UNDER CHAPTER 4731. OF THE 2,647
61
REVISED CODE, OR ANY COMBINATION OF SUCH PHYSICIANS AND 2,648
HOSPITALS. SUCH CONTROL IS PRESUMED TO EXIST IF AT LEAST EIGHTY 2,649
PER CENT OF THE VOTING RIGHTS OR GOVERNANCE RIGHTS OF A PROVIDER 2,650
SPONSORED ORGANIZATION ARE DIRECTLY OR INDIRECTLY OWNED, 2,651
CONTROLLED, OR OTHERWISE HELD BY ANY COMBINATION OF THE 2,652
PHYSICIANS AND HOSPITALS DESCRIBED IN THIS DIVISION. 2,653
(X) "SOLICITATION DOCUMENT" MEANS THE WRITTEN MATERIALS 2,655
PROVIDED TO PROSPECTIVE SUBSCRIBERS OR ENROLLEES, OR BOTH, AND 2,656
USED FOR ADVERTISING AND MARKETING TO INDUCE ENROLLMENT IN THE 2,657
HEALTH CARE PLANS OF A HEALTH INSURING CORPORATION. 2,658
(Y) "SUBSCRIBER" MEANS A PERSON WHO IS RESPONSIBLE FOR 2,661
MAKING PAYMENTS TO A HEALTH INSURING CORPORATION FOR 2,662
PARTICIPATION IN A HEALTH CARE PLAN, OR AN ENROLLEE WHOSE 2,663
EMPLOYMENT OR OTHER STATUS IS THE BASIS OF ELIGIBILITY FOR 2,664
ENROLLMENT IN A HEALTH INSURING CORPORATION.
(Z) "URGENT CARE SERVICES" MEANS THOSE HEALTH CARE 2,667
SERVICES THAT ARE APPROPRIATELY PROVIDED FOR AN UNFORESEEN 2,668
CONDITION OF A KIND THAT USUALLY REQUIRES MEDICAL ATTENTION 2,669
WITHOUT DELAY BUT THAT DOES NOT POSE A THREAT TO THE LIFE, LIMB, 2,670
OR PERMANENT HEALTH OF THE INJURED OR ILL PERSON, AND MAY INCLUDE 2,672
SUCH HEALTH CARE SERVICES PROVIDED OUT OF THE HEALTH INSURING 2,673
CORPORATION'S APPROVED SERVICE AREA PURSUANT TO INDEMNITY 2,674
PAYMENTS OR SERVICE AGREEMENTS.
Sec. 1751.02. (A) NOTWITHSTANDING ANY LAW IN THIS STATE 2,676
TO THE CONTRARY, ANY CORPORATION, AS DEFINED IN SECTION 1751.01 2,678
OF THE REVISED CODE, MAY APPLY TO THE SUPERINTENDENT OF INSURANCE 2,680
FOR A CERTIFICATE OF AUTHORITY TO ESTABLISH AND OPERATE A HEALTH 2,681
INSURING CORPORATION. IF THE CORPORATION APPLYING FOR A 2,682
CERTIFICATE OF AUTHORITY IS A FOREIGN CORPORATION DOMICILED IN A 2,683
STATE WITHOUT LAWS SIMILAR TO THOSE OF THIS CHAPTER, THE 2,685
CORPORATION MUST FORM A DOMESTIC CORPORATION TO APPLY FOR,
OBTAIN, AND MAINTAIN A CERTIFICATE OF AUTHORITY UNDER THIS 2,686
CHAPTER.
(B) NO PERSON SHALL ESTABLISH, OPERATE, OR PERFORM THE 2,689
62
SERVICES OF A HEALTH INSURING CORPORATION IN THIS STATE WITHOUT 2,691
OBTAINING A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. 2,692
(C) EXCEPT AS PROVIDED BY DIVISION (D) OF THIS SECTION, NO 2,695
POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR INSTITUTION OF 2,696
THIS STATE, OR CORPORATION FORMED BY OR ON BEHALF OF ANY
POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR INSTITUTION OF 2,697
THIS STATE, SHALL ESTABLISH, OPERATE, OR PERFORM THE SERVICES OF 2,698
A HEALTH INSURING CORPORATION. NOTHING IN THIS SECTION SHALL BE 2,701
CONSTRUED TO PRECLUDE A BOARD OF COUNTY COMMISSIONERS, A COUNTY 2,702
BOARD OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES, AN 2,703
ALCOHOL AND DRUG ADDICTION SERVICES BOARD, A BOARD OF ALCOHOL, 2,704
DRUG ADDICTION, AND MENTAL HEALTH SERVICES, OR A COMMUNITY MENTAL 2,705
HEALTH BOARD, OR A PUBLIC ENTITY FORMED BY OR ON BEHALF OF ANY OF 2,706
THESE BOARDS, FROM USING MANAGED CARE TECHNIQUES IN CARRYING OUT 2,707
THE BOARD'S OR PUBLIC ENTITY'S DUTIES PURSUANT TO THE 2,708
REQUIREMENTS OF CHAPTERS 307., 329., 340., AND 5126. OF THE 2,710
REVISED CODE. HOWEVER, NO SUCH BOARD OR PUBLIC ENTITY MAY 2,712
OPERATE SO AS TO COMPETE IN THE PRIVATE SECTOR WITH HEALTH 2,713
INSURING CORPORATIONS HOLDING CERTIFICATES OF AUTHORITY UNDER 2,714
THIS CHAPTER.
(D) A CORPORATION FORMED BY OR ON BEHALF OF A PUBLICLY 2,716
OWNED, OPERATED, OR FUNDED HOSPITAL OR HEALTH CARE FACILITY MAY 2,717
APPLY TO THE SUPERINTENDENT FOR A CERTIFICATE OF AUTHORITY UNDER 2,719
DIVISION (A) OF THIS SECTION TO ESTABLISH AND OPERATE A HEALTH 2,720
INSURING CORPORATION.
(E) A HEALTH INSURING CORPORATION SHALL OPERATE IN THIS 2,723
STATE IN COMPLIANCE WITH THIS CHAPTER AND WITH SECTIONS 3702.51 2,724
TO 3702.62 OF THE REVISED CODE, AND SHALL OPERATE IN CONFORMITY 2,727
WITH ITS FILINGS WITH THE SUPERINTENDENT UNDER THIS CHAPTER, 2,728
INCLUDING FILINGS MADE PURSUANT TO SECTIONS 1751.03, 1751.11, 2,729
1751.12, AND 1751.31 OF THE REVISED CODE. 2,731
(F) AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED 2,735
CODE NEED NOT OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,736
INSURING CORPORATION TO OFFER AN OPEN PANEL PLAN AS LONG AS THE 2,737
63
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE OPEN 2,738
PANEL PLAN RECEIVE THEIR COMPENSATION DIRECTLY FROM THE INSURER. 2,739
IF THE PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE 2,740
OPEN PANEL PLAN RECEIVE THEIR COMPENSATION FROM ANY PERSON OTHER 2,741
THAN THE INSURER, OR IF THE INSURER OFFERS A CLOSED PANEL PLAN, 2,742
THE INSURER MUST OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,743
INSURING CORPORATION.
(G) AN INTERMEDIARY ORGANIZATION NEED NOT OBTAIN A 2,746
CERTIFICATE OF AUTHORITY AS A HEALTH INSURING CORPORATION, 2,747
REGARDLESS OF THE METHOD OF REIMBURSEMENT TO THE INTERMEDIARY 2,748
ORGANIZATION, AS LONG AS A HEALTH INSURING CORPORATION OR A 2,750
SELF-INSURED EMPLOYER MAINTAINS THE ULTIMATE RESPONSIBILITY TO 2,751
ASSURE DELIVERY OF ALL HEALTH CARE SERVICES REQUIRED BY THE
CONTRACT BETWEEN THE HEALTH INSURING CORPORATION AND THE 2,752
SUBSCRIBER AND THE LAWS OF THIS STATE OR BETWEEN THE SELF-INSURED 2,753
EMPLOYER AND ITS EMPLOYEES. 2,754
NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE ANY 2,756
HEALTH CARE FACILITY, PROVIDER, HEALTH DELIVERY NETWORK, OR 2,757
INTERMEDIARY ORGANIZATION THAT CONTRACTS WITH A HEALTH INSURING 2,758
CORPORATION OR SELF-INSURED EMPLOYER, REGARDLESS OF THE METHOD OF 2,760
REIMBURSEMENT TO THE HEALTH CARE FACILITY, PROVIDER, HEALTH
DELIVERY NETWORK, OR INTERMEDIARY ORGANIZATION, TO OBTAIN A 2,761
CERTIFICATE OF AUTHORITY AS A HEALTH INSURING CORPORATION UNDER 2,762
THIS CHAPTER, UNLESS OTHERWISE PROVIDED, IN THE CASE OF CONTRACTS 2,764
WITH A SELF-INSURED EMPLOYER, BY OPERATION OF THE "EMPLOYEE 2,766
RETIREMENT INCOME SECURITY ACT OF 1974," 88 STAT. 829, 29 2,771
U.S.C.A. 1001, AS AMENDED. 2,772
(H) ANY HEALTH DELIVERY NETWORK DOING BUSINESS IN THIS 2,775
STATE THAT IS NOT REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY 2,776
UNDER THIS CHAPTER SHALL CERTIFY TO THE SUPERINTENDENT ANNUALLY, 2,777
NOT LATER THAN THE FIRST DAY OF JULY, AND SHALL PROVIDE A 2,779
STATEMENT SIGNED BY THE HIGHEST RANKING OFFICIAL WHICH INCLUDES 2,780
THE FOLLOWING INFORMATION:
(1) THE HEALTH DELIVERY NETWORK'S FULL NAME AND THE 2,782
64
ADDRESS OF ITS PRINCIPAL PLACE OF BUSINESS; 2,783
(2) A STATEMENT THAT THE HEALTH DELIVERY NETWORK IS NOT 2,785
REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 2,786
TO CONDUCT ITS BUSINESS. 2,787
(I) THE SUPERINTENDENT SHALL NOT ISSUE A CERTIFICATE OF 2,790
AUTHORITY TO A HEALTH INSURING CORPORATION THAT IS A PROVIDER 2,791
SPONSORED ORGANIZATION UNLESS ALL HEALTH CARE PLANS TO BE OFFERED 2,792
BY THE HEALTH INSURING CORPORATION PROVIDE BASIC HEALTH CARE 2,793
SERVICES. SUBSTANTIALLY ALL OF THE PHYSICIANS AND HOSPITALS WITH 2,794
OWNERSHIP OR CONTROL OF THE PROVIDER SPONSORED ORGANIZATION, AS 2,795
DEFINED IN DIVISION (W) OF SECTION 1751.01 OF THE REVISED CODE, 2,798
SHALL ALSO BE PARTICIPATING PROVIDERS FOR THE PROVISION OF BASIC 2,799
HEALTH CARE SERVICES FOR HEALTH CARE PLANS OFFERED BY THE 2,800
PROVIDER SPONSORED ORGANIZATION. IF A HEALTH INSURING 2,801
CORPORATION THAT IS A PROVIDER SPONSORED ORGANIZATION OFFERS 2,802
HEALTH CARE PLANS THAT DO NOT PROVIDE BASIC HEALTH CARE SERVICES, 2,803
THE HEALTH INSURING CORPORATION SHALL BE DEEMED, FOR PURPOSES OF 2,804
SECTION 1751.35 OF THE REVISED CODE, TO HAVE FAILED TO 2,805
SUBSTANTIALLY COMPLY WITH THIS CHAPTER. 2,806
(J) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO APPLY TO 2,808
ANY MULTIPLE EMPLOYER WELFARE ARRANGEMENT OPERATING PURSUANT TO 2,809
CHAPTER 1739. OF THE REVISED CODE. 2,810
(K) ANY PERSON WHO VIOLATES DIVISION (B) OF THIS SECTION, 2,814
AND ANY HEALTH DELIVERY NETWORK THAT FAILS TO COMPLY WITH 2,815
DIVISION (H) OF THIS SECTION, IS SUBJECT TO THE PENALTIES SET 2,816
FORTH IN SECTION 1751.45 OF THE REVISED CODE. 2,818
Sec. 1751.03. (A) EACH APPLICATION FOR A CERTIFICATE OF 2,821
AUTHORITY UNDER THIS CHAPTER SHALL BE VERIFIED BY AN OFFICER OR 2,822
AUTHORIZED REPRESENTATIVE OF THE APPLICANT, SHALL BE IN A FORMAT 2,823
PRESCRIBED BY THE SUPERINTENDENT OF INSURANCE, AND SHALL SET 2,824
FORTH OR BE ACCOMPANIED BY THE FOLLOWING: 2,825
(1) A CERTIFIED COPY OF THE APPLICANT'S ARTICLES OF 2,827
INCORPORATION AND ALL AMENDMENTS TO THE ARTICLES OF 2,828
INCORPORATION; 2,829
65
(2) A COPY OF ANY REGULATIONS ADOPTED FOR THE GOVERNMENT 2,831
OF THE CORPORATION, ANY BYLAWS, AND ANY SIMILAR DOCUMENTS, AND A 2,832
COPY OF ALL AMENDMENTS TO THESE REGULATIONS, BYLAWS, AND 2,833
DOCUMENTS. THE CORPORATE SECRETARY SHALL CERTIFY THAT THESE 2,834
REGULATIONS, BYLAWS, DOCUMENTS, AND AMENDMENTS HAVE BEEN PROPERLY 2,836
ADOPTED OR APPROVED.
(3) A LIST OF THE NAMES, ADDRESSES, AND OFFICIAL POSITIONS 2,839
OF THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE APPLICANT, 2,840
INCLUDING ALL MEMBERS OF THE BOARD, THE PRINCIPAL OFFICERS, AND 2,841
THE PERSON RESPONSIBLE FOR COMPLETING OR FILING FINANCIAL 2,842
STATEMENTS WITH THE DEPARTMENT OF INSURANCE, ACCOMPANIED BY A 2,843
COMPLETED ORIGINAL BIOGRAPHICAL AFFIDAVIT AND RELEASE OF 2,844
INFORMATION FOR EACH OF THESE PERSONS ON FORMS ACCEPTABLE TO THE 2,845
DEPARTMENT;
(4) A FULL AND COMPLETE DISCLOSURE OF THE EXTENT AND 2,847
NATURE OF ANY CONTRACTUAL OR OTHER FINANCIAL ARRANGEMENT BETWEEN 2,848
THE APPLICANT AND ANY PROVIDER OR A PERSON LISTED IN DIVISION 2,850
(A)(3) OF THIS SECTION, INCLUDING, BUT NOT LIMITED TO, A FULL AND 2,851
COMPLETE DISCLOSURE OF THE FINANCIAL INTEREST HELD BY ANY SUCH 2,852
PROVIDER OR PERSON IN ANY HEALTH CARE FACILITY, PROVIDER, OR 2,853
INSURER THAT HAS ENTERED INTO A FINANCIAL RELATIONSHIP WITH THE 2,854
HEALTH INSURING CORPORATION; 2,855
(5) A DESCRIPTION OF THE APPLICANT, ITS FACILITIES, AND 2,857
ITS PERSONNEL, INCLUDING, BUT NOT LIMITED TO, THE LOCATION, HOURS 2,859
OF OPERATION, AND TELEPHONE NUMBERS OF ALL CONTRACTED FACILITIES; 2,860
(6) THE APPLICANT'S PROJECTED ANNUAL ENROLLEE POPULATION 2,862
OVER A THREE-YEAR PERIOD; 2,863
(7) A CLEAR AND SPECIFIC DESCRIPTION OF THE HEALTH CARE 2,865
PLAN OR PLANS TO BE USED BY THE APPLICANT, INCLUDING A 2,866
DESCRIPTION OF THE PROPOSED PROVIDERS, PROCEDURES FOR ACCESSING 2,867
CARE, AND THE FORM OF ALL PROPOSED AND EXISTING CONTRACTS 2,868
RELATING TO THE ADMINISTRATION, DELIVERY, OR FINANCING OF HEALTH 2,869
CARE SERVICES; 2,870
(8) A COPY OF EACH TYPE OF EVIDENCE OF COVERAGE AND 2,872
66
IDENTIFICATION CARD OR SIMILAR DOCUMENT TO BE ISSUED TO 2,873
SUBSCRIBERS; 2,874
(9) A COPY OF EACH TYPE OF INDIVIDUAL OR GROUP POLICY, 2,876
CONTRACT, OR AGREEMENT TO BE USED; 2,877
(10) THE SCHEDULE OF THE PROPOSED CONTRACTUAL PERIODIC 2,879
PREPAYMENTS OR PREMIUM RATES, OR BOTH, ACCOMPANIED BY APPROPRIATE 2,880
SUPPORTING DATA; 2,881
(11) A FINANCIAL PLAN WHICH PROVIDES A THREE-YEAR 2,883
PROJECTION OF OPERATING RESULTS, INCLUDING THE PROJECTED 2,884
EXPENSES, INCOME, AND SOURCES OF WORKING CAPITAL; 2,885
(12) THE ENROLLEE COMPLAINT PROCEDURE TO BE UTILIZED AS 2,887
REQUIRED UNDER SECTION 1751.19 OF THE REVISED CODE; 2,890
(13) A DESCRIPTION OF THE PROCEDURES AND PROGRAMS TO BE 2,892
IMPLEMENTED ON AN ONGOING BASIS TO ASSURE THE QUALITY OF HEALTH 2,893
CARE SERVICES DELIVERED TO ENROLLEES; 2,894
(14) A STATEMENT DESCRIBING THE GEOGRAPHIC AREA OR AREAS 2,896
TO BE SERVED, BY COUNTY; 2,897
(15) A COPY OF ALL SOLICITATION DOCUMENTS; 2,899
(16) A BALANCE SHEET AND OTHER FINANCIAL STATEMENTS 2,901
SHOWING THE APPLICANT'S ASSETS, LIABILITIES, INCOME, AND OTHER 2,902
SOURCES OF FINANCIAL SUPPORT; 2,903
(17) A DESCRIPTION OF THE NATURE AND EXTENT OF ANY 2,905
REINSURANCE PROGRAM TO BE IMPLEMENTED, AND A DEMONSTRATION THAT 2,906
ERRORS AND OMISSION INSURANCE AND, IF APPROPRIATE, FIDELITY 2,907
INSURANCE, WILL BE IN PLACE UPON THE APPLICANT'S RECEIPT OF A 2,908
CERTIFICATE OF AUTHORITY; 2,909
(18) COPIES OF ALL PROPOSED OR IN FORCE RELATED-PARTY OR 2,911
INTERCOMPANY AGREEMENTS WITH AN EXPLANATION OF THE FINANCIAL 2,912
IMPACT OF THESE AGREEMENTS ON THE APPLICANT. IF THE APPLICANT 2,913
INTENDS TO ENTER INTO A CONTRACT FOR MANAGERIAL OR ADMINISTRATIVE 2,915
SERVICES, WITH EITHER AN AFFILIATED OR AN UNAFFILIATED PERSON,
THE APPLICANT SHALL PROVIDE A COPY OF THE CONTRACT AND A DETAILED 2,916
DESCRIPTION OF THE PERSON TO PROVIDE THESE SERVICES. THE 2,918
DESCRIPTION SHALL INCLUDE THAT PERSON'S EXPERIENCE IN MANAGING OR 2,919
67
ADMINISTERING HEALTH CARE PLANS, A COPY OF THAT PERSON'S MOST 2,920
RECENT AUDITED FINANCIAL STATEMENT, AND A COMPLETED BIOGRAPHICAL 2,921
AFFIDAVIT ON A FORM ACCEPTABLE TO THE SUPERINTENDENT FOR EACH OF 2,922
THAT PERSON'S PRINCIPAL OFFICERS AND BOARD MEMBERS AND FOR ANY 2,923
ADDITIONAL EMPLOYEE TO BE DIRECTLY INVOLVED IN PROVIDING 2,924
MANAGERIAL OR ADMINISTRATIVE SERVICES TO THE HEALTH INSURING 2,925
CORPORATION. IF THE PERSON TO PROVIDE MANAGERIAL OR 2,926
ADMINISTRATIVE SERVICES IS AFFILIATED WITH THE HEALTH INSURING 2,927
CORPORATION, THE CONTRACT MUST PROVIDE FOR PAYMENT FOR SERVICES 2,928
BASED ON ACTUAL COSTS.
(19) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,930
ADMITTED ASSETS OF THE APPLICANT HAVE NOT BEEN AND WILL NOT BE 2,931
PLEDGED OR HYPOTHECATED; 2,932
(20) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,934
APPLICANT WILL SUBMIT MONTHLY FINANCIAL STATEMENTS DURING THE 2,935
FIRST YEAR OF OPERATIONS; 2,936
(21) THE NAME AND ADDRESS OF THE APPLICANT'S OHIO 2,939
STATUTORY AGENT FOR SERVICE OF PROCESS, NOTICE, OR DEMAND; 2,940
(22) COPIES OF ALL DOCUMENTS THE APPLICANT FILED WITH THE 2,942
SECRETARY OF STATE; 2,943
(23) THE LOCATION OF THOSE BOOKS AND RECORDS OF THE 2,945
APPLICANT THAT MUST BE MAINTAINED IN OHIO; 2,946
(24) THE APPLICANT'S FEDERAL IDENTIFICATION NUMBER, 2,948
CORPORATE ADDRESS, AND MAILING ADDRESS; 2,949
(25) AN INTERNAL AND EXTERNAL ORGANIZATIONAL CHART; 2,952
(26) A LIST OF THE ASSETS REPRESENTING THE INITIAL NET 2,954
WORTH OF THE APPLICANT; 2,955
(27) IF THE APPLICANT HAS A PARENT COMPANY, THE PARENT 2,957
COMPANY'S GUARANTY, ON A FORM ACCEPTABLE TO THE SUPERINTENDENT, 2,958
THAT THE APPLICANT WILL MAINTAIN OHIO'S MINIMUM NET WORTH. IF NO 2,961
PARENT COMPANY EXISTS, A STATEMENT REGARDING THE AVAILABILITY OF 2,962
FUTURE FUNDS IF NEEDED.
(28) THE NAMES AND ADDRESSES OF THE APPLICANT'S ACTUARY 2,964
AND EXTERNAL AUDITORS; 2,965
68
(29) IF THE APPLICANT IS A FOREIGN CORPORATION, A COPY OF 2,967
THE MOST RECENT FINANCIAL STATEMENTS FILED WITH THE INSURANCE 2,968
REGULATORY AGENCY IN THE APPLICANT'S STATE OF DOMICILE; 2,969
(30) IF THE APPLICANT IS A FOREIGN CORPORATION, A 2,971
STATEMENT FROM THE INSURANCE REGULATORY AGENCY OF THE APPLICANT'S 2,972
STATE OF DOMICILE STATING THAT THE REGULATORY AGENCY HAS NO 2,973
OBJECTION TO THE APPLICANT APPLYING FOR AN OHIO LICENSE AND THAT 2,974
THE APPLICANT IS IN GOOD STANDING IN THE APPLICANT'S STATE OF 2,975
DOMICILE; 2,976
(31) ANY OTHER INFORMATION THAT THE SUPERINTENDENT MAY 2,978
REQUIRE. 2,979
(B)(1) A HEALTH INSURING CORPORATION, UNLESS OTHERWISE 2,982
PROVIDED FOR IN THIS CHAPTER, SHALL FILE A TIMELY NOTICE WITH THE 2,983
SUPERINTENDENT DESCRIBING ANY CHANGE TO THE CORPORATION'S 2,984
ARTICLES OF INCORPORATION OR REGULATIONS, OR ANY MAJOR 2,985
MODIFICATION TO ITS OPERATIONS AS SET OUT IN THE INFORMATION 2,986
REQUIRED BY DIVISION (A) OF THIS SECTION THAT AFFECTS ANY OF THE 2,988
FOLLOWING:
(a) THE SOLVENCY OF THE HEALTH INSURING CORPORATION; 2,991
(b) THE HEALTH INSURING CORPORATION'S CONTINUED PROVISION 2,994
OF SERVICES THAT IT HAS CONTRACTED TO PROVIDE; 2,995
(c) THE MANNER IN WHICH THE HEALTH INSURING CORPORATION 2,998
CONDUCTS ITS BUSINESS.
(2) IF THE CHANGE OR MODIFICATION IS TO BE THE RESULT OF 3,000
AN ACTION TO BE TAKEN BY THE HEALTH INSURING CORPORATION, THE 3,001
NOTICE SHALL BE FILED WITH THE SUPERINTENDENT PRIOR TO THE HEALTH 3,002
INSURING CORPORATION TAKING THE ACTION. THE ACTION SHALL BE 3,004
DEEMED APPROVED IF THE SUPERINTENDENT DOES NOT DISAPPROVE IT 3,005
WITHIN SIXTY DAYS OF FILING. 3,006
(C)(1) NO HEALTH INSURING CORPORATION SHALL EXPAND ITS 3,009
APPROVED SERVICE AREA UNTIL A COPY OF THE REQUEST FOR EXPANSION, 3,010
ACCOMPANIED BY DOCUMENTATION OF THE NETWORK OF PROVIDERS, 3,011
ENROLLMENT PROJECTIONS, PLAN OF OPERATION, AND ANY OTHER CHANGES 3,012
HAVE BEEN FILED WITH THE SUPERINTENDENT. 3,013
69
(2) WITHIN TEN CALENDAR DAYS AFTER RECEIPT OF A COMPLETE 3,015
FILING UNDER DIVISION (C)(1) OF THIS SECTION, THE SUPERINTENDENT 3,017
SHALL REFER THE APPROPRIATE JURISDICTIONAL ISSUES TO THE DIRECTOR 3,018
OF HEALTH PURSUANT TO SECTION 1751.04 OF THE REVISED CODE. 3,020
(3) WITHIN SEVENTY-FIVE DAYS AFTER THE SUPERINTENDENT'S 3,022
RECEIPT OF A COMPLETE FILING UNDER DIVISION (C)(1) OF THIS 3,024
SECTION, THE SUPERINTENDENT SHALL DETERMINE WHETHER THE PLAN FOR 3,025
EXPANSION IS LAWFUL, FAIR, AND REASONABLE. THE SUPERINTENDENT 3,026
MAY NOT MAKE A DETERMINATION UNTIL THE SUPERINTENDENT HAS 3,027
RECEIVED THE DIRECTOR'S CERTIFICATION OF COMPLIANCE, WHICH THE 3,028
DIRECTOR SHALL FURNISH WITHIN FORTY-FIVE DAYS AFTER REFERRAL 3,029
UNDER DIVISION (C)(2) OF THIS SECTION. THE DIRECTOR SHALL NOT 3,031
CERTIFY THAT THE REQUIREMENTS OF SECTION 1751.04 OF THE REVISED 3,033
CODE ARE NOT MET, UNLESS THE APPLICANT HAS BEEN GIVEN AN 3,034
OPPORTUNITY FOR A HEARING AS PROVIDED IN DIVISION (D) OF SECTION 3,036
1751.04 OF THE REVISED CODE. THE FORTY-FIVE-DAY AND 3,037
SEVENTY-FIVE-DAY REVIEW PERIODS PROVIDED FOR IN DIVISION (C)(3) 3,039
OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON WHICH THE 3,040
NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS MAILED 3,041
AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A FINAL 3,042
CERTIFICATION. 3,043
(4) IF THE SUPERINTENDENT HAS NOT APPROVED OR DISAPPROVED 3,045
ALL OR A PORTION OF A SERVICE AREA EXPANSION WITHIN THE 3,046
SEVENTY-FIVE-DAY PERIOD PROVIDED FOR IN DIVISION (C)(3) OF THIS 3,048
SECTION, THE FILING SHALL BE DEEMED APPROVED. 3,049
(5) DISAPPROVAL OF ALL OR A PORTION OF THE FILING SHALL BE 3,052
EFFECTED BY WRITTEN NOTICE, WHICH SHALL STATE THE GROUNDS FOR THE 3,053
ORDER OF DISAPPROVAL AND SHALL BE GIVEN IN ACCORDANCE WITH 3,054
CHAPTER 119. OF THE REVISED CODE.
Sec. 1751.04. (A) UPON THE RECEIPT BY THE SUPERINTENDENT 3,057
OF INSURANCE OF A COMPLETE APPLICATION FOR A CERTIFICATE OF 3,058
AUTHORITY TO ESTABLISH OR OPERATE A HEALTH INSURING CORPORATION, 3,059
WHICH APPLICATION SETS FORTH OR IS ACCOMPANIED BY THE INFORMATION 3,060
AND DOCUMENTS REQUIRED BY DIVISION (A) OF SECTION 1751.03 OF THE 3,062
70
REVISED CODE, THE SUPERINTENDENT SHALL TRANSMIT COPIES OF THE 3,064
APPLICATION AND ACCOMPANYING DOCUMENTS TO THE DIRECTOR OF HEALTH. 3,065
(B) THE DIRECTOR SHALL REVIEW THE APPLICATION AND 3,068
ACCOMPANYING DOCUMENTS AND MAKE FINDINGS AS TO WHETHER THE 3,069
APPLICANT FOR A CERTIFICATE OF AUTHORITY HAS DONE ALL OF THE 3,070
FOLLOWING WITH RESPECT TO ANY BASIC HEALTH CARE SERVICES AND 3,071
SUPPLEMENTAL HEALTH CARE SERVICES TO BE FURNISHED: 3,072
(1) DEMONSTRATED THE WILLINGNESS AND POTENTIAL ABILITY TO 3,074
ENSURE THAT ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL 3,075
HEALTH CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE WILL 3,077
BE PROVIDED TO ALL ITS ENROLLEES AS PROMPTLY AS IS APPROPRIATE 3,078
AND IN A MANNER THAT ASSURES CONTINUITY; 3,079
(2) MADE EFFECTIVE ARRANGEMENTS TO ENSURE THAT ITS 3,081
ENROLLEES HAVE RELIABLE ACCESS TO QUALIFIED PROVIDERS IN THOSE 3,082
SPECIALTIES THAT ARE GENERALLY AVAILABLE IN THE GEOGRAPHIC AREA 3,083
OR AREAS TO BE SERVED BY THE APPLICANT AND THAT ARE NECESSARY TO 3,084
PROVIDE ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 3,085
CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE; 3,087
(3) MADE APPROPRIATE ARRANGEMENTS FOR THE AVAILABILITY OF 3,089
SHORT-TERM HEALTH CARE SERVICES IN EMERGENCIES WITHIN THE 3,090
GEOGRAPHIC AREA OR AREAS TO BE SERVED BY THE APPLICANT, 3,091
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK, AND FOR THE 3,092
PROVISION OF ADEQUATE COVERAGE WHENEVER AN OUT-OF-AREA EMERGENCY 3,093
ARISES; 3,094
(4) MADE APPROPRIATE ARRANGEMENTS FOR AN ONGOING 3,096
EVALUATION AND ASSURANCE OF THE QUALITY OF HEALTH CARE SERVICES 3,097
PROVIDED TO ENROLLEES AND THE ADEQUACY OF THE PERSONNEL, 3,098
FACILITIES, AND EQUIPMENT BY OR THROUGH WHICH THE SERVICES ARE 3,099
RENDERED;
(5) DEVELOPED A PROCEDURE TO GATHER AND REPORT STATISTICS 3,101
RELATING TO THE COST AND EFFECTIVENESS OF ITS OPERATIONS, THE 3,102
PATTERN OF UTILIZATION OF ITS SERVICES, AND THE QUALITY, 3,103
AVAILABILITY, AND ACCESSIBILITY OF ITS SERVICES. 3,104
(C) WITHIN NINETY DAYS OF THE DIRECTOR'S RECEIPT OF THE 3,106
71
APPLICATION FOR ISSUANCE OF A CERTIFICATE OF AUTHORITY, THE 3,108
DIRECTOR SHALL CERTIFY TO THE SUPERINTENDENT WHETHER OR NOT THE 3,109
APPLICANT MEETS THE REQUIREMENTS OF DIVISION (B) OF THIS SECTION 3,110
AND SECTIONS 3702.51 TO 3702.62 OF THE REVISED CODE. IF THE 3,111
DIRECTOR CERTIFIES THAT THE APPLICANT DOES NOT MEET THESE 3,112
REQUIREMENTS, THE DIRECTOR SHALL SPECIFY IN WHAT RESPECTS IT IS 3,113
DEFICIENT. HOWEVER, THE DIRECTOR SHALL NOT CERTIFY THAT THE 3,114
REQUIREMENTS OF THIS SECTION ARE NOT MET UNLESS THE APPLICANT HAS 3,115
BEEN GIVEN AN OPPORTUNITY FOR A HEARING. 3,116
(D) IF THE APPLICANT REQUESTS A HEARING, THE DIRECTOR 3,119
SHALL HOLD A HEARING BEFORE CERTIFYING THAT THE APPLICANT DOES 3,120
NOT MEET THE REQUIREMENTS OF THIS SECTION. THE HEARING SHALL BE 3,121
HELD IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,123
(E) THE NINETY-DAY REVIEW PERIOD PROVIDED FOR UNDER 3,126
DIVISION (C) OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON 3,128
WHICH THE NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS 3,129
MAILED AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A 3,130
FINAL CERTIFICATION ORDER.
Sec. 1751.05. (A) THE SUPERINTENDENT OF INSURANCE SHALL 3,133
ISSUE OR DENY A CERTIFICATE OF AUTHORITY TO ESTABLISH OR OPERATE 3,134
A HEALTH INSURING CORPORATION TO ANY CORPORATION FILING AN 3,135
APPLICATION PURSUANT TO SECTION 1751.03 OF THE REVISED CODE 3,137
WITHIN FORTY-FIVE DAYS OF THE SUPERINTENDENT'S RECEIPT OF THE 3,138
CERTIFICATION FROM THE DIRECTOR OF HEALTH UNDER DIVISION (C) OF 3,139
SECTION 1751.04 OF THE REVISED CODE. A CERTIFICATE OF AUTHORITY 3,140
SHALL BE ISSUED UPON PAYMENT OF THE APPLICATION FEE PRESCRIBED IN 3,141
SECTION 1751.44 OF THE REVISED CODE IF THE SUPERINTENDENT IS 3,142
SATISFIED THAT THE FOLLOWING CONDITIONS ARE MET: 3,143
(1) THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS 3,146
OF THE APPLICANT ARE COMPETENT, TRUSTWORTHY, AND POSSESS GOOD 3,147
REPUTATIONS.
(2) THE DIRECTOR CERTIFIES, IN ACCORDANCE WITH DIVISION 3,149
(C) OF SECTION 1751.04 OF THE REVISED CODE, THAT THE 3,150
ORGANIZATION'S PROPOSED PLAN OF OPERATION MEETS THE REQUIREMENTS 3,151
72
OF DIVISION (B) OF THAT SECTION AND SECTIONS 3702.51 TO 3702.62 3,153
OF THE REVISED CODE. IF, AFTER THE DIRECTOR HAS CERTIFIED 3,154
COMPLIANCE, THE APPLICATION IS AMENDED IN A MANNER THAT AFFECTS 3,155
ITS APPROVAL UNDER SECTION 1751.04 OF THE REVISED CODE, THE 3,156
SUPERINTENDENT SHALL REQUEST THE DIRECTOR TO REVIEW AND RECERTIFY 3,157
THE AMENDED PLAN OF OPERATION. WITHIN FORTY-FIVE DAYS OF RECEIPT 3,158
OF THE AMENDED PLAN FROM THE SUPERINTENDENT, THE DIRECTOR SHALL 3,159
CERTIFY TO THE SUPERINTENDENT, PURSUANT TO SECTION 1751.04 OF THE 3,160
REVISED CODE, WHETHER OR NOT THE AMENDED PLAN MEETS THE 3,162
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. THE 3,163
SUPERINTENDENT'S FORTY-FIVE-DAY REVIEW PERIOD SHALL CEASE TO RUN 3,164
AS OF THE DATE ON WHICH THE AMENDED PLAN IS TRANSMITTED TO THE 3,165
DIRECTOR AND SHALL REMAIN SUSPENDED UNTIL THE SUPERINTENDENT 3,166
RECEIVES A NEW CERTIFICATION FROM THE DIRECTOR.
(3) THE APPLICANT CONSTITUTES AN APPROPRIATE MECHANISM TO 3,168
EFFECTIVELY PROVIDE OR ARRANGE FOR THE PROVISION OF THE BASIC 3,169
HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH CARE SERVICES, OR 3,170
SPECIALTY HEALTH CARE SERVICES TO BE PROVIDED TO ENROLLEES. 3,171
(4) THE APPLICANT IS FINANCIALLY RESPONSIBLE, COMPLIES 3,173
WITH SECTION 1751.28 OF THE REVISED CODE, AND MAY REASONABLY BE 3,175
EXPECTED TO MEET ITS OBLIGATIONS TO ENROLLEES AND PROSPECTIVE 3,176
ENROLLEES. IN MAKING THIS DETERMINATION, THE SUPERINTENDENT MAY 3,177
CONSIDER: 3,178
(a) THE FINANCIAL SOUNDNESS OF THE APPLICANT'S 3,180
ARRANGEMENTS FOR HEALTH CARE SERVICES, INCLUDING THE APPLICANT'S 3,181
PROPOSED CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUMS AND THE USE 3,182
OF COPAYMENTS OR DEDUCTIBLES; 3,183
(b) THE ADEQUACY OF WORKING CAPITAL; 3,185
(c) ANY AGREEMENT WITH AN INSURER, A GOVERNMENT, OR ANY 3,188
OTHER PERSON FOR INSURING THE PAYMENT OF THE COST OF HEALTH CARE 3,189
SERVICES OR PROVIDING FOR AUTOMATIC APPLICABILITY OF AN 3,190
ALTERNATIVE COVERAGE IN THE EVENT OF DISCONTINUANCE OF THE HEALTH 3,191
INSURING CORPORATION'S OPERATIONS; 3,192
(d) ANY AGREEMENT WITH PROVIDERS OR HEALTH CARE FACILITIES 3,194
73
FOR THE PROVISION OF HEALTH CARE SERVICES; 3,195
(e) ANY DEPOSIT OF SECURITIES SUBMITTED IN ACCORDANCE WITH 3,198
SECTION 1751.27 OF THE REVISED CODE AS A GUARANTEE THAT THE 3,199
OBLIGATIONS WILL BE PERFORMED. 3,200
(5) THE APPLICANT HAS SUBMITTED DOCUMENTATION OF AN 3,202
ARRANGEMENT TO PROVIDE HEALTH CARE SERVICES TO ITS ENROLLEES 3,203
UNTIL THE EXPIRATION OF THE ENROLLEES' CONTRACTS WITH THE 3,204
APPLICANT IF A HEALTH CARE PLAN OR THE OPERATIONS OF THE HEALTH 3,205
INSURING CORPORATION ARE DISCONTINUED PRIOR TO THE EXPIRATION OF 3,206
THE ENROLLEES' CONTRACTS. AN ARRANGEMENT TO PROVIDE HEALTH CARE 3,207
SERVICES MAY BE MADE BY USING ANY ONE, OR ANY COMBINATION, OF THE 3,209
FOLLOWING METHODS:
(a) THE MAINTENANCE OF INSOLVENCY INSURANCE; 3,211
(b) A PROVISION IN CONTRACTS WITH PROVIDERS AND HEALTH 3,214
CARE FACILITIES, BUT NO HEALTH INSURING CORPORATION SHALL RELY 3,215
SOLELY ON SUCH A PROVISION FOR MORE THAN THIRTY DAYS; 3,216
(c) AN AGREEMENT WITH OTHER HEALTH INSURING CORPORATIONS 3,219
OR INSURERS, PROVIDING ENROLLEES WITH AUTOMATIC CONVERSION RIGHTS 3,220
UPON THE DISCONTINUATION OF A HEALTH CARE PLAN OR THE HEALTH 3,221
INSURING CORPORATION'S OPERATIONS; 3,222
(d) SUCH OTHER METHODS AS APPROVED BY THE SUPERINTENDENT. 3,224
(6) NOTHING IN THE APPLICANT'S PROPOSED METHOD OF 3,226
OPERATION, AS SHOWN BY THE INFORMATION SUBMITTED PURSUANT TO 3,227
SECTION 1751.03 OF THE REVISED CODE OR BY INDEPENDENT 3,229
INVESTIGATION, WILL CAUSE HARM TO AN ENROLLEE OR TO THE PUBLIC AT 3,231
LARGE, AS DETERMINED BY THE SUPERINTENDENT.
(7) ANY DEFICIENCIES CERTIFIED BY THE DIRECTOR HAVE BEEN 3,233
CORRECTED. 3,234
(8) THE APPLICANT HAS DEPOSITED SECURITIES AS SET FORTH IN 3,237
SECTION 1751.27 OF THE REVISED CODE.
(B) IF AN APPLICANT ELECTS TO FULFILL THE REQUIREMENTS OF 3,240
DIVISION (A)(5) OF THIS SECTION THROUGH AN AGREEMENT WITH OTHER 3,242
HEALTH INSURING CORPORATIONS OR INSURERS, THE AGREEMENT SHALL 3,243
REQUIRE THOSE HEALTH INSURING CORPORATIONS OR INSURERS TO GIVE 3,244
74
THIRTY DAYS' NOTICE TO THE SUPERINTENDENT PRIOR TO CANCELLATION 3,245
OR DISCONTINUATION OF THE AGREEMENT FOR ANY REASON. 3,246
(C) A CERTIFICATE OF AUTHORITY SHALL BE DENIED ONLY AFTER 3,249
COMPLIANCE WITH THE REQUIREMENTS OF SECTION 1751.36 OF THE 3,250
REVISED CODE.
Sec. 1751.06. UPON OBTAINING A CERTIFICATE OF AUTHORITY AS 3,252
REQUIRED UNDER THIS CHAPTER, A HEALTH INSURING CORPORATION MAY DO 3,254
ALL OF THE FOLLOWING:
(A) ENROLL INDIVIDUALS AND THEIR DEPENDENTS IN EITHER OF 3,257
THE FOLLOWING CIRCUMSTANCES: 3,258
(1) THE INDIVIDUAL RESIDES IN THE APPROVED SERVICE AREA. 3,261
(2) THE INDIVIDUAL'S PLACE OF EMPLOYMENT IS LOCATED IN THE 3,264
APPROVED SERVICE AREA AND THE INDIVIDUAL HAS AGREED TO RECEIVE 3,265
HEALTH CARE SERVICES IN ACCORDANCE WITH THE EVIDENCE OF COVERAGE. 3,266
(B) CONTRACT WITH PROVIDERS AND HEALTH CARE FACILITIES FOR 3,269
THE HEALTH CARE SERVICES TO WHICH ENROLLEES ARE ENTITLED UNDER 3,270
THE TERMS OF THE HEALTH INSURING CORPORATION'S HEALTH CARE 3,271
CONTRACTS;
(C) CONTRACT WITH INSURANCE COMPANIES AUTHORIZED TO DO 3,274
BUSINESS IN THIS STATE FOR INSURANCE, INDEMNITY, OR REIMBURSEMENT 3,275
AGAINST THE COST OF PROVIDING EMERGENCY AND NONEMERGENCY HEALTH 3,276
CARE SERVICES FOR ENROLLEES, SUBJECT TO THE PROVISIONS SET FORTH 3,277
IN THIS CHAPTER AND THE LIMITATIONS SET FORTH IN THE REVISED 3,279
CODE;
(D) CONTRACT WITH ANY PERSON PURSUANT TO THE REQUIREMENTS 3,282
OF DIVISION (A)(18) OF SECTION 1751.03 OF THE REVISED CODE FOR 3,284
MANAGERIAL OR ADMINISTRATIVE SERVICES, OR FOR DATA PROCESSING, 3,285
ACTUARIAL ANALYSIS, BILLING SERVICES, OR ANY OTHER SERVICES 3,286
AUTHORIZED BY THE SUPERINTENDENT OF INSURANCE. HOWEVER, A HEALTH 3,288
INSURING CORPORATION SHALL NOT ENTER INTO A CONTRACT FOR ANY OF 3,289
THE SERVICES LISTED IN THIS DIVISION WITH AN INSURANCE COMPANY 3,290
THAT IS NOT AUTHORIZED TO ENGAGE IN THE BUSINESS OF INSURANCE IN 3,291
THIS STATE.
(E) ACCEPT FROM GOVERNMENTAL AGENCIES, PRIVATE AGENCIES, 3,294
75
CORPORATIONS, ASSOCIATIONS, GROUPS, INDIVIDUALS, OR OTHER 3,295
PERSONS, PAYMENTS COVERING ALL OR PART OF THE COSTS OF PLANNING, 3,296
DEVELOPMENT, CONSTRUCTION, AND THE PROVISION OF HEALTH CARE 3,297
SERVICES;
(F) PURCHASE, LEASE, CONSTRUCT, RENOVATE, OPERATE, OR 3,300
MAINTAIN HEALTH CARE FACILITIES, AND THEIR ANCILLARY EQUIPMENT, 3,301
AND ANY PROPERTY NECESSARY IN THE TRANSACTION OF THE BUSINESS OF 3,302
THE HEALTH INSURING CORPORATION. 3,303
NOTHING IN THIS SECTION SHALL BE CONSTRUED AS PROHIBITING A 3,305
HEALTH INSURING CORPORATION WITHOUT OTHER COMMERCIAL ENROLLMENT 3,306
FROM CONTRACTING SOLELY WITH FEDERAL HEALTH CARE PROGRAMS 3,307
REGULATED BY FEDERAL REGULATORY BODIES.
NOTHING IN THIS SECTION SHALL BE CONSTRUED TO LIMIT THE 3,309
AUTHORITY OF A HEALTH INSURING CORPORATION TO PERFORM THOSE 3,310
FUNCTIONS NOT OTHERWISE PROHIBITED BY LAW. 3,311
Sec. 1751.07. ANY TRUSTEE, DIRECTOR, OFFICER, OR EMPLOYEE 3,313
OF A HEALTH INSURING CORPORATION WHO RECEIVES, COLLECTS, 3,314
DISBURSES, OR INVESTS FUNDS IN CONNECTION WITH THE ACTIVITIES OF 3,315
THE HEALTH INSURING CORPORATION SHALL BE RESPONSIBLE FOR SUCH 3,316
FUNDS IN A FIDUCIARY RELATIONSHIP TO THE CORPORATION. 3,317
Sec. 1751.08. (A) EXCEPT AS OTHERWISE SPECIFICALLY 3,320
PROVIDED IN THIS CHAPTER OR TITLE XXXIX OF THE REVISED CODE, 3,322
PROVISIONS OF TITLE XXXIX OF THE REVISED CODE SHALL NOT BE 3,323
APPLICABLE TO ANY HEALTH INSURING CORPORATION HOLDING A 3,324
CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. THIS DIVISION SHALL 3,325
NOT APPLY TO AN INSURER LICENSED AND REGULATED PURSUANT TO TITLE 3,327
XXXIX OF THE REVISED CODE EXCEPT WITH RESPECT TO ITS HEALTH 3,329
INSURING CORPORATION ACTIVITIES AUTHORIZED AND REGULATED PURSUANT 3,330
TO THIS CHAPTER.
(B) FOR THE PURPOSE OF CLARIFYING JURISDICTION UNDER THE 3,334
"BANKRUPTCY REFORM ACT OF 1978," 92 STAT. 2549, 11 U.S.C.A. 101, 3,336
AND IN RECOGNITION OF THE RIGHT OF THIS STATE TO REGULATE
DOMESTIC INSURANCE COMPANIES UNDER THE "McCARRAN-FERGUSON ACT," 3,338
59 STAT. 33 (1945), 15 U.S.C.A. 1011, A HEALTH INSURING 3,341
76
CORPORATION IS DEEMED TO BE A DOMESTIC INSURANCE COMPANY. 3,342
(C) SOLICITATION OF ENROLLEES BY A HEALTH INSURING 3,345
CORPORATION HOLDING A CERTIFICATE OF AUTHORITY UNDER THIS 3,346
CHAPTER, OR ITS REPRESENTATIVES, SHALL NOT BE CONSTRUED TO 3,347
VIOLATE ANY PROVISION OF LAW RELATING TO SOLICITATION OR 3,348
ADVERTISING BY HEALTH PROFESSIONALS.
(D) ANY HEALTH INSURING CORPORATION HOLDING A CERTIFICATE 3,351
OF AUTHORITY UNDER THIS CHAPTER SHALL NOT BE CONSIDERED TO BE 3,352
PRACTICING MEDICINE. 3,353
Sec. 1751.11. (A) EVERY SUBSCRIBER OF A HEALTH INSURING 3,356
CORPORATION IS ENTITLED TO AN EVIDENCE OF COVERAGE FOR THE HEALTH 3,357
CARE PLAN UNDER WHICH HEALTH CARE BENEFITS ARE PROVIDED. 3,359
(B) EVERY SUBSCRIBER OF A HEALTH INSURING CORPORATION THAT 3,361
OFFERS BASIC HEALTH CARE SERVICES IS ENTITLED TO AN 3,362
IDENTIFICATION CARD OR SIMILAR DOCUMENT THAT SPECIFIES THE HEALTH 3,363
INSURING CORPORATION'S NAME AS STATED IN ITS ARTICLES OF 3,364
INCORPORATION, AND ANY TRADE OR FICTITIOUS NAMES USED BY THE 3,365
HEALTH INSURING CORPORATION. THE IDENTIFICATION CARD OR DOCUMENT 3,366
SHALL LIST AT LEAST ONE TELEPHONE NUMBER THAT PROVIDES THE 3,367
SUBSCRIBER WITH ACCESS TO HEALTH CARE ON A 3,368
TWENTY-FOUR-HOUR-PER-DAY, SEVEN-DAY-PER-WEEK BASIS.
(C) NO EVIDENCE OF COVERAGE, OR AMENDMENT TO THE EVIDENCE 3,370
OF COVERAGE, SHALL BE DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR 3,371
USED, UNTIL THE FORM OF THE EVIDENCE OF COVERAGE OR AMENDMENT HAS 3,372
BEEN FILED BY THE HEALTH INSURING CORPORATION WITH THE 3,373
SUPERINTENDENT OF INSURANCE. IF THE SUPERINTENDENT DOES NOT 3,374
DISAPPROVE THE EVIDENCE OF COVERAGE OR AMENDMENT WITHIN SIXTY 3,375
DAYS AFTER IT IS FILED IT SHALL BE DEEMED APPROVED, UNLESS THE 3,376
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE EVIDENCE OF COVERAGE 3,377
OR AMENDMENT. WITH RESPECT TO AN AMENDMENT TO AN APPROVED 3,378
EVIDENCE OF COVERAGE, THE SUPERINTENDENT ONLY MAY DISAPPROVE 3,379
PROVISIONS AMENDED OR ADDED TO THE EVIDENCE OF COVERAGE. IF THE 3,380
SUPERINTENDENT DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT ANY 3,381
EVIDENCE OF COVERAGE OR AMENDMENT FAILS TO MEET THE REQUIREMENTS 3,382
77
OF THIS SECTION, THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH 3,383
INSURING CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH 3,384
INSURING CORPORATION TO USE SUCH EVIDENCE OF COVERAGE OR 3,385
AMENDMENT. AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,387
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,388
WITHDRAW AN APPROVAL, DEEMED OR ACTUAL, OF ANY EVIDENCE OF
COVERAGE OR AMENDMENT ON ANY OF THE GROUNDS STATED IN THIS 3,389
SECTION. SUCH DISAPPROVAL SHALL BE EFFECTED BY A WRITTEN ORDER, 3,390
WHICH SHALL STATE THE GROUNDS FOR DISAPPROVAL AND SHALL BE ISSUED 3,392
IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,394
(D) NO EVIDENCE OF COVERAGE OR AMENDMENT SHALL BE 3,396
DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR USED: 3,397
(1) IF IT CONTAINS PROVISIONS OR STATEMENTS THAT ARE 3,399
INEQUITABLE, UNTRUE, MISLEADING, OR DECEPTIVE; 3,400
(2) UNLESS IT CONTAINS A CLEAR, CONCISE, AND COMPLETE 3,402
STATEMENT OF THE FOLLOWING: 3,403
(a) THE HEALTH CARE SERVICES AND INSURANCE OR OTHER 3,406
BENEFITS, IF ANY, TO WHICH THE ENROLLEE IS ENTITLED UNDER THE 3,407
HEALTH CARE PLAN;
(b) ANY EXCLUSIONS OR LIMITATIONS ON THE HEALTH CARE 3,410
SERVICES, TYPE OF HEALTH CARE SERVICES, BENEFITS, OR TYPE OF 3,411
BENEFITS TO BE PROVIDED, INCLUDING COPAYMENTS OR DEDUCTIBLES; 3,412
(c) THE ENROLLEE'S PERSONAL FINANCIAL OBLIGATION FOR 3,414
NON-COVERED SERVICES; 3,415
(d) WHERE AND IN WHAT MANNER GENERAL INFORMATION AND 3,418
INFORMATION AS TO HOW SERVICES MAY BE OBTAINED IS AVAILABLE, 3,419
INCLUDING THE TELEPHONE NUMBER; 3,420
(e) THE PREMIUM RATE WITH RESPECT TO INDIVIDUAL AND 3,422
CONVERSION CONTRACTS, AND RELEVANT COPAYMENT PROVISIONS WITH 3,423
RESPECT TO ALL CONTRACTS. THE STATEMENT OF THE PREMIUM RATE, 3,424
HOWEVER, MAY BE CONTAINED IN A SEPARATE INSERT. 3,425
(f) THE METHOD UTILIZED BY THE HEALTH INSURING CORPORATION 3,428
FOR RESOLVING ENROLLEE COMPLAINTS. 3,429
(3) UNLESS IT PROVIDES FOR THE CONTINUATION OF AN 3,431
78
ENROLLEE'S COVERAGE, IN THE EVENT THAT THE ENROLLEE'S COVERAGE 3,432
UNDER THE POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT TERMINATES 3,433
WHILE THE ENROLLEE IS RECEIVING INPATIENT CARE IN A HOSPITAL. 3,434
THIS CONTINUATION OF COVERAGE SHALL TERMINATE AT THE EARLIEST 3,435
OCCURRENCE OF ANY OF THE FOLLOWING: 3,436
(a) THE ENROLLEE'S DISCHARGE FROM THE HOSPITAL; 3,438
(b) THE DETERMINATION BY THE ENROLLEE'S ATTENDING 3,440
PHYSICIAN THAT INPATIENT CARE IS NO LONGER MEDICALLY INDICATED 3,441
FOR THE ENROLLEE;
(c) THE ENROLLEE'S REACHING THE LIMIT FOR CONTRACTUAL 3,443
BENEFITS. 3,444
(4) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,446
SUBSTANCE, THAT THE HEALTH INSURING CORPORATION IS NOT A MEMBER 3,447
OF ANY GUARANTY FUND, AND THAT IN THE EVENT OF THE HEALTH 3,448
INSURING CORPORATION'S INSOLVENCY, THE ENROLLEE IS PROTECTED ONLY 3,450
TO THE EXTENT THAT THE HOLD HARMLESS PROVISION REQUIRED BY
SECTION 1751.13 OF THE REVISED CODE APPLIES TO THE HEALTH CARE 3,452
SERVICES RENDERED; 3,453
(5) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,455
SUBSTANCE, THAT IN THE EVENT OF THE INSOLVENCY OF THE HEALTH 3,456
INSURING CORPORATION, THE ENROLLEE MAY BE FINANCIALLY RESPONSIBLE 3,458
FOR HEALTH CARE SERVICES RENDERED BY A PROVIDER OR HEALTH CARE 3,459
FACILITY THAT IS NOT UNDER CONTRACT TO THE HEALTH INSURING 3,460
CORPORATION, WHETHER OR NOT THE HEALTH INSURING CORPORATION 3,461
AUTHORIZED THE USE OF THE PROVIDER OR HEALTH CARE FACILITY. 3,462
(E) NOTWITHSTANDING DIVISION (D) OF THIS SECTION, A HEALTH 3,466
INSURING CORPORATION MAY USE AN EVIDENCE OF COVERAGE THAT
PROVIDES FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,468
XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,470
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 3,471
MEDICARE COST CONTRACT, OR AN EVIDENCE OF COVERAGE THAT PROVIDES 3,472
FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL 3,473
EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR 3,476
AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE OF 3,477
79
BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY ACT," 3,479
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS THE 3,480
MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 3,482
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 3,483
CODE, OR AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE 3,484
OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE PROGRAM 3,485
REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE FOLLOWING
APPLY: 3,486
(1) THE EVIDENCE OF COVERAGE HAS BEEN APPROVED BY THE 3,489
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 3,490
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 3,491
HUMAN SERVICES.
(2) THE EVIDENCE OF COVERAGE IS FILED WITH THE 3,493
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 3,494
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,496
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,497
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,498
Sec. 1751.12. (A)(1) NO CONTRACTUAL PERIODIC PREPAYMENT 3,501
AND NO PREMIUM RATE FOR NONGROUP AND CONVERSION POLICIES FOR 3,502
HEALTH CARE SERVICES, OR ANY AMENDMENT TO THEM, MAY BE USED BY 3,503
ANY HEALTH INSURING CORPORATION AT ANY TIME UNTIL THE CONTRACTUAL 3,504
PERIODIC PREPAYMENT AND PREMIUM RATE, OR AMENDMENT, HAVE BEEN 3,505
FILED WITH THE SUPERINTENDENT OF INSURANCE, AND SHALL NOT BE 3,506
EFFECTIVE UNTIL THE EXPIRATION OF SIXTY DAYS AFTER THEIR FILING 3,507
UNLESS THE SUPERINTENDENT SOONER GIVES APPROVAL. THE 3,508
SUPERINTENDENT SHALL DISAPPROVE THE FILING, IF THE SUPERINTENDENT 3,509
DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT THE CONTRACTUAL 3,510
PERIODIC PREPAYMENT OR PREMIUM RATE, OR AMENDMENT, IS NOT IN 3,511
ACCORDANCE WITH SOUND ACTUARIAL PRINCIPLES OR IS NOT REASONABLY 3,512
RELATED TO THE APPLICABLE COVERAGE AND CHARACTERISTICS OF THE 3,513
APPLICABLE CLASS OF ENROLLEES. THE SUPERINTENDENT SHALL NOTIFY 3,514
THE HEALTH INSURING CORPORATION OF THE DISAPPROVAL, AND IT SHALL 3,515
THEREAFTER BE UNLAWFUL FOR THE HEALTH INSURING CORPORATION TO USE 3,516
THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, OR 3,517
80
AMENDMENT.
(2) NO CONTRACTUAL PERIODIC PREPAYMENT FOR GROUP POLICIES 3,520
FOR HEALTH CARE SERVICES SHALL BE USED UNTIL THE CONTRACTUAL 3,521
PERIODIC PREPAYMENT HAS BEEN FILED WITH THE SUPERINTENDENT. THE 3,522
SUPERINTENDENT MAY REJECT A FILING MADE UNDER DIVISION (A)(2) OF 3,523
THIS SECTION AT ANY TIME, WITH AT LEAST THIRTY DAYS' WRITTEN 3,524
NOTICE TO A HEALTH INSURING CORPORATION, IF THE CONTRACTUAL 3,525
PERIODIC PREPAYMENT IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,527
PRINCIPLES OR IS NOT REASONABLY RELATED TO THE APPLICABLE 3,528
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,529
ENROLLEES.
(3) AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,531
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,532
WITHDRAW THE APPROVAL GIVEN UNDER DIVISION (A)(1) OF THIS 3,533
SECTION, DEEMED OR ACTUAL, OF ANY CONTRACTUAL PERIODIC PREPAYMENT 3,535
OR PREMIUM RATE, OR AMENDMENT, BASED ON INFORMATION THAT EITHER 3,536
OF THE FOLLOWING APPLIES:
(a) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,539
OR AMENDMENT, IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,540
PRINCIPLES.
(b) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,543
OR AMENDMENT, IS NOT REASONABLY RELATED TO THE APPLICABLE 3,544
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,545
ENROLLEES.
(4) ANY DISAPPROVAL UNDER DIVISION (A)(1) OF THIS SECTION, 3,547
ANY REJECTION OF A FILING MADE UNDER DIVISION (A)(2) OF THIS 3,549
SECTION, OR ANY WITHDRAWAL OF APPROVAL UNDER DIVISION (A)(3) OF 3,550
THIS SECTION, SHALL BE EFFECTED BY A WRITTEN NOTICE, WHICH SHALL 3,551
STATE THE SPECIFIC BASIS FOR THE DISAPPROVAL, REJECTION, OR 3,552
WITHDRAWAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. OF 3,553
THE REVISED CODE. 3,554
(B) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 3,557
INSURING CORPORATION MAY USE A CONTRACTUAL PERIODIC PREPAYMENT OR 3,558
PREMIUM RATE FOR POLICIES USED FOR THE COVERAGE OF BENEFICIARIES 3,559
81
ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 3,561
620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE 3,563
RISK CONTRACT OR MEDICARE COST CONTRACT, OR FOR POLICIES USED FOR 3,564
THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEES 3,565
HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR FOR 3,568
POLICIES USED FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,569
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,572
U.S.C.A. 301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM 3,574
OR MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES 3,575
UNDER CHAPTER 5111. OF THE REVISED CODE, OR FOR POLICIES USED FOR 3,576
THE COVERAGE OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE 3,577
PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE 3,578
FOLLOWING APPLY: 3,579
(1) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE 3,581
HAS BEEN APPROVED BY THE UNITED STATES DEPARTMENT OF HEALTH AND 3,582
HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL MANAGEMENT, 3,584
OR THE OHIO DEPARTMENT OF HUMAN SERVICES.
(2) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE IS 3,586
FILED WITH THE SUPERINTENDENT PRIOR TO USE AND IS ACCOMPANIED BY 3,587
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,589
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,591
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,593
(C) THE ADMINISTRATIVE EXPENSE PORTION OF ALL CONTRACTUAL 3,596
PERIODIC PREPAYMENT OR PREMIUM RATE FILINGS SUBMITTED TO THE 3,597
SUPERINTENDENT FOR REVIEW MUST REFLECT THE ACTUAL COST OF 3,598
ADMINISTERING THE PRODUCT. THE SUPERINTENDENT MAY REQUIRE THAT 3,599
THE ADMINISTRATIVE EXPENSE PORTION OF THE FILINGS BE ITEMIZED AND 3,600
SUPPORTED.
(D)(1) COPAYMENTS AND DEDUCTIBLES MUST BE REASONABLE AND 3,603
MUST NOT BE A BARRIER TO THE NECESSARY UTILIZATION OF SERVICES BY 3,604
ENROLLEES.
(2) A HEALTH INSURING CORPORATION MAY NOT IMPOSE COPAYMENT 3,607
CHARGES ON BASIC HEALTH CARE SERVICES THAT EXCEED THIRTY PER CENT 3,608
OF THE TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE 3,609
82
SERVICE, EXCEPT FOR EMERGENCY HEALTH SERVICES AND URGENT CARE 3,610
SERVICES. THE TOTAL COST OF PROVIDING A HEALTH CARE SERVICE IS 3,611
THE COST TO THE HEALTH INSURING CORPORATION OF PROVIDING THE 3,612
HEALTH CARE SERVICE TO THE ENROLLEE AS REDUCED BY ANY APPLICABLE 3,613
PROVIDER DISCOUNT. AN OPEN PANEL PLAN MAY NOT IMPOSE COPAYMENTS 3,614
ON OUT-OF-NETWORK BENEFITS THAT EXCEED FIFTY PER CENT OF THE 3,615
TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE SERVICE. 3,616
(3) TO ENSURE THAT COPAYMENTS ARE NOT A BARRIER TO THE 3,618
UTILIZATION OF BASIC HEALTH CARE SERVICES, A HEALTH INSURING 3,619
CORPORATION MAY NOT IMPOSE, IN ANY CONTRACT YEAR, ON ANY 3,620
SUBSCRIBER OR ENROLLEE, COPAYMENTS THAT EXCEED TWO HUNDRED PER 3,621
CENT OF THE TOTAL ANNUAL PREMIUM RATE TO THE SUBSCRIBER OR 3,622
ENROLLEES. THIS LIMITATION OF TWO HUNDRED PER CENT DOES NOT 3,624
INCLUDE ANY REASONABLE COPAYMENTS THAT ARE NOT A BARRIER TO THE 3,625
NECESSARY UTILIZATION OF HEALTH CARE SERVICES BY ENROLLEES AND 3,626
THAT ARE IMPOSED ON PHYSICIAN OFFICE VISITS, EMERGENCY HEALTH 3,627
SERVICES, URGENT CARE SERVICES, SUPPLEMENTAL HEALTH CARE 3,628
SERVICES, OR SPECIALTY HEALTH CARE SERVICES.
(E) A HEALTH INSURING CORPORATION SHALL NOT IMPOSE 3,631
LIFETIME MAXIMUMS ON BASIC HEALTH CARE SERVICES. HOWEVER, A 3,632
HEALTH INSURING CORPORATION MAY ESTABLISH A BENEFIT LIMIT FOR 3,633
INPATIENT HOSPITAL SERVICES THAT ARE PROVIDED PURSUANT TO A 3,634
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT FOR SUPPLEMENTAL 3,635
HEALTH CARE SERVICES.
Sec. 1751.13. (A)(1) A HEALTH INSURING CORPORATION SHALL, 3,638
EITHER DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS FOR THE 3,639
PROVISION OF HEALTH CARE SERVICES WITH A SUFFICIENT NUMBER AND 3,640
TYPES OF PROVIDERS AND HEALTH CARE FACILITIES TO ENSURE THAT ALL 3,641
COVERED HEALTH CARE SERVICES WILL BE ACCESSIBLE TO ENROLLEES FROM 3,642
A CONTRACTED PROVIDER OR HEALTH CARE FACILITY. 3,643
(2) WHEN A HEALTH INSURING CORPORATION IS UNABLE TO 3,645
PROVIDE A COVERED HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,646
OR HEALTH CARE FACILITY, THE HEALTH INSURING CORPORATION MUST 3,647
PROVIDE THAT HEALTH CARE SERVICE FROM A NONCONTRACTED PROVIDER OR 3,649
83
HEALTH CARE FACILITY CONSISTENT WITH THE TERMS OF THE ENROLLEE'S 3,650
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT. THE HEALTH INSURING 3,651
CORPORATION SHALL EITHER ENSURE THAT THE HEALTH CARE SERVICE BE 3,652
PROVIDED AT NO GREATER COST TO THE ENROLLEE THAN IF THE ENROLLEE 3,653
HAD OBTAINED THE HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,654
OR HEALTH CARE FACILITY, OR MAKE OTHER ARRANGEMENTS ACCEPTABLE TO 3,655
THE SUPERINTENDENT OF INSURANCE. 3,656
(3) NOTHING IN THIS SECTION SHALL PROHIBIT A HEALTH 3,658
INSURING CORPORATION FROM ENTERING INTO CONTRACTS WITH 3,659
OUT-OF-STATE PROVIDERS OR HEALTH CARE FACILITIES THAT ARE 3,660
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THAT 3,661
STATE. 3,662
(B)(1) A HEALTH INSURING CORPORATION SHALL, EITHER 3,665
DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS WITH ALL PROVIDERS 3,666
AND HEALTH CARE FACILITIES THROUGH WHICH HEALTH CARE SERVICES ARE 3,667
PROVIDED TO ITS ENROLLEES.
(2) A HEALTH INSURING CORPORATION, UPON WRITTEN REQUEST, 3,669
SHALL ASSIST ITS CONTRACTED PROVIDERS IN FINDING STOP-LOSS OR 3,670
REINSURANCE CARRIERS.
(C) A HEALTH INSURING CORPORATION SHALL FILE AN ANNUAL 3,671
CERTIFICATE WITH THE SUPERINTENDENT CERTIFYING THAT ALL PROVIDER 3,672
CONTRACTS AND CONTRACTS WITH HEALTH CARE FACILITIES THROUGH WHICH 3,673
HEALTH CARE SERVICES ARE BEING PROVIDED CONTAIN THE FOLLOWING: 3,674
(1) A DESCRIPTION OF THE METHOD BY WHICH THE PROVIDER OR 3,676
HEALTH CARE FACILITY WILL BE NOTIFIED OF THE SPECIFIC HEALTH CARE 3,678
SERVICES FOR WHICH THE PROVIDER OR HEALTH CARE FACILITY WILL BE 3,679
RESPONSIBLE, INCLUDING ANY LIMITATIONS OR CONDITIONS ON SUCH 3,680
SERVICES;
(2) THE SPECIFIC HOLD HARMLESS PROVISION SPECIFYING 3,682
PROTECTION OF ENROLLEES SET FORTH AS FOLLOWS: 3,683
"[PROVIDER/HEALTH CARE FACILITY< AGREES THAT IN NO EVENT, 3,686
INCLUDING BUT NOT LIMITED TO NONPAYMENT BY THE HEALTH INSURING 3,687
CORPORATION, INSOLVENCY OF THE HEALTH INSURING CORPORATION, OR 3,688
BREACH OF THIS AGREEMENT, SHALL [PROVIDER/HEALTH CARE FACILITY< 3,690
84
BILL, CHARGE, COLLECT A DEPOSIT FROM, SEEK REMUNERATION OR 3,691
REIMBURSEMENT FROM, OR HAVE ANY RECOURSE AGAINST, A SUBSCRIBER, 3,692
ENROLLEE, PERSON TO WHOM HEALTH CARE SERVICES HAVE BEEN PROVIDED, 3,694
OR PERSON ACTING ON BEHALF OF THE COVERED ENROLLEE, FOR HEALTH 3,695
CARE SERVICES PROVIDED PURSUANT TO THIS AGREEMENT. THIS DOES NOT 3,696
PROHIBIT [PROVIDER/HEALTH CARE FACILITY< FROM COLLECTING 3,697
CO-INSURANCE, DEDUCTIBLES, OR COPAYMENTS AS SPECIFICALLY PROVIDED 3,699
IN THE EVIDENCE OF COVERAGE, OR FEES FOR UNCOVERED HEALTH CARE 3,700
SERVICES DELIVERED ON A FEE-FOR-SERVICE BASIS TO PERSONS 3,701
REFERENCED ABOVE, NOR FROM ANY RECOURSE AGAINST THE HEALTH 3,702
INSURING CORPORATION OR ITS SUCCESSOR."
(3) PROVISIONS REQUIRING THE PROVIDER OR HEALTH CARE 3,704
FACILITY TO CONTINUE TO PROVIDE COVERED HEALTH CARE SERVICES TO 3,705
ENROLLEES IN THE EVENT OF THE HEALTH INSURING CORPORATION'S 3,706
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. THE PROVISIONS SHALL 3,708
REQUIRE THE PROVIDER OR HEALTH CARE FACILITY TO CONTINUE TO 3,709
PROVIDE COVERED HEALTH CARE SERVICES TO ENROLLEES AS NEEDED TO 3,710
COMPLETE ANY MEDICALLY NECESSARY PROCEDURES COMMENCED BUT 3,711
UNFINISHED AT THE TIME OF THE HEALTH INSURING CORPORATION'S
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. IF AN ENROLLEE IS 3,712
RECEIVING NECESSARY INPATIENT CARE AT A HOSPITAL, THE PROVISIONS 3,713
MAY LIMIT THE REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES 3,714
RELATING TO THAT INPATIENT CARE IN ACCORDANCE WITH DIVISION 3,716
(D)(3) OF SECTION 1751.11 OF THE REVISED CODE, AND MAY ALSO LIMIT 3,717
SUCH REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES TO THE 3,718
PERIOD ENDING THIRTY DAYS AFTER THE HEALTH INSURING CORPORATION'S 3,719
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. 3,720
THE PROVISIONS REQUIRED BY DIVISION (C)(3) OF THIS SECTION 3,723
SHALL NOT REQUIRE ANY PROVIDER OR HEALTH CARE FACILITY TO 3,724
CONTINUE TO PROVIDE ANY COVERED HEALTH CARE SERVICE AFTER THE
OCCURRENCE OF ANY OF THE FOLLOWING: 3,725
(a) THE END OF THE THIRTY-DAY PERIOD FOLLOWING THE ENTRY OF 3,728
A LIQUIDATION ORDER UNDER CHAPTER 3903. OF THE REVISED CODE; 3,729
(b) THE END OF THE ENROLLEE'S PERIOD OF COVERAGE FOR A 3,731
85
CONTRACTUAL PREPAYMENT OR PREMIUM; 3,732
(c) THE ENROLLEE OBTAINS EQUIVALENT COVERAGE WITH ANOTHER 3,734
HEALTH INSURING CORPORATION OR INSURER, OR THE ENROLLEE'S 3,735
EMPLOYER OBTAINS SUCH COVERAGE FOR THE ENROLLEE; 3,736
(d) THE ENROLLEE OR THE ENROLLEE'S EMPLOYER TERMINATES 3,738
COVERAGE UNDER THE CONTRACT; 3,739
(e) A LIQUIDATOR EFFECTS A TRANSFER OF THE HEALTH INSURING 3,742
CORPORATION'S OBLIGATIONS UNDER THE CONTRACT UNDER DIVISION 3,743
(A)(8) OF SECTION 3903.21 OF THE REVISED CODE. 3,744
(4) A PROVISION CLEARLY STATING THE RIGHTS AND 3,746
RESPONSIBILITIES OF THE HEALTH INSURING CORPORATION, AND OF THE 3,747
CONTRACTED PROVIDERS AND HEALTH CARE FACILITIES, WITH RESPECT TO 3,748
ADMINISTRATIVE POLICIES AND PROGRAMS, INCLUDING, BUT NOT LIMITED 3,749
TO, PAYMENTS SYSTEMS, UTILIZATION REVIEW, QUALITY ASSESSMENT AND 3,750
IMPROVEMENT PROGRAMS, CREDENTIALING, CONFIDENTIALITY 3,751
REQUIREMENTS, AND ANY APPLICABLE FEDERAL OR STATE PROGRAMS. 3,753
(5) A PROVISION REGARDING THE AVAILABILITY AND 3,755
CONFIDENTIALITY OF THOSE HEALTH RECORDS MAINTAINED BY PROVIDERS 3,756
AND HEALTH CARE FACILITIES TO MONITOR AND EVALUATE THE QUALITY OF 3,758
CARE, TO CONDUCT EVALUATIONS AND AUDITS, AND TO DETERMINE ON A 3,759
CONCURRENT OR RETROSPECTIVE BASIS THE NECESSITY OF AND
APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED TO ENROLLEES. 3,760
THE PROVISION SHALL INCLUDE TERMS REQUIRING THE PROVIDER OR 3,761
HEALTH CARE FACILITY TO MAKE THESE HEALTH RECORDS AVAILABLE TO 3,762
APPROPRIATE STATE AND FEDERAL AUTHORITIES INVOLVED IN ASSESSING 3,763
THE QUALITY OF CARE OR IN INVESTIGATING THE GRIEVANCES OR 3,764
COMPLAINTS OF ENROLLEES, AND REQUIRING THE PROVIDER OR HEALTH 3,765
CARE FACILITY TO COMPLY WITH APPLICABLE STATE AND FEDERAL LAWS 3,766
RELATED TO THE CONFIDENTIALITY OF MEDICAL OR HEALTH RECORDS. 3,768
(6) A PROVISION THAT STATES THAT CONTRACTUAL RIGHTS AND 3,770
RESPONSIBILITIES MAY NOT BE ASSIGNED OR DELEGATED BY THE PROVIDER 3,772
OR HEALTH CARE FACILITY WITHOUT THE PRIOR WRITTEN CONSENT OF THE 3,773
HEALTH INSURING CORPORATION;
(7) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,775
86
FACILITY TO MAINTAIN ADEQUATE PROFESSIONAL LIABILITY AND 3,776
MALPRACTICE INSURANCE. THE PROVISION SHALL ALSO REQUIRE THE 3,777
PROVIDER OR HEALTH CARE FACILITY TO NOTIFY THE HEALTH INSURING 3,778
CORPORATION NOT MORE THAN TEN DAYS AFTER THE PROVIDER'S OR HEALTH 3,780
CARE FACILITY'S RECEIPT OF NOTICE OF ANY REDUCTION OR
CANCELLATION OF SUCH COVERAGE. 3,781
(8) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,783
FACILITY TO OBSERVE, PROTECT, AND PROMOTE THE RIGHTS OF ENROLLEES 3,785
AS PATIENTS;
(9) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,787
FACILITY TO PROVIDE HEALTH CARE SERVICES WITHOUT DISCRIMINATION 3,788
ON THE BASIS OF A PATIENT'S PARTICIPATION IN THE HEALTH CARE 3,789
PLAN, AGE, SEX, ETHNICITY, RELIGION, SEXUAL PREFERENCE, HEALTH 3,790
STATUS, OR DISABILITY, AND WITHOUT REGARD TO THE SOURCE OF 3,791
PAYMENTS MADE FOR HEALTH CARE SERVICES RENDERED TO A PATIENT. 3,792
THIS REQUIREMENT SHALL NOT APPLY TO CIRCUMSTANCES WHEN THE 3,793
PROVIDER OR HEALTH CARE FACILITY APPROPRIATELY DOES NOT RENDER 3,794
SERVICES DUE TO LIMITATIONS ARISING FROM THE PROVIDER'S OR HEALTH 3,796
CARE FACILITY'S LACK OF TRAINING, EXPERIENCE, OR SKILL, OR DUE TO 3,797
LICENSING RESTRICTIONS.
(10) A PROVISION CONTAINING THE SPECIFICS OF ANY 3,799
OBLIGATION ON THE PROVIDER OR HEALTH CARE FACILITY TO PROVIDE, OR 3,801
TO ARRANGE FOR THE PROVISION OF, COVERED HEALTH CARE SERVICES
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK; 3,802
(11) A PROVISION SETTING FORTH PROCEDURES FOR THE 3,804
RESOLUTION OF DISPUTES ARISING OUT OF THE CONTRACT; 3,805
(12) A PROVISION STATING THAT THE HOLD HARMLESS PROVISION 3,807
REQUIRED BY DIVISION (C)(2) OF THIS SECTION SHALL SURVIVE THE 3,809
TERMINATION OF THE CONTRACT WITH RESPECT TO SERVICES COVERED AND 3,810
PROVIDED UNDER THE CONTRACT DURING THE TIME THE CONTRACT WAS IN 3,811
EFFECT, REGARDLESS OF THE REASON FOR THE TERMINATION, INCLUDING
THE INSOLVENCY OF THE HEALTH INSURING CORPORATION; 3,812
(13) A PROVISION REQUIRING THOSE TERMS THAT ARE USED IN 3,814
THE CONTRACT AND THAT ARE DEFINED BY THIS CHAPTER, BE USED IN THE 3,816
87
CONTRACT IN A MANNER CONSISTENT WITH THOSE DEFINITIONS. 3,817
(D) NO HEALTH INSURING CORPORATION CONTRACT WITH A 3,820
PROVIDER OR HEALTH CARE FACILITY SHALL DO EITHER OF THE 3,821
FOLLOWING:
(1) OFFER AN INDUCEMENT TO THE PROVIDER OR HEALTH CARE 3,823
FACILITY, DIRECTLY OR INDIRECTLY, TO REDUCE OR LIMIT MEDICALLY 3,824
NECESSARY HEALTH CARE SERVICES TO A COVERED ENROLLEE; 3,825
(2) PENALIZE A PROVIDER OR HEALTH CARE FACILITY THAT 3,827
ASSISTS AN ENROLLEE TO SEEK A RECONSIDERATION OF THE HEALTH 3,828
INSURING CORPORATION'S DECISION TO DENY OR LIMIT BENEFITS TO THE 3,829
ENROLLEE. 3,830
(E) ANY CONTRACT BETWEEN A HEALTH INSURING CORPORATION AND 3,833
AN INTERMEDIARY ORGANIZATION SHALL CLEARLY SPECIFY THAT THE 3,834
HEALTH INSURING CORPORATION MUST APPROVE OR DISAPPROVE THE 3,835
PARTICIPATION OF ANY PROVIDER OR HEALTH CARE FACILITY WITH WHICH 3,836
THE INTERMEDIARY ORGANIZATION CONTRACTS. 3,837
(F) IF AN INTERMEDIARY ORGANIZATION THAT IS NOT A HEALTH 3,839
DELIVERY NETWORK CONTRACTING SOLELY WITH SELF-INSURED EMPLOYERS 3,840
SUBCONTRACTS WITH A PROVIDER OR HEALTH CARE FACILITY, THE 3,841
SUBCONTRACT WITH THE PROVIDER OR HEALTH CARE FACILITY SHALL DO 3,842
ALL OF THE FOLLOWING:
(1) CONTAIN THE PROVISIONS REQUIRED BY DIVISIONS (C) AND 3,845
(G) OF THIS SECTION, AS MADE APPLICABLE TO AN INTERMEDIARY 3,846
ORGANIZATION, WITHOUT THE INCLUSION OF INDUCEMENTS OR PENALTIES 3,847
DESCRIBED IN DIVISION (D) OF THIS SECTION; 3,848
(2) ACKNOWLEDGE THAT THE HEALTH INSURING CORPORATION IS A 3,850
THIRD-PARTY BENEFICIARY TO THE AGREEMENT; 3,851
(3) ACKNOWLEDGE THE HEALTH INSURING CORPORATION'S ROLE IN 3,853
APPROVING THE PARTICIPATION OF THE PROVIDER OR HEALTH CARE 3,854
FACILITY, PURSUANT TO DIVISION (E) OF THIS SECTION. 3,856
(G) ANY PROVIDER CONTRACT OR CONTRACT WITH A HEALTH CARE 3,859
FACILITY SHALL CLEARLY SPECIFY THE HEALTH INSURING CORPORATION'S 3,860
STATUTORY RESPONSIBILITY TO MONITOR AND OVERSEE THE OFFERING OF 3,861
COVERED HEALTH CARE SERVICES TO ITS ENROLLEES. 3,862
88
(H)(1) A HEALTH INSURING CORPORATION SHALL MAINTAIN ITS 3,865
PROVIDER CONTRACTS AND ITS CONTRACTS WITH HEALTH CARE FACILITIES 3,866
AT ONE OR MORE OF ITS PLACES OF BUSINESS IN THIS STATE, AND SHALL 3,867
PROVIDE COPIES OF THESE CONTRACTS TO FACILITATE REGULATORY REVIEW 3,868
UPON WRITTEN NOTICE BY THE SUPERINTENDENT OF INSURANCE. 3,869
(2) ANY CONTRACT WITH AN INTERMEDIARY ORGANIZATION SHALL 3,871
INCLUDE PROVISIONS REQUIRING THE INTERMEDIARY ORGANIZATION TO 3,872
PROVIDE THE SUPERINTENDENT WITH REGULATORY ACCESS TO ALL BOOKS, 3,873
RECORDS, FINANCIAL INFORMATION, AND DOCUMENTS RELATED TO THE 3,874
PROVISION OF HEALTH CARE SERVICES TO SUBSCRIBERS AND ENROLLEES 3,875
UNDER THE CONTRACT. THE CONTRACT SHALL REQUIRE THE INTERMEDIARY 3,876
ORGANIZATION TO MAINTAIN SUCH BOOKS, RECORDS, FINANCIAL 3,877
INFORMATION, AND DOCUMENTS AT ITS PRINCIPAL PLACE OF BUSINESS IN 3,878
THIS STATE AND TO PRESERVE THEM FOR AT LEAST THREE YEARS IN A 3,879
MANNER THAT FACILITATES REGULATORY REVIEW. 3,880
(I) A HEALTH INSURING CORPORATION SHALL PROVIDE NOTICE OF 3,883
THE TERMINATION OF ANY CONTRACT WITH A PRIMARY CARE PHYSICIAN OR 3,884
HOSPITAL.
(J) DIVISIONS (A) AND (B) OF THIS SECTION DO NOT APPLY TO 3,887
ANY HEALTH INSURING CORPORATION THAT, ON THE EFFECTIVE DATE OF 3,888
THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO 3,889
OPERATE UNDER CHAPTER 1740. OF THE REVISED CODE. 3,890
Sec. 1751.14. (A) ANY POLICY, CONTRACT, OR AGREEMENT FOR 3,893
HEALTH CARE SERVICES AUTHORIZED BY THIS CHAPTER THAT IS ISSUED, 3,894
DELIVERED, OR RENEWED IN THIS STATE AND THAT PROVIDES THAT 3,895
COVERAGE OF AN UNMARRIED DEPENDENT CHILD WILL TERMINATE UPON 3,896
ATTAINMENT OF THE LIMITING AGE FOR DEPENDENT CHILDREN SPECIFIED 3,897
IN THE POLICY, CONTRACT, OR AGREEMENT, SHALL ALSO PROVIDE IN 3,898
SUBSTANCE THAT ATTAINMENT OF THE LIMITING AGE SHALL NOT OPERATE 3,899
TO TERMINATE THE COVERAGE OF THE CHILD IF THE CHILD IS AND 3,900
CONTINUES TO BE BOTH:
(1) INCAPABLE OF SELF-SUSTAINING EMPLOYMENT BY REASON OF 3,902
MENTAL RETARDATION OR PHYSICAL HANDICAP; 3,903
(2) PRIMARILY DEPENDENT UPON THE SUBSCRIBER FOR SUPPORT 3,905
89
AND MAINTENANCE. 3,906
(B) PROOF OF INCAPACITY AND DEPENDENCE FOR PURPOSES OF 3,908
DIVISION (A) OF THIS SECTION SHALL BE FURNISHED TO THE HEALTH 3,909
INSURING CORPORATION WITHIN THIRTY-ONE DAYS OF THE CHILD'S 3,911
ATTAINMENT OF THE LIMITING AGE. UPON REQUEST, BUT NOT MORE 3,912
FREQUENTLY THAN ANNUALLY, THE HEALTH INSURING CORPORATION MAY 3,913
REQUIRE PROOF SATISFACTORY TO IT OF THE CONTINUANCE OF SUCH 3,914
INCAPACITY AND DEPENDENCY.
(C) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 3,917
A HEALTH INSURING CORPORATION TO COVER A DEPENDENT CHILD WHO IS 3,918
MENTALLY RETARDED OR PHYSICALLY HANDICAPPED IF THE POLICY, 3,919
CONTRACT, OR AGREEMENT IS UNDERWRITTEN ON EVIDENCE OF 3,920
INSURABILITY BASED ON HEALTH FACTORS SET FORTH IN THE 3,921
APPLICATION, OR IF THE DEPENDENT CHILD DOES NOT SATISFY THE 3,922
CONDITIONS OF THE POLICY, CONTRACT, OR AGREEMENT AS TO ANY 3,923
REQUIREMENT FOR EVIDENCE OF INSURABILITY OR ANY OTHER PROVISION 3,924
OF THE POLICY, CONTRACT, OR AGREEMENT, SATISFACTION OF WHICH IS 3,925
REQUIRED FOR COVERAGE THEREUNDER TO TAKE EFFECT. IN ANY SUCH 3,926
CASE, THE TERMS OF THE POLICY, CONTRACT, OR AGREEMENT SHALL APPLY 3,927
WITH REGARD TO THE COVERAGE OR EXCLUSION OF THE DEPENDENT FROM 3,928
SUCH COVERAGE.
(D) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 3,931
CORPORATION, POLICY, CONTRACT, OR AGREEMENT OFFERING ONLY 3,932
SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE
SERVICES. 3,933
Sec. 1751.15. (A) AFTER A HEALTH INSURING CORPORATION HAS 3,936
FURNISHED, DIRECTLY OR INDIRECTLY, BASIC HEALTH CARE SERVICES FOR 3,937
A PERIOD OF TWENTY-FOUR MONTHS, AND IF IT CURRENTLY MEETS THE 3,938
FINANCIAL REQUIREMENTS SET FORTH IN SECTION 1751.28 OF THE 3,940
REVISED CODE AND HAD NET INCOME AS REPORTED TO THE SUPERINTENDENT 3,941
OF INSURANCE FOR AT LEAST ONE OF THE PRECEDING FOUR CALENDAR 3,942
QUARTERS, IT SHALL HOLD AN ANNUAL OPEN ENROLLMENT PERIOD OF NOT 3,943
LESS THAN THIRTY DAYS DURING ITS MONTH OF LICENSURE. 3,944
(B) DURING THE OPEN ENROLLMENT PERIOD DESCRIBED IN 3,946
90
DIVISION (A) OF THIS SECTION, THE HEALTH INSURING CORPORATION 3,947
SHALL ACCEPT APPLICANTS AND THEIR DEPENDENTS IN THE ORDER IN 3,948
WHICH THEY APPLY FOR ENROLLMENT AND IN ACCORDANCE WITH ANY OF THE 3,949
FOLLOWING:
(1) UP TO ITS CAPACITY, AS DETERMINED BY THE HEALTH 3,951
INSURING CORPORATION SUBJECT TO REVIEW BY THE SUPERINTENDENT; 3,952
(2) IF LESS THAN ITS CAPACITY, ONE PER CENT OF THE HEALTH 3,954
INSURING CORPORATION'S TOTAL NUMBER OF SUBSCRIBERS RESIDING IN 3,955
THIS STATE AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF 3,957
DECEMBER.
(C) WHERE A HEALTH INSURING CORPORATION DEMONSTRATES TO 3,960
THE SATISFACTION OF THE SUPERINTENDENT THAT SUCH OPEN ENROLLMENT 3,961
WOULD JEOPARDIZE ITS ECONOMIC VIABILITY, THE SUPERINTENDENT MAY 3,962
DO ANY OF THE FOLLOWING: 3,963
(1) WAIVE THE REQUIREMENT FOR OPEN ENROLLMENT; 3,965
(2) IMPOSE A LIMIT ON THE NUMBER OF APPLICANTS AND THEIR 3,967
DEPENDENTS THAT MUST BE ENROLLED; 3,968
(3) AUTHORIZE SUCH UNDERWRITING RESTRICTIONS UPON OPEN 3,970
ENROLLMENT AS ARE NECESSARY TO DO ANY OF THE FOLLOWING: 3,971
(a) PRESERVE ITS FINANCIAL STABILITY; 3,973
(b) PREVENT EXCESSIVE ADVERSE SELECTION; 3,975
(c) AVOID UNREASONABLY HIGH OR UNMARKETABLE CHARGES FOR 3,977
COVERAGE OF HEALTH CARE SERVICES. 3,978
(D)(1) A REQUEST TO THE SUPERINTENDENT UNDER DIVISION (C) 3,981
OF THIS SECTION FOR ANY RESTRICTION, LIMIT, OR WAIVER DURING AN
OPEN ENROLLMENT PERIOD MUST BE ACCOMPANIED BY SUPPORTING 3,983
DOCUMENTATION, INCLUDING FINANCIAL DATA. IN REVIEWING THE 3,984
REQUEST, THE SUPERINTENDENT MAY CONSIDER VARIOUS FACTORS, 3,985
INCLUDING THE SIZE OF THE HEALTH INSURING CORPORATION, THE HEALTH 3,986
INSURING CORPORATION'S NET WORTH AND PROFITABILITY, THE HEALTH 3,987
INSURING CORPORATION'S DELIVERY SYSTEM STRUCTURE, AND THE EFFECT 3,988
ON PROFITABILITY OF PRIOR OPEN ENROLLMENTS. 3,989
(2) ANY ACTION TAKEN BY THE SUPERINTENDENT UNDER DIVISION 3,991
(C) OF THIS SECTION SHALL BE EFFECTIVE FOR A PERIOD OF NOT MORE 3,993
91
THAN ONE YEAR. AT THE EXPIRATION OF SUCH TIME, A NEW 3,994
DEMONSTRATION OF THE HEALTH INSURING CORPORATION'S NEED FOR THE 3,995
RESTRICTION, LIMIT, OR WAIVER SHALL BE MADE BEFORE A NEW 3,996
RESTRICTION, LIMIT, OR WAIVER IS GRANTED BY THE SUPERINTENDENT. 3,997
(3) IRRESPECTIVE OF THE GRANTING OF ANY RESTRICTION, 3,999
LIMIT, OR WAIVER BY THE SUPERINTENDENT, A HEALTH INSURING 4,000
CORPORATION MAY REJECT AN APPLICANT OR A DEPENDENT OF THE 4,001
APPLICANT DURING ITS OPEN ENROLLMENT PERIOD IF THE APPLICANT OR 4,002
DEPENDENT: 4,003
(a) WAS ELIGIBLE FOR AND WAS COVERED UNDER ANY 4,006
EMPLOYER-SPONSORED HEALTH CARE COVERAGE, OR IF EMPLOYER-SPONSORED 4,007
HEALTH CARE COVERAGE WAS AVAILABLE AT THE TIME OF OPEN 4,008
ENROLLMENT;
(b) IS ELIGIBLE FOR CONVERSION OR CONTINUATION COVERAGE 4,011
UNDER STATE OR FEDERAL LAW; 4,012
(c) IS ELIGIBLE FOR MEDICARE, AND THE HEALTH INSURING 4,015
CORPORATION DOES NOT HAVE AN AGREEMENT ON APPROPRIATE PAYMENT 4,016
MECHANISMS WITH THE GOVERNMENTAL AGENCY ADMINISTERING THE 4,017
MEDICARE PROGRAM.
(E) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED 4,020
EITHER TO ENROLL APPLICANTS OR THEIR DEPENDENTS WHO ARE CONFINED 4,021
TO A HEALTH CARE FACILITY BECAUSE OF CHRONIC ILLNESS, PERMANENT 4,022
INJURY, OR OTHER INFIRMITY THAT WOULD CAUSE ECONOMIC IMPAIRMENT 4,023
TO THE HEALTH INSURING CORPORATION IF SUCH APPLICANTS OR THEIR 4,024
DEPENDENTS WERE ENROLLED OR TO MAKE THE EFFECTIVE DATE OF 4,025
BENEFITS FOR APPLICANTS OR THEIR DEPENDENTS ENROLLED UNDER THIS 4,026
SECTION EARLIER THAN NINETY DAYS AFTER THE DATE OF ENROLLMENT. 4,027
(F) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO 4,030
COVER THE FEES OR COSTS, OR BOTH, FOR ANY BASIC HEALTH CARE 4,031
SERVICE RELATED TO A TRANSPLANT OF A BODY ORGAN IF THE TRANSPLANT 4,032
OCCURS WITHIN ONE YEAR AFTER THE EFFECTIVE DATE OF AN ENROLLEE'S 4,033
COVERAGE UNDER THIS SECTION. THIS LIMITATION ON COVERAGE DOES 4,034
NOT APPLY TO A NEWLY BORN CHILD WHO MEETS THE REQUIREMENTS FOR 4,035
COVERAGE UNDER SECTION 1751.61 OF THE REVISED CODE. 4,037
92
(G) EACH HEALTH INSURING CORPORATION REQUIRED TO HOLD AN 4,040
OPEN ENROLLMENT PURSUANT TO DIVISION (A) OF THIS SECTION SHALL 4,042
FILE WITH THE SUPERINTENDENT, NOT LATER THAN SIXTY DAYS PRIOR TO 4,043
THE COMMENCEMENT OF THE PROPOSED OPEN ENROLLMENT PERIOD, THE 4,044
FOLLOWING DOCUMENTS:
(1) THE PROPOSED PUBLIC NOTICE OF OPEN ENROLLMENT; 4,046
(2) THE EVIDENCE OF COVERAGE APPROVED PURSUANT TO SECTION 4,048
1751.11 OF THE REVISED CODE THAT WILL BE USED DURING OPEN 4,051
ENROLLMENT;
(3) THE CONTRACTUAL PERIODIC PREPAYMENT AND PREMIUM RATE 4,053
APPROVED PURSUANT TO SECTION 1751.12 OF THE REVISED CODE THAT 4,056
WILL BE APPLICABLE DURING OPEN ENROLLMENT; 4,057
(4) ANY SOLICITATION DOCUMENT APPROVED PURSUANT TO SECTION 4,060
1751.31 OF THE REVISED CODE TO BE SENT TO APPLICANTS, INCLUDING 4,062
THE APPLICATION FORM THAT WILL BE USED DURING OPEN ENROLLMENT; 4,063
(5) A LIST OF THE PROPOSED DATES OF PUBLICATION OF THE 4,065
PUBLIC NOTICE, AND THE NAMES OF THE NEWSPAPERS IN WHICH THE 4,066
NOTICE WILL APPEAR; 4,067
(6) ANY REQUEST FOR A RESTRICTION, LIMIT, OR WAIVER WITH 4,069
RESPECT TO THE OPEN ENROLLMENT PERIOD, ALONG WITH ANY SUPPORTING 4,070
DOCUMENTATION. 4,071
(H)(1) AN OPEN ENROLLMENT PERIOD SHALL NOT SATISFY THE 4,074
REQUIREMENTS OF THIS SECTION UNLESS THE HEALTH INSURING 4,075
CORPORATION PROVIDES ADEQUATE PUBLIC NOTICE IN ACCORDANCE WITH 4,076
DIVISIONS (H)(2) AND (3) OF THIS SECTION. NO PUBLIC NOTICE SHALL 4,078
BE USED UNTIL THE FORM OF THE PUBLIC NOTICE HAS BEEN FILED BY THE 4,079
HEALTH INSURING CORPORATION WITH THE SUPERINTENDENT. IF THE 4,080
SUPERINTENDENT DOES NOT DISAPPROVE THE PUBLIC NOTICE WITHIN SIXTY 4,081
DAYS AFTER IT IS FILED, IT SHALL BE DEEMED APPROVED, UNLESS THE 4,082
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE PUBLIC NOTICE. IF 4,083
THE SUPERINTENDENT DETERMINES WITHIN THIS SIXTY-DAY PERIOD THAT 4,084
THE PUBLIC NOTICE FAILS TO MEET THE REQUIREMENTS OF THIS SECTION, 4,085
THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH INSURING 4,086
CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH INSURING 4,087
93
CORPORATION TO USE THE PUBLIC NOTICE. SUCH DISAPPROVAL SHALL BE 4,088
EFFECTED BY A WRITTEN ORDER, WHICH SHALL STATE THE GROUNDS FOR 4,089
DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. 4,091
OF THE REVISED CODE. 4,093
(2) A PUBLIC NOTICE PURSUANT TO DIVISION (H)(1) OF THIS 4,096
SECTION SHALL BE PUBLISHED IN AT LEAST ONE NEWSPAPER OF GENERAL 4,097
CIRCULATION IN EACH COUNTY IN THE HEALTH INSURING CORPORATION'S 4,098
SERVICE AREA, AT LEAST ONCE IN EACH OF THE TWO WEEKS IMMEDIATELY 4,099
PRECEDING THE MONTH IN WHICH THE OPEN ENROLLMENT IS TO OCCUR AND 4,100
IN EACH WEEK OF THAT MONTH, OR UNTIL THE ENROLLMENT LIMITATION IS 4,101
REACHED, WHICHEVER OCCURS FIRST. THE NOTICE PUBLISHED DURING THE 4,102
LAST WEEK OF OPEN ENROLLMENT SHALL APPEAR NOT LESS THAN FIVE DAYS 4,103
BEFORE THE END OF THE OPEN ENROLLMENT PERIOD. IT SHALL BE AT 4,104
LEAST TWO NEWSPAPER COLUMNS WIDE OR TWO AND ONE-HALF INCHES WIDE, 4,106
WHICHEVER IS LARGER. THE FIRST TWO LINES OF THE TEXT SHALL BE 4,107
PUBLISHED IN NOT LESS THAN TWELVE-POINT, BOLDFACE TYPE. THE 4,108
REMAINDER OF THE TEXT OF THE NOTICE SHALL BE PUBLISHED IN NOT 4,109
LESS THAN EIGHT-POINT TYPE. THE ENTIRE PUBLIC NOTICE SHALL BE 4,110
SURROUNDED BY A CONTINUOUS BLACK LINE NOT LESS THAN ONE-EIGHTH OF 4,111
AN INCH WIDE.
(3) THE FOLLOWING INFORMATION SHALL BE INCLUDED IN THE 4,113
PUBLIC NOTICE PROVIDED UNDER DIVISION (H)(2) OF THIS SECTION: 4,115
(a) THE DATES THAT OPEN ENROLLMENT WILL BE HELD AND THE 4,118
DATE COVERAGE OBTAINED UNDER THE OPEN ENROLLMENT WILL BECOME 4,119
EFFECTIVE;
(b) NOTICE THAT AN APPLICANT OR THE APPLICANT'S DEPENDENTS 4,122
WILL NOT BE DENIED COVERAGE DURING OPEN ENROLLMENT BECAUSE OF A 4,123
PREEXISTING HEALTH CONDITION, BUT THAT SOME LIMITATIONS AND 4,124
RESTRICTIONS MAY APPLY; 4,125
(c) THE ADDRESS WHERE A PERSON MAY OBTAIN AN APPLICATION; 4,128
(d) THE TELEPHONE NUMBER THAT A PERSON MAY CALL TO REQUEST 4,131
AN APPLICATION OR TO ASK QUESTIONS; 4,132
(e) THE DATE THE FIRST PAYMENT WILL BE DUE; 4,135
(f) THE ACTUAL RATES OR RANGE OF RATES THAT WILL BE 4,138
94
APPLICABLE FOR APPLICANTS;
(g) ANY LIMITATION GRANTED BY THE SUPERINTENDENT ON THE 4,141
NUMBER OF APPLICATIONS THAT WILL BE ACCEPTED BY THE HEALTH 4,142
INSURING CORPORATION.
(4) WITHIN THIRTY DAYS AFTER THE END OF AN OPEN ENROLLMENT 4,145
PERIOD, THE HEALTH INSURING CORPORATION SHALL SUBMIT TO THE 4,146
SUPERINTENDENT PROOF OF PUBLICATION FOR THE PUBLIC NOTICES, AND 4,147
SHALL REPORT THE TOTAL NUMBER OF APPLICANTS AND THEIR DEPENDENTS 4,148
ENROLLED DURING THE OPEN ENROLLMENT PERIOD. 4,149
(I)(1) NO HEALTH INSURING CORPORATION MAY EMPLOY ANY 4,152
SCHEME, PLAN, OR DEVICE THAT RESTRICTS THE ABILITY OF ANY PERSON 4,153
TO ENROLL DURING OPEN ENROLLMENT. 4,154
(2) NO HEALTH INSURING CORPORATION MAY REQUIRE ENROLLMENT 4,156
TO BE MADE IN PERSON. EVERY HEALTH INSURING CORPORATION SHALL 4,157
PERMIT APPLICATION FOR COVERAGE BY MAIL. A REPRESENTATIVE OF THE 4,159
HEALTH INSURING CORPORATION MAY VISIT AN APPLICANT WHO HAS
SUBMITTED AN APPLICATION BY MAIL, IN ORDER TO EXPLAIN THE 4,160
OPERATIONS OF THE HEALTH INSURING CORPORATION AND TO ANSWER ANY 4,161
QUESTIONS THE APPLICANT MAY HAVE. EVERY HEALTH INSURING 4,162
CORPORATION SHALL MAKE OPEN ENROLLMENT APPLICATIONS AND 4,163
SOLICITATION DOCUMENTS READILY AVAILABLE TO ANY POTENTIAL 4,164
APPLICANT WHO REQUESTS SUCH MATERIAL. 4,165
(J) AN APPLICATION POSTMARKED ON THE LAST DAY OF AN OPEN 4,168
ENROLLMENT PERIOD SHALL QUALIFY AS A VALID APPLICATION, 4,169
REGARDLESS OF THE DATE ON WHICH IT IS RECEIVED BY THE HEALTH 4,170
INSURING CORPORATION.
(K) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 4,172
CORPORATION THAT OFFERS ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR 4,174
SPECIALTY HEALTH CARE SERVICES, OR TO ANY HEALTH INSURING
CORPORATION THAT OFFERS PLANS ONLY THROUGH TITLE XVIII OR TITLE 4,177
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,179
U.S.C.A. 301, AS AMENDED, AND THAT HAS NO OTHER COMMERCIAL 4,180
ENROLLMENT, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 4,181
PLANS ONLY THROUGH OTHER FEDERAL HEALTH CARE PROGRAMS REGULATED 4,182
95
BY FEDERAL REGULATORY BODIES AND THAT HAS NO OTHER COMMERCIAL 4,183
ENROLLMENT.
Sec. 1751.16. (A) EXCEPT AS PROVIDED IN DIVISION (F) OF 4,186
THIS SECTION, EVERY GROUP CONTRACT ISSUED BY A HEALTH INSURING 4,187
CORPORATION SHALL PROVIDE AN OPTION FOR CONVERSION TO AN 4,188
INDIVIDUAL CONTRACT ISSUED ON A DIRECT-PAYMENT BASIS TO ANY 4,189
SUBSCRIBER COVERED BY THE GROUP CONTRACT WHO TERMINATES 4,190
EMPLOYMENT OR MEMBERSHIP IN THE GROUP, UNLESS: 4,191
(1) TERMINATION OF THE CONVERSION OPTION OR CONTRACT IS 4,193
BASED UPON NONPAYMENT OF PREMIUM AFTER REASONABLE NOTICE IN 4,194
WRITING HAS BEEN GIVEN BY THE HEALTH INSURING CORPORATION TO THE 4,195
SUBSCRIBER. 4,196
(2) THE SUBSCRIBER IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,198
BENEFITS AT LEAST COMPARABLE TO THE GROUP CONTRACT UNDER ANY OF 4,199
THE FOLLOWING: 4,200
(a) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,203
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,204
(b) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,207
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,209
TO THE BENEFITS UNDER DIVISION (A)(2)(a) OF THIS SECTION; 4,210
(c) ANY POLICY OF INSURANCE OR HEALTH CARE PLAN PROVIDING 4,213
COVERAGE AT LEAST COMPARABLE TO THE BENEFITS UNDER DIVISION 4,214
(A)(2)(a) OF THIS SECTION. 4,215
(B) THE DIRECT-PAYMENT CONTRACT OFFERED BY THE HEALTH 4,218
INSURING CORPORATION PURSUANT TO DIVISION (A) OF THIS SECTION 4,219
SHALL PROVIDE BENEFITS COMPARABLE TO THE BENEFITS BEING PROVIDED 4,220
BY ANY OF THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO 4,221
INDIVIDUAL SUBSCRIBERS BY THE HEALTH INSURING CORPORATION. THE 4,222
CONTRACT MAY CONTAIN A COORDINATION OF BENEFITS PROVISION AS 4,223
APPROVED BY THE SUPERINTENDENT OF INSURANCE. 4,224
(C) THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,227
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,229
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,230
COVERED BY THE GROUP CONTRACT; 4,231
96
(2) TO A CHILD SOLELY WITH RESPECT TO THE CHILD UPON THE 4,233
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE GROUP 4,234
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT; 4,235
(3) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,237
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,238
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER. 4,240
(D) NO HEALTH INSURING CORPORATION SHALL DO ANY OF THE 4,243
FOLLOWING:
(1) USE AGE AS THE BASIS FOR REFUSING TO RENEW A CONVERTED 4,246
CONTRACT;
(2) REQUIRE A SUBSCRIBER TO PRODUCE EVIDENCE OF 4,248
INSURABILITY IN ORDER TO EXERCISE THE OPTION FOR CONVERSION 4,249
PROVIDED BY THIS SECTION; 4,250
(3) INCLUDE PREEXISTING CONDITION LIMITATIONS IN A 4,252
CONVERTED CONTRACT. 4,253
(E) WRITTEN NOTICE OF THE CONVERSION OPTION PROVIDED BY 4,256
THIS SECTION SHALL BE GIVEN TO THE SUBSCRIBER BY THE HEALTH 4,257
INSURING CORPORATION BY MAIL. THE NOTICE SHALL BE SENT TO THE 4,258
SUBSCRIBER'S ADDRESS IN THE RECORDS OF THE EMPLOYER UPON RECEIPT 4,259
OF NOTICE FROM THE EMPLOYER OF THE EVENT GIVING RISE TO THE 4,260
CONVERSION OPTION. IF THE SUBSCRIBER HAS NOT RECEIVED NOTICE OF 4,261
THE CONVERSION PRIVILEGE AT LEAST FIFTEEN DAYS PRIOR TO THE 4,262
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD, THEN THE 4,263
SUBSCRIBER SHALL HAVE AN ADDITIONAL PERIOD WITHIN WHICH TO 4,264
EXERCISE THE PRIVILEGE. THIS ADDITIONAL PERIOD SHALL EXPIRE 4,265
FIFTEEN DAYS AFTER THE SUBSCRIBER RECEIVES NOTICE, BUT IN NO 4,266
EVENT SHALL THE PERIOD EXTEND BEYOND SIXTY DAYS AFTER THE 4,267
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD. 4,268
(F) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 4,271
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,272
HEALTH CARE SERVICES.
Sec. 1751.17. (A) AS USED IN THIS SECTION, "NONGROUP 4,275
CONTRACT" MEANS A CONTRACT ISSUED BY A HEALTH INSURING 4,276
CORPORATION TO AN INDIVIDUAL WHO MAKES DIRECT APPLICATION FOR 4,277
97
COVERAGE UNDER THE CONTRACT AND WHO, IF REQUIRED BY THE HEALTH 4,278
INSURING CORPORATION, SUBMITS TO MEDICAL UNDERWRITING. "NONGROUP 4,279
CONTRACT" DOES NOT INCLUDE GROUP CONVERSION COVERAGE, COVERAGE 4,280
OBTAINED THROUGH OPEN ENROLLMENT, OR COVERAGE ISSUED ON THE BASIS 4,281
OF MEMBERSHIP IN A GROUP. 4,282
(B) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 4,286
EVERY NONGROUP CONTRACT THAT IS ISSUED BY A HEALTH INSURING 4,287
CORPORATION AND THAT MAKES AVAILABLE BASIC HEALTH CARE SERVICES 4,288
SHALL PROVIDE AN OPTION FOR CONVERSION TO A CONTRACT ISSUED ON A 4,289
DIRECT-PAYMENT BASIS TO AN ENROLLEE COVERED BY THE NONGROUP 4,290
CONTRACT. THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,291
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,293
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,294
COVERED BY THE NONGROUP CONTRACT; 4,295
(2) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,297
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,298
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER; 4,300
(3) TO A CHILD SOLELY WITH RESPECT TO THE CHILD, UPON THE 4,302
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE NONGROUP 4,304
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT. 4,305
(C) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,308
DIVISION (B) OF THIS SECTION SHALL NOT BE MADE AVAILABLE TO AN 4,310
ENROLLEE IF ANY OF THE FOLLOWING APPLIES: 4,311
(1) THE ENROLLEE IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,313
BENEFITS AT LEAST COMPARABLE TO THE NONGROUP CONTRACT UNDER ANY 4,314
OF THE FOLLOWING: 4,315
(a) THE MEDICAL ASSISTANCE PROGRAM UNDER CHAPTER 5111. OF 4,318
THE REVISED CODE;
(b) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,321
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,322
(c) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,324
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,326
TO THE BENEFITS OFFERED UNDER DIVISION (C)(1)(a) OR (b) OF THIS 4,327
SECTION.
98
(2) THE NONGROUP CONTRACT UNDER WHICH THE ENROLLEE WAS 4,329
COVERED WAS TERMINATED DUE TO NONPAYMENT OF A PREMIUM RATE. 4,330
(3) THE ENROLLEE IS ELIGIBLE FOR GROUP COVERAGE PROVIDED 4,332
BY, OR AVAILABLE THROUGH, AN EMPLOYER OR ASSOCIATION AND THE 4,333
GROUP COVERAGE PROVIDES BENEFITS COMPARABLE TO THE BENEFITS 4,334
PROVIDED UNDER A DIRECT PAYMENT CONTRACT. 4,335
(D) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,337
DIVISION (B) OF THIS SECTION SHALL PROVIDE BENEFITS THAT ARE AT 4,338
LEAST COMPARABLE TO THE BENEFITS PROVIDED BY THE NONGROUP 4,340
CONTRACT UNDER WHICH THE ENROLLEE WAS COVERED AT THE TIME OF THE 4,341
OCCURRENCE OF ANY OF THE EVENTS SET FORTH IN DIVISION (B) OF THIS 4,342
SECTION. THE COVERAGE PROVIDED UNDER THE DIRECT PAYMENT CONTRACT 4,344
SHALL BE CONTINUOUS, PROVIDED THAT THE ENROLLEE MAKES THE 4,345
REQUIRED PREMIUM RATE PAYMENT WITHIN THE THIRTY-DAY PERIOD 4,346
IMMEDIATELY FOLLOWING THE OCCURRENCE OF THE EVENT, AND MAY BE 4,347
TERMINATED FOR NONPAYMENT OF ANY REQUIRED PREMIUM RATE PAYMENT. 4,348
(E) THE EVIDENCE OF COVERAGE OF EVERY NONGROUP CONTRACT 4,351
SHALL CONTAIN NOTICE THAT AN OPTION FOR CONVERSION TO A CONTRACT 4,352
ISSUED ON A DIRECT-PAYMENT BASIS IS AVAILABLE, IN ACCORDANCE WITH 4,353
THIS SECTION, TO ANY ENROLLEE COVERED BY THE CONTRACT. 4,354
(F) BENEFITS OTHERWISE PAYABLE TO AN ENROLLEE UNDER A 4,357
DIRECT PAYMENT CONTRACT SHALL BE REDUCED BY THE AMOUNT OF ANY 4,358
BENEFITS AVAILABLE TO THE ENROLLEE UNDER ANY APPLICABLE GROUP 4,359
HEALTH INSURING CORPORATION CONTRACT OR GROUP SICKNESS AND 4,360
ACCIDENT INSURANCE POLICY.
(G) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 4,363
REQUIRING A HEALTH INSURING CORPORATION TO OFFER NONGROUP 4,364
CONTRACTS.
(H) THIS SECTION DOES NOT APPLY TO ANY NONGROUP CONTRACT 4,367
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,368
HEALTH CARE SERVICES. 4,369
Sec. 1751.18. (A)(1) NO HEALTH INSURING CORPORATION SHALL 4,372
CANCEL OR FAIL TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE 4,373
BECAUSE OF THE SUBSCRIBER'S OR ENROLLEE'S HEALTH STATUS OR 4,374
99
REQUIREMENT FOR HEALTH CARE SERVICES, OR FOR ANY OTHER REASON 4,375
DESIGNATED UNDER RULES ADOPTED BY THE SUPERINTENDENT OF
INSURANCE. 4,376
(2) UNLESS OTHERWISE REQUIRED BY STATE OR FEDERAL LAW, NO 4,378
HEALTH INSURING CORPORATION, OR HEALTH CARE FACILITY OR PROVIDER 4,379
THROUGH WHICH THE HEALTH INSURING CORPORATION HAS MADE 4,380
ARRANGEMENTS TO PROVIDE HEALTH CARE SERVICES, SHALL DISCRIMINATE 4,381
AGAINST ANY INDIVIDUAL WITH REGARD TO ENROLLMENT, DISENROLLMENT, 4,382
OR THE QUALITY OF HEALTH CARE SERVICES RENDERED, ON THE BASIS OF 4,383
THE INDIVIDUAL'S RACE, COLOR, SEX, AGE, RELIGION, STATE OF 4,384
HEALTH, OR STATUS AS A RECIPIENT OF MEDICARE OR MEDICAL 4,385
ASSISTANCE UNDER TITLE XVIII OR XIX OF THE "SOCIAL SECURITY ACT," 4,387
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. HOWEVER, A 4,390
HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO ACCEPT A 4,391
RECIPIENT OF MEDICARE OR MEDICAL ASSISTANCE, IF AN AGREEMENT HAS 4,392
NOT BEEN REACHED ON APPROPRIATE PAYMENT MECHANISMS BETWEEN THE 4,393
HEALTH INSURING CORPORATION AND THE GOVERNMENTAL AGENCY 4,394
ADMINISTERING THESE PROGRAMS. FURTHER, EXCEPT DURING A PERIOD OF 4,395
OPEN ENROLLMENT UNDER SECTION 1751.15 OF THE REVISED CODE, A 4,397
HEALTH INSURING CORPORATION MAY REJECT AN APPLICANT FOR NONGROUP 4,398
ENROLLMENT ON THE BASIS OF THE STATE OF HEALTH OF THE APPLICANT. 4,399
(B) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 4,402
TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE FOR ANY OF THE 4,403
FOLLOWING REASONS:
(1) FAILURE OF THE SUBSCRIBER OR ENROLLEE TO PAY, OR TO 4,405
HAVE PAID ON THE SUBSCRIBER'S OR ENROLLEE'S BEHALF, THE REQUIRED 4,406
PREMIUM RATE OR OTHER CHARGE; 4,407
(2) FRAUD OR FORGERY; 4,409
(3) ANY MATERIAL MISREPRESENTATION ON THE APPLICATION FOR 4,411
COVERAGE; 4,412
(4) THE SUBSCRIBER'S OR ENROLLEE'S PERMITTING THE USE OF 4,414
AN IDENTIFICATION CARD OR SIMILAR DOCUMENTS BY ANOTHER PERSON, 4,415
ALLOWING THAT PERSON TO RECEIVE SERVICES FOR WHICH THAT PERSON IS 4,417
NOT ENTITLED;
100
(5) THE SUBSCRIBER'S OR ENROLLEE'S INABILITY TO ESTABLISH 4,419
OR MAINTAIN A PROVIDER-PATIENT RELATIONSHIP WITH ANY PROVIDER 4,420
ASSOCIATED WITH THE HEALTH INSURING CORPORATION, WHICH INABILITY 4,421
MAY INCLUDE THE SUBSCRIBER'S OR ENROLLEE'S DISRUPTIVE OR ABUSIVE 4,422
BEHAVIOR TOWARD PROVIDERS OR THE STAFF OF THE HEALTH CARE PLAN. 4,424
(C) A SUBSCRIBER OR ENROLLEE MAY APPEAL ANY ACTION OR 4,427
DECISION OF THE HEALTH INSURING CORPORATION UNDER DIVISION (B) OF 4,429
THIS SECTION. TO APPEAL, THE SUBSCRIBER OR ENROLLEE MAY SUBMIT A 4,430
WRITTEN COMPLAINT TO THE HEALTH INSURING CORPORATION PURSUANT TO 4,431
SECTION 1751.19 OF THE REVISED CODE. THE SUBSCRIBER OR ENROLLEE 4,432
MAY, WITHIN THIRTY DAYS AFTER RECEIVING A WRITTEN RESPONSE FROM 4,433
THE HEALTH INSURING CORPORATION, APPEAL THE HEALTH INSURING 4,434
CORPORATION'S ACTION OR DECISION TO THE SUPERINTENDENT. 4,435
Sec. 1751.19. (A) A HEALTH INSURING CORPORATION SHALL 4,438
ESTABLISH AND MAINTAIN A COMPLAINT SYSTEM THAT HAS BEEN APPROVED 4,439
BY THE SUPERINTENDENT OF INSURANCE TO PROVIDE ADEQUATE AND 4,440
REASONABLE PROCEDURES FOR THE EXPEDITIOUS RESOLUTION OF WRITTEN 4,441
COMPLAINTS INITIATED BY SUBSCRIBERS OR ENROLLEES CONCERNING ANY 4,442
MATTER RELATING TO SERVICES PROVIDED, DIRECTLY OR INDIRECTLY, BY 4,443
THE HEALTH INSURING CORPORATION, INCLUDING, BUT NOT LIMITED TO, 4,444
CLAIMS REGARDING THE SCOPE OF COVERAGE FOR HEALTH CARE SERVICES, 4,445
AND DENIALS, CANCELLATIONS, OR NONRENEWALS OF COVERAGE. 4,446
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE A TIMELY 4,449
WRITTEN RESPONSE TO EACH WRITTEN COMPLAINT IT RECEIVES. 4,450
RESPONSES TO WRITTEN COMPLAINTS RELATING TO QUALITY OR 4,451
APPROPRIATENESS OF CARE SHALL SET FORTH A STATEMENT INFORMING THE 4,452
COMPLAINANT IN DETAIL OF ANY RIGHTS THE COMPLAINANT MAY HAVE TO 4,453
SUBMIT SUCH COMPLAINT TO ANY PROFESSIONAL PEER REVIEW 4,454
ORGANIZATION OR HEALTH INSURING CORPORATION PEER REVIEW COMMITTEE 4,455
THAT HAS BEEN SET UP TO MONITOR THE QUALITY OR APPROPRIATENESS OF 4,456
PROVIDER SERVICES RENDERED. SUCH STATEMENT SHALL SET FORTH THE 4,457
NAME OF THE PEER REVIEW ORGANIZATION OR HEALTH INSURING 4,458
CORPORATION PEER REVIEW COMMITTEE, ITS ADDRESS, TELEPHONE NUMBER, 4,459
AND ANY OTHER PERTINENT DATA THAT WILL ENABLE THE COMPLAINANT TO 4,460
101
SEEK FURTHER INDEPENDENT REVIEW OF THE COMPLAINT. SUCH APPEAL 4,461
SHALL NOT BE MADE TO THE PEER REVIEW CORPORATION OR HEALTH 4,462
INSURING CORPORATION PEER REVIEW COMMITTEE UNTIL THE COMPLAINT 4,463
SYSTEM OF THE HEALTH INSURING CORPORATION HAS BEEN EXHAUSTED. 4,464
(C) COPIES OF COMPLAINTS AND RESPONSES, INCLUDING MEDICAL 4,467
RECORDS RELATED TO THOSE COMPLAINTS, SHALL BE AVAILABLE TO THE 4,468
SUPERINTENDENT AND THE DIRECTOR OF HEALTH FOR INSPECTION FOR 4,469
THREE YEARS. ANY DOCUMENT OR INFORMATION PROVIDED TO THE 4,470
SUPERINTENDENT PURSUANT TO THIS DIVISION THAT CONTAINS A MEDICAL 4,471
RECORD IS CONFIDENTIAL, AND IS NOT A PUBLIC RECORD SUBJECT TO 4,472
SECTION 149.43 OF THE REVISED CODE.
(D) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 4,475
MAINTAIN A PROCEDURE TO ACCEPT COMPLAINTS OVER THE TELEPHONE OR 4,476
IN PERSON. THESE COMPLAINTS ARE NOT SUBJECT TO THE REPORTING 4,477
REQUIREMENT UNDER DIVISION (C) OF SECTION 1751.32 OF THE REVISED 4,479
CODE.
Sec. 1751.20. (A) NO HEALTH INSURING CORPORATION, OR 4,482
AGENT, EMPLOYEE, OR REPRESENTATIVE OF A HEALTH INSURING 4,483
CORPORATION, SHALL USE ANY ADVERTISEMENT OR SOLICITATION 4,484
DOCUMENT, OR SHALL ENGAGE IN ANY ACTIVITY, THAT IS UNFAIR, 4,485
UNTRUE, MISLEADING, OR DECEPTIVE.
(B) NO HEALTH INSURING CORPORATION SHALL USE A NAME THAT 4,488
IS DECEPTIVELY SIMILAR TO THE NAME OR DESCRIPTION OF ANY 4,489
INSURANCE OR SURETY CORPORATION DOING BUSINESS IN THIS STATE. 4,490
(C) ALL SOLICITATION DOCUMENTS, ADVERTISEMENTS, EVIDENCES 4,493
OF COVERAGE, AND ENROLLEE IDENTIFICATION CARDS USED BY A HEALTH 4,494
INSURING CORPORATION SHALL CONTAIN THE HEALTH INSURING 4,495
CORPORATION'S NAME. THE USE OF A TRADE NAME, AN INSURANCE GROUP 4,496
DESIGNATION, THE NAME OF A PARENT COMPANY, THE NAME OF A DIVISION 4,497
OF AN AFFILIATED INSURANCE COMPANY, A SERVICE MARK, A SLOGAN, A 4,498
SYMBOL, OR OTHER DEVICE, WITHOUT THE NAME OF THE HEALTH INSURING 4,499
CORPORATION AS STATED IN ITS ARTICLES OF INCORPORATION, SHALL NOT 4,500
SATISFY THIS REQUIREMENT IF THE USAGE WOULD HAVE THE CAPACITY AND 4,501
TENDENCY TO MISLEAD OR DECEIVE PERSONS AS TO THE TRUE IDENTITY OF 4,502
102
THE HEALTH INSURING CORPORATION. 4,503
(D) NO SOLICITATION DOCUMENT OR ADVERTISEMENT USED BY A 4,506
HEALTH INSURING CORPORATION SHALL CONTAIN ANY WORDS, SYMBOLS, OR 4,507
PHYSICAL MATERIALS THAT ARE SO SIMILAR IN CONTENT, PHRASEOLOGY, 4,508
SHAPE, COLOR, OR OTHER CHARACTERISTIC TO THOSE USED BY AN AGENCY 4,509
OF THE FEDERAL GOVERNMENT OR THIS STATE, THAT PROSPECTIVE 4,510
ENROLLEES MAY BE LED TO BELIEVE THAT THE SOLICITATION DOCUMENT OR 4,511
ADVERTISEMENT IS CONNECTED WITH AN AGENCY OF THE FEDERAL 4,512
GOVERNMENT OR THIS STATE. 4,513
(E) THIS SECTION DOES NOT APPLY TO THE COVERAGE OF 4,515
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 4,517
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 4,520
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 4,521
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 4,522
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 4,524
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 4,525
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 4,527
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 4,528
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 4,530
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 4,531
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY. 4,532
Sec. 1751.21. (A) A PEER REVIEW COMMITTEE OF A HOSPITAL 4,535
OR OTHER HEALTH CARE FACILITY OR PROVIDER, OR OF AN INTERMEDIARY 4,536
ORGANIZATION OR HEALTH DELIVERY NETWORK, WITH WHICH A HEALTH 4,537
INSURING CORPORATION HAS A CONTRACT FOR HEALTH CARE SERVICES MAY 4,538
PROVIDE TO A PEER REVIEW COMMITTEE OF THE HEALTH INSURING 4,539
CORPORATION ANY INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,540
RECORDS RELATING TO ANY MATTER THAT IS THE SUBJECT OF EVALUATION 4,541
OR REVIEW BY THE PEER REVIEW COMMITTEES, IF CONSENT IS PROVIDED 4,542
BY THE HEALTH CARE FACILITY AND ANY PHYSICIAN OR OTHER PROVIDER 4,543
WHOSE PROFESSIONAL QUALIFICATIONS OR ACTIVITIES ARE THE SUBJECT 4,544
OF EVALUATION OR REVIEW. 4,545
(B) ANY IMMUNITY FROM LIABILITY FOR DAMAGES THAT IS 4,548
PROVIDED UNDER SECTION 2305.25 OF THE REVISED CODE AND THAT WOULD 4,550
103
OTHERWISE APPLY WITH RESPECT TO THE CONDUCT OF ANY PEER REVIEW 4,551
COMMITTEE DESCRIBED IN DIVISION (A) OF THIS SECTION SHALL 4,553
CONTINUE TO APPLY, NOTWITHSTANDING THE PROVISION OF INFORMATION 4,554
AS PERMITTED UNDER DIVISION (A) OF THIS SECTION. 4,555
(C) THE INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,558
RECORDS DESCRIBED IN DIVISION (A) OF THIS SECTION, IF OTHERWISE 4,560
PROTECTED UNDER SECTION 2305.251 OF THE REVISED CODE, SHALL NOT 4,562
BE CONSTRUED AS BEING AVAILABLE FOR DISCOVERY OR FOR USE IN ANY 4,563
CIVIL ACTION SOLELY ON THE BASIS THAT THEY WERE PROVIDED BY THE 4,564
PEER REVIEW COMMITTEE AS PERMITTED UNDER DIVISION (A) OF THIS 4,565
SECTION. 4,566
Sec. 1751.25. THE FUNDS OF A HEALTH INSURING CORPORATION 4,568
SHALL BE INVESTED ONLY IN SECURITIES OR OTHER INVESTMENTS OR 4,569
ASSETS THAT CONSTITUTE PERMISSIBLE INVESTMENTS UNDER SECTION 4,570
1751.26 OR 3925.08 OF THE REVISED CODE. 4,571
Sec. 1751.26. (A) FOR PURPOSES OF THIS SECTION, REAL 4,574
ESTATE USED FOR "THE ACCOMMODATION OF THE HEALTH INSURING 4,575
CORPORATION'S BUSINESS OPERATIONS" INCLUDES THE HEALTH INSURING 4,576
CORPORATION'S HOME OFFICE, BRANCH OFFICE, MEDICAL FACILITIES, AND 4,577
FIELD OFFICE OPERATIONS. 4,578
(B) NO HEALTH INSURING CORPORATION SHALL PURCHASE, HOLD, 4,581
OR CONVEY REAL ESTATE, OR ANY INTEREST IN REAL ESTATE, TO BE USED 4,582
AS AN INVESTMENT FOR THE PRODUCTION OF INCOME, TO BE DEVELOPED 4,583
FOR THE PRODUCTION OF INCOME, OR TO BE OTHERWISE USED FOR 4,584
PURPOSES OTHER THAN THE ACCOMMODATION OF THE HEALTH INSURING 4,585
CORPORATION'S BUSINESS OPERATIONS, WITHOUT THE PRIOR APPROVAL OF 4,586
THE SUPERINTENDENT OF INSURANCE. 4,587
(C)(1) NO HEALTH INSURING CORPORATION SHALL INVEST, 4,590
WITHOUT THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT 4,591
EXCEEDS FORTY PER CENT OF ITS ADMITTED ASSETS AS OF THE 4,592
IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE 4,593
USED FOR THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S 4,594
BUSINESS OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION 4,595
PROVIDES HEALTH CARE SERVICES. 4,596
104
(2) NO HEALTH INSURING CORPORATION SHALL INVEST, WITHOUT 4,598
THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT EXCEEDS 4,599
TWENTY-FIVE PER CENT OF ITS ADMITTED ASSETS AS OF THE IMMEDIATELY 4,601
PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE USED FOR 4,603
THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S BUSINESS 4,604
OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION DOES NOT 4,605
PROVIDE HEALTH CARE SERVICES.
Sec. 1751.27. (A) EACH HEALTH INSURING CORPORATION 4,608
HOLDING A CERTIFICATE OF AUTHORITY TO OPERATE IN THIS STATE SHALL 4,609
HAVE DEPOSITED SECURITIES WITH THE SUPERINTENDENT OF INSURANCE OR 4,610
AN APPROVED CUSTODIAN IN THE AMOUNT REQUIRED BY THIS DIVISION. 4,611
(1) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,614
BASIC HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS 4,615
THAN TWO HUNDRED FIFTY THOUSAND DOLLARS.
(2) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,618
ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT 4,619
OF NOT LESS THAN ONE HUNDRED FIFTY THOUSAND DOLLARS.
(3) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,621
ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF 4,622
NOT LESS THAN SEVENTY-FIVE THOUSAND DOLLARS. 4,623
(4) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,626
BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH CARE 4,627
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN FOUR HUNDRED 4,628
THOUSAND DOLLARS.
(5) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,630
BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,631
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN THREE HUNDRED 4,632
TWENTY-FIVE THOUSAND DOLLARS. 4,633
(B) THE SECURITIES DEPOSITED UNDER DIVISION (A) OF THIS 4,637
SECTION SHALL BE HELD AS SECURITY FOR THE FULFILLMENT OF THE 4,638
OBLIGATIONS OF THE HEALTH INSURING CORPORATION TO ITS ENROLLEES 4,639
UNDER THIS CHAPTER.
(C) THE INTEREST FROM THE DEPOSIT MADE UNDER DIVISION (A) 4,643
OF THIS SECTION SHALL ACCRUE TO THE HEALTH INSURING CORPORATION 4,644
105
THAT MADE THE DEPOSIT. THE DEPOSIT SHALL BE CONSIDERED TO BE AN 4,645
ADMITTED ASSET OF THE HEALTH INSURING CORPORATION. 4,646
(D) THE SUPERINTENDENT SHALL ADOPT RULES SETTING FORTH THE 4,649
QUALIFICATIONS AND RESPONSIBILITIES OF AN APPROVED CUSTODIAN. 4,650
Sec. 1751.28. (A) AS USED IN THIS SECTION: 4,653
(1) "ADMITTED ASSETS" INCLUDES THE INVESTMENTS AUTHORIZED 4,655
BY SECTION 1751.25 OF THE REVISED CODE, AND, IN ADDITION TO THESE 4,657
INVESTMENTS, ONLY THE FOLLOWING:
(a) PETTY CASH AND OTHER CASH FUNDS THAT ARE IN THE HEALTH 4,660
INSURING CORPORATION'S PRINCIPAL OFFICE OR ANY OFFICIAL BRANCH 4,661
OFFICE AND THAT ARE UNDER THE CONTROL OF THE CORPORATION; 4,662
(b) IMMEDIATELY WITHDRAWABLE FUNDS ON DEPOSIT IN DEMAND 4,664
ACCOUNTS IN A BANK OR TRUST COMPANY, OR SIMILAR FUNDS THAT ARE 4,665
ACTUALLY IN THE HEALTH INSURING CORPORATION'S PRINCIPAL OFFICE OR 4,666
ANY OFFICIAL BRANCH OFFICE AT STATEMENT DATE AND THAT ARE IN 4,667
TRANSIT TO THE BANK OR TRUST COMPANY WITH AUTHENTIC DEPOSIT 4,668
CREDIT GIVEN PRIOR TO THE CLOSE OF BUSINESS ON THE FIFTH BANK 4,669
BUSINESS DAY FOLLOWING THE STATEMENT DATE; 4,670
(c) THE AMOUNT FAIRLY ESTIMATED AS RECOVERABLE ON CASH 4,673
DEPOSITED IN A BANK OR TRUST COMPANY THE OPERATIONS OF WHICH HAVE 4,674
BEEN SUSPENDED OR FOR WHICH A RECEIVER HAS BEEN APPOINTED, IF 4,675
QUALIFYING UNDER THIS SECTION PRIOR TO THE SUSPENSION OF 4,676
OPERATIONS OF OR THE APPOINTMENT OF A RECEIVER FOR THE BANK OR 4,677
TRUST COMPANY;
(d) BILLS AND ACCOUNTS RECEIVABLE COLLATERALIZED BY 4,680
SECURITIES OF THE KIND IN WHICH THE HEALTH INSURING CORPORATION 4,681
MAY INVEST;
(e) PREMIUMS RECEIVABLE FROM GROUPS OR INDIVIDUALS THAT 4,684
ARE NOT MORE THAN NINETY DAYS PAST DUE; 4,685
(f) ACCOUNTS RECEIVABLE THAT ARE NOT MORE THAN NINETY DAYS 4,688
PAST DUE;
(g) AMOUNTS DUE UNDER REINSURANCE ARRANGEMENTS FROM 4,691
INSURANCE COMPANIES AUTHORIZED TO DO BUSINESS IN THIS STATE; 4,692
(h) TAX REFUNDS DUE FROM THE UNITED STATES OR ANY STATE; 4,696
106
(i) THE INTEREST ACCRUED ON MORTGAGE LOANS THAT CONFORM TO 4,699
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON AN 4,700
INDIVIDUAL LOAN AN AGGREGATE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,701
ACCRUED INTEREST; 4,702
(j) THE RENTS ACCRUED AND OWING TO THE HEALTH INSURING 4,705
CORPORATION ON REAL AND PERSONAL PROPERTY, DIRECTLY OR 4,706
BENEFICIALLY OWNED, NOT EXCEEDING ON EACH INDIVIDUAL PROPERTY THE 4,707
AMOUNT OF ONE YEAR'S TOTAL DUE AND ACCRUED RENT; 4,708
(k) INTEREST OR RENTS ACCRUED ON CONDITIONAL SALES 4,711
AGREEMENTS, SECURITY INTERESTS, CHATTEL MORTGAGES, AND REAL OR 4,712
PERSONAL PROPERTY UNDER LEASE TO OTHER CORPORATIONS, THAT CONFORM 4,713
TO SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON ANY 4,715
INDIVIDUAL INVESTMENT THE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,716
ACCRUED INTEREST OR RENT; 4,717
(l) THE FIXED AND REQUIRED INTEREST DUE AND ACCRUED ON 4,720
BONDS AND OTHER SIMILAR EVIDENCES OF INDEBTEDNESS, THAT CONFORM 4,721
TO SECTION 3925.08 OF THE REVISED CODE, AND NOT IN DEFAULT; 4,722
(m) DIVIDENDS RECEIVABLE ON SHARES OF STOCK THAT CONFORM 4,725
TO SECTION 3925.08 OF THE REVISED CODE, PROVIDED THAT THE MARKET 4,726
PRICE TAKEN FOR VALUATION PURPOSES DOES NOT INCLUDE THE VALUE OF 4,727
THE DIVIDEND;
(n) THE INTEREST OR DIVIDENDS DUE AND PAYABLE, BUT NOT 4,730
CREDITED, ON DEPOSITS IN BANKS AND TRUST COMPANIES OR ON ACCOUNTS 4,731
WITH SAVINGS AND LOAN ASSOCIATIONS; 4,732
(o) INTEREST ACCRUED ON SECURED LOANS THAT CONFORM TO 4,735
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING THE AMOUNT OF 4,738
ONE YEAR'S INTEREST ON ANY LOAN;
(p) INTEREST ACCRUED ON TAX ANTICIPATION WARRANTS; 4,741
(q) THE AMORTIZED VALUE OF ELECTRONIC COMPUTER OR DATA 4,744
PROCESSING MACHINES OR SYSTEMS PURCHASED FOR USE IN CONNECTION 4,745
WITH THE BUSINESS OF THE HEALTH INSURING CORPORATION, INCLUDING 4,746
SOFTWARE PURCHASED AND DEVELOPED SPECIFICALLY FOR THE USE AND 4,747
PURPOSES OF THE CORPORATION;
(r) THE COST OF FURNITURE, EQUIPMENT, AND MEDICAL 4,750
107
EQUIPMENT, LESS ACCUMULATED DEPRECIATION ON THE FURNITURE AND 4,751
EQUIPMENT TO BE APPLIED PRO RATA OVER A PERIOD NOT TO EXCEED FIVE 4,752
YEARS, AND OF MEDICAL AND PHARMACEUTICAL SUPPLIES, THAT ARE UNDER 4,753
THE CONTROL OF THE HEALTH INSURING CORPORATION, PROVIDED THESE 4,754
ASSETS DO NOT EXCEED FIFTEEN PER CENT OF ADMITTED ASSETS; 4,755
(s) AMOUNTS DUE FROM AFFILIATES TO THE EXTENT THAT THE 4,758
AFFILIATE HAS LIQUID ASSETS WITH WHICH TO PAY THE BALANCE AND 4,759
MAINTAIN ITS ACCOUNTS ON A CURRENT BASIS. ANY AMOUNT OUTSTANDING 4,760
MORE THAN THREE MONTHS SHALL BE CONSIDERED NOT CURRENT. 4,761
(2) "LIABILITIES" MEANS THE LIABILITIES OF THE HEALTH 4,763
INSURING CORPORATION AS DETERMINED BY THE SUPERINTENDENT OF 4,764
INSURANCE. 4,765
(B) ALL ADMITTED ASSETS OF A HEALTH INSURING CORPORATION 4,768
MUST BE HELD IN THE HEALTH INSURING CORPORATION'S NAME AND MUST 4,769
BE FREE AND CLEAR OF ANY ENCUMBRANCES, PLEDGES, OR HYPOTHECATION. 4,770
(C)(1) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,773
PROVIDE BASIC HEALTH CARE SERVICES, WHICH HEALTH INSURING 4,774
CORPORATION IS NOT A PROVIDER SPONSORED ORGANIZATION, SHALL 4,775
MAINTAIN TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN 4,776
PER CENT OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO 4,777
TIME SHALL THE CORPORATION'S NET WORTH BE LESS THAN ONE MILLION 4,778
TWO HUNDRED THOUSAND DOLLARS.
(2) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,780
PROVIDE ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN 4,781
TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT 4,782
OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL 4,784
THE CORPORATION'S NET WORTH BE LESS THAN FIVE HUNDRED THOUSAND 4,785
DOLLARS.
(3) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,787
PROVIDE ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN TOTAL 4,788
ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE 4,789
LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL THE 4,790
CORPORATION'S NET WORTH BE LESS THAN TWO HUNDRED FIFTY THOUSAND 4,791
DOLLARS. 4,792
108
(4) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,794
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 4,795
CARE SERVICES, WHICH HEALTH INSURING CORPORATION IS NOT A 4,796
PROVIDER SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED 4,797
ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE 4,798
LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL THE 4,799
CORPORATION'S NET WORTH BE LESS THAN ONE MILLION SEVEN HUNDRED 4,800
THOUSAND DOLLARS. 4,801
(5) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,803
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,804
SERVICES, WHICH HEALTH INSURING CORPORATION IS NOT A PROVIDER 4,805
SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED ASSETS 4,806
EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF 4,807
THE CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,808
WORTH BE LESS THAN ONE MILLION FOUR HUNDRED FIFTY THOUSAND 4,809
DOLLARS.
(6) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,811
PROVIDE BASIC HEALTH CARE SERVICES, WHICH HEALTH INSURING 4,812
CORPORATION IS A PROVIDER SPONSORED ORGANIZATION, SHALL MAINTAIN 4,813
TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT 4,814
OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL 4,815
THE CORPORATION'S NET WORTH BE LESS THAN ONE MILLION DOLLARS. 4,816
(7) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,818
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 4,819
CARE SERVICES, WHICH HEALTH INSURING CORPORATION IS A PROVIDER 4,820
SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED ASSETS 4,821
EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF 4,822
THE CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,824
WORTH BE LESS THAN ONE MILLION FIVE HUNDRED THOUSAND DOLLARS. 4,825
(8) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,827
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,828
SERVICES, WHICH HEALTH INSURING CORPORATION IS A PROVIDER 4,829
SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED ASSETS 4,830
EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF 4,831
109
THE CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,833
WORTH BE LESS THAN ONE MILLION TWO HUNDRED FIFTY THOUSAND
DOLLARS. 4,834
(D) THE ADMITTED VALUE OF ANY REAL ESTATE OWNED BY A 4,837
HEALTH INSURING CORPORATION, WHETHER USED FOR THE ACCOMMODATION 4,838
OF THE HEALTH INSURING CORPORATION'S BUSINESS OPERATIONS OR 4,839
OTHERWISE, SHALL BE THE ORIGINAL COST PLUS THE COST OF 4,840
IMPROVEMENTS, LESS ENCUMBRANCES AND ACCUMULATED DEPRECIATION. 4,841
(E) THE NET WORTH OTHERWISE REQUIRED BY THIS SECTION SHALL 4,843
BE REDUCED BY AN AMOUNT REPRESENTING CREDIT GIVEN TO RESERVE 4,844
LIABILITIES WHEN A HEALTH INSURING CORPORATION CARRIES 4,845
REINSURANCE WITH AN ADMITTED REINSURER. HOWEVER, SUCH AN AMOUNT 4,846
SHALL NOT AFFECT THE MINIMUM AMOUNTS SET FORTH IN THIS SECTION 4,847
AND SECTION 1751.27 OF THE REVISED CODE.
Sec. 1751.31. (A) ANY CHANGES IN A HEALTH INSURING 4,850
CORPORATION'S SOLICITATION DOCUMENT SHALL BE FILED WITH THE 4,851
SUPERINTENDENT OF INSURANCE. THE SUPERINTENDENT, WITHIN SIXTY 4,852
DAYS OF FILING, MAY DISAPPROVE ANY SOLICITATION DOCUMENT OR 4,853
AMENDMENT TO IT ON ANY OF THE GROUNDS STATED IN THIS SECTION. 4,854
SUCH DISAPPROVAL SHALL BE EFFECTED BY WRITTEN NOTICE TO THE 4,855
HEALTH INSURING CORPORATION. THE NOTICE SHALL STATE THE GROUNDS 4,856
FOR DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 4,857
119. OF THE REVISED CODE. 4,858
(B) THE SOLICITATION DOCUMENT SHALL CONTAIN ALL 4,861
INFORMATION NECESSARY TO ENABLE A CONSUMER TO MAKE AN INFORMED 4,862
CHOICE AS TO WHETHER OR NOT TO ENROLL IN THE HEALTH INSURING 4,863
CORPORATION. THE INFORMATION SHALL INCLUDE A SPECIFIC 4,864
DESCRIPTION OF THE HEALTH CARE SERVICES TO BE AVAILABLE AND THE 4,865
APPROXIMATE NUMBER AND TYPE OF FULL-TIME EQUIVALENT MEDICAL 4,866
PRACTITIONERS. THE INFORMATION SHALL BE PRESENTED IN THE 4,867
SOLICITATION DOCUMENT IN A MANNER THAT IS CLEAR, CONCISE, AND 4,868
INTELLIGIBLE TO PROSPECTIVE APPLICANTS IN THE PROPOSED SERVICE 4,869
AREA.
(C) EVERY POTENTIAL APPLICANT WHOSE SUBSCRIPTION TO A 4,872
110
HEALTH CARE PLAN IS SOLICITED SHALL RECEIVE, AT OR BEFORE THE 4,873
TIME OF SOLICITATION, A SOLICITATION DOCUMENT APPROVED BY THE 4,874
SUPERINTENDENT.
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 4,877
INSURING CORPORATION MAY USE A SOLICITATION DOCUMENT THAT THE 4,878
CORPORATION USES IN CONNECTION WITH POLICIES FOR BENEFICIARIES OF 4,879
TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,881
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 4,883
MEDICARE COST CONTRACT, OR FOR POLICIES FOR BENEFICIARIES OF THE 4,884
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 4,886
8905, OR FOR POLICIES FOR BENEFICIARIES OF TITLE XIX OF THE 4,888
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 4,891
AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, 4,892
PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 4,893
5111. OF THE REVISED CODE, OR FOR POLICIES FOR BENEFICIARIES OF 4,894
ANY OTHER FEDERAL HEALTH CARE PROGRAM REGULATED BY A FEDERAL 4,895
REGULATORY BODY, IF BOTH OF THE FOLLOWING APPLY: 4,896
(1) THE SOLICITATION DOCUMENT HAS BEEN APPROVED BY THE 4,898
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 4,899
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 4,901
HUMAN SERVICES.
(2) THE SOLICITATION DOCUMENT IS FILED WITH THE 4,903
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 4,904
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 4,907
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 4,909
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 4,911
(E) NO HEALTH INSURING CORPORATION, OR ITS AGENTS OR 4,914
REPRESENTATIVES, SHALL USE MONETARY OR OTHER VALUABLE 4,915
CONSIDERATION, ENGAGE IN MISLEADING OR DECEPTIVE PRACTICES, OR 4,916
MAKE UNTRUE, MISLEADING, OR DECEPTIVE REPRESENTATIONS TO INDUCE 4,917
ENROLLMENT. NOTHING IN THIS DIVISION SHALL PROHIBIT INCENTIVE 4,918
FORMS OF REMUNERATION SUCH AS COMMISSION SALES PROGRAMS FOR THE 4,919
HEALTH INSURING CORPORATION'S EMPLOYEES AND AGENTS. 4,920
(F) ANY PERSON OBLIGATED FOR ANY PART OF A PREMIUM RATE IN 4,923
111
CONNECTION WITH AN ENROLLMENT AGREEMENT, IN ADDITION TO ANY RIGHT 4,924
OTHERWISE AVAILABLE TO REVOKE AN OFFER, MAY CANCEL SUCH AGREEMENT 4,925
WITHIN SEVENTY-TWO HOURS AFTER HAVING SIGNED THE AGREEMENT OR 4,926
OFFER TO ENROLL. CANCELLATION OCCURS WHEN WRITTEN NOTICE OF THE 4,927
CANCELLATION IS GIVEN TO THE HEALTH INSURING CORPORATION OR ITS 4,928
AGENTS OR OTHER REPRESENTATIVES. A NOTICE OF CANCELLATION MAILED 4,929
TO THE HEALTH INSURING CORPORATION SHALL BE CONSIDERED TO HAVE 4,930
BEEN FILED ON ITS POSTMARK DATE. 4,931
(G) NOTHING IN THIS SECTION SHALL PROHIBIT HEALTHY 4,933
LIFESTYLE PROGRAMS. 4,934
Sec. 1751.32. EACH HEALTH INSURING CORPORATION, ANNUALLY, 4,936
ON OR BEFORE THE FIRST DAY OF MARCH, SHALL FILE A REPORT WITH THE 4,938
SUPERINTENDENT OF INSURANCE AND THE DIRECTOR OF HEALTH, COVERING 4,939
THE PRECEDING CALENDAR YEAR.
THE REPORT SHALL BE VERIFIED BY AN OFFICER OF THE HEALTH 4,941
INSURING CORPORATION, SHALL BE IN THE FORM THE SUPERINTENDENT 4,942
PRESCRIBES, AND SHALL INCLUDE: 4,943
(A) A FINANCIAL STATEMENT OF THE HEALTH INSURING 4,946
CORPORATION, INCLUDING ITS BALANCE SHEET AND RECEIPTS AND 4,947
DISBURSEMENTS FOR THE PRECEDING YEAR, WHICH REFLECT, AT A 4,948
MINIMUM:
(1) ALL PREMIUM RATE AND OTHER PAYMENTS RECEIVED FOR 4,950
HEALTH CARE SERVICES RENDERED; 4,951
(2) EXPENDITURES WITH RESPECT TO ALL CATEGORIES OF 4,953
PROVIDERS, FACILITIES, INSURANCE COMPANIES, AND OTHER PERSONS 4,954
ENGAGED TO FULFILL OBLIGATIONS OF THE HEALTH INSURING CORPORATION 4,956
ARISING OUT OF ITS HEALTH CARE POLICIES, CONTRACTS, CERTIFICATES, 4,957
AND AGREEMENTS;
(3) EXPENDITURES FOR CAPITAL IMPROVEMENTS OR ADDITIONS 4,959
THERETO, INCLUDING, BUT NOT LIMITED TO, CONSTRUCTION, RENOVATION, 4,961
OR PURCHASE OF FACILITIES AND EQUIPMENT.
(B) A DESCRIPTION OF THE ENROLLEE POPULATION AND 4,964
COMPOSITION, GROUP AND NONGROUP;
(C) A SUMMARY OF ENROLLEE WRITTEN COMPLAINTS AND THEIR 4,967
112
DISPOSITION;
(D) A STATEMENT OF THE NUMBER OF SUBSCRIBER POLICIES, 4,970
CONTRACTS, CERTIFICATES, AND AGREEMENTS THAT HAVE BEEN TERMINATED 4,971
BY ACTION OF THE HEALTH INSURING CORPORATION, INCLUDING THE 4,972
NUMBER OF ENROLLEES AFFECTED; 4,973
(E) A SUMMARY OF THE INFORMATION COMPILED PURSUANT TO 4,976
DIVISION (B)(5) OF SECTION 1751.04 OF THE REVISED CODE; 4,977
(F) A CURRENT REPORT OF THE NAMES AND ADDRESSES OF THE 4,980
PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS OF THE HEALTH 4,981
INSURING CORPORATION AS REQUIRED BY SECTION 1751.03 OF THE 4,982
REVISED CODE. ADDITIONALLY, THE REPORT SHALL INCLUDE THE AMOUNT 4,984
OF WAGES, EXPENSE REIMBURSEMENTS, AND OTHER PAYMENTS TO THESE 4,985
PERSONS FOR SERVICES TO THE HEALTH INSURING CORPORATION, AND 4,986
SHALL INCLUDE A FULL DISCLOSURE OF THE FINANCIAL INTERESTS 4,987
RELATED TO THE OPERATIONS OF THE HEALTH INSURING CORPORATION 4,988
ACQUIRED BY THESE PERSONS DURING THE PRECEDING YEAR. 4,989
(G) AN AUDIT REPORT CERTIFIED BY AN INDEPENDENT CERTIFIED 4,992
PUBLIC ACCOUNTANT IN THE FORM PRESCRIBED BY THE SUPERINTENDENT BY 4,993
RULE;
(H) AN ACTUARIAL OPINION IN THE FORM PRESCRIBED BY THE 4,996
SUPERINTENDENT BY RULE;
(I) ANY OTHER INFORMATION RELATING TO THE PERFORMANCE OF 4,999
THE HEALTH INSURING CORPORATION THAT IS NECESSARY TO ENABLE THE 5,000
SUPERINTENDENT TO CARRY OUT THE SUPERINTENDENT'S DUTIES UNDER 5,001
THIS CHAPTER.
Sec. 1751.33. (A) EACH HEALTH INSURING CORPORATION SHALL 5,003
PROVIDE TO ITS SUBSCRIBERS, BY MAIL, A DESCRIPTION OF THE HEALTH 5,004
INSURING CORPORATION, ITS METHOD OF OPERATION, ITS SERVICE AREA, 5,005
ITS MOST RECENT PROVIDER LIST, AND ITS COMPLAINT PROCEDURE 5,006
ESTABLISHED PURSUANT TO SECTION 1751.19 OF THE REVISED CODE. A 5,008
HEALTH INSURING CORPORATION PROVIDING BASIC HEALTH CARE SERVICES 5,009
OR SUPPLEMENTAL HEALTH CARE SERVICES SHALL PROVIDE THIS 5,010
INFORMATION ANNUALLY. A HEALTH INSURING CORPORATION PROVIDING
ONLY SPECIALTY HEALTH CARE SERVICES SHALL PROVIDE THIS 5,011
113
INFORMATION BIENNIALLY.
(B) EACH HEALTH INSURING CORPORATION, UPON THE REQUEST OF 5,014
A SUBSCRIBER, SHALL MAKE AVAILABLE ITS MOST RECENT STATUTORY 5,015
FINANCIAL STATEMENT.
Sec. 1751.34. (A) EACH HEALTH INSURING CORPORATION AND 5,018
EACH APPLICANT FOR A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 5,019
SHALL BE SUBJECT TO EXAMINATION BY THE SUPERINTENDENT OF 5,020
INSURANCE IN ACCORDANCE WITH SECTION 3901.07 OF THE REVISED CODE. 5,022
SECTION 3901.07 OF THE REVISED CODE SHALL GOVERN EVERY ASPECT OF 5,024
THE EXAMINATION, INCLUDING THE CIRCUMSTANCES UNDER AND FREQUENCY 5,025
WITH WHICH IT IS CONDUCTED, THE AUTHORITY OF THE SUPERINTENDENT 5,026
AND ANY EXAMINER OR OTHER PERSON APPOINTED BY THE SUPERINTENDENT, 5,027
THE LIABILITY FOR THE ASSESSMENT OF EXPENSES INCURRED IN 5,028
CONDUCTING THE EXAMINATION, AND THE REMITTANCE OF THE ASSESSMENT 5,029
TO THE SUPERINTENDENT'S EXAMINATION FUND.
(B) THE DIRECTOR OF HEALTH SHALL MAKE AN EXAMINATION 5,032
CONCERNING THE MATTERS SUBJECT TO THE DIRECTOR'S CONSIDERATION IN 5,033
SECTION 1751.04 OF THE REVISED CODE AS OFTEN AS THE DIRECTOR 5,034
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF THE 5,036
PEOPLE OF THIS STATE, BUT NOT LESS FREQUENTLY THAN ONCE EVERY 5,037
THREE YEARS. THE EXPENSES OF SUCH EXAMINATIONS SHALL BE ASSESSED 5,038
AGAINST THE HEALTH INSURING CORPORATION BEING EXAMINED IN THE 5,039
MANNER IN WHICH EXPENSES OF EXAMINATIONS ARE ASSESSED AGAINST AN 5,040
INSURANCE COMPANY UNDER SECTION 3901.07 OF THE REVISED CODE. 5,041
(C) AN EXAMINATION, PURSUANT TO SECTION 3901.07 OF THE 5,044
REVISED CODE, OF AN INSURANCE COMPANY HOLDING A CERTIFICATE OF 5,045
AUTHORITY UNDER THIS CHAPTER TO ORGANIZE AND OPERATE A HEALTH 5,046
INSURING CORPORATION SHALL INCLUDE AN EXAMINATION OF THE HEALTH 5,047
INSURING CORPORATION PURSUANT TO THIS SECTION AND THE EXAMINATION 5,048
SHALL SATISFY THE REQUIREMENTS OF DIVISIONS (A) AND (B) OF THIS 5,050
SECTION.
(D) THE SUPERINTENDENT MAY CONDUCT MARKET CONDUCT 5,053
EXAMINATIONS PURSUANT TO SECTION 3901.011 OF THE REVISED CODE OF 5,055
ANY HEALTH INSURING CORPORATION AS OFTEN AS THE SUPERINTENDENT 5,056
114
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF 5,057
SUBSCRIBERS AND ENROLLEES. THE EXPENSES OF SUCH MARKET CONDUCT 5,058
EXAMINATIONS SHALL BE ASSESSED AGAINST THE HEALTH INSURING 5,059
CORPORATION BEING EXAMINED. ALL COSTS, ASSESSMENTS, OR FINES 5,060
COLLECTED UNDER THIS DIVISION SHALL BE PAID INTO THE STATE 5,061
TREASURY TO THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING 5,062
FUND.
Sec. 1751.35. (A) THE SUPERINTENDENT OF INSURANCE MAY 5,065
SUSPEND OR REVOKE ANY CERTIFICATE OF AUTHORITY ISSUED TO A HEALTH 5,066
INSURING CORPORATION UNDER THIS CHAPTER IF THE SUPERINTENDENT 5,067
FINDS THAT:
(1) THE HEALTH INSURING CORPORATION IS OPERATING IN 5,069
CONTRAVENTION OF ITS ARTICLES OF INCORPORATION, ITS HEALTH CARE 5,070
PLAN OR PLANS, OR IN A MANNER CONTRARY TO THAT DESCRIBED IN AND 5,071
REASONABLY INFERRED FROM ANY OTHER INFORMATION SUBMITTED UNDER 5,072
SECTION 1751.03 OF THE REVISED CODE, UNLESS AMENDMENTS TO SUCH 5,074
SUBMISSIONS HAVE BEEN FILED AND HAVE TAKEN EFFECT IN COMPLIANCE 5,075
WITH THIS CHAPTER. 5,076
(2) THE HEALTH INSURING CORPORATION FAILS TO ISSUE 5,078
EVIDENCES OF COVERAGE IN COMPLIANCE WITH THE REQUIREMENTS OF 5,079
SECTION 1751.11 OF THE REVISED CODE. 5,081
(3) THE CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUM RATES 5,083
USED DO NOT COMPLY WITH THE REQUIREMENTS OF SECTION 1751.12 OF 5,084
THE REVISED CODE. 5,085
(4) THE HEALTH INSURING CORPORATION ENTERS INTO A 5,087
CONTRACT, AGREEMENT, OR OTHER ARRANGEMENT WITH ANY HEALTH CARE 5,088
FACILITY OR PROVIDER, THAT DOES NOT COMPLY WITH THE REQUIREMENTS 5,089
OF SECTION 1751.13 OF THE REVISED CODE, OR THE CORPORATION FAILS 5,091
TO PROVIDE AN ANNUAL CERTIFICATE AS REQUIRED BY SECTION 1751.13 5,092
OF THE REVISED CODE. 5,094
(5) THE DIRECTOR OF HEALTH HAS CERTIFIED, AFTER A HEARING 5,096
CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, 5,098
THAT THE HEALTH INSURING CORPORATION NO LONGER MEETS THE 5,099
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. 5,101
115
(6) THE HEALTH INSURING CORPORATION IS NO LONGER 5,103
FINANCIALLY RESPONSIBLE AND MAY REASONABLY BE EXPECTED TO BE 5,104
UNABLE TO MEET ITS OBLIGATIONS TO ENROLLEES OR PROSPECTIVE 5,105
ENROLLEES. 5,106
(7) THE HEALTH INSURING CORPORATION HAS FAILED TO 5,108
IMPLEMENT THE COMPLAINT SYSTEM THAT COMPLIES WITH THE 5,109
REQUIREMENTS OF SECTION 1751.19 OF THE REVISED CODE. 5,112
(8) THE HEALTH INSURING CORPORATION, OR ANY AGENT OR 5,114
REPRESENTATIVE OF THE CORPORATION, HAS ADVERTISED, MERCHANDISED, 5,115
OR SOLICITED ON ITS BEHALF IN CONTRAVENTION OF THE REQUIREMENTS 5,116
OF SECTION 1751.31 OF THE REVISED CODE. 5,117
(9) THE HEALTH INSURING CORPORATION HAS UNLAWFULLY 5,119
DISCRIMINATED AGAINST ANY ENROLLEE OR PROSPECTIVE ENROLLEE WITH 5,120
RESPECT TO ENROLLMENT, DISENROLLMENT, OR PRICE OR QUALITY OF 5,121
HEALTH CARE SERVICES. 5,122
(10) THE CONTINUED OPERATION OF THE HEALTH INSURING 5,124
CORPORATION WOULD BE HAZARDOUS OR OTHERWISE DETRIMENTAL TO ITS 5,125
ENROLLEES. 5,126
(11) THE HEALTH INSURING CORPORATION HAS SUBMITTED FALSE 5,128
INFORMATION IN ANY FILING OR SUBMISSION REQUIRED UNDER THIS 5,129
CHAPTER OR ANY RULE ADOPTED UNDER THIS CHAPTER. 5,130
(12) THE HEALTH INSURING CORPORATION HAS OTHERWISE FAILED 5,132
TO SUBSTANTIALLY COMPLY WITH THIS CHAPTER OR ANY RULE ADOPTED 5,133
UNDER THIS CHAPTER. 5,134
(13) THE HEALTH INSURING CORPORATION IS NOT OPERATING A 5,136
HEALTH CARE PLAN. 5,137
(B) A CERTIFICATE OF AUTHORITY SHALL BE SUSPENDED OR 5,140
REVOKED ONLY AFTER COMPLIANCE WITH THE REQUIREMENTS OF CHAPTER 5,141
119. OF THE REVISED CODE. 5,142
(C) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,145
CORPORATION IS SUSPENDED, THE HEALTH INSURING CORPORATION, DURING 5,146
THE PERIOD OF SUSPENSION, SHALL NOT ENROLL ANY ADDITIONAL 5,147
SUBSCRIBERS OR ENROLLEES EXCEPT NEWBORN CHILDREN OR OTHER NEWLY 5,148
ACQUIRED DEPENDENTS OF EXISTING SUBSCRIBERS OR ENROLLEES, AND 5,149
116
SHALL NOT ENGAGE IN ANY ADVERTISING OR SOLICITATION WHATSOEVER. 5,150
(D) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,153
CORPORATION IS REVOKED, THE HEALTH INSURING CORPORATION, 5,154
FOLLOWING THE EFFECTIVE DATE OF THE ORDER OF REVOCATION, SHALL 5,155
CONDUCT NO FURTHER BUSINESS EXCEPT AS MAY BE ESSENTIAL TO THE 5,156
ORDERLY CONCLUSION OF THE AFFAIRS OF THE HEALTH INSURING 5,157
CORPORATION. THE HEALTH INSURING CORPORATION SHALL ENGAGE IN NO 5,158
FURTHER ADVERTISING OR SOLICITATION WHATSOEVER. THE 5,159
SUPERINTENDENT, BY WRITTEN ORDER, MAY PERMIT SUCH FURTHER 5,160
OPERATION OF THE HEALTH INSURING CORPORATION AS THE 5,161
SUPERINTENDENT MAY FIND TO BE IN THE BEST INTEREST OF ENROLLEES, 5,162
TO THE END THAT ENROLLEES WILL BE AFFORDED THE GREATEST PRACTICAL 5,163
OPPORTUNITY TO OBTAIN CONTINUING HEALTH CARE COVERAGE. 5,164
Sec. 1751.36. (A) WHEN THE SUPERINTENDENT OF INSURANCE 5,167
HAS CAUSE TO BELIEVE THAT GROUNDS FOR THE DENIAL OF AN 5,168
APPLICATION FOR A CERTIFICATE OF AUTHORITY EXIST, OR THAT GROUNDS 5,169
FOR THE SUSPENSION OR REVOCATION OF A CERTIFICATE OF AUTHORITY 5,170
EXIST, THE SUPERINTENDENT SHALL NOTIFY THE APPLICANT OR HEALTH 5,171
INSURING CORPORATION AND THE DIRECTOR OF HEALTH IN WRITING, 5,172
SPECIFICALLY STATING THE GROUNDS FOR THE DENIAL, SUSPENSION, OR 5,173
REVOCATION AND SETTING A DATE OF AT LEAST THIRTY DAYS AFTER THE 5,174
NOTIFICATION FOR A HEARING ON THE MATTER.
(B) THE RECOMMENDATIONS AND FINDINGS OF THE DIRECTOR OF 5,177
HEALTH WITH RESPECT TO MATTERS SUBJECT TO THE DIRECTOR'S 5,178
CONSIDERATION UNDER SECTION 1751.04 OF THE REVISED CODE, PROVIDED 5,180
IN CONNECTION WITH ANY DECISION REGARDING THE DENIAL, SUSPENSION, 5,181
OR REVOCATION OF A CERTIFICATE OF AUTHORITY, SHALL BE REVIEWED 5,182
AND CONSIDERED BY THE SUPERINTENDENT. AFTER THE HEARING 5,183
AUTHORIZED BY DIVISION (A) OF THIS SECTION, OR UPON THE FAILURE 5,185
OF THE APPLICANT OR HEALTH INSURING CORPORATION TO APPEAR AT THE 5,186
HEARING, THE SUPERINTENDENT SHALL TAKE SUCH ACTION AS IN 5,187
ACCORDANCE WITH LAW AND THE EVIDENCE. THE ACTION SHALL BE SET 5,188
OUT IN WRITTEN FINDINGS WHICH SHALL BE MAILED TO THE APPLICANT OR 5,189
HEALTH INSURING CORPORATION WITH A COPY TO THE DIRECTOR OF
117
HEALTH. THE ACTION OF THE SUPERINTENDENT IS SUBJECT TO REVIEW IN 5,191
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, EXCEPT THAT A 5,193
CERTIFICATION BY THE DIRECTOR UNDER DIVISION (D) OF SECTION 5,195
1751.04 OR DIVISION (A)(5) OF SECTION 1751.35 OF THE REVISED CODE 5,197
THAT WAS MADE IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE 5,198
SHALL BE FINAL AS TO THE MATTERS CERTIFIED.
(C) CHAPTER 119. OF THE REVISED CODE APPLIES TO 5,200
PROCEEDINGS UNDER THIS SECTION TO THE EXTENT THAT IT IS NOT IN 5,201
CONFLICT WITH DIVISIONS (A) AND (B) OF THIS SECTION. 5,202
Sec. 1751.38. (A) AS USED IN THIS SECTION, "AGENT" MEANS 5,205
A PERSON APPOINTED BY A HEALTH INSURING CORPORATION TO ENGAGE IN 5,206
THE SOLICITATION OR ENROLLMENT OF SUBSCRIBERS OR ENROLLEES. 5,207
(B) AGENTS OF HEALTH INSURING CORPORATIONS SHALL BE 5,210
LICENSED PURSUANT TO SECTION 3905.01 OR 3905.18 OF THE REVISED 5,213
CODE.
(C) SECTIONS 3905.01, 3905.03, 3905.05, 3905.16 TO 5,216
3905.18, 3905.181, 3905.19, 3905.23, 3905.40, 3905.41, 3905.42, 5,217
3905.46 TO 3905.48, 3905.481, 3905.482, 3905.486, 3905.49, 5,218
3905.50, 3905.71 TO 3905.79, AND 3905.99 OF THE REVISED CODE 5,219
SHALL APPLY TO HEALTH INSURING CORPORATIONS AND THE AGENTS OF 5,220
HEALTH INSURING CORPORATIONS IN THE SAME MANNER IN WHICH THESE 5,221
SECTIONS APPLY TO INSURERS AND AGENTS OF INSURERS. 5,222
Sec. 1751.40. (A) NOTWITHSTANDING ANY PROVISION OF TITLE 5,224
XXXIX OF THE REVISED CODE, ANY INSURANCE COMPANY HOLDING A 5,228
CERTIFICATE OF AUTHORITY ISSUED PURSUANT TO TITLE XXXIX OF THE 5,230
REVISED CODE, OR ANY CORPORATION THAT IS A SUBSIDIARY OR 5,231
AFFILIATE OF THE INSURANCE COMPANY, MAY APPLY FOR AND OBTAIN A 5,232
CERTIFICATE OF AUTHORITY TO ORGANIZE AND OPERATE A HEALTH 5,233
INSURING CORPORATION IN COMPLIANCE WITH THIS CHAPTER. 5,234
NOTWITHSTANDING ANY OTHER LAW THAT MAY BE INCONSISTENT WITH THIS 5,235
DIVISION, ANY TWO OR MORE SUCH INSURANCE COMPANIES, OR
SUBSIDIARIES OR AFFILIATES THEREOF, MAY JOINTLY ORGANIZE AND 5,236
OPERATE A HEALTH INSURING CORPORATION UNDER THIS CHAPTER. THE 5,237
BUSINESS OF INSURANCE IS DEEMED TO INCLUDE THE PROVIDING OF 5,238
118
HEALTH CARE BY A HEALTH INSURING CORPORATION OWNED OR OPERATED BY 5,240
AN INSURANCE COMPANY OR A SUBSIDIARY OR AFFILIATE OF AN INSURANCE 5,241
COMPANY.
(B) NOTWITHSTANDING ANY PROVISION OF ANY INSURANCE LAWS OF 5,244
THIS STATE, AN INSURANCE COMPANY MAY CONTRACT WITH A HEALTH 5,245
INSURING CORPORATION TO PROVIDE INSURANCE OR SIMILAR PROTECTION 5,246
AGAINST THE COST OF CARE PROVIDED THROUGH HEALTH INSURING 5,247
CORPORATIONS AND TO PROVIDE COVERAGE IN THE EVENT OF THE FAILURE 5,248
OF THE HEALTH INSURING CORPORATION TO MEET ITS OBLIGATIONS. THE 5,249
ENROLLEES OF A HEALTH INSURING CORPORATION CONSTITUTE A 5,250
PERMISSIBLE GROUP UNDER SUCH LAWS. AMONG OTHER THINGS, UNDER 5,251
SUCH CONTRACTS, THE INSURER MAY MAKE BENEFIT PAYMENTS TO HEALTH 5,252
INSURING CORPORATIONS FOR HEALTH CARE SERVICES RENDERED BY 5,253
FACILITIES AND PROVIDERS PURSUANT TO A HEALTH CARE PLAN. 5,254
Sec. 1751.42. ANY REHABILITATION, LIQUIDATION, 5,256
SUPERVISION, OR CONSERVATION OF A HEALTH INSURING CORPORATION 5,257
SHALL BE DEEMED TO BE THE REHABILITATION, LIQUIDATION, 5,258
SUPERVISION, OR CONSERVATION OF AN INSURANCE COMPANY AND SHALL BE 5,259
CONDUCTED UNDER THE SUPERVISION OF THE SUPERINTENDENT OF 5,260
INSURANCE PURSUANT TO CHAPTER 3903. OF THE REVISED CODE. 5,263
Sec. 1751.44. (A) EACH HEALTH INSURING CORPORATION SHALL 5,266
PAY TO THE SUPERINTENDENT OF INSURANCE THE FOLLOWING FEES: 5,267
(1) FOR FILING AN APPLICATION FOR A CERTIFICATE OF 5,269
AUTHORITY, FIFTEEN HUNDRED DOLLARS; 5,270
(2) FOR FILING A REQUEST FOR A SERVICE AREA EXPANSION 5,272
UNDER SECTION 1751.03 OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,274
(3) FOR FILING A MAJOR MODIFICATION UNDER SECTION 1751.03 5,276
OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,279
(4) FOR FILING EACH ANNUAL REPORT, TWENTY-FIVE DOLLARS; 5,282
(5) FOR ALL OTHER REQUIRED FILINGS FOR WHICH NO FILING FEE 5,285
IS OTHERWISE PROVIDED FOR BY THIS CHAPTER, FIFTY DOLLARS. 5,286
(B) ALL FEES COLLECTED UNDER THIS SECTION SHALL BE PAID 5,289
INTO THE STATE TREASURY TO THE CREDIT OF THE DEPARTMENT OF 5,290
INSURANCE OPERATING FUND.
119
Sec. 1751.45. (A) IN LIEU OF THE SUSPENSION OR REVOCATION 5,293
OF A CERTIFICATE OF AUTHORITY UNDER SECTION 1751.35 OF THE 5,294
REVISED CODE, THE SUPERINTENDENT OF INSURANCE, PURSUANT TO AN 5,296
ADJUDICATION HEARING INITIATED AND CONDUCTED IN ACCORDANCE WITH 5,297
CHAPTER 119. OF THE REVISED CODE, OR BY CONSENT OF THE HEALTH 5,299
INSURING CORPORATION WITHOUT AN ADJUDICATION HEARING, MAY LEVY AN 5,300
ADMINISTRATIVE PENALTY. THE ADMINISTRATIVE PENALTY SHALL BE IN
AN AMOUNT DETERMINED BY THE SUPERINTENDENT, BUT THE 5,302
ADMINISTRATIVE PENALTY SHALL NOT EXCEED ONE HUNDRED THOUSAND 5,303
DOLLARS PER VIOLATION. ADDITIONALLY, THE SUPERINTENDENT MAY 5,304
REQUIRE THE HEALTH INSURING CORPORATION TO CORRECT ANY DEFICIENCY 5,306
THAT MAY BE THE BASIS FOR THE SUSPENSION OR REVOCATION OF THE 5,307
HEALTH INSURING CORPORATION'S CERTIFICATE OF AUTHORITY. ALL 5,308
PENALTIES COLLECTED SHALL BE PAID INTO THE STATE TREASURY TO THE 5,309
CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING FUND. 5,310
(B) IF THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH FOR 5,313
ANY REASON HAS CAUSE TO BELIEVE THAT ANY VIOLATION OF THIS 5,314
CHAPTER HAS OCCURRED OR IS THREATENED, THE SUPERINTENDENT OR THE 5,315
DIRECTOR MAY GIVE NOTICE TO THE HEALTH INSURING CORPORATION AND 5,316
TO THE REPRESENTATIVES OR OTHER PERSONS WHO APPEAR TO BE INVOLVED 5,317
IN THE SUSPECTED VIOLATION TO ARRANGE A CONFERENCE WITH THE 5,318
SUSPECTED VIOLATORS OR THEIR AUTHORIZED REPRESENTATIVES FOR THE 5,319
PURPOSE OF ATTEMPTING TO ASCERTAIN THE FACTS RELATING TO THE 5,320
SUSPECTED VIOLATION, AND, IF IT APPEARS THAT ANY VIOLATION HAS 5,321
OCCURRED OR IS THREATENED, TO ARRIVE AT AN ADEQUATE AND EFFECTIVE 5,323
MEANS OF CORRECTING OR PREVENTING THE VIOLATION.
PROCEEDINGS UNDER THIS DIVISION SHALL NOT BE COVERED BY ANY 5,326
FORMAL PROCEDURAL REQUIREMENTS, AND MAY BE CONDUCTED IN THE
MANNER THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH MAY CONSIDER 5,327
APPROPRIATE UNDER THE CIRCUMSTANCES. 5,328
(C)(1) THE SUPERINTENDENT MAY ISSUE AN ORDER DIRECTING A 5,331
HEALTH INSURING CORPORATION OR A REPRESENTATIVE OF THE HEALTH 5,332
INSURING CORPORATION TO CEASE AND DESIST FROM ENGAGING IN ANY ACT 5,333
OR PRACTICE IN VIOLATION OF THIS CHAPTER. WITHIN THIRTY DAYS 5,334
120
AFTER SERVICE OF THE ORDER TO CEASE AND DESIST, THE RESPONDENT 5,335
MAY REQUEST A HEARING ON THE QUESTION OF WHETHER ACTS OR 5,336
PRACTICES IN VIOLATION OF THIS CHAPTER HAVE OCCURRED. SUCH 5,337
HEARINGS SHALL BE CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF 5,338
THE REVISED CODE AND JUDICIAL REVIEW SHALL BE AVAILABLE AS 5,340
PROVIDED BY THAT CHAPTER.
(2) IF THE SUPERINTENDENT HAS REASONABLE CAUSE TO BELIEVE 5,342
THAT AN ORDER ISSUED PURSUANT TO THIS DIVISION HAS BEEN VIOLATED 5,343
IN WHOLE OR IN PART, THE SUPERINTENDENT MAY REQUEST THE ATTORNEY 5,344
GENERAL TO COMMENCE AND PROSECUTE ANY APPROPRIATE ACTION OR 5,345
PROCEEDING IN THE NAME OF THE STATE AGAINST THE VIOLATORS IN THE 5,346
COURT OF COMMON PLEAS OF FRANKLIN COUNTY. THE COURT IN ANY SUCH 5,349
ACTION OR PROCEEDING MAY LEVY CIVIL PENALTIES, NOT TO EXCEED ONE 5,350
HUNDRED THOUSAND DOLLARS PER VIOLATION, IN ADDITION TO ANY OTHER 5,351
APPROPRIATE RELIEF, INCLUDING REQUIRING A VIOLATOR TO PAY THE 5,352
EXPENSES REASONABLY INCURRED BY THE SUPERINTENDENT IN ENFORCING 5,353
THE ORDER. THE PENALTIES AND FEES COLLECTED UNDER THIS DIVISION 5,354
SHALL BE PAID INTO THE STATE TREASURY TO THE CREDIT OF THE 5,355
DEPARTMENT OF INSURANCE OPERATING FUND.
Sec. 1751.46. (A) THE SUPERINTENDENT OF INSURANCE AND THE 5,358
DIRECTOR OF HEALTH MAY CONTRACT WITH QUALIFIED PERSONS TO MAKE 5,359
RECOMMENDATIONS CONCERNING THE DETERMINATIONS REQUIRED TO BE MADE 5,360
BY THE SUPERINTENDENT OR THE DIRECTOR RELATIVE TO AN EXPANSION OF 5,361
A SERVICE AREA PURSUANT TO DIVISION (C) OF SECTION 1751.03 OF THE 5,363
REVISED CODE, AN APPLICATION FOR A CERTIFICATE OF AUTHORITY 5,365
PURSUANT TO SECTIONS 1751.04 AND 1751.05 OF THE REVISED CODE, A 5,367
CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE PURSUANT TO 5,368
SECTION 1751.12 OF THE REVISED CODE, AND AN EXAMINATION PURSUANT 5,370
TO DIVISION (B) OF SECTION 1751.34 OF THE REVISED CODE. THE 5,372
RECOMMENDATIONS MAY BE ACCEPTED IN FULL OR IN PART, OR MAY BE 5,373
REJECTED, BY THE SUPERINTENDENT OR DIRECTOR. 5,374
(B) NO QUALIFIED PERSON PLACED ON CONTRACT BY THE 5,377
SUPERINTENDENT OR THE DIRECTOR PURSUANT TO DIVISION (A) OF THIS 5,379
SECTION SHALL HAVE A CONFLICT OF INTEREST WITH THE DEPARTMENT OF 5,380
121
INSURANCE, THE DEPARTMENT OF HEALTH, OR THE HEALTH INSURING 5,381
CORPORATION.
Sec. 1751.47. (A) THE SUPERINTENDENT OF INSURANCE SHALL 5,383
ADOPT THE FORMS, INSTRUCTIONS, AND MANUALS PRESCRIBED BY THE 5,385
NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS FOR THE 5,386
PREPARATION AND FILING OF STATUTORY FINANCIAL STATEMENTS AND 5,387
OTHER FINANCIAL INFORMATION. HOWEVER, THE SUPERINTENDENT MAY BY 5,388
RULE ADOPT MODIFICATIONS TO SUCH PRESCRIBED FORMS, INSTRUCTIONS, 5,389
AND MANUALS AS THE SUPERINTENDENT CONSIDERS TO BE NECESSARY. 5,390
(B) FOR PURPOSES OF PREPARING STATUTORY FINANCIAL 5,393
STATEMENTS AND OTHER FINANCIAL INFORMATION INVOLVING 5,394
CIRCUMSTANCES NOT ADDRESSED BY THE FORMS, INSTRUCTIONS, AND 5,395
MANUALS PRESCRIBED BY THE NATIONAL ASSOCIATION OF INSURANCE 5,396
COMMISSIONERS, THE SUPERINTENDENT MAY DETERMINE ACCOUNTING 5,397
PRACTICES AND METHODS TO BE USED BY HEALTH INSURING CORPORATIONS. 5,398
(C) THE SUPERINTENDENT SHALL FURNISH EACH DOMESTIC HEALTH 5,401
INSURING CORPORATION A COPY OF THE FORMS FOR THE FILING OF THOSE 5,402
STATUTORY FINANCIAL STATEMENTS AND OTHER FINANCIAL INFORMATION AS 5,403
THE CORPORATION IS REQUIRED TO FILE WITH THE SUPERINTENDENT. 5,404
Sec. 1751.48. (A) THE SUPERINTENDENT OF INSURANCE MAY 5,407
ADOPT RULES AS ARE NECESSARY TO CARRY OUT THE PROVISIONS OF THIS 5,408
CHAPTER. THESE RULES SHALL BE ADOPTED IN ACCORDANCE WITH CHAPTER 5,409
119. OF THE REVISED CODE. 5,410
(B) THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS TO THE 5,413
SUPERINTENDENT FOR RULES THAT ARE NECESSARY TO ENABLE THE 5,414
DIRECTOR TO CARRY OUT THE DIRECTOR'S RESPONSIBILITIES UNDER THIS 5,415
CHAPTER, INCLUDING RULES THAT PRESCRIBE STANDARDS RELATING TO THE 5,416
REQUIREMENTS SET FORTH IN DIVISION (B) OF SECTION 1751.04 OF THE 5,418
REVISED CODE. IN ADOPTING ANY RULES PERTAINING TO THE DIRECTOR'S 5,420
RESPONSIBILITIES, THE SUPERINTENDENT SHALL CONSIDER THE 5,421
RECOMMENDATIONS OF THE DIRECTOR. 5,422
Sec. 1751.51. IF A HEALTH CARE PLAN OF A HEALTH INSURING 5,424
CORPORATION COVERS HEALTH CARE SERVICES THAT MAY BE LEGALLY 5,425
PERFORMED BY A CLASS OF PROVIDERS REFERRED TO IN SECTION 3923.23 5,426
122
OR 3923.231 OF THE REVISED CODE BUT WOULD RESTRICT AN ENROLLEE'S 5,429
ABILITY TO RECEIVE THESE HEALTH CARE SERVICES FROM MEMBERS OF 5,430
THAT CLASS IN ANY MANNER THAT DIFFERS FROM AN ENROLLEE'S ABILITY 5,431
UNDER THE HEALTH CARE PLAN TO RECEIVE THESE HEALTH CARE SERVICES 5,432
FROM ANY OTHER CLASS OF PROVIDERS THAT MAY LEGALLY PERFORM THESE 5,433
HEALTH CARE SERVICES, THEN THE HEALTH INSURING CORPORATION SHALL 5,434
DO BOTH OF THE FOLLOWING:
(A) SET FORTH, WITHIN ANY EVIDENCE OF COVERAGE PERTAINING 5,437
TO THE HEALTH CARE PLAN, UNDER A HEADING THAT READS "RESTRICTIONS 5,438
ON CHOICE OF PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT 5,440
OF THE RESTRICTION THAT CONFORMS TO THE REQUIREMENTS OF SECTION 5,441
1751.11 OF THE REVISED CODE; 5,442
(B) SET FORTH, WITHIN ANY SOLICITATION DOCUMENT PERTAINING 5,445
TO THE HEALTH CARE PLAN AND WITHIN ANY SOLICITATION MATERIALS 5,446
PERTAINING TO THE HEALTH CARE PLAN THAT THE HEALTH INSURING 5,447
CORPORATION PROVIDES TO ANY EMPLOYER OR ANY EMPLOYEE BENEFIT 5,448
FUND, UNDER A HEADING THAT READS "RESTRICTIONS ON CHOICE OF 5,449
PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT OF THE 5,451
RESTRICTION, SUCH STATEMENT BEING SUBJECT TO PRIOR APPROVAL BY 5,452
THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH THE SAME FORM 5,453
AND CONTENT REQUIREMENTS THAT ARE SPECIFIED IN SECTION 1751.11 OF 5,454
THE REVISED CODE WITH REGARD TO EVIDENCE OF COVERAGE. 5,455
Sec. 1751.52. (A) ALL APPLICATIONS, FILINGS, AND REPORTS 5,458
REQUIRED UNDER THIS CHAPTER SHALL BE TREATED AS PUBLIC DOCUMENTS 5,459
AFTER THE DATE THE APPLICATION, FILING, OR REPORT BECOMES 5,460
EFFECTIVE, REGARDLESS OF THE APPLICATION OF THE UNIFORM TRADE 5,461
SECRETS ACT SET FORTH IN SECTIONS 1333.61 TO 1333.69 OF THE 5,463
REVISED CODE.
(B) ANY DATA OR INFORMATION PERTAINING TO THE DIAGNOSIS, 5,466
TREATMENT, OR HEALTH OF ANY ENROLLEE OR APPLICANT FOR ENROLLMENT 5,467
THAT IS OBTAINED BY THE HEALTH INSURING CORPORATION FROM THE 5,468
ENROLLEE OR APPLICANT, OR FROM ANY HEALTH CARE FACILITY OR 5,469
PROVIDER, SHALL BE HELD IN CONFIDENCE AND SHALL NOT BE DISCLOSED 5,470
TO ANY PERSON EXCEPT UNDER ONE OF THE FOLLOWING CIRCUMSTANCES: 5,471
123
(1) TO THE EXTENT THAT IT MAY BE NECESSARY TO CARRY OUT 5,473
THE PURPOSES OF THIS CHAPTER; 5,474
(2) UPON THE EXPRESS CONSENT OF THE ENROLLEE OR APPLICANT; 5,477
(3) PURSUANT TO STATUTE OR COURT ORDER FOR THE PRODUCTION 5,479
OF EVIDENCE; 5,480
(4) IN THE EVENT OF CLAIM LITIGATION BETWEEN SUCH PERSON 5,482
AND THE HEALTH INSURING CORPORATION WHEREIN SUCH DATA OR 5,483
INFORMATION IS PERTINENT. 5,484
(C) A HEALTH INSURING CORPORATION SHALL BE ENTITLED TO 5,487
CLAIM ANY STATUTORY PRIVILEGES AGAINST DISCLOSURE UNDER DIVISION 5,488
(B) OF THIS SECTION THAT THE FACILITY OR PROVIDER WHO FURNISHED 5,490
THE DATA OR INFORMATION TO THE HEALTH INSURING CORPORATION IS 5,491
ENTITLED TO CLAIM.
Sec. 1751.53. (A) AS USED IN THIS SECTION: 5,493
(1) "GROUP CONTRACT" MEANS A GROUP HEALTH INSURING 5,495
CORPORATION CONTRACT COVERING EMPLOYEES THAT MEETS EITHER OF THE 5,496
FOLLOWING CONDITIONS: 5,497
(a) THE CONTRACT WAS ISSUED BY AN ENTITY THAT, ON THE 5,500
EFFECTIVE DATE OF THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY 5,501
OR LICENSE TO OPERATE UNDER CHAPTER 1738. OR 1742. OF THE REVISED 5,503
CODE, AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S 5,504
EMPLOYMENT IS TERMINATED.
(b) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,507
RENEWED IN THIS STATE AFTER THE EFFECTIVE DATE OF THIS SECTION 5,508
AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S EMPLOYMENT IS 5,509
TERMINATED.
(2) "ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE TO WHOM ALL OF 5,511
THE FOLLOWING APPLY: 5,512
(a) THE EMPLOYEE HAS BEEN CONTINUOUSLY COVERED UNDER A 5,515
GROUP CONTRACT OR UNDER THE CONTRACT AND ANY PRIOR SIMILAR GROUP 5,516
COVERAGE REPLACED BY THE CONTRACT, DURING THE ENTIRE THREE-MONTH 5,517
PERIOD PRECEDING THE TERMINATION OF THE EMPLOYEE'S EMPLOYMENT. 5,518
(b) THE EMPLOYEE IS ENTITLED, AT THE TIME OF THE 5,521
TERMINATION OF THIS EMPLOYMENT, TO UNEMPLOYMENT COMPENSATION 5,522
124
BENEFITS UNDER CHAPTER 4141. OF THE REVISED CODE. 5,523
(c) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,526
OR ELIGIBLE FOR COVERAGE BY MEDICARE UNDER TITLE XVIII OF THE 5,528
"SOCIAL SECURITY ACT, "49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 5,530
AMENDED.
(d) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,533
OR ELIGIBLE FOR COVERAGE BY ANY OTHER INSURED OR UNINSURED 5,534
ARRANGEMENT THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL COVERAGE 5,535
FOR INDIVIDUALS IN A GROUP AND UNDER WHICH THE EMPLOYEE WAS NOT 5,536
COVERED IMMEDIATELY PRIOR TO THE TERMINATION OF EMPLOYMENT. A 5,537
PERSON ELIGIBLE FOR CONTINUATION OF COVERAGE UNDER THIS SECTION, 5,538
WHO IS ALSO ELIGIBLE FOR COVERAGE UNDER SECTION 3923.123 OF THE 5,540
REVISED CODE, MAY ELECT EITHER COVERAGE, BUT NOT BOTH. A PERSON 5,541
WHO ELECTS CONTINUATION OF COVERAGE MAY ELECT ANY COVERAGE 5,542
AVAILABLE UNDER SECTION 3923.123 OF THE REVISED CODE UPON THE 5,544
TERMINATION OF THE CONTINUATION OF COVERAGE. 5,545
(B) A GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,548
EMPLOYEE MAY CONTINUE THE COVERAGE UNDER THE CONTRACT, FOR THE 5,549
EMPLOYEE AND THE EMPLOYEE'S ELIGIBLE DEPENDENTS, FOR A PERIOD OF 5,550
SIX MONTHS AFTER THE DATE THAT THE GROUP COVERAGE WOULD OTHERWISE 5,551
TERMINATE BY REASON OF THE TERMINATION OF THE EMPLOYEE'S 5,552
EMPLOYMENT. EACH CERTIFICATE OF COVERAGE ISSUED TO EMPLOYEES 5,553
UNDER THE CONTRACT SHALL INCLUDE A NOTICE OF THE EMPLOYEE'S 5,554
PRIVILEGE OF CONTINUATION.
(C) ALL OF THE FOLLOWING APPLY TO THE CONTINUATION OF 5,557
GROUP COVERAGE REQUIRED UNDER DIVISION (B) OF THIS SECTION: 5,559
(1) CONTINUATION NEED NOT INCLUDE ANY SUPPLEMENTAL HEALTH 5,561
CARE SERVICES BENEFITS OR SPECIALTY HEALTH CARE SERVICES BENEFITS 5,562
PROVIDED BY THE GROUP CONTRACT. 5,563
(2) THE EMPLOYER SHALL NOTIFY THE EMPLOYEE OF THE RIGHT OF 5,566
CONTINUATION AT THE TIME THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,567
THE TERMINATION OF EMPLOYMENT. THE NOTICE SHALL INFORM THE
EMPLOYEE OF THE AMOUNT OF CONTRIBUTION REQUIRED BY THE EMPLOYER 5,568
UNDER DIVISION (C)(4) OF THIS SECTION. 5,570
125
(3) THE EMPLOYEE SHALL FILE A WRITTEN ELECTION OF 5,572
CONTINUATION WITH THE EMPLOYER AND PAY THE EMPLOYER THE FIRST 5,573
CONTRIBUTION REQUIRED UNDER DIVISION (C)(4) OF THIS SECTION. THE 5,575
REQUEST AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER 5,576
THAN THE EARLIER OF ANY OF THE FOLLOWING DATES: 5,577
(a) THIRTY-ONE DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,580
COVERAGE WOULD OTHERWISE TERMINATE; 5,581
(b) TEN DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,584
COVERAGE WOULD OTHERWISE TERMINATE, IF THE EMPLOYER HAS NOTIFIED 5,585
THE EMPLOYEE OF THE RIGHT OF CONTINUATION PRIOR TO THIS DATE; 5,586
(c) TEN DAYS AFTER THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,589
THE RIGHT OF CONTINUATION, IF THE NOTICE IS GIVEN AFTER THE DATE 5,590
ON WHICH THE EMPLOYEE'S COVERAGE WOULD OTHERWISE TERMINATE. 5,591
(4) THE EMPLOYEE MUST PAY TO THE EMPLOYER, ON A MONTHLY 5,593
BASIS, IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED BY THE 5,594
EMPLOYER. THE AMOUNT REQUIRED SHALL NOT EXCEED THE GROUP RATE 5,595
FOR THE INSURANCE BEING CONTINUED UNDER THE POLICY ON THE DUE 5,596
DATE OF EACH PAYMENT. 5,597
(5) THE EMPLOYEE'S PRIVILEGE TO CONTINUE COVERAGE AND THE 5,599
COVERAGE UNDER ANY CONTINUATION CEASES IF ANY OF THE FOLLOWING 5,600
OCCURS: 5,601
(a) THE EMPLOYEE CEASES TO BE AN ELIGIBLE EMPLOYEE UNDER 5,603
DIVISION (A)(2)(c) OR (d) OF THIS SECTION; 5,605
(b) A PERIOD OF SIX MONTHS EXPIRES AFTER THE DATE THAT THE 5,608
EMPLOYEE'S COVERAGE UNDER THE GROUP CONTRACT WOULD OTHERWISE HAVE 5,609
TERMINATED BECAUSE OF THE TERMINATION OF EMPLOYMENT; 5,610
(c) THE EMPLOYEE FAILS TO MAKE A TIMELY PAYMENT OF A 5,613
REQUIRED CONTRIBUTION, IN WHICH EVENT THE COVERAGE SHALL CEASE AT 5,614
THE END OF THE COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE; 5,615
(d) THE GROUP CONTRACT IS TERMINATED, OR THE EMPLOYER 5,618
TERMINATES PARTICIPATION UNDER THE CONTRACT, UNLESS THE EMPLOYER 5,619
REPLACES THE COVERAGE BY SIMILAR COVERAGE UNDER ANOTHER CONTRACT 5,620
OR OTHER GROUP HEALTH ARRANGEMENT. IF THE EMPLOYER REPLACES THE 5,621
CONTRACT WITH SIMILAR GROUP HEALTH COVERAGE, ALL OF THE FOLLOWING 5,622
126
APPLY:
(i) THE MEMBER SHALL BE COVERED UNDER THE REPLACEMENT 5,625
COVERAGE, FOR THE BALANCE OF THE PERIOD THAT THE MEMBER WOULD 5,626
HAVE REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT 5,627
BEEN TERMINATED.
(ii) THE MINIMUM LEVEL OF BENEFITS UNDER THE REPLACEMENT 5,630
COVERAGE SHALL BE THE APPLICABLE LEVEL OF BENEFITS OF THE 5,631
CONTRACT REPLACED REDUCED BY ANY BENEFITS PAYABLE UNDER THE 5,632
CONTRACT REPLACED.
(iii) THE CONTRACT REPLACED SHALL CONTINUE TO PROVIDE 5,635
BENEFITS TO THE EXTENT OF ITS ACCRUED LIABILITIES AND EXTENSIONS 5,636
OF BENEFITS AS IF THE REPLACEMENT HAD NOT OCCURRED. 5,637
(D) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,640
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,641
HEALTH CARE SERVICES.
Sec. 1751.54. (A) AS USED IN THIS SECTION: 5,643
(1) "ELIGIBLE PERSON" MEANS ANY PERSON WHO, AT THE TIME A 5,645
RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, IS COVERED UNDER A 5,647
GROUP CONTRACT AND IS EITHER OF THE FOLLOWING:
(a) AN EMPLOYEE WHO IS A RESERVIST CALLED OR ORDERED TO 5,650
ACTIVE DUTY;
(b) THE SPOUSE OR A DEPENDENT CHILD OF AN EMPLOYEE 5,653
DESCRIBED IN DIVISION (A)(1)(a) OF THIS SECTION. 5,654
(2) "GROUP CONTRACT" INCLUDES ANY GROUP HEALTH INSURING 5,656
CORPORATION CONTRACT THAT SATISFIES ALL OF THE FOLLOWING: 5,657
(a) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,660
RENEWED IN THIS STATE ON OR AFTER THE EFFECTIVE DATE OF THIS 5,661
SECTION.
(b) THE CONTRACT COVERS EMPLOYEES FOR HEALTH CARE 5,664
SERVICES, INCLUDING BASIC HEALTH CARE SERVICES. 5,665
(c) THE CONTRACT IS IN EFFECT AND COVERS AN ELIGIBLE 5,668
PERSON AT THE TIME A RESERVIST IS CALLED OR ORDERED TO ACTIVE 5,669
DUTY.
(3) "RESERVIST" MEANS A MEMBER OF A RESERVE COMPONENT OF 5,671
127
THE ARMED FORCES OF THE UNITED STATES. "RESERVIST" INCLUDES A 5,673
MEMBER OF THE OHIO NATIONAL GUARD AND THE OHIO AIR NATIONAL 5,675
GUARD. 5,676
(B) EVERY GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,679
PERSON MAY CONTINUE THE COVERAGE UNDER THE CONTRACT FOR A PERIOD 5,680
OF EIGHTEEN MONTHS AFTER THE DATE ON WHICH THE COVERAGE WOULD 5,681
OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR ORDERED TO 5,682
ACTIVE DUTY.
(C)(1) AN ELIGIBLE PERSON MAY EXTEND THE EIGHTEEN-MONTH 5,685
PERIOD OF CONTINUATION OF COVERAGE TO A THIRTY-SIX-MONTH PERIOD 5,686
OF CONTINUATION OF COVERAGE, IF ANY OF THE FOLLOWING OCCURS 5,687
DURING THE EIGHTEEN-MONTH PERIOD: 5,688
(a) THE DEATH OF THE RESERVIST; 5,691
(b) THE DIVORCE OR SEPARATION OF A RESERVIST FROM THE 5,694
RESERVIST'S SPOUSE;
(c) THE CESSATION OF DEPENDENCY OF A CHILD PURSUANT TO THE 5,697
TERMS OF THE CONTRACT. 5,698
(2) THE THIRTY-SIX-MONTH PERIOD OF CONTINUATION OF 5,700
COVERAGE IS DEEMED TO BEGIN ON THE DATE ON WHICH THE COVERAGE 5,701
WOULD OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR 5,702
ORDERED TO ACTIVE DUTY. 5,703
(3) THE EMPLOYER MAY BEGIN THE THIRTY-SIX-MONTH PERIOD ON 5,705
THE DATE OF ANY OCCURRENCE DESCRIBED IN DIVISION (C)(1) OF THIS 5,707
SECTION.
(D) ALL OF THE FOLLOWING APPLY TO ANY CONTINUATION OF 5,710
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,711
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION: 5,713
(1) THE CONTINUATION OF COVERAGE SHALL PROVIDE THE SAME 5,715
BENEFITS AS THOSE PROVIDED TO ANY SIMILARLY SITUATED ELIGIBLE 5,716
PERSON WHO IS COVERED UNDER THE SAME GROUP CONTRACT AND AN 5,717
EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE DUTY. 5,719
(2) AN EMPLOYER SHALL NOTIFY EACH EMPLOYEE OF THE RIGHT OF 5,722
CONTINUATION OF COVERAGE AT THE TIME OF EMPLOYMENT. AT THE TIME 5,723
THE RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, THE EMPLOYER 5,724
128
SHALL NOTIFY EACH ELIGIBLE PERSON OF THE REQUIREMENTS FOR THE 5,725
CONTINUATION OF COVERAGE.
(3) EACH CERTIFICATE OF COVERAGE ISSUED BY A HEALTH 5,727
INSURING CORPORATION TO AN EMPLOYEE UNDER THE GROUP CONTRACT 5,728
SHALL INCLUDE A NOTICE OF THE ELIGIBLE PERSON'S RIGHT OF 5,729
CONTINUATION OF COVERAGE. 5,730
(4) AN ELIGIBLE PERSON SHALL FILE A WRITTEN ELECTION OF 5,732
CONTINUATION OF COVERAGE WITH THE EMPLOYER AND PAY THE EMPLOYER 5,733
THE FIRST CONTRIBUTION REQUIRED UNDER DIVISION (D)(5) OF THIS 5,735
SECTION. THE WRITTEN ELECTION AND PAYMENT MUST BE RECEIVED BY 5,736
THE EMPLOYER NO LATER THAN THIRTY-ONE DAYS AFTER THE DATE ON 5,737
WHICH THE ELIGIBLE PERSON'S COVERAGE WOULD OTHERWISE TERMINATE. 5,738
IF THE EMPLOYER NOTIFIES THE ELIGIBLE PERSON OF THE RIGHT OF 5,739
CONTINUATION OF COVERAGE AFTER THE DATE ON WHICH THE ELIGIBLE 5,740
PERSON'S COVERAGE WOULD OTHERWISE TERMINATE, THE WRITTEN ELECTION 5,741
AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER THAN 5,742
THIRTY-ONE DAYS AFTER THE DATE OF THE NOTIFICATION. 5,743
(5)(a) EXCEPT AS PROVIDED IN DIVISION (D)(5)(b) OF THIS 5,746
SECTION, THE ELIGIBLE PERSON SHALL PAY TO THE EMPLOYER, ON A 5,747
MONTHLY BASIS AND IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED 5,748
BY THE EMPLOYER. THE AMOUNT SHALL NOT EXCEED ONE HUNDRED TWO PER 5,749
CENT OF THE GROUP RATE FOR THE COVERAGE BEING CONTINUED UNDER THE 5,750
GROUP CONTRACT ON THE DUE DATE OF EACH PAYMENT. 5,751
(b) THE EMPLOYER MAY PAY A PORTION OR ALL OF THE ELIGIBLE 5,754
PERSON'S CONTRIBUTION.
(E) THE ELIGIBLE PERSON'S RIGHT TO ANY CONTINUATION OF 5,757
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,758
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION CEASES ON THE 5,761
DATE ON WHICH ANY OF THE FOLLOWING OCCURS:
(1) THE ELIGIBLE PERSON, WHETHER AS AN EMPLOYEE OR 5,763
OTHERWISE, BECOMES COVERED BY ANOTHER GROUP CONTRACT OR OTHER 5,764
GROUP HEALTH PLAN OR ARRANGEMENT THAT DOES NOT CONTAIN ANY 5,765
EXCLUSION OR LIMITATION WITH RESPECT TO ANY PREEXISTING CONDITION 5,767
OF THAT ELIGIBLE PERSON. FOR PURPOSES OF DIVISION (E)(1) OF THIS 5,768
129
SECTION, A GROUP CONTRACT OR OTHER GROUP HEALTH PLAN OR 5,769
ARRANGEMENT DOES NOT INCLUDE THE CIVILIAN HEALTH AND MEDICAL 5,770
PROGRAM OF THE UNIFORMED SERVICES AS DEFINED IN PUBLIC LAW 5,772
99-661, 100 STAT. 3898 (1986), 10 U.S.C.A. 1072. 5,774
(2) THE PERIOD OF EITHER EIGHTEEN MONTHS PROVIDED UNDER 5,776
DIVISION (B) OF THIS SECTION OR THIRTY-SIX MONTHS PROVIDED UNDER 5,778
DIVISION (C) OF THIS SECTION EXPIRES. 5,780
(3) THE ELIGIBLE PERSON FAILS TO MAKE A TIMELY PAYMENT OF 5,782
A REQUIRED CONTRIBUTION, IN WHICH CASE THE COVERAGE CEASES AT THE 5,784
END OF THE PERIOD OF COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE. 5,785
(4) THE GROUP CONTRACT, OR PARTICIPATION UNDER THE GROUP 5,787
CONTRACT, IS TERMINATED, UNLESS THE EMPLOYER, IN ACCORDANCE WITH 5,788
DIVISION (F) OF THIS SECTION, REPLACES THE COVERAGE WITH SIMILAR 5,790
COVERAGE UNDER ANOTHER GROUP CONTRACT OR OTHER GROUP HEALTH PLAN 5,791
OR ARRANGEMENT.
(F) IF THE EMPLOYER REPLACES THE GROUP CONTRACT WITH 5,794
SIMILAR COVERAGE AS DESCRIBED IN DIVISION (E)(4) OF THIS SECTION, 5,796
BOTH OF THE FOLLOWING APPLY:
(1) THE ELIGIBLE PERSON IS COVERED UNDER THE REPLACEMENT 5,798
COVERAGE FOR THE BALANCE OF THE PERIOD THAT THE PERSON WOULD HAVE 5,800
REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT BEEN 5,801
TERMINATED.
(2) THE LEVEL OF BENEFITS UNDER THE REPLACEMENT COVERAGE 5,803
IS THE SAME AS THE LEVEL OF BENEFITS PROVIDED TO ANY SIMILARLY 5,804
SITUATED ELIGIBLE PERSON WHO IS COVERED UNDER THE GROUP CONTRACT 5,805
AND AN EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE 5,806
DUTY. 5,807
(G) UPON THE RESERVIST'S RELEASE FROM ACTIVE DUTY AND THE 5,810
RESERVIST'S RETURN TO EMPLOYMENT FOR THE EMPLOYER BY WHOM THE 5,811
RESERVIST WAS EMPLOYED AT THE TIME THE RESERVIST WAS CALLED OR 5,812
ORDERED TO ACTIVE DUTY, BOTH OF THE FOLLOWING APPLY: 5,813
(1) EVERY ELIGIBLE PERSON IS ENTITLED, WITHOUT ANY WAITING 5,816
PERIOD, TO COVERAGE UNDER THE EMPLOYER'S GROUP CONTRACT THAT IS 5,817
IN EFFECT AT THE TIME OF THE RESERVIST'S RETURN TO EMPLOYMENT. 5,818
130
(2) EVERY ELIGIBLE PERSON IS ENTITLED TO ALL BENEFITS 5,820
UNDER THE GROUP CONTRACT DESCRIBED IN DIVISION (G)(1) OF THIS 5,822
SECTION FROM THE DATE OF THE ORIGINAL COVERAGE UNDER THE 5,823
CONTRACT.
(H)(1) NO HEALTH INSURING CORPORATION SHALL FAIL TO 5,826
PROVIDE FOR A CONTINUATION OF COVERAGE, OR AN EXTENSION OF A 5,827
CONTINUATION OF COVERAGE, IN A GROUP CONTRACT AS REQUIRED BY AND 5,828
IN ACCORDANCE WITH THE TERMS AND CONDITIONS SET FORTH UNDER THIS 5,829
SECTION.
(2) NO HEALTH INSURING CORPORATION SHALL FAIL TO ISSUE A 5,831
CERTIFICATE OF COVERAGE IN COMPLIANCE WITH DIVISION (D)(3) OF 5,833
THIS SECTION.
(3) NO EMPLOYER SHALL FAIL TO PROVIDE AN EMPLOYEE OR 5,835
ELIGIBLE PERSON WITH NOTICE OF THE RIGHT TO A CONTINUATION OF 5,836
COVERAGE UNDER A GROUP CONTRACT IN ACCORDANCE WITH DIVISION 5,838
(D)(2) OF THIS SECTION.
(I) WHOEVER VIOLATES DIVISION (H)(1), (2), OR (3) OF THIS 5,842
SECTION IS DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT 5,843
OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 5,844
TO 3901.26 OF THE REVISED CODE. 5,845
(J) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT THAT 5,848
IS SUBJECT TO SECTION 5923.051 OF THE REVISED CODE. 5,850
(K) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,853
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,854
HEALTH CARE SERVICES.
Sec. 1751.55. A HEALTH INSURING CORPORATION POLICY, 5,856
CONTRACT, OR AGREEMENT SHALL NOT BE CONSTRUED TO EXCLUDE ILLNESS 5,857
OR INJURY UPON THE GROUND THAT THE SUBSCRIBER MIGHT HAVE ELECTED 5,858
TO HAVE SUCH ILLNESS OR INJURY COVERED BY WORKERS' COMPENSATION 5,859
UNDER DIVISION (A)(3) OF SECTION 4123.01 OF THE REVISED CODE 5,862
UNLESS THE POLICY, CONTRACT, OR AGREEMENT CLEARLY EXCLUDES WORK 5,863
OR OCCUPATIONAL RELATED ILLNESS OR INJURY, OR THE POLICY, 5,864
CONTRACT, OR AGREEMENT, OR A SEPARATE WRITING SIGNED BY THE 5,865
SUBSCRIBER, INFORMS THE SUBSCRIBER THAT SUCH COVERAGE IS EXCLUDED 5,866
131
AND MAY BE AVAILABLE TO THE SUBSCRIBER UNDER WORKERS' 5,867
COMPENSATION AS THE SOLE PROPRIETOR OF A BUSINESS, A MEMBER OF A 5,868
PARTNERSHIP, OR AN OFFICER OF A FAMILY FARM CORPORATION. 5,869
Sec. 1751.56. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,872
CORPORATION POLICY, CONTRACT, OR AGREEMENT SHALL BE DELIVERED, 5,873
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE, IF THE POLICY, 5,874
CONTRACT, OR AGREEMENT EXCLUDES OR REDUCES THE BENEFITS PAYABLE 5,875
TO OR ON BEHALF OF AN INSURED BECAUSE BENEFITS ARE ALSO PAYABLE 5,876
OR HAVE BEEN PAID UNDER A SUPPLEMENTAL SICKNESS AND ACCIDENT 5,877
INSURANCE POLICY TO WHICH ALL OF THE FOLLOWING APPLY: 5,878
(1) THE POLICY COVERS A SPECIFIED DISEASE OR A LIMITED 5,880
PLAN OF COVERAGE. 5,881
(2) THE POLICY IS SPECIFICALLY DESIGNED, ADVERTISED, 5,883
REPRESENTED, AND SOLD AS A SUPPLEMENT TO OTHER BASIC SICKNESS AND 5,885
ACCIDENT INSURANCE COVERAGE.
(3) THE ENTIRE PREMIUM FOR THE POLICY IS PAID BY THE 5,887
INSURED, THE INSURED'S FAMILY, OR THE INSURED'S GUARDIAN. 5,888
(B) THIS SECTION APPLIES TO SUPPLEMENTAL SICKNESS AND 5,891
ACCIDENT INSURANCE POLICIES IRRESPECTIVE OF THE MODE OR CHANNEL 5,892
OF PREMIUM PAYMENT TO THE INSURER OR OF ANY REDUCTION IN THE 5,893
PREMIUM BY VIRTUE OF THE INSURED'S MEMBERSHIP IN ANY HEALTH 5,894
INSURING CORPORATION OR THE INSURED'S STATUS AS AN EMPLOYEE. 5,895
Sec. 1751.59. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,898
CORPORATION POLICY, CONTRACT, OR AGREEMENT PROVIDING FAMILY 5,899
COVERAGE MAY BE DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 5,900
THIS STATE, UNLESS THE POLICY, CONTRACT, OR AGREEMENT COVERS 5,901
ADOPTED CHILDREN OF THE SUBSCRIBER ON THE SAME BASIS AS OTHER 5,902
DEPENDENTS.
(B) THE COVERAGE REQUIRED BY THIS SECTION IS SUBJECT TO 5,905
THE REQUIREMENTS AND RESTRICTIONS SET FORTH IN SECTION 3924.51 OF 5,906
THE REVISED CODE. COVERAGE FOR DEPENDENT CHILDREN LIVING OUTSIDE 5,909
THE HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA MUST BE 5,910
PROVIDED IF A COURT ORDER REQUIRES THE SUBSCRIBER TO PROVIDE 5,911
HEALTH CARE COVERAGE.
132
Sec. 1751.60. (A) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) 5,914
AND (F) OF THIS SECTION, EVERY PROVIDER OR HEALTH CARE FACILITY 5,916
THAT CONTRACTS WITH A HEALTH INSURING CORPORATION TO PROVIDE 5,917
HEALTH CARE SERVICES TO THE HEALTH INSURING CORPORATION'S 5,918
ENROLLEES OR SUBSCRIBERS SHALL SEEK COMPENSATION FOR COVERED 5,919
SERVICES SOLELY FROM THE HEALTH INSURING CORPORATION AND NOT, 5,920
UNDER ANY CIRCUMSTANCES, FROM THE ENROLLEES OR SUBSCRIBERS, 5,921
EXCEPT FOR APPROVED DEDUCTIBLES AND COPAYMENTS. 5,922
(B) NO SUBSCRIBER OR ENROLLEE OF A HEALTH INSURING 5,925
CORPORATION IS LIABLE TO ANY CONTRACTING PROVIDER OR HEALTH CARE 5,926
FACILITY FOR THE COST OF ANY COVERED HEALTH CARE SERVICES, IF THE 5,927
SUBSCRIBER OR ENROLLEE HAS ACTED IN ACCORDANCE WITH THE EVIDENCE 5,928
OF COVERAGE.
(C) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) AND (F) OF 5,932
THIS SECTION, EVERY CONTRACT BETWEEN A HEALTH INSURING 5,933
CORPORATION AND PROVIDER OR HEALTH CARE FACILITY SHALL CONTAIN A 5,934
PROVISION APPROVED BY THE SUPERINTENDENT OF INSURANCE REQUIRING 5,935
THE PROVIDER OR HEALTH CARE FACILITY TO SEEK COMPENSATION SOLELY 5,936
FROM THE HEALTH INSURING CORPORATION AND NOT, UNDER ANY 5,937
CIRCUMSTANCES, FROM THE SUBSCRIBER OR ENROLLEE, EXCEPT FOR 5,938
APPROVED DEDUCTIBLES AND COPAYMENTS. 5,939
(D) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 5,942
PREVENTING A PROVIDER OR HEALTH CARE FACILITY FROM BILLING THE 5,943
ENROLLEE OR SUBSCRIBER OF A HEALTH INSURING CORPORATION FOR 5,944
NONCOVERED SERVICES.
(E) UPON APPLICATION BY A HEALTH INSURING CORPORATION AND 5,947
A PROVIDER OR HEALTH CARE FACILITY, THE SUPERINTENDENT MAY WAIVE 5,948
THE REQUIREMENTS OF DIVISIONS (A) AND (C) OF THIS SECTION WHEN, 5,950
IN ADDITION TO THE RESERVE REQUIREMENTS CONTAINED IN SECTION 5,951
1751.28 OF THE REVISED CODE, THE HEALTH INSURING CORPORATION 5,954
PROVIDES SUFFICIENT ASSURANCES TO THE SUPERINTENDENT THAT THE 5,955
PROVIDER OR HEALTH CARE FACILITY HAS BEEN PROVIDED WITH FINANCIAL 5,956
GUARANTEES. NO WAIVER OF THE REQUIREMENTS OF DIVISIONS (A) AND 5,958
(C) OF THIS SECTION IS EFFECTIVE AS TO ENROLLEES OR SUBSCRIBERS 5,959
133
FOR WHOM THE HEALTH INSURING CORPORATION IS COMPENSATED UNDER A 5,960
PROVIDER AGREEMENT OR RISK CONTRACT ENTERED INTO PURSUANT TO 5,962
CHAPTER 5111. OR 5115. OF THE REVISED CODE. 5,964
(F) THE REQUIREMENTS OF DIVISIONS (A) TO (C) OF THIS 5,968
SECTION APPLY ONLY TO HEALTH CARE SERVICES PROVIDED TO AN 5,969
ENROLLEE OR SUBSCRIBER PRIOR TO THE EFFECTIVE DATE OF A 5,970
TERMINATION OF A CONTRACT BETWEEN THE HEALTH INSURING CORPORATION 5,971
AND THE PROVIDER OR HEALTH CARE FACILITY. 5,972
Sec. 1751.61. (A) EACH INDIVIDUAL OR GROUP EVIDENCE OF 5,975
COVERAGE THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED BY A 5,976
HEALTH INSURING CORPORATION IN THIS STATE, AND THAT PROVIDES 5,977
COVERAGE FOR FAMILY MEMBERS OF A SUBSCRIBER, ALSO SHALL PROVIDE 5,978
THAT COVERAGE APPLICABLE TO CHILDREN IS PAYABLE FROM THE MOMENT 5,979
OF BIRTH WITH RESPECT TO A NEWLY BORN CHILD OF THE SUBSCRIBER OR 5,980
SUBSCRIBER'S SPOUSE. 5,981
(B) COVERAGE FOR A NEWLY BORN CHILD IS EFFECTIVE FOR A 5,984
PERIOD OF THIRTY-ONE DAYS FROM THE DATE OF BIRTH. 5,985
(C) TO CONTINUE COVERAGE FOR A NEWLY BORN CHILD BEYOND THE 5,988
THIRTY-ONE DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION, 5,990
THE SUBSCRIBER SHALL NOTIFY THE HEALTH INSURING CORPORATION 5,991
WITHIN THAT PERIOD.
(D) IF PAYMENT OF A SPECIFIC PREMIUM RATE IS REQUIRED TO 5,994
PROVIDE COVERAGE UNDER THIS SECTION FOR AN ADDITIONAL CHILD, THE 5,995
EVIDENCE OF COVERAGE MAY REQUIRE THE SUBSCRIBER TO MAKE THIS 5,996
PAYMENT TO THE HEALTH INSURING CORPORATION WITHIN THE THIRTY-ONE 5,997
DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION IN ORDER TO 5,999
CONTINUE THE COVERAGE BEYOND THAT PERIOD. 6,000
Sec. 1751.62. (A) AS USED IN THIS SECTION, "SCREENING 6,003
MAMMOGRAPHY" MEANS A RADIOLOGIC EXAMINATION UTILIZED TO DETECT 6,004
UNSUSPECTED BREAST CANCER AT AN EARLY STAGE IN AN ASYMPTOMATIC 6,005
WOMAN AND INCLUDES THE X-RAY EXAMINATION OF THE BREAST USING 6,006
EQUIPMENT THAT IS DEDICATED SPECIFICALLY FOR MAMMOGRAPHY, 6,007
INCLUDING THE X-RAY TUBE, FILTER, COMPRESSION DEVICE, SCREENS, 6,008
FILM, AND CASSETTES, AND THAT HAS AN AVERAGE RADIATION EXPOSURE 6,009
134
DELIVERY OF LESS THAN ONE RAD MID-BREAST. "SCREENING 6,010
MAMMOGRAPHY" INCLUDES TWO VIEWS FOR EACH BREAST. THE TERM ALSO 6,011
INCLUDES THE PROFESSIONAL INTERPRETATION OF THE FILM. 6,012
"SCREENING MAMMOGRAPHY" DOES NOT INCLUDE DIAGNOSTIC 6,014
MAMMOGRAPHY. 6,015
(B) EVERY INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION 6,018
POLICY, CONTRACT, OR AGREEMENT PROVIDING BASIC HEALTH CARE 6,019
SERVICES THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 6,020
THIS STATE SHALL PROVIDE BENEFITS FOR THE EXPENSES OF BOTH OF THE 6,021
FOLLOWING: 6,022
(1) SCREENING MAMMOGRAPHY TO DETECT THE PRESENCE OF BREAST 6,025
CANCER IN ADULT WOMEN;
(2) CYTOLOGIC SCREENING FOR THE PRESENCE OF CERVICAL 6,027
CANCER. 6,028
(C) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,032
SECTION SHALL COVER EXPENSES IN ACCORDANCE WITH ALL OF THE 6,033
FOLLOWING:
(1) IF A WOMAN IS AT LEAST THIRTY-FIVE YEARS OF AGE BUT 6,035
UNDER FORTY YEARS OF AGE, ONE SCREENING MAMMOGRAPHY; 6,036
(2) IF A WOMAN IS AT LEAST FORTY YEARS OF AGE BUT UNDER 6,038
FIFTY YEARS OF AGE, EITHER OF THE FOLLOWING: 6,039
(a) ONE SCREENING MAMMOGRAPHY EVERY TWO YEARS; 6,042
(b) IF A LICENSED PHYSICIAN HAS DETERMINED THAT THE WOMAN 6,045
HAS RISK FACTORS TO BREAST CANCER, ONE SCREENING MAMMOGRAPHY 6,046
EVERY YEAR.
(3) IF A WOMAN IS AT LEAST FIFTY YEARS OF AGE BUT UNDER 6,048
SIXTY-FIVE YEARS OF AGE, ONE SCREENING MAMMOGRAPHY EVERY YEAR. 6,050
(D)(1) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,054
SECTION SHALL NOT EXCEED EIGHTY-FIVE DOLLARS PER YEAR UNLESS A 6,055
LOWER AMOUNT IS ESTABLISHED PURSUANT TO A PROVIDER CONTRACT. 6,056
(2) THE BENEFIT PAID IN ACCORDANCE WITH DIVISION (D)(1) OF 6,059
THIS SECTION SHALL CONSTITUTE FULL PAYMENT. NO INSTITUTIONAL OR 6,060
PROFESSIONAL HEALTH CARE PROVIDER SHALL SEEK OR RECEIVE 6,061
REMUNERATION IN EXCESS OF THE PAYMENT MADE IN ACCORDANCE WITH 6,062
135
DIVISION (D)(1) OF THIS SECTION, EXCEPT FOR APPROVED DEDUCTIBLES 6,064
AND COPAYMENTS.
(E) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,068
SECTION SHALL BE PROVIDED ONLY FOR SCREENING MAMMOGRAPHIES THAT 6,069
ARE PERFORMED IN A HEALTH CARE FACILITY OR MOBILE MAMMOGRAPHY 6,070
SCREENING UNIT THAT IS ACCREDITED UNDER THE AMERICAN COLLEGE OF 6,071
RADIOLOGY MAMMOGRAPHY ACCREDITATION PROGRAM OR IN A HOSPITAL AS 6,072
DEFINED IN SECTION 3727.01 OF THE REVISED CODE. 6,074
(F) THE BENEFITS PROVIDED UNDER DIVISIONS (B)(1) AND (2) 6,078
OF THIS SECTION SHALL BE PROVIDED ACCORDING TO THE TERMS OF THE 6,079
SUBSCRIBER CONTRACT.
(G) THE BENEFITS PROVIDED UNDER DIVISION (B)(2) OF THIS 6,083
SECTION SHALL BE PROVIDED ONLY FOR CYTOLOGIC SCREENINGS THAT ARE 6,084
PROCESSED AND INTERPRETED IN A LABORATORY CERTIFIED BY THE 6,085
COLLEGE OF AMERICAN PATHOLOGISTS OR IN A HOSPITAL AS DEFINED IN 6,086
SECTION 3727.01 OF THE REVISED CODE. 6,088
Sec. 1751.63. SECTIONS 3923.41 TO 3923.48 OF THE REVISED 6,091
CODE APPLY TO EVERY HEALTH INSURING CORPORATION THAT OFFERS 6,092
LONG-TERM CARE AND THAT HOLDS A CERTIFICATE OF AUTHORITY UNDER 6,093
THIS CHAPTER.
Sec. 1751.64. (A) AS USED IN THIS SECTION, "GENETIC 6,096
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 6,097
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 6,098
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 6,099
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 6,100
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 6,101
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 6,102
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 6,103
DISORDERS.
(B) NO HEALTH INSURING CORPORATION, IN PROCESSING AN 6,106
APPLICATION FOR COVERAGE FOR HEALTH CARE SERVICES UNDER AN 6,107
INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, CONTRACT, 6,108
OR AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,109
CONTRACT, OR AGREEMENT, SHALL DO ANY OF THE FOLLOWING: 6,110
136
(1) REQUIRE AN INDIVIDUAL SEEKING COVERAGE TO SUBMIT TO 6,112
GENETIC SCREENING OR TESTING; 6,113
(2) TAKE INTO CONSIDERATION, OTHER THAN IN ACCORDANCE WITH 6,116
DIVISION (F) OF THIS SECTION, THE RESULTS OF GENETIC SCREENING OR 6,117
TESTING;
(3) MAKE ANY INQUIRY TO DETERMINE THE RESULTS OF GENETIC 6,119
SCREENING OR TESTING; 6,120
(4) MAKE A DECISION ADVERSE TO THE APPLICANT BASED ON 6,122
ENTRIES IN MEDICAL RECORDS OR OTHER REPORTS OF GENETIC SCREENING 6,123
OR TESTING. 6,124
(C) IN DEVELOPING AND ASKING QUESTIONS REGARDING MEDICAL 6,127
HISTORIES OF APPLICANTS FOR COVERAGE UNDER AN INDIVIDUAL OR GROUP 6,128
HEALTH INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT, NO 6,129
HEALTH INSURING CORPORATION SHALL ASK FOR THE RESULTS OF GENETIC 6,130
SCREENING OR TESTING OR ASK QUESTIONS DESIGNED TO ASCERTAIN THE 6,131
RESULTS OF GENETIC SCREENING OR TESTING. 6,132
(D) NO HEALTH INSURING CORPORATION SHALL CANCEL OR REFUSE 6,135
TO ISSUE OR RENEW COVERAGE FOR HEALTH CARE SERVICES BASED ON THE 6,136
RESULTS OF GENETIC SCREENING OR TESTING. 6,137
(E) NO HEALTH INSURING CORPORATION SHALL DELIVER, ISSUE 6,140
FOR DELIVERY, OR RENEW AN INDIVIDUAL OR GROUP POLICY, CONTRACT, 6,141
OR AGREEMENT IN THIS STATE THAT LIMITS BENEFITS BASED ON THE 6,142
RESULTS OF GENETIC SCREENING OR TESTING. 6,143
(F) A HEALTH INSURING CORPORATION MAY CONSIDER THE RESULTS 6,146
OF GENETIC SCREENING OR TESTING IF THE RESULTS ARE VOLUNTARILY 6,147
SUBMITTED BY AN APPLICANT FOR COVERAGE OR RENEWAL OF COVERAGE AND 6,148
THE RESULTS ARE FAVORABLE TO THE APPLICANT. 6,149
(G) A VIOLATION OF THIS SECTION IS AN UNFAIR AND DECEPTIVE 6,152
ACT OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 6,153
3901.19 TO 3901.26 OF THE REVISED CODE. 6,155
Sec. 1751.65. (A) AS USED IN THIS SECTION, "GENETIC 6,158
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 6,159
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 6,160
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 6,161
137
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 6,162
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 6,163
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 6,164
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 6,165
DISORDERS. 6,166
(B) UPON THE REPEAL OF SECTION 1751.64 OF THE REVISED 6,170
CODE, NO HEALTH INSURING CORPORATION SHALL DO EITHER OF THE 6,171
FOLLOWING:
(1) CONSIDER, IN A MANNER ADVERSE TO AN APPLICANT OR 6,173
INSURED, ANY INFORMATION OBTAINED FROM GENETIC SCREENING OR 6,174
TESTING CONDUCTED PRIOR TO THE REPEAL OF SECTION 1751.64 OF THE 6,176
REVISED CODE IN PROCESSING AN APPLICATION FOR COVERAGE FOR HEALTH 6,178
CARE SERVICES UNDER AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,179
AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,180
CONTRACT, OR AGREEMENT; 6,181
(2) INQUIRE, DIRECTLY OR INDIRECTLY, INTO THE RESULTS OF 6,183
GENETIC SCREENING OR TESTING CONDUCTED PRIOR TO THE REPEAL OF 6,184
SECTION 1751.64 OF THE REVISED CODE, OR USE SUCH INFORMATION, IN 6,187
WHOLE OR IN PART, TO CANCEL, REFUSE TO ISSUE OR RENEW, OR LIMIT 6,188
BENEFITS UNDER, AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,189
AGREEMENT.
(C) ANY HEALTH INSURING CORPORATION THAT HAS ENGAGED IN, 6,192
IS ENGAGED IN, OR IS ABOUT TO ENGAGE IN A VIOLATION OF DIVISION 6,194
(B) OF THIS SECTION IS SUBJECT TO THE JURISDICTION OF THE 6,195
SUPERINTENDENT OF INSURANCE UNDER SECTION 3901.04 OF THE REVISED 6,196
CODE.
Sec. 1751.66. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 6,199
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES COVERAGE 6,200
FOR PRESCRIPTION DRUGS SHALL LIMIT OR EXCLUDE COVERAGE FOR ANY 6,201
DRUG APPROVED BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION 6,202
ON THE BASIS THAT THE DRUG HAS NOT BEEN APPROVED BY THE UNITED 6,203
STATES FOOD AND DRUG ADMINISTRATION FOR THE TREATMENT OF THE 6,204
PARTICULAR INDICATION FOR WHICH THE DRUG HAS BEEN PRESCRIBED, 6,205
PROVIDED THE DRUG HAS BEEN RECOGNIZED AS SAFE AND EFFECTIVE FOR 6,206
138
TREATMENT OF THAT INDICATION IN ONE OR MORE OF THE STANDARD 6,207
MEDICAL REFERENCE COMPENDIA SPECIFIED IN DIVISION (B)(1) OF THIS 6,209
SECTION OR IN MEDICAL LITERATURE THAT MEETS THE CRITERIA 6,210
SPECIFIED IN DIVISION (B)(2) OF THIS SECTION. 6,211
(B)(1) THE COMPENDIA ACCEPTED FOR PURPOSES OF DIVISION (A) 6,214
OF THIS SECTION ARE THE FOLLOWING:
(a) THE "AMA DRUG EVALUATIONS," A PUBLICATION OF THE 6,217
AMERICAN MEDICAL ASSOCIATION;
(b) THE "AHFS (AMERICAN HOSPITAL FORMULARY SERVICE) DRUG 6,220
INFORMATION," A PUBLICATION OF THE AMERICAN SOCIETY OF HEALTH 6,221
SYSTEM PHARMACISTS;
(c) "DRUG INFORMATION FOR THE HEALTH CARE PROVIDER," A 6,224
PUBLICATION OF THE UNITED STATES PHARMACOPOEIA CONVENTION. 6,225
(2) MEDICAL LITERATURE MAY BE ACCEPTED FOR PURPOSES OF 6,227
DIVISION (A) OF THIS SECTION ONLY IF ALL OF THE FOLLOWING APPLY: 6,229
(a) TWO ARTICLES FROM MAJOR PEER-REVIEWED PROFESSIONAL 6,232
MEDICAL JOURNALS HAVE RECOGNIZED, BASED ON SCIENTIFIC OR MEDICAL 6,233
CRITERIA, THE DRUG'S SAFETY AND EFFECTIVENESS FOR TREATMENT OF 6,234
THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,235
(b) NO ARTICLE FROM A MAJOR PEER-REVIEWED PROFESSIONAL 6,238
MEDICAL JOURNAL HAS CONCLUDED, BASED ON SCIENTIFIC OR MEDICAL 6,239
CRITERIA, THAT THE DRUG IS UNSAFE OR INEFFECTIVE OR THAT THE 6,240
DRUG'S SAFETY AND EFFECTIVENESS CANNOT BE DETERMINED FOR THE 6,241
TREATMENT OF THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,242
(c) EACH ARTICLE MEETS THE UNIFORM REQUIREMENTS FOR 6,245
MANUSCRIPTS SUBMITTED TO BIOMEDICAL JOURNALS ESTABLISHED BY THE 6,246
INTERNATIONAL COMMITTEE OF MEDICAL JOURNAL EDITORS OR IS 6,247
PUBLISHED IN A JOURNAL SPECIFIED BY THE UNITED STATES DEPARTMENT 6,248
OF HEALTH AND HUMAN SERVICES PURSUANT TO SECTION 1861(t)(2)(B) OF 6,249
THE "SOCIAL SECURITY ACT," 107 STAT. 591 (1993), 42 U.S.C. 1395 6,252
(x)(t)(2)(B), AS AMENDED, AS ACCEPTED PEER-REVIEWED MEDICAL 6,253
LITERATURE.
(C) COVERAGE OF A DRUG REQUIRED BY DIVISION (A) OF THIS 6,257
SECTION INCLUDES MEDICALLY NECESSARY SERVICES ASSOCIATED WITH THE 6,258
139
ADMINISTRATION OF THE DRUG.
(D) DIVISION (A) OF THIS SECTION SHALL NOT BE CONSTRUED TO 6,262
DO ANY OF THE FOLLOWING:
(1) REQUIRE COVERAGE FOR ANY DRUG IF THE UNITED STATES 6,266
FOOD AND DRUG ADMINISTRATION HAS DETERMINED ITS USE TO BE 6,267
CONTRAINDICATED FOR THE TREATMENT OF THE PARTICULAR INDICATION 6,268
FOR WHICH THE DRUG HAS BEEN PRESCRIBED; 6,269
(2) REQUIRE COVERAGE FOR EXPERIMENTAL DRUGS NOT APPROVED 6,271
FOR ANY INDICATION BY THE UNITED STATES FOOD AND DRUG 6,274
ADMINISTRATION; 6,275
(3) ALTER ANY LAW WITH REGARD TO PROVISIONS LIMITING THE 6,277
COVERAGE OF DRUGS THAT HAVE NOT BEEN APPROVED BY THE UNITED 6,280
STATES FOOD AND DRUG ADMINISTRATION; 6,281
(4) REQUIRE REIMBURSEMENT OR COVERAGE FOR ANY DRUG NOT 6,283
INCLUDED IN THE DRUG FORMULARY OR LIST OF COVERED DRUGS SPECIFIED 6,285
IN A HEALTH INSURING CORPORATION CONTRACT;
(5) PROHIBIT A HEALTH INSURING CORPORATION FROM LIMITING 6,287
OR EXCLUDING COVERAGE OF A DRUG, PROVIDED THAT THE DECISION TO 6,288
LIMIT OR EXCLUDE COVERAGE OF THE DRUG IS NOT BASED PRIMARILY ON 6,289
THE COVERAGE OF DRUGS REQUIRED BY THIS SECTION. 6,290
(E) THIS SECTION APPLIES ONLY TO HEALTH INSURING 6,293
CORPORATION POLICIES, CONTRACTS, AND AGREEMENTS THAT ARE 6,294
DESCRIBED IN DIVISION (A) OF THIS SECTION AND THAT ARE DELIVERED, 6,296
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE ON OR AFTER JULY 1, 6,297
1997.
Sec. 1751.67. (A) EACH INDIVIDUAL OR GROUP HEALTH 6,299
INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT DELIVERED, 6,300
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE THAT PROVIDES 6,301
MATERNITY BENEFITS SHALL PROVIDE COVERAGE OF INPATIENT CARE AND 6,302
FOLLOW-UP CARE FOR A MOTHER AND HER NEWBORN AS FOLLOWS: 6,303
(1) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,305
MINIMUM OF FORTY-EIGHT HOURS OF INPATIENT CARE FOLLOWING A NORMAL 6,306
VAGINAL DELIVERY AND A MINIMUM OF NINETY-SIX HOURS OF INPATIENT 6,307
CARE FOLLOWING A CESAREAN DELIVERY. SERVICES COVERED AS 6,308
140
INPATIENT CARE SHALL INCLUDE MEDICAL, EDUCATIONAL, AND ANY OTHER 6,309
SERVICES THAT ARE CONSISTENT WITH THE INPATIENT CARE RECOMMENDED 6,310
IN THE PROTOCOLS AND GUIDELINES DEVELOPED BY NATIONAL 6,311
ORGANIZATIONS THAT REPRESENT PEDIATRIC, OBSTETRIC, AND NURSING 6,312
PROFESSIONALS.
(2) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,314
PHYSICIAN-DIRECTED SOURCE OF FOLLOW-UP CARE. SERVICES COVERED AS 6,316
FOLLOW-UP CARE SHALL INCLUDE PHYSICAL ASSESSMENT OF THE MOTHER 6,317
AND NEWBORN, PARENT EDUCATION, ASSISTANCE AND TRAINING IN BREAST 6,318
OR BOTTLE FEEDING, ASSESSMENT OF THE HOME SUPPORT SYSTEM,
PERFORMANCE OF ANY MEDICALLY NECESSARY AND APPROPRIATE CLINICAL 6,319
TESTS, AND ANY OTHER SERVICES THAT ARE CONSISTENT WITH THE 6,320
FOLLOW-UP CARE RECOMMENDED IN THE PROTOCOLS AND GUIDELINES 6,321
DEVELOPED BY NATIONAL ORGANIZATIONS THAT REPRESENT PEDIATRIC, 6,322
OBSTETRIC, AND NURSING PROFESSIONALS. THE COVERAGE SHALL APPLY 6,323
TO SERVICES PROVIDED IN A MEDICAL SETTING OR THROUGH HOME HEALTH 6,324
CARE VISITS. THE COVERAGE SHALL APPLY TO A HOME HEALTH CARE 6,325
VISIT ONLY IF THE PROVIDER WHO CONDUCTS THE VISIT IS 6,326
KNOWLEDGEABLE AND EXPERIENCED IN MATERNITY AND NEWBORN CARE. 6,327
WHEN A DECISION IS MADE IN ACCORDANCE WITH DIVISION (B) OF 6,330
THIS SECTION TO DISCHARGE A MOTHER OR NEWBORN PRIOR TO THE
EXPIRATION OF THE APPLICABLE NUMBER OF HOURS OF INPATIENT CARE 6,331
REQUIRED TO BE COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL 6,332
APPLY TO ALL FOLLOW-UP CARE THAT IS PROVIDED WITHIN FORTY-EIGHT 6,333
HOURS AFTER DISCHARGE. WHEN A MOTHER OR NEWBORN RECEIVES AT 6,334
LEAST THE NUMBER OF HOURS OF INPATIENT CARE REQUIRED TO BE 6,335
COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL APPLY TO FOLLOW-UP 6,336
CARE THAT IS DETERMINED TO BE MEDICALLY NECESSARY BY THE PROVIDER 6,338
RESPONSIBLE FOR DISCHARGING THE MOTHER OR NEWBORN.
(B) ANY DECISION TO SHORTEN THE LENGTH OF INPATIENT STAY 6,340
TO LESS THAN THAT SPECIFIED UNDER DIVISION (A)(1) OF THIS SECTION 6,342
SHALL BE MADE BY THE PHYSICIAN ATTENDING THE MOTHER OR NEWBORN, 6,343
EXCEPT THAT IF A NURSE-MIDWIFE IS ATTENDING THE MOTHER IN 6,344
COLLABORATION WITH A PHYSICIAN, THE DECISION MAY BE MADE BY THE 6,345
141
NURSE-MIDWIFE. DECISIONS REGARDING EARLY DISCHARGE SHALL BE MADE 6,346
ONLY AFTER CONFERRING WITH THE MOTHER OR A PERSON RESPONSIBLE FOR 6,347
THE MOTHER OR NEWBORN. FOR PURPOSES OF THIS DIVISION, A PERSON 6,348
RESPONSIBLE FOR THE MOTHER OR NEWBORN MAY INCLUDE A PARENT, 6,349
GUARDIAN, OR ANY OTHER PERSON WITH AUTHORITY TO MAKE MEDICAL 6,350
DECISIONS FOR THE MOTHER OR NEWBORN.
(C)(1) NO HEALTH INSURING CORPORATION MAY DO EITHER OF THE 6,353
FOLLOWING:
(a) TERMINATE THE PARTICIPATION OF A PROVIDER OR HEALTH 6,355
CARE FACILITY IN AN INDIVIDUAL OR GROUP HEALTH CARE PLAN SOLELY 6,356
FOR MAKING RECOMMENDATIONS FOR INPATIENT OR FOLLOW-UP CARE FOR A 6,357
PARTICULAR MOTHER OR NEWBORN THAT ARE CONSISTENT WITH THE CARE 6,358
REQUIRED TO BE COVERED BY THIS SECTION; 6,359
(b) ESTABLISH OR OFFER MONETARY OR OTHER FINANCIAL 6,361
INCENTIVES FOR THE PURPOSE OF ENCOURAGING A PERSON TO DECLINE THE 6,363
INPATIENT OR FOLLOW-UP CARE REQUIRED TO BE COVERED BY THIS
SECTION. 6,364
(2) WHOEVER VIOLATES DIVISION (C)(1)(a) OR (b) OF THIS 6,367
SECTION HAS ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE IN 6,368
THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 6,369
THE REVISED CODE.
(D) THIS SECTION DOES NOT DO ANY OF THE FOLLOWING: 6,371
(1) REQUIRE A POLICY, CONTRACT, OR AGREEMENT TO COVER 6,373
INPATIENT OR FOLLOW-UP CARE THAT IS NOT RECEIVED IN ACCORDANCE 6,374
WITH THE POLICY'S, CONTRACT'S, OR AGREEMENT'S TERMS PERTAINING TO 6,375
THE PROVIDERS AND FACILITIES FROM WHICH AN INDIVIDUAL IS 6,376
AUTHORIZED TO RECEIVE HEALTH CARE SERVICES; 6,377
(2) REQUIRE A MOTHER OR NEWBORN TO STAY IN A HOSPITAL OR 6,379
OTHER INPATIENT SETTING FOR A FIXED PERIOD OF TIME FOLLOWING 6,380
DELIVERY;
(3) REQUIRE A CHILD TO BE DELIVERED IN A HOSPITAL OR OTHER 6,382
INPATIENT SETTING; 6,383
(4) AUTHORIZE A NURSE-MIDWIFE TO PRACTICE BEYOND THE 6,385
AUTHORITY TO PRACTICE NURSE-MIDWIFERY IN ACCORDANCE WITH CHAPTER 6,386
142
4723. OF THE REVISED CODE; 6,387
(5) ESTABLISH MINIMUM STANDARDS OF MEDICAL DIAGNOSIS, 6,389
CARE, OR TREATMENT FOR INPATIENT OR FOLLOW-UP CARE FOR A MOTHER 6,390
OR NEWBORN. A DEVIATION FROM THE CARE REQUIRED TO BE COVERED 6,391
UNDER THIS SECTION SHALL NOT, SOLELY ON THE BASIS OF THIS 6,392
SECTION, GIVE RISE TO A MEDICAL CLAIM OR TO DERIVATIVE CLAIMS FOR 6,393
RELIEF, AS THOSE TERMS ARE DEFINED IN SECTION 2305.11 OF THE 6,395
REVISED CODE.
Sec. 1751.70. (A) AN EMPLOYEE OF THE STATE, OF ANY 6,398
POLITICAL SUBDIVISION OF THE STATE, OR OF ANY INSTITUTION 6,399
SUPPORTED IN WHOLE OR IN PART BY THE STATE, MAY AUTHORIZE THE 6,400
DEDUCTION FROM THE EMPLOYEE'S SALARY OR WAGES OF THE AMOUNT OF 6,401
THE EMPLOYEE'S PREMIUM RATE TO ANY HEALTH INSURING CORPORATION 6,402
HOLDING A CERTIFICATE OF AUTHORITY PURSUANT TO THIS CHAPTER. THE 6,404
EMPLOYEE'S AUTHORIZATION SHALL BE EVIDENCED BY APPROVAL OF THE 6,405
HEAD OF THE DEPARTMENT, DIVISION, OFFICE, OR INSTITUTION IN WHICH 6,406
THE EMPLOYEE IS EMPLOYED.
(B) IN THE CASE OF EMPLOYEES OF THE STATE, THE EMPLOYEE'S 6,409
AUTHORIZATION SHALL BE DIRECTED TO AND FILED WITH THE DIRECTOR OF 6,410
ADMINISTRATIVE SERVICES. IN THE CASE OF EMPLOYEES OF A POLITICAL 6,411
SUBDIVISION, THE EMPLOYEE'S AUTHORIZATION SHALL BE DIRECTED TO 6,412
AND FILED WITH THE FISCAL OFFICER OF SUCH POLITICAL SUBDIVISION. 6,413
IN THE CASE OF EMPLOYEES OF ANY INSTITUTION SUPPORTED IN WHOLE OR 6,414
IN PART BY THE STATE, THE EMPLOYEE'S AUTHORIZATION SHALL BE 6,415
DIRECTED TO AND FILED WITH THE FISCAL OFFICER OF SUCH 6,416
INSTITUTION.
(C) UPON THE FILING OF THE EMPLOYEE'S AUTHORIZATION IN 6,419
ACCORDANCE WITH DIVISION (B) OF THIS SECTION, THE DIRECTOR OR 6,421
FISCAL OFFICER SHALL PROVIDE FOR PAYMENT TO THE HEALTH INSURING 6,422
CORPORATION REFERRED TO IN THE EMPLOYEE'S AUTHORIZATION, FOR THE 6,423
AMOUNT COVERING THE SUM OF THE DEDUCTIONS THEREBY AUTHORIZED. 6,424
Sec. 1751.71. EACH HEALTH INSURING CORPORATION SUBJECT TO 6,426
THIS CHAPTER MAY ACCEPT FROM GOVERNMENTAL AGENCIES, OR FROM 6,427
PRIVATE PERSONS, PAYMENTS COVERING ALL OR PART OF THE COST OF 6,428
143
POLICIES, CONTRACTS, AND AGREEMENTS ENTERED INTO BETWEEN THE 6,429
HEALTH INSURING CORPORATION AND ITS SUBSCRIBERS OR GROUPS OF 6,430
SUBSCRIBERS.
Sec. 1901.111. (A) As used in this section, "health care 6,439
coverage" means sickness and accident insurance or other coverage 6,440
of hospitalization, surgical care, major medical care, 6,441
disability, dental care, eye care, medical care, hearing aids, 6,442
and prescription drugs, or any combination of those benefits or 6,443
services. 6,444
(B) The legislative authority, after consultation with the 6,446
judges of the municipal court, shall negotiate and contract for, 6,447
purchase, or otherwise procure group health care coverage for the 6,448
judges and their spouses and dependents from insurance companies 6,449
authorized to engage in the business of insurance in this state 6,450
under Title XXXIX of the Revised Code, medical care corporations 6,451
organized under Chapter 1737. of the Revised Code, OR health care 6,453
INSURING corporations organized HOLDING CERTIFICATES OF AUTHORITY 6,454
under Chapter 1738. 1751. of the Revised Code, or health 6,455
maintenance organizations organized under Chapter 1742. of the 6,456
Revised Code, except that if the county or municipal corporation 6,457
served by the legislative authority provides group health care 6,458
coverage for its employees, the group health care coverage 6,459
required by this section shall be provided, if possible, through 6,460
the policy or plan under which the group health care coverage is 6,461
provided for the county or municipal corporation employees. 6,462
(C) The portion of the costs, premiums, or charges for the 6,464
group health care coverage procured pursuant to division (B) of 6,465
this section that is not paid by the judges of the municipal 6,466
court, or all of the costs, premiums, or charges for the group 6,467
health care coverage if the judges will not be paying any such 6,468
portion, shall be paid as follows: 6,469
(1) If the municipal court is a county-operated municipal 6,471
court, the portion of the costs, premiums, or charges or all of 6,472
the costs, premiums, or charges shall be paid out of the treasury 6,473
144
of the county. 6,474
(2) If the municipal court is not a county-operated 6,476
municipal court, the portion of the costs, premiums, or charges 6,477
or all of the costs, premiums, or charges shall be paid in 6,478
three-fifths and two-fifths shares from the city treasury and 6,479
appropriate county treasuries as described in division (C) of 6,480
section 1901.11 of the Revised Code. The three-fifths share of a 6,481
city treasury is subject to apportionment under section 1901.026 6,482
of the Revised Code. 6,483
Sec. 1901.312. (A) As used in this section, "health care 6,492
coverage" has the same meaning as in section 1901.111 of the 6,493
Revised Code. 6,494
(B) The legislative authority, after consultation with 6,496
the clerk and deputy clerks of the municipal court, shall 6,497
negotiate and contract for, purchase, or otherwise procure group 6,498
health care coverage for the clerk and deputy clerks and their 6,499
spouses and dependents from insurance companies authorized to 6,500
engage in the business of insurance in this state under Title 6,501
XXXIX of the Revised Code, medical care corporations organized 6,502
under Chapter 1737. of the Revised Code, OR health care INSURING 6,504
corporations organized HOLDING CERTIFICATES OF AUTHORITY under 6,505
Chapter 1738. 1751. of the Revised Code, or health maintenance 6,507
organizations organized under Chapter 1742. of the Revised Code, 6,508
except that if the county or municipal corporation served by the 6,509
legislative authority provides group health care coverage for its 6,510
employees, the group health care coverage required by this 6,511
section shall be provided, if possible, through the policy or 6,512
plan under which the group health care coverage is provided for 6,513
the county or municipal corporation employees.
(C) The portion of the costs, premiums, or charges for the 6,515
group health care coverage procured pursuant to division (B) of 6,516
this section that is not paid by the clerk and deputy clerks of 6,517
the municipal court, or all of the costs, premiums, or charges 6,518
for the group health care coverage if the clerk and deputy clerks 6,519
145
will not be paying any such portion, shall be paid as follows: 6,520
(1) If the municipal court is a county-operated municipal 6,522
court, the portion of the costs, premiums, or charges or all of 6,523
the costs, premiums, or charges shall be paid out of the treasury 6,524
of the county. 6,525
(2)(a) If the municipal court is not a county-operated 6,527
municipal court, the portion of the costs, premiums, or charges 6,528
in connection with the clerk or all of the costs, premiums, or 6,529
charges in connection with the clerk shall be paid in 6,530
three-fifths and two-fifths shares from the city treasury and 6,531
appropriate county treasuries as described in division (C) of 6,532
section 1901.31 of the Revised Code. The three-fifths share of a 6,533
city treasury is subject to apportionment under section 1901.026 6,534
of the Revised Code. 6,535
(b) If the municipal court is not a county-operated 6,537
municipal court, the portion of the costs, premiums, or charges 6,538
in connection with the deputy clerks or all of the costs, 6,539
premiums, or charges in connection with the deputy clerks shall 6,540
be paid from the city treasury and shall be subject to 6,541
apportionment under section 1901.026 of the Revised Code. 6,542
(D) This section does not apply to the clerk of the 6,544
Auglaize county, Hamilton county, Portage county, or Wayne county 6,545
municipal court, if health care coverage is provided to the clerk 6,546
by virtue of his THE CLERK'S employment as the clerk of the court 6,548
of common pleas of Auglaize county, Hamilton county, Portage
county, or Wayne county. 6,549
Sec. 2133.12. (A) The death of a qualified patient or 6,558
other patient resulting from the withholding or withdrawal of 6,559
life-sustaining treatment in accordance with this chapter does 6,560
not constitute a suicide, aggravated murder, murder, or any other 6,561
homicide offense for any purpose. 6,562
(B)(1) The execution of a declaration shall not do either 6,564
of the following: 6,565
(a) Affect the sale, procurement, issuance, or renewal of 6,567
146
any policy of life insurance or annuity, notwithstanding any term 6,568
of a policy or annuity to the contrary; 6,569
(b) Be deemed to modify or invalidate the terms of any 6,571
policy of life insurance or annuity that is in effect on October 6,572
10, 1991. 6,573
(2) Notwithstanding any term of a policy of life insurance 6,575
or annuity to the contrary, the withholding or withdrawal of 6,576
life-sustaining treatment from an insured, qualified patient or 6,577
other patient in accordance with this chapter shall not impair or 6,578
invalidate any policy of life insurance or annuity. 6,579
(3) Notwithstanding any term of a policy or plan to the 6,581
contrary, the use or continuation, or the withholding or 6,582
withdrawal, of life-sustaining treatment from an insured, 6,583
qualified patient or other patient in accordance with this 6,584
chapter shall not impair or invalidate any policy of health 6,585
insurance or any health care benefit plan. 6,586
(4) No physician, health care facility, other health care 6,588
provider, person authorized to engage in the business of 6,589
insurance in this state under Title XXXIX of the Revised Code, 6,590
medical care corporation, health care INSURING corporation, 6,592
health maintenance organization, other health care plan, legal 6,593
entity that is self-insured and provides benefits to its 6,594
employees or members, or other person shall require any 6,595
individual to execute or refrain from executing a declaration, or 6,596
shall require an individual to revoke or refrain from revoking a 6,597
declaration, as a condition of being insured or of receiving 6,598
health care benefits or services. 6,599
(C)(1) This chapter does not create any presumption 6,601
concerning the intention of an individual who has revoked or has 6,602
not executed a declaration with respect to the use or 6,603
continuation, or the withholding or withdrawal, of 6,604
life-sustaining treatment if he THE INDIVIDUAL should be in a 6,605
terminal condition or in a permanently unconscious state at any 6,606
time.
147
(2) This chapter does not affect the right of a qualified 6,608
patient or other patient to make informed decisions regarding the 6,609
use or continuation, or the withholding or withdrawal, of 6,610
life-sustaining treatment as long as he THE QUALIFIED PATIENT OR 6,611
OTHER PATIENT is able to make those decisions. 6,614
(3) This chapter does not require a physician, other 6,616
health care personnel, or a health care facility to take action 6,617
that is contrary to reasonable medical standards. 6,618
(4) This chapter and, if applicable, a declaration do not 6,620
affect or limit the authority of a physician or a health care 6,621
facility to provide or not to provide life-sustaining treatment 6,622
to a person in accordance with reasonable medical standards 6,623
applicable in an emergency situation. 6,624
(D) Nothing in this chapter condones, authorizes, or 6,626
approves of mercy killing, assisted suicide, or euthanasia. 6,627
(E)(1) This chapter does not affect the responsibility of 6,629
the attending physician of a qualified patient or other patient, 6,630
or other health care personnel acting under the direction of the 6,631
patient's attending physician, to provide comfort care to the 6,632
patient. Nothing in this chapter precludes the attending 6,633
physician of a qualified patient or other patient who carries out 6,634
the responsibility to provide comfort care to the patient in good 6,635
faith and while acting within the scope of his THE ATTENDING 6,636
PHYSICIAN'S authority from prescribing, dispensing, 6,639
administering, or causing to be administered any particular 6,640
medical procedure, treatment, intervention, or other measure to 6,641
the patient, including, but not limited to, prescribing, 6,642
dispensing, administering, or causing to be administered by 6,643
judicious titration or in another manner any form of medication, 6,644
for the purpose of diminishing his THE QUALIFIED PATIENT'S OR 6,645
OTHER PATIENT'S pain or discomfort and not for the purpose of 6,646
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,647
PATIENT'S death, even though the medical procedure, treatment, 6,649
intervention, or other measure may appear to hasten or increase 6,650
148
the risk of the patient's death. Nothing in this chapter 6,651
precludes health care personnel acting under the direction of the 6,652
patient's attending physician who carry out the responsibility to 6,653
provide comfort care to the patient in good faith and while 6,654
acting within the scope of their authority from dispensing, 6,655
administering, or causing to be administered any particular 6,656
medical procedure, treatment, intervention, or other measure to 6,657
the patient, including, but not limited to, dispensing, 6,658
administering, or causing to be administered by judicious 6,659
titration or in another manner any form of medication, for the 6,660
purpose of diminishing his THE QUALIFIED PATIENT'S OR OTHER 6,661
PATIENT'S pain or discomfort and not for the purpose of 6,663
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,664
PATIENT'S death, even though the medical procedure, treatment, 6,665
intervention, or other measure may appear to hasten or increase 6,666
the risk of the patient's death.
(2)(a) If, at any time, a person described in division 6,668
(A)(2)(a)(i) of section 2133.05 of the Revised Code or the 6,669
individual or a majority of the individuals in either of the 6,670
first two classes of individuals that pertain to a declarant in 6,671
the descending order of priority set forth in division 6,672
(A)(2)(a)(ii) of section 2133.05 of the Revised Code believes in 6,673
good faith that both of the following circumstances apply, the 6,674
person or the individual or majority of individuals in either of 6,675
the first two classes of individuals may commence an action in 6,676
the probate court of the county in which a declarant who is in a 6,677
terminal condition or permanently unconscious state is located 6,678
for the issuance of an order mandating the use or continuation of 6,679
comfort care in connection with the declarant in a manner that is 6,680
consistent with division (E)(1) of this section: 6,681
(i) Comfort care is not being used or continued in 6,683
connection with the declarant. 6,684
(ii) The withholding or withdrawal of the comfort care is 6,686
contrary to division (E)(1) of this section. 6,687
149
(b) If a declarant did not designate in his THE 6,689
DECLARANT'S declaration a person as described in division 6,690
(A)(2)(a)(i) of section 2133.05 of the Revised Code and if, at 6,691
any time, a priority individual or any member of a priority class 6,692
of individuals under division (A)(2)(a)(ii) of section 2133.05 of 6,693
the Revised Code or, at any time, the individual or a majority of 6,694
the individuals in the next class of individuals that pertains to 6,695
the declarant in the descending order of priority set forth in 6,696
that division believes in good faith that both of the following 6,697
circumstances apply, the priority individual, the member of the 6,698
priority class of individuals, or the individual or majority of 6,699
individuals in the next class of individuals that pertains to the 6,700
declarant may commence an action in the probate court of the 6,701
county in which a declarant who is in a terminal condition or 6,702
permanently unconscious state is located for the issuance of an 6,703
order mandating the use or continuation of comfort care in 6,704
connection with the declarant in a manner that is consistent with 6,705
division (E)(1) of this section: 6,706
(i) Comfort care is not being used or continued in 6,708
connection with the declarant. 6,709
(ii) The withholding or withdrawal of the comfort care is 6,711
contrary to division (E)(1) of this section. 6,712
(c) If, at any time, a priority individual or any member 6,714
of a priority class of individuals under division (B) of section 6,715
2133.08 of the Revised Code or, at any time, the individual or a 6,716
majority of the individuals in the next class of individuals that 6,717
pertains to the patient in the descending order of priority set 6,718
forth in that division believes in good faith that both of the 6,719
following circumstances apply, the priority individual, the 6,720
member of the priority class of individuals, or the individual or 6,721
majority of individuals in the next class of individuals that 6,722
pertains to the patient may commence an action in the probate 6,723
court of the county in which a patient as described in division 6,724
(A) of section 2133.08 of the Revised Code is located for the 6,725
150
issuance of an order mandating the use or continuation of comfort 6,726
care in connection with the patient in a manner that is 6,727
consistent with division (E)(1) of this section: 6,728
(i) Comfort care is not being used or continued in 6,730
connection with the patient. 6,731
(ii) The withholding or withdrawal of the comfort care is 6,733
contrary to division (E)(1) of this section. 6,734
Sec. 2305.25. (A) No health care entity and no individual 6,744
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 6,745
following corporations shall be liable in damages to any person 6,746
for any acts, omissions, decisions, or other conduct within the 6,747
scope of the functions of the board, committee, or corporation: 6,748
(1) A peer review committee of a hospital, a nonprofit 6,750
health care corporation which is a member of the hospital or of 6,751
which the hospital is a member, or a community mental health 6,752
center; 6,753
(2) A board or committee of a hospital or of a nonprofit 6,756
health care corporation which is a member of the hospital or of 6,757
which the hospital is a member reviewing professional
qualifications or activities of the hospital medical staff or 6,758
applicants for admission to the medical staff; 6,759
(3) A utilization committee of a state or local society 6,761
composed of doctors of medicine or doctors of osteopathic 6,762
medicine and surgery or doctors of podiatric medicine; 6,763
(4) A peer review committee of nursing home providers or 6,765
administrators, including a corporation engaged in performing the 6,767
functions of a peer review committee of nursing home providers or 6,768
administrators, or a corporation engaged in the functions of
another type of peer review or professional standards review 6,769
committee; 6,770
(5) A peer review committee, professional standards review 6,772
committee, or arbitration committee of a state or local society 6,773
composed of doctors of medicine, doctors of osteopathic medicine 6,774
151
and surgery, doctors of dentistry, doctors of optometry, doctors 6,775
of podiatric medicine, psychologists, or registered pharmacists; 6,776
(6) A peer review committee of a health maintenance 6,778
organization INSURING CORPORATION that has at least a two-thirds 6,779
majority of member physicians in active practice and that 6,781
conducts professional credentialing and quality review activities 6,782
involving the competence or professional conduct of health care 6,783
providers, which conduct adversely affects, or could adversely 6,784
affect, the health or welfare of any patient. For purposes of 6,785
this division, "health maintenance organization INSURING 6,786
CORPORATION" includes wholly owned subsidiaries of a health 6,788
maintenance organization INSURING CORPORATION. 6,789
(7) A peer review committee of any insurer authorized 6,791
under Title XXXIX of the Revised Code to do the business of 6,792
sickness and accident insurance in this state that has at least a 6,793
two-thirds majority of physicians in active practice and that 6,794
conducts professional credentialing and quality review activities 6,795
involving the competence or professional conduct of health care 6,796
providers, which conduct adversely affects, or could adversely 6,797
affect, the health or welfare of any patient; 6,798
(8) A peer review committee of any insurer authorized 6,800
under Title XXXIX of the Revised Code to do the business of 6,801
sickness and accident insurance in this state that has at least a 6,802
two-thirds majority of physicians in active practice and that 6,803
conducts professional credentialing and quality review activities 6,804
involving the competence or professional conduct of a health care 6,805
facility that has contracted with the insurer to provide health 6,806
care services to insureds, which conduct adversely affects, or 6,807
could adversely affect, the health or welfare of any patient; 6,808
(9) A quality assurance committee of a state correctional 6,810
institution operated by the department of rehabilitation and 6,812
correction;
(10) A quality assurance committee of the central office 6,814
of the department of rehabilitation and correction or department 6,816
152
of mental health.
(11) A peer review committee of an insurer authorized 6,818
under Title XXXIX of the Revised Code to do the business of 6,819
medical professional liability insurance in this state and that 6,820
conducts professional quality review activities involving the 6,821
competence or professional conduct of health care providers, 6,822
which conduct adversely affects, or could affect, the health or
welfare of any patient; 6,823
(12) A peer review committee of a health care entity. 6,825
(B)(1) A hospital shall be presumed to not be negligent in 6,827
the credentialing of a qualified person if the hospital proves by 6,828
a preponderance of the evidence that at the time of the alleged 6,829
negligent credentialing of the qualified person it was accredited 6,830
by the joint commission on accreditation of health care 6,831
organizations, the American osteopathic association, or the
national committee for quality assurance. 6,832
(2) The presumption that a hospital is not negligent as 6,834
provided in division (B)(1) of this section may be rebutted only 6,835
by proof, by a preponderance of the evidence, of any of the 6,836
following:
(a) The credentialing and review requirements of the 6,838
accrediting organization did not apply to the hospital, the 6,839
qualified person, or the type of professional care that is the 6,840
basis of the claim against the hospital.
(b) The hospital failed to comply with all material 6,842
credentialing and review requirements of the accrediting 6,843
organization that applied to the qualified person. 6,844
(c) The hospital, through its medical staff executive 6,846
committee or its governing body and sufficiently in advance to 6,847
take appropriate action, knew that a previously competent 6,848
qualified person with staff privileges at the hospital had 6,849
developed a pattern of incompetence that indicated that the 6,850
qualified person's privileges should have been limited prior to 6,851
treating the plaintiff at the hospital. 6,852
153
(d) The hospital, through its medical staff executive 6,854
committee or its governing body and sufficiently in advance to 6,855
take appropriate action, knew that a previously competent 6,856
qualified person with staff privileges at the hospital would 6,857
provide fraudulent medical treatment but failed to limit the 6,858
qualified person's privileges prior to treating the plaintiff at 6,859
the hospital. 6,860
(3) If the plaintiff fails to rebut the presumption 6,862
provided in division (B)(1) of this section, upon the motion of 6,863
the hospital, the court shall enter judgment in favor of the 6,864
hospital on the claim of negligent credentialing.
(C) Nothing in this section otherwise shall relieve any 6,866
individual or health care entity from liability arising from 6,867
treatment of a patient. Nothing in this section shall be 6,868
construed as creating an exception to section 2305.251 of the 6,869
Revised Code.
(D) No person who provides information under this section 6,871
without malice and in the reasonable belief that the information 6,873
is warranted by the facts known to the person shall be subject to 6,874
suit for civil damages as a result of providing the information. 6,875
(E) For purposes of this section: 6,877
(1) "Peer review committee" means a utilization review 6,879
committee, quality assurance committee, quality improvement 6,880
committee, tissue committee, credentialing committee, or other 6,881
committee that conducts professional credentialing and quality 6,882
review activities involving the competence or professional 6,883
conduct of health care practitioners.
(2) "Health care entity" means a government entity, a 6,885
for-profit or nonprofit corporation, a limited liability company, 6,886
a partnership, a professional corporation, a state or local 6,887
society as described in division (A)(3) of this section, or other 6,888
health care organization, including, but not limited to, health 6,889
care entities described in division (A) of this section, whether 6,890
acting on its own behalf or on behalf of or in affiliation with 6,891
154
other health care entities, that conducts, as part of its
purpose, professional credentialing or quality review activities 6,892
involving the competence or professional conduct of health care 6,893
practitioners or providers. 6,894
(3) "Hospital" means either of the following: 6,896
(a) An institution that has been registered or licensed by 6,898
the Ohio department of health as a hospital; 6,899
(b) An entity, other than an insurance company authorized 6,901
to do business in this state, that owns, controls, or is 6,902
affiliated with an institution that has been registered or 6,904
licensed by the Ohio department of health as a hospital.
(4) "Qualified person" means a member of the medical staff 6,906
of a hospital or a person who has professional privileges at a 6,907
hospital pursuant to section 3701.351 of the Revised Code. 6,908
(F) This section shall be considered to be purely remedial 6,911
in its operation and shall be applied in a remedial manner in any 6,912
civil action in which this section is relevant, whether the civil 6,913
action is pending in court or commenced on or after the effective 6,914
date of this section, regardless of when the cause of action 6,915
accrued and notwithstanding any other section of the Revised Code 6,917
or prior rule of law of this state.
Sec. 2913.47. (A) As used in this section: 6,927
(1) "Data" has the same meaning as in section 2913.01 of 6,929
the Revised Code and additionally includes any other 6,930
representation of information, knowledge, facts, concepts, or 6,931
instructions that are being or have been prepared in a formalized 6,932
manner. 6,933
(2) "Deceptive" means that a statement, in whole or in 6,935
part, would cause another to be deceived because it contains a 6,936
misleading representation, withholds information, prevents the 6,937
acquisition of information, or by any other conduct, act, or 6,938
omission creates, confirms, or perpetuates a false impression, 6,939
including, but not limited to, a false impression as to law, 6,940
value, state of mind, or other objective or subjective fact. 6,941
155
(3) "Insurer" means any person that is authorized to 6,943
engage in the business of insurance in this state under Title 6,944
XXXIX of the Revised Code;, the Ohio fair plan underwriting 6,945
association created under section 3929.43 of the Revised Code;, 6,946
any prepaid dental plan, medical care corporation, health care 6,949
INSURING corporation, dental care corporation, or health 6,951
maintenance organization; and any legal entity that is
self-insured and provides benefits to its employees or members. 6,952
(4) "Policy" means a policy, certificate, contract, or 6,954
plan that is issued by an insurer. 6,955
(5) "Statement" includes, but is not limited to, any 6,957
notice, letter, or memorandum; proof of loss; bill of lading; 6,958
receipt for payment; invoice, account, or other financial 6,959
statement; estimate of property damage; bill for services; 6,960
diagnosis or prognosis; prescription; hospital, medical, or 6,961
dental chart or other record; x-ray, photograph, videotape, or 6,962
movie film; test result; other evidence of loss, injury, or 6,963
expense; computer-generated document; and data in any form. 6,964
(B) No person, with purpose to defraud or knowing that the 6,966
person is facilitating a fraud, shall do either of the following: 6,967
(1) Present to, or cause to be presented to, an insurer 6,969
any written or oral statement that is part of, or in support of, 6,970
an application for insurance, a claim for payment pursuant to a 6,971
policy, or a claim for any other benefit pursuant to a policy, 6,972
knowing that the statement, or any part of the statement, is 6,973
false or deceptive; 6,974
(2) Assist, aid, abet, solicit, procure, or conspire with 6,976
another to prepare or make any written or oral statement that is 6,977
intended to be presented to an insurer as part of, or in support 6,978
of, an application for insurance, a claim for payment pursuant to 6,979
a policy, or a claim for any other benefit pursuant to a policy, 6,980
knowing that the statement, or any part of the statement, is 6,981
false or deceptive. 6,982
(C) Whoever violates this section is guilty of insurance 6,984
156
fraud. Except as otherwise provided in this division, insurance 6,985
fraud is a misdemeanor of the first degree. If the amount of the 6,986
claim that is false or deceptive is five hundred dollars or more 6,987
and is less than five thousand dollars, insurance fraud is a 6,988
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 6,990
than one hundred thousand dollars, insurance fraud is a felony of 6,991
the fourth degree. If the amount of the claim that is false or 6,993
deceptive is one hundred thousand dollars or more, insurance 6,994
fraud is a felony of the third degree.
(D) This section shall not be construed to abrogate, 6,996
waive, or modify division (A) of section 2317.02 of the Revised 6,997
Code. 6,998
Sec. 3105.71. (A) If a party to an action for divorce, 7,007
annulment, dissolution of marriage, or legal separation was the 7,008
named insured or subscriber under, or the policyholder, 7,009
certificate holder, or contract holder of, a policy, contract, or 7,010
plan of health insurance that provided health insurance coverage 7,011
for his THAT PARTY'S spouse and dependents immediately prior to 7,012
the filing of the action, that party shall not cancel or 7,013
otherwise terminate or cause the termination of such coverage for 7,014
which the spouse and dependents would otherwise be eligible until 7,015
the court determines that the party is no longer responsible for 7,016
providing such health insurance coverage for his THAT PARTY'S 7,017
spouse and dependents.
(B) If the party responsible for providing health 7,019
insurance coverage for his THAT PARTY'S spouse and dependents 7,020
under division (A) of this section fails to provide that coverage 7,021
in accordance with that division, the court shall issue an order 7,022
that includes all of the following: 7,023
(1) A requirement that the party make payment to his THAT 7,025
PARTY'S spouse in the amount of any premium he THAT PARTY failed 7,027
to pay or contribution he THAT PARTY failed to make that resulted 7,028
in his THAT PARTY'S failure to provide health insurance coverage 7,029
157
in compliance with division (A) of this section;
(2) A requirement that the party make payment to his THAT 7,031
PARTY'S spouse for reimbursement of any hospital, surgical, and 7,032
medical expenses incurred as a result of his THAT PARTY'S failure 7,033
to comply with division (A) of this section; 7,034
(3) A requirement that, if the party fails to comply with 7,036
divisions (B)(1) and (2) of this section, the employer of the 7,037
party deduct from the party's earnings an amount necessary to 7,038
make any payments required under divisions (B)(1) and (2) of this 7,039
section. 7,040
(C) If the party responsible for providing health 7,042
insurance coverage for his THAT PARTY'S spouse and dependents 7,043
under division (A) of this section cancels or otherwise 7,044
terminates or causes the termination of such coverage for which 7,045
the spouse and dependents would otherwise be eligible, the spouse 7,046
may apply to the insurer, health maintenance organization 7,047
INSURING CORPORATION, or other third-party payer that provided 7,048
the coverage for a policy or contract of health insurance. The 7,049
spouse and dependents shall have the same rights and be subject 7,050
to the same limitations as a person applying for or covered under 7,051
a converted or separate policy under section 3923.32 of the 7,052
Revised Code upon the divorce, annulment, dissolution of 7,053
marriage, or the legal separation of the spouse from the named 7,054
insured.
Sec. 3111.241. (A) As used in this section, "insurer" 7,063
means any person that is authorized to engage in the business of 7,064
insurance in this state under Title XXXIX of the Revised Code;, 7,065
any prepaid dental plan, medical care corporation, health care 7,066
INSURING corporation, dental care corporation, or health 7,067
maintenance organization; and any legal entity that is 7,068
self-insured and provides benefits to its employees or members. 7,069
(B) If an administrative officer of a child support 7,071
enforcement agency issues an administrative support order under 7,072
section 3111.20, 3111.21, or 3111.22 of the Revised Code, in 7,073
158
addition to any requirements in those sections, the agency also 7,075
shall issue a separate order that includes all of the following: 7,076
(1) A requirement that the obligor under the child support 7,078
order obtain health insurance coverage for the children who are 7,079
the subject of the administrative child support order from an 7,080
insurer that provides a group health insurance or health care 7,081
policy, contract, or plan that is specified in the order and a 7,082
requirement that the obligor, no later than thirty days after the 7,083
issuance of the order under division (B)(1) of this section, 7,084
furnish written proof to the child support enforcement agency 7,085
that the required health insurance coverage has been obtained, if 7,086
that coverage is available at a reasonable cost through a group 7,087
health insurance or health care policy, contract, or plan offered 7,088
by the obligor's employer or through any other group health 7,089
insurance or health care policy, contract, or plan available to 7,090
the obligor and if health insurance coverage for the children is 7,091
not available for a more reasonable cost through a group health 7,092
insurance or health care policy, contract, or plan available to 7,093
the obligee under the administrative child support order; 7,094
(2) If the obligor is required under division (B)(1) of 7,096
this section to obtain health insurance coverage for the children 7,097
who are the subject of the administrative child support order, a 7,098
requirement that the obligor supply the obligee with information 7,099
regarding the benefits, limitations, and exclusions of the health 7,100
insurance coverage, copies of any insurance forms necessary to 7,101
receive reimbursement, payment, or other benefits under the 7,102
health insurance coverage, and a copy of any necessary insurance 7,103
cards, a requirement that the obligor submit a copy of the 7,104
administrative order issued pursuant to division (B) of this 7,105
section to the insurer at the time that the obligor makes 7,106
application to enroll the children in the health insurance or 7,107
health care policy, contract, or plan, and a requirement that the 7,108
obligor, no later than thirty days after the issuance of the 7,109
administrative order under division (B)(2) of this section, 7,110
159
furnish written proof to the child support enforcement agency 7,111
that division (B)(2) of this section has been complied with; 7,112
(3) A requirement that the obligee under the 7,114
administrative child support order obtain health insurance 7,115
coverage for the children who are the subject of the 7,116
administrative child support order from an insurer that provides 7,117
a group health insurance or health care policy, contract, or plan 7,118
that is specified in the administrative order and a requirement 7,119
that the obligee, no later than thirty days after the issuance of 7,120
the administrative order under division (B)(1) of this section, 7,121
furnish written proof to the child support enforcement agency 7,122
that the required health insurance coverage has been obtained, if 7,123
that coverage is available through a group health insurance or 7,124
health care policy, contract, or plan offered by the obligee's 7,125
employer or through any other group health insurance or health 7,126
care policy, contract, or plan available to the obligee and if 7,127
that coverage is available at a more reasonable cost than health 7,128
insurance coverage for the children through a group health 7,129
insurance or health care policy, contract, or plan available to 7,130
the obligor; 7,131
(4) If the obligee is required under division (B)(3) of 7,133
this section to obtain health insurance coverage for the children 7,134
who are the subject of the administrative child support order, a 7,135
requirement that the obligee submit a copy of the administrative 7,136
order issued pursuant to division (B) of this section to the 7,137
insurer at the time that the obligee makes application to enroll 7,138
the children in the health insurance or health care policy, 7,139
contract, or plan; 7,140
(5) A list of the group health insurance and health care 7,142
policies, contracts, and plans that the child support enforcement 7,143
agency determines are available at a reasonable cost to the 7,144
obligor or to the obligee and the name of the insurer that issues 7,145
each policy, contract, or plan; 7,146
(6) A statement setting forth the name, address, and 7,148
160
telephone number of the individual who is to be reimbursed for 7,149
out-of-pocket medical, optical, hospital, dental, or prescription 7,150
expenses paid for each child who is the subject of the 7,151
administrative child support order and a statement that the 7,152
insurer that provides the health insurance coverage for the 7,153
children may continue making payment for medical, optical, 7,154
hospital, dental, or prescription services directly to any health 7,155
care provider in accordance with the applicable health insurance 7,156
or health care policy, contract, or plan; 7,157
(7) A requirement that the obligor and the obligee 7,159
designate the children who are the subject of the administrative 7,160
child support order as covered dependents under any health 7,161
insurance or health care policy, contract, or plan for which they 7,162
contract; 7,163
(8) A requirement that the obligor, the obligee, or both 7,165
of them under a formula established by the child support 7,166
enforcement agency pay copayment or deductible costs required 7,167
under the health insurance or health care policy, contract, or 7,168
plan that covers the children; 7,169
(9) If health insurance coverage for the children who are 7,171
the subject of the administrative order is not available at a 7,172
reasonable cost through a group health insurance or health care 7,173
policy, contract, or plan offered by the obligor's employer or 7,174
through any other group health insurance or health care policy, 7,175
contract, or plan available to the obligor and is not available 7,176
at a reasonable cost through a group health insurance or health 7,177
care policy, contract, or plan offered by the obligee's employer 7,178
or through any other group health insurance or health care 7,179
policy, contract, or plan available to the obligee, a requirement 7,180
that the obligor and the obligee share liability for the cost of 7,181
the medical and health care needs of the children who are the 7,182
subject of the administrative order, under an equitable formula 7,183
established by the agency, and a requirement that if, after the 7,184
issuance of the order, health insurance coverage for the children 7,185
161
who are the subject of the administrative order becomes available 7,186
at a reasonable cost through a group health insurance or health 7,187
care policy, contract, or plan offered by the obligor's or 7,188
obligee's employer or through any other group health insurance or 7,189
health care policy, contract, or plan available to the obligor or 7,190
obligee, the obligor or obligee to whom the coverage becomes 7,191
available immediately inform the agency of that fact. 7,192
(10) A notice that, if the obligor is required under 7,194
divisions (B)(1) and (2) of this section to obtain health 7,195
insurance coverage for the children who are the subject of the 7,196
administrative child support order and if the obligor fails to 7,197
comply with the requirements of those divisions, the child 7,198
support enforcement agency immediately shall issue an 7,199
administrative order to the employer of the obligor, upon written 7,200
notice from the child support enforcement agency, requiring the 7,201
employer to take whatever action is necessary to make application 7,202
to enroll the obligor in any available group health insurance or 7,203
health care policy, contract, or plan with coverage for the 7,204
children who are the subject of the administrative child support 7,205
order, to submit a copy of the administrative order issued 7,206
pursuant to division (B) of this section to the insurer at the 7,207
time that the employer makes application to enroll the children 7,208
in the health insurance or health care policy, contract, or plan, 7,209
and, if the obligor's application is accepted, to deduct any 7,210
additional amount from the obligor's earnings necessary to pay 7,211
any additional cost for that health insurance coverage; 7,212
(11) A notice that during the time that an order under 7,214
this section is in effect, the employer of the obligor is 7,215
required to release to the obligee or the child support 7,216
enforcement agency upon written request any necessary information 7,217
on the health insurance coverage of the obligor, including, but 7,218
not limited to, the name and address of the insurer and any 7,219
policy, contract, or plan number, and to otherwise comply with 7,220
this section and any court order issued under this section; 7,221
162
(12) A statement setting forth the full name and date of 7,223
birth of each child who is the subject of the administrative 7,224
child support order; 7,225
(13) A requirement that the obligor and the obligee comply 7,227
with any requirement described in division (B)(1), (2), (3), (4), 7,228
or (7) of this section that is contained in the order issued 7,229
under this section no later than thirty days after the issuance 7,230
of the order. 7,231
(C) If an administrative officer of a child support 7,233
enforcement agency issues an administrative support order under 7,234
section 3111.20, 3111.21, or 3111.22 of the Revised Code, the 7,235
child support enforcement agency, in addition to any requirements 7,237
in those sections and in lieu of an order issued under division 7,238
(B) of this section, may issue a separate order requiring both 7,239
the obligor and the obligee to obtain health insurance coverage 7,240
for the children who are the subject of the administrative child 7,241
support order, if health insurance coverage is available for the 7,242
children and if the agency determines that the coverage is 7,243
available at a reasonable cost to both the obligor and the 7,244
obligee and that the dual coverage by both parents would provide 7,245
for coordination of medical benefits without unnecessary 7,246
duplication of coverage. If the agency issues an order under 7,247
this division, it shall include in the order any of the 7,248
requirements, notices, and information set forth in divisions 7,249
(B)(1) to (13) of this section that are applicable. 7,250
(D) Any administrative order issued under this section 7,252
shall be binding upon the obligor and the obligee, their 7,253
employers, and any insurer that provides health insurance 7,254
coverage for either of them or their children. The agency shall 7,255
send a copy of any administrative order issued under this section 7,256
that contains any requirement or notice described in division 7,257
(B)(1), (2), (3), (4), (7), (8), or (10) of this section by 7,258
ordinary mail to the obligor, the obligee, and any employer that 7,259
is subject to the administrative order. The agency shall send a 7,260
163
copy of any administrative order issued under this section that 7,261
contains any requirement contained in division (B)(9) of this 7,262
section by ordinary mail to the obligor and obligee. 7,263
(E) If an obligor does not comply with any administrative 7,265
order issued under this section that contains any requirement or 7,266
notice described in division (B)(1), (2), (4), (7), (8), or (10) 7,267
of this section within thirty days after the administrative order 7,268
is issued, the child support enforcement agency shall notify the 7,269
court of common pleas of the county in which the agency is 7,270
located in writing of the failure of the obligor to comply with 7,271
the administrative order. Upon receipt of the notice from the 7,272
agency, the court shall issue an order to the employer of the 7,273
obligor requiring the employer to take whatever action is 7,274
necessary to make application to enroll the obligor in any 7,275
available group health insurance or health care policy, contract, 7,276
or plan with coverage for the children who are the subject of the 7,277
administrative child support order, to submit a copy of the 7,278
administrative order issued pursuant to division (B) of this 7,279
section to the insurer at the time that the employer makes 7,280
application to enroll the children in the health insurance or 7,281
health care policy, contract, or plan, and, if the obligor's 7,282
application is accepted, to deduct from the wages or other income 7,283
of the obligor the cost of the coverage for the children. Upon 7,284
receipt of any court order under this division, the employer 7,285
shall take whatever action is necessary to comply with the court 7,286
order. 7,287
During the time that any administrative or court order 7,289
issued under this section is in effect and after the employer has 7,290
received a copy of the administrative or court order, the 7,291
employer of the obligor who is the subject of the administrative 7,292
or court order shall comply with the administrative or court 7,293
order and, upon request from the obligee or agency, shall release 7,294
to the obligee and the child support enforcement agency all 7,295
information about the obligor's health insurance coverage that is 7,296
164
necessary to ensure compliance with this section or any 7,297
administrative or court order issued under this section, 7,298
including, but not limited to, the name and address of the 7,299
insurer and any policy, contract, or plan number. Any 7,300
information provided by an employer pursuant to this division 7,301
shall be used only for the purpose of the enforcement of an 7,302
administrative or court order issued under this section. 7,303
Any employer who receives a copy of an administrative or 7,305
court order issued under this section shall notify the child 7,306
support enforcement agency of any change in or the termination of 7,307
the obligor's health insurance coverage that is maintained 7,308
pursuant to an order issued under this section. 7,309
(F) Any insurer that receives a copy of an administrative 7,311
order issued under this section shall comply with this section 7,312
and any administrative order issued under this section, 7,313
regardless of the residence of the children. If an insurer 7,314
provides health insurance coverage for the children who are the 7,315
subject of an administrative child support order in accordance 7,316
with an order issued under this section, the insurer shall 7,317
reimburse the parent, who is designated to receive reimbursement 7,318
in the administrative order issued under this section, for 7,319
covered out-of-pocket medical, optical, hospital, dental, or 7,320
prescription expenses incurred on behalf of the children subject 7,321
to the administrative order. 7,322
(G) If an obligee under an administrative child support 7,324
order is eligible for medical assistance under Chapter 5111. or 7,325
5115. of the Revised Code and the obligor has obtained health 7,326
insurance coverage pursuant to an administrative order issued 7,327
under division (B) of this section, the obligee shall notify any 7,328
physician, hospital, or other provider of medical services for 7,329
which medical assistance is available of the name and address of 7,330
the obligor's insurer and of the number of the obligor's health 7,331
insurance or health care policy, contract, or plan. Any 7,332
physician, hospital, or other provider of medical services for 7,333
165
which medical assistance is available under Chapter 5111. or 7,334
5115. of the Revised Code who is notified under this division of 7,335
the existence of a health insurance or health care policy, 7,336
contract, or plan with coverage for children who are eligible for 7,337
medical assistance first shall bill the insurer for any services 7,338
provided for those children. If the insurer fails to pay all or 7,339
any part of a claim filed under this division by the physician, 7,340
hospital, or other medical services provider and the services for 7,341
which the claim is filed are covered by Chapter 5111. or 5115. of 7,342
the Revised Code, the physician, hospital, or other medical 7,344
services provider shall bill the remaining unpaid costs of the 7,345
services in accordance with Chapter 5111. or 5115. of the Revised 7,346
Code.
(H) Any obligor who fails to comply with an administrative 7,348
order issued under this section is liable to the obligee for any 7,349
medical expenses incurred as a result of the failure to comply 7,350
with the administrative order. 7,351
(I) Nothing in this section shall be construed to require 7,353
an insurer to accept for enrollment any child who does not meet 7,354
the underwriting standards of the health insurance or health care 7,355
policy, contract, or plan for which application is made. 7,356
(J) If any person fails to comply with an administrative 7,358
order issued under this section, the agency may bring an action 7,359
under section 3111.242 of the Revised Code in the juvenile court 7,360
of the county in which the agency is located requesting the court 7,361
to find the obligor or any other person in contempt pursuant to 7,363
section 2705.02 of the Revised Code.
Sec. 3113.217. (A) As used in this section: 7,372
(1) "Obligor," "obligee," and "child support enforcement 7,374
agency" have the same meanings as in section 3113.21 of the 7,375
Revised Code. 7,376
(2) "Insurer" means any person that is authorized to 7,378
engage in the business of insurance in this state under Title 7,379
XXXIX of the Revised Code;, any prepaid dental plan, medical care 7,381
166
corporation, health care INSURING corporation, dental care 7,383
corporation, or health maintenance organization; and any legal 7,384
entity that is self-insured and provides benefits to its 7,385
employees or members.
(B) In any action or proceeding in which a child support 7,387
order is issued or modified on or after July 1, 1990, under 7,388
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,389
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,391
3113.07, 3113.216, or 3113.31 of the Revised Code, the child 7,393
support enforcement agency shall determine whether the obligor or 7,394
obligee has satisfactory health insurance coverage, other than 7,395
medical assistance under Title XIX of the "Social Security Act," 7,396
49 Stat. 620 (1935), 42 U.S.C. 301, as amended, for the children 7,397
who are the subject of the child support order. If the agency 7,398
determines that neither the obligor nor the obligee has 7,399
satisfactory health insurance coverage for the children, it shall 7,400
file a motion with the court requesting the court to issue an 7,401
order in accordance with divisions (C) to (K) of this section. 7,402
(C) In any action or proceeding in which a child support 7,404
order is issued or modified on or after July 1, 1990, under 7,405
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,406
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,408
3113.07, 3113.216, or 3113.31 of the Revised Code, in addition to 7,410
any requirements in those sections, the court also shall issue a 7,411
separate order that includes all of the following: 7,412
(1) A requirement that the obligor under the child support 7,414
order obtain health insurance coverage for the children who are 7,415
the subject of the child support order from an insurer that 7,416
provides a group health insurance or health care policy, 7,417
contract, or plan that is specified in the order and a 7,418
requirement that the obligor, no later than thirty days after the 7,419
issuance of the order under division (C)(1) of this section, 7,420
furnish written proof to the child support enforcement agency 7,421
that the required health insurance coverage has been obtained, if 7,422
167
that coverage is available at a reasonable cost through a group 7,423
health insurance or health care policy, contract, or plan offered 7,424
by the obligor's employer or through any other group health 7,425
insurance or health care policy, contract, or plan available to 7,426
the obligor and if health insurance coverage for the children is 7,427
not available for a more reasonable cost through a group health 7,428
insurance or health care policy, contract, or plan available to 7,429
the obligee under the child support order; 7,430
(2) If the obligor is required under division (C)(1) of 7,432
this section to obtain health insurance coverage for the children 7,433
who are the subject of the child support order, a requirement 7,434
that the obligor supply the obligee with information regarding 7,435
the benefits, limitations, and exclusions of the health insurance 7,436
coverage, copies of any insurance forms necessary to receive 7,437
reimbursement, payment, or other benefits under the health 7,438
insurance coverage, and a copy of any necessary insurance cards, 7,439
a requirement that the obligor submit a copy of the court order 7,440
issued pursuant to division (C) of this section to the insurer at 7,441
the time that the obligor makes application to enroll the 7,442
children in the health insurance or health care policy, contract, 7,443
or plan, and a requirement that the obligor, no later than thirty 7,444
days after the issuance of the order under division (C)(2) of 7,445
this section, furnish written proof to the child support 7,446
enforcement agency that division (C)(2) of this section has been 7,447
complied with; 7,448
(3) A requirement that the obligee under the child support 7,450
order obtain health insurance coverage for the children who are 7,451
the subject of the child support order from an insurer that 7,452
provides a group health insurance or health care policy, 7,453
contract, or plan that is specified in the order and a 7,454
requirement that the obligee, no later than thirty days after the 7,455
issuance of the order under division (C)(1) of this section, 7,456
furnish written proof to the child support enforcement agency 7,457
that the required health insurance coverage has been obtained, if 7,458
168
that coverage is available through a group health insurance or 7,459
health care policy, contract, or plan offered by the obligee's 7,460
employer or through any other group health insurance or health 7,461
care policy, contract, or plan available to the obligee and if 7,462
that coverage is available at a more reasonable cost than health 7,463
insurance coverage for the children through a group health 7,464
insurance or health care policy, contract, or plan available to 7,465
the obligor; 7,466
(4) If the obligee is required under division (C)(3) of 7,468
this section to obtain health insurance coverage for the children 7,469
who are the subject of the child support order, a requirement 7,470
that the obligee submit a copy of the court order issued pursuant 7,471
to division (C) of this section to the insurer at the time that 7,472
the obligee makes application to enroll the children in the 7,473
health insurance or health care policy, contract, or plan; 7,474
(5) A list of the group health insurance and health care 7,476
policies, contracts, and plans that the court determines are 7,477
available at a reasonable cost to the obligor or to the obligee 7,478
and the name of the insurer that issues each policy, contract, or 7,479
plan; 7,480
(6) A statement setting forth the name, address, and 7,482
telephone number of the individual who is to be reimbursed for 7,483
out-of-pocket medical, optical, hospital, dental, or prescription 7,484
expenses paid for each child who is the subject of the support 7,485
order and a statement that the insurer that provides the health 7,486
insurance coverage for the children may continue making payment 7,487
for medical, optical, hospital, dental, or prescription services 7,488
directly to any health care provider in accordance with the 7,489
applicable health insurance or health care policy, contract, or 7,490
plan; 7,491
(7) A requirement that the obligor and the obligee 7,493
designate the children who are the subject of the child support 7,494
order as covered dependents under any health insurance or health 7,495
care policy, contract, or plan for which they contract; 7,496
169
(8) A requirement that the obligor, the obligee, or both 7,498
of them under a formula established by the court pay co-payment 7,499
or deductible costs required under the health insurance or health 7,500
care policy, contract, or plan that covers the children; 7,501
(9) If health insurance coverage for the children who are 7,503
the subject of the order is not available at a reasonable cost 7,504
through a group health insurance or health care policy, contract, 7,505
or plan offered by the obligor's employer or through any other 7,506
group health insurance or health care policy, contract, or plan 7,507
available to the obligor and is not available at a reasonable 7,508
cost through a group health insurance or health care policy, 7,509
contract, or plan offered by the obligee's employer or through 7,510
any other group health insurance or health care policy, contract, 7,511
or plan available to the obligee, a requirement that the obligor 7,512
and the obligee share liability for the cost of the medical and 7,513
health care needs of the children who are the subject of the 7,514
order, under an equitable formula established by the court, and a 7,515
requirement that if, after the issuance of the order, health 7,516
insurance coverage for the children who are the subject of the 7,517
order becomes available at a reasonable cost through a group 7,518
health insurance or health care policy, contract, or plan offered 7,519
by the obligor's or obligee's employer or through any other group 7,520
health insurance or health care policy, contract, or plan 7,521
available to the obligor or obligee, the obligor or obligee to 7,522
whom the coverage becomes available immediately inform the court 7,523
of that fact. 7,524
(10) A notice that, if the obligor is required under 7,526
divisions (C)(1) and (2) of this section to obtain health 7,527
insurance coverage for the children who are the subject of the 7,528
child support order and if the obligor fails to comply with the 7,529
requirements of those divisions, the court immediately shall 7,530
issue an order to the employer of the obligor, upon written 7,531
notice from the child support enforcement agency, requiring the 7,532
employer to take whatever action is necessary to make application 7,533
170
to enroll the obligor in any available group health insurance or 7,534
health care policy, contract, or plan with coverage for the 7,535
children who are the subject of the child support order, to 7,536
submit a copy of the court order issued pursuant to division (C) 7,537
of this section to the insurer at the time that the employer 7,538
makes application to enroll the children in the health insurance 7,539
or health care policy, contract, or plan, and, if the obligor's 7,540
application is accepted, to deduct any additional amount from the 7,541
obligor's earnings necessary to pay any additional cost for that 7,542
health insurance coverage; 7,543
(11) A notice that during the time that an order under 7,545
this section is in effect, the employer of the obligor is 7,546
required to release to the obligee or the child support 7,547
enforcement agency upon written request any necessary information 7,548
on the health insurance coverage of the obligor, including, but 7,549
not limited to, the name and address of the insurer and any 7,550
policy, contract, or plan number, and to otherwise comply with 7,551
this section and any court order issued under this section; 7,552
(12) A statement setting forth the full name and date of 7,554
birth of each child who is the subject of the child support 7,555
order; 7,556
(13) A requirement that the obligor and the obligee comply 7,558
with any requirement described in division (C)(1), (2), (3), (4), 7,559
or (7) of this section that is contained in the order issued 7,560
under this section no later than thirty days after the issuance 7,561
of the order. 7,562
(D) In any action in which a child support order is issued 7,564
or modified on or after July 1, 1990, under Chapter 3115. or 7,565
section 2151.23, 2151.231, 2151.33, 2151.36, 2151.49, 3105.18, 7,566
3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 3113.07, 3113.216, 7,568
or 3113.31 of the Revised Code, the court, in addition to any 7,569
requirements in those sections and in lieu of an order issued 7,570
under division (C) of this section, may issue a separate order 7,571
requiring both the obligor and the obligee to obtain health 7,572
171
insurance coverage for the children who are the subject of the 7,573
child support order, if health insurance coverage is available 7,574
for the children and if the court determines that the coverage is 7,575
available at a reasonable cost to both the obligor and the 7,576
obligee and that the dual coverage by both parents would provide 7,577
for coordination of medical benefits without unnecessary 7,578
duplication of coverage. If the court issues an order under this 7,579
division, it shall include in the order any of the requirements, 7,580
notices, and information set forth in divisions (C)(1) to (13) of 7,581
this section that are applicable. 7,582
(E) Any order issued under this section shall be binding 7,584
upon the obligor and the obligee, their employers, and any 7,585
insurer that provides health insurance coverage for either of 7,586
them or their children. The court shall send a copy of any order 7,587
issued under this section that contains any requirement or notice 7,588
described in division (C)(1), (2), (3), (4), (7), (8), or (10) of 7,589
this section by ordinary mail to the obligor, the obligee, and 7,590
any employer that is subject to the order. The court shall send 7,591
a copy of any order issued under this section that contains any 7,592
requirement contained in division (C)(9) of this section by 7,593
ordinary mail to the obligor and obligee. 7,594
(F) If an obligor does not comply with any order issued 7,596
under this section that contains any requirement or notice 7,597
described in division (C)(1), (2), (4), (7), (8), or (10) of this 7,598
section within thirty days after the order is issued, the child 7,599
support enforcement agency shall notify the court in writing of 7,600
the failure of the obligor to comply with the order. Upon 7,601
receipt of the notice from the agency, the court shall issue an 7,602
order to the employer of the obligor requiring the employer to 7,603
take whatever action is necessary to make application to enroll 7,604
the obligor in any available group health insurance or health 7,605
care policy, contract, or plan with coverage for the children who 7,606
are the subject of the child support order, to submit a copy of 7,607
the court order issued pursuant to division (C) of this section 7,608
172
to the insurer at the time that the employer makes application to 7,609
enroll the children in the health insurance or health care 7,610
policy, contract, or plan, and, if the obligor's application is 7,611
accepted, to deduct from the wages or other income of the obligor 7,612
the cost of the coverage for the children. Upon receipt of any 7,613
order under this division, the employer shall take whatever 7,614
action is necessary to comply with the order. 7,615
During the time that any order issued under this section is 7,617
in effect and after the employer has received a copy of the 7,618
order, the employer of the obligor who is the subject of the 7,619
order shall comply with the order and, upon request from the 7,620
obligee or agency, shall release to the obligee and the child 7,621
support enforcement agency all information about the obligor's 7,622
health insurance coverage that is necessary to ensure compliance 7,623
with this section or any order issued under this section, 7,624
including, but not limited to, the name and address of the 7,625
insurer and any policy, contract, or plan number. Any 7,626
information provided by an employer pursuant to this division 7,627
shall be used only for the purpose of the enforcement of an order 7,628
issued under this section. 7,629
Any employer who receives a copy of an order issued under 7,631
this section shall notify the child support enforcement agency of 7,632
any change in or the termination of the obligor's health 7,633
insurance coverage that is maintained pursuant to an order issued 7,634
under this section. 7,635
(G) Any insurer that receives a copy of an order issued 7,637
under this section shall comply with this section and any order 7,638
issued under this section, regardless of the residence of the 7,639
children. If an insurer provides health insurance coverage for 7,640
the children who are the subject of a child support order in 7,641
accordance with an order issued under this section, the insurer 7,642
shall reimburse the parent, who is designated to receive 7,643
reimbursement in the order issued under this section, for covered 7,644
out-of-pocket medical, optical, hospital, dental, or prescription 7,645
173
expenses incurred on behalf of the children subject to the order. 7,646
(H) If an obligee under a child support order is eligible 7,648
for medical assistance under Chapter 5111. or 5115. of the 7,649
Revised Code and the obligor has obtained health insurance 7,650
coverage pursuant to an order issued under division (C) of this 7,651
section, the obligee shall notify any physician, hospital, or 7,652
other provider of medical services for which medical assistance 7,653
is available of the name and address of the obligor's insurer and 7,654
of the number of the obligor's health insurance or health care 7,655
policy, contract, or plan. Any physician, hospital, or other 7,656
provider of medical services for which medical assistance is 7,657
available under Chapter 5111. or 5115. of the Revised Code who is 7,658
notified under this division of the existence of a health 7,659
insurance or health care policy, contract, or plan with coverage 7,660
for children who are eligible for medical assistance first shall 7,661
bill the insurer for any services provided for those children. 7,662
If the insurer fails to pay all or any part of a claim filed 7,663
under this division by the physician, hospital, or other medical 7,664
services provider and the services for which the claim is filed 7,665
are covered by Chapter 5111. or 5115. of the Revised Code, the 7,666
physician, hospital, or other medical services provider shall 7,667
bill the remaining unpaid costs of the services in accordance 7,668
with Chapter 5111. or 5115. of the Revised Code. 7,669
(I) Any obligor who fails to comply with an order issued 7,671
under this section is liable to the obligee for any medical 7,672
expenses incurred as a result of the failure to comply with the 7,673
order. 7,674
(J) Whoever violates an order issued under this section 7,676
may be punished as for contempt under Chapter 2705. of the 7,677
Revised Code. If an obligor is found in contempt under that 7,678
chapter for failing to comply with an order issued under this 7,679
section and if the obligor previously has been found in contempt 7,680
under that chapter, the court shall consider the obligor's 7,681
failure to comply with the court's order as a change in 7,682
174
circumstances for the purpose of modification of the amount of 7,683
support due under the child support order that is the basis of 7,684
the order issued under this section. 7,685
(K) Nothing in this section shall be construed to require 7,687
an insurer to accept for enrollment any child who does not meet 7,688
the underwriting standards of the health insurance or health care 7,689
policy, contract, or plan for which application is made. 7,690
(L) Notwithstanding section 3109.01 of the Revised Code, 7,692
if a court issues an order under this section requiring a parent 7,693
to obtain health insurance coverage for the children who are the 7,694
subject of a child support order, the order shall remain in 7,695
effect beyond the child's eighteenth birthday as long as the 7,696
child continuously attends on a full-time basis any recognized 7,697
and accredited high school. Any parent ordered to obtain health 7,698
insurance coverage for the children who are the subject of a 7,699
child support order shall continue to obtain the coverage for the 7,700
children under the order, including during seasonal vacation 7,701
periods, until the order terminates. 7,702
Sec. 3307.74. (A) The state teachers retirement board may 7,711
enter into an agreement with insurance companies, medical or 7,712
health care INSURING corporations, health maintenance 7,713
organizations, or government agencies authorized to do business 7,715
in the state for issuance of a policy or contract of health, 7,716
medical, hospital, or surgical benefits, or any combination 7,717
thereof, for those individuals receiving service retirement or a 7,718
disability or survivor benefit subscribing to the plan. 7,720
Notwithstanding any other provision of this chapter, the policy 7,722
or contract may also include coverage for any eligible
individual's spouse and dependent children and for any of the 7,724
individual's sponsored dependents as the board considers 7,725
appropriate. If all or any portion of the policy or contract 7,726
premium is to be paid by any individual receiving service 7,727
retirement or a disability or survivor benefit, the individual 7,728
shall, by written authorization, instruct the board to deduct the 7,730
175
premium agreed to be paid by the individual to the companies, 7,731
associations, corporations, or agencies. 7,732
The board may contract for coverage on the basis of part or 7,735
all of the cost of the coverage to be paid from appropriate funds 7,736
of the state teachers retirement system. The cost paid from the 7,737
funds of the system shall be included in the employer's 7,739
contribution rate provided by section 3307.53 of the Revised 7,740
Code.
The board may provide for self-insurance of risk or level 7,742
of risk as set forth in the contract with the companies, 7,743
corporations, or agencies, and may provide through the 7,744
self-insurance method specific benefits as authorized by the 7,745
rules of the board. 7,746
(B) If the board provides health, medical, hospital, or 7,748
surgical benefits through any means other than a health 7,749
maintenance organization INSURING CORPORATION, it shall offer to 7,750
each individual eligible for the benefits the alternative of 7,753
receiving benefits through enrollment in a health maintenance
organization INSURING CORPORATION, if all of the following apply: 7,755
(1) The health maintenance organization INSURING 7,757
CORPORATION provides HEALTH CARE services in the geographical 7,759
area in which the individual lives; 7,760
(2) The eligible individual was receiving health care 7,762
benefits through a health maintenance organization OR A HEALTH 7,764
INSURING CORPORATION before retirement; 7,765
(3) The rate and coverage provided by the health 7,767
maintenance organization INSURING CORPORATION to eligible 7,768
individuals is comparable to that currently provided by the board 7,771
under division (A) of this section. If the rate or coverage 7,772
provided by the health maintenance organization INSURING 7,773
CORPORATION is not comparable to that currently provided by the 7,775
board under division (A) of this section, the board may deduct 7,776
the additional cost from the eligible individual's monthly 7,777
benefit.
176
The health maintenance organization INSURING CORPORATION 7,779
shall accept as an enrollee any eligible individual who requests 7,781
enrollment.
The board shall permit each eligible individual to change 7,783
from one plan to another at least once a year at a time 7,784
determined by the board. 7,785
(C) The board shall, beginning the month following receipt 7,787
of satisfactory evidence of the payment for coverage, make a 7,788
monthly payment to each recipient of service retirement, or a 7,789
disability or survivor benefit under the state teachers 7,790
retirement system who is eligible for insurance coverage under 7,791
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,792
42 U.S.C.A. 1395j, as amended. The payment shall be the lesser 7,793
of an amount equal to the basic premium for such coverage, or an 7,795
amount equal to the basic premium in effect on April 10, 1991. 7,796
(D) The board shall establish by rule requirements for the 7,798
coordination of any coverage, payment, or benefit provided under 7,800
this section or section 3307.405 of the Revised Code with any 7,802
similar coverage, payment, or benefit made available to the same 7,803
individual by the public employees retirement system, police and 7,804
firemen's disability and pension fund, school employees 7,805
retirement system, or state highway patrol retirement system. 7,806
(E) The board shall make all other necessary rules 7,808
pursuant to the purpose and intent of this section. 7,809
Sec. 3307.741. The state teachers retirement board shall 7,818
establish a program under which members of the retirement system, 7,819
employers on behalf of members, and persons receiving service, 7,820
disability, or survivor benefits are permitted to participate in 7,821
contracts for long-term health care insurance. Participation may 7,822
include dependents and family members. If a participant in a 7,823
contract for long-term care insurance leaves his employment, he 7,824
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 7,826
members may, at their election, continue to participate in a 7,828
program established under this section in the same manner as if 7,829
177
he THE PARTICIPANT had not left his employment, except that no 7,831
part of the cost of the insurance shall be paid by his THE 7,832
PARTICIPANT'S former employer.
Such program may be established independently or jointly 7,834
with one or more of the other retirement systems. For purposes 7,835
of this section, "retirement systems" has the same meaning as in 7,836
division (A) of section 145.581 of the Revised Code. 7,837
The board may enter into an agreement with insurance 7,839
companies, medical or health care INSURING corporations, health 7,841
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 7,842
insurance policy or contract. However, prior to entering into 7,843
such an agreement with an insurance company, medical or health 7,844
care INSURING corporation, or health maintenance organization, 7,846
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 7,848
or organization. The board shall not enter into the agreement 7,849
if, according to that certification, the company, OR corporation, 7,850
or organization is insolvent, is determined by the superintendent 7,851
to be potentially unable to fulfill its contractual obligations, 7,853
or is placed under an order of rehabilitation or conservation by 7,854
a court of competent jurisdiction or under an order of 7,855
supervision by the superintendent. 7,856
The board shall adopt rules in accordance with section 7,858
111.15 of the Revised Code governing the program. The rules 7,859
shall establish methods of payment for participation under this 7,860
section, which may include establishment of a payroll deduction 7,861
plan under section 3307.281 of the Revised Code, deduction of the 7,862
full premium charged from a person's service, disability, or 7,863
survivor benefit, or any other method of payment considered 7,864
appropriate by the board. If the program is established jointly 7,865
with one or more of the other retirement systems, the rules also 7,866
shall establish the terms and conditions of such joint 7,867
participation. 7,868
178
Sec. 3309.69. (A) As used in this section, "ineligible 7,877
individual" means all of the following: 7,878
(1) A former member receiving benefits pursuant to section 7,880
3309.34, 3309.35, 3309.36, 3309.38, or 3309.381 of the Revised 7,881
Code for whom eligibility is established more than five years 7,882
after June 13, 1981, and who, at the time of establishing 7,883
eligibility, has accrued less than ten years of service credit, 7,884
exclusive of credit obtained after January 29, 1981, pursuant to 7,885
sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised 7,886
Code; 7,887
(2) The spouse of the former member; 7,889
(3) The beneficiary of the former member receiving 7,891
benefits pursuant to section 3309.46 of the Revised Code. 7,892
(B) The school employees retirement board may enter into 7,894
an agreement with insurance companies, medical or health care 7,895
INSURING corporations, health maintenance organizations, or 7,897
government agencies authorized to do business in the state for 7,898
issuance of a policy or contract of health, medical, hospital, or 7,899
surgical benefits, or any combination thereof, for those 7,900
individuals receiving service retirement or a disability or 7,901
survivor benefit subscribing to the plan and their eligible 7,903
dependents.
If all or any portion of the policy or contract premium is 7,905
to be paid by any individual receiving service retirement or a 7,907
disability or survivor benefit, the person shall, by written 7,908
authorization, instruct the board to deduct the premiums agreed 7,909
to be paid by the individual to the companies, corporations, or 7,911
agencies.
The board may contract for coverage on the basis of part or 7,914
all of the cost of the coverage to be paid from appropriate funds 7,915
of the school employees retirement system. The cost paid from 7,916
the funds of the system shall be included in the employer's 7,918
contribution rate provided by sections 3309.49 and 3309.491 of 7,919
the Revised Code. The board shall not pay or reimburse the cost 7,920
179
for health care under this section or section 3309.375 of the 7,921
Revised Code for any ineligible individual. 7,922
The board may provide for self-insurance of risk or level 7,924
of risk as set forth in the contract with the companies, 7,925
corporations, or agencies, and may provide through the 7,926
self-insurance method specific benefits as authorized by the 7,927
rules of the board. 7,928
(C) If the board provides health, medical, hospital, or 7,930
surgical benefits through any means other than a health 7,931
maintenance organization INSURING CORPORATION, it shall offer to 7,932
each individual eligible for the benefits the alternative of 7,935
receiving benefits through enrollment in a health maintenance 7,937
organization INSURING CORPORATION, if all of the following apply: 7,939
(1) The health maintenance organization INSURING 7,941
CORPORATION provides HEALTH CARE services in the geographical 7,943
area in which the individual lives; 7,944
(2) The eligible individual was receiving health care 7,946
benefits through a health maintenance organization OR A HEALTH 7,947
INSURING CORPORATION before retirement; 7,949
(3) The rate and coverage provided by the health 7,951
maintenance organization INSURING CORPORATION to eligible 7,952
individuals is comparable to that currently provided by the board 7,954
under division (B) of this section. If the rate or coverage 7,955
provided by the health maintenance organization INSURING 7,956
CORPORATION is not comparable to that currently provided by the 7,958
board under division (B) of this section, the board may deduct 7,959
the additional cost from the eligible individual's monthly 7,960
benefit.
The health maintenance organization INSURING CORPORATION 7,962
shall accept as an enrollee any eligible individual who requests 7,964
enrollment.
The board shall permit each eligible individual to change 7,966
from one plan to another at least once a year at a time 7,967
determined by the board. 7,968
180
(D) The board shall, beginning the month following receipt 7,970
of satisfactory evidence of the payment for coverage, make a 7,971
monthly payment to each recipient of service retirement, or a 7,972
disability or survivor benefit under the school employees 7,973
retirement system who is eligible for insurance coverage under 7,974
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,975
42 U.S.C.A. 1395j, as amended, except that the board shall make 7,976
no such payment to any ineligible individual. The amount of the 7,977
payment shall be the lesser of an amount equal to the basic 7,978
premium for such coverage, or an amount equal to the basic 7,980
premium in effect on January 1, 1988.
(E) The board shall establish by rule requirements for the 7,982
coordination of any coverage, payment, or benefit provided under 7,984
this section or section 3309.375 of the Revised Code with any 7,986
similar coverage, payment, or benefit made available to the same 7,987
individual by the public employees retirement system, police and 7,988
firemen's disability and pension fund, state teachers retirement 7,989
system, or state highway patrol retirement system. 7,990
(F) The board shall make all other necessary rules 7,992
pursuant to the purpose and intent of this section. 7,993
Sec. 3309.691. The school employees retirement board shall 8,002
establish a program under which members of the retirement system, 8,003
employers on behalf of members, and persons receiving service, 8,004
disability, or survivor benefits are permitted to participate in 8,005
contracts for long-term health care insurance. Participation may 8,006
include dependents and family members. If a participant in a 8,007
contract for long-term care insurance leaves his employment, he 8,008
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 8,010
members may, at their election, continue to participate in a
program established under this section in the same manner as if 8,011
he THE PARTICIPANT had not left his employment, except that no 8,012
part of the cost of the insurance shall be paid by his THE 8,013
PARTICIPANT'S former employer. 8,014
Such program may be established independently or jointly 8,016
181
with one or more of the other retirement systems. For purposes 8,017
of this section, "retirement systems" has the same meaning as in 8,018
division (A) of section 145.581 of the Revised Code. 8,019
The board may enter into an agreement with insurance 8,021
companies, medical or health care INSURING corporations, health 8,023
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 8,024
insurance policy or contract. However, prior to entering into 8,025
such an agreement with an insurance company, medical or health 8,026
care INSURING corporation, or health maintenance organization, 8,028
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 8,030
or organization. The board shall not enter into the agreement 8,031
if, according to that certification, the company, OR corporation, 8,032
or organization is insolvent, is determined by the superintendent 8,033
to be potentially unable to fulfill its contractual obligations, 8,035
or is placed under an order of rehabilitation or conservation by 8,036
a court of competent jurisdiction or under an order of 8,037
supervision by the superintendent. 8,038
The board shall adopt rules in accordance with section 8,040
111.15 of the Revised Code governing the program. The rules 8,041
shall establish methods of payment for participation under this 8,042
section, which may include establishment of a payroll deduction 8,043
plan under section 3309.27 of the Revised Code, deduction of the 8,044
full premium charged from a person's service, disability, or 8,045
survivor benefit, or any other method of payment considered 8,046
appropriate by the board. If the program is established jointly 8,047
with one or more of the other retirement systems, the rules also 8,048
shall establish the terms and conditions of such joint 8,049
participation. 8,050
Sec. 3313.202. (A) The board of education of a school 8,059
district may procure and pay all or part of the cost of group 8,060
term life, hospitalization, surgical care, or major medical 8,061
insurance, disability, dental care, vision care, medical care, 8,062
182
hearing aids, prescription drugs, sickness and accident 8,063
insurance, group legal services, or a combination of any of the 8,064
foregoing types of insurance or coverage, whether issued by an 8,065
insurance company or a medical care corporation, health care 8,066
INSURING corporation, dental care corporation, or health 8,068
maintenance organization duly licensed by this state, covering 8,069
the teaching or nonteaching employees of the school district, or 8,070
a combination of both, or the dependent children and spouses of 8,071
such employees, provided if such coverage affects only the 8,072
teaching employees of the district such coverage shall be with 8,073
the consent of a majority of such employees of the school 8,074
district, or if such coverage affects only the nonteaching 8,075
employees of the district such coverage shall be with the consent 8,076
of a majority of such employees. If such coverage is proposed to 8,077
cover all the employees of a school district, both teaching and 8,078
nonteaching employees, such coverage shall be with the consent of 8,079
a majority of all the employees of a school district. A board of 8,080
education shall continue to carry, on payroll records, all school 8,081
employees whose sick leave accumulation has expired, or who are 8,082
on a disability leave of absence or an approved leave of absence, 8,083
for the purpose of group term life, hospitalization, surgical, 8,084
major medical, or any other insurance. A board of education may 8,085
pay all or part of such coverage except when such employees are 8,086
on an approved leave of absence, or on a disability leave of 8,087
absence for that period exceeding two years. As used in this 8,088
section, "teaching employees" means any person employed in the 8,089
public schools of this state in a position for which the person 8,090
is required to have a certificate or license pursuant to sections 8,091
3319.22 to 3319.31 of the Revised Code. "Nonteaching employees" 8,092
as used in this section means any person employed in the public 8,093
schools of the state in a position for which the person is not 8,094
required to have a certificate or license issued pursuant to 8,095
sections 3319.22 to 3319.31 of the Revised Code. 8,096
(B) The board of education of a school district may enter 8,098
183
into an agreement with a jointly administered trust fund which 8,099
receives contributions pursuant to a collective bargaining 8,100
agreement entered into between the board and any collective 8,101
bargaining representative of the employees of the board for the 8,102
purpose of providing for self-insurance of all risk in the 8,103
provision of fringe benefits similar to those that may be paid 8,104
pursuant to division (A) of this section, and may provide through 8,105
the self-insurance method specific fringe benefits as authorized 8,106
by the rules of the board of trustees of the jointly administered 8,107
trust fund. Benefits provided under this section include, but 8,108
are not limited to, hospitalization, surgical care, major medical 8,109
care, disability, dental care, vision care, medical care, hearing 8,110
aids, prescription drugs, group life insurance, sickness and 8,111
accident insurance, group legal services, or a combination of the 8,112
above benefits, for the employees and their dependents. 8,113
(C) Notwithstanding any other provision of the Revised 8,115
Code, the board of education and any collective bargaining 8,116
representative of employees of the board may agree in a 8,117
collective bargaining agreement that any mutually agreed fringe 8,118
benefit, including, but not limited to, hospitalization, surgical 8,119
care, major medical care, disability, dental care, vision care, 8,120
medical care, hearing aids, prescription drugs, group life 8,121
insurance, sickness and accident insurance, group legal services, 8,122
or a combination thereof, for employees and their dependents be 8,123
provided through a mutually agreed upon contribution to a jointly 8,124
administered trust fund. The amount, type, and structure of 8,125
fringe benefits provided under this division are subject to the 8,126
determination of the board of trustees of the jointly 8,127
administered trust fund. Notwithstanding any other provision of 8,128
the Revised Code, competitive bidding does not apply to the 8,129
purchase of fringe benefits for employees under this division 8,130
through a jointly administered trust fund. 8,131
(D) Any elected or appointed member of the board of 8,133
education and the dependent children and spouse of the member may 8,134
184
be covered, at the option of the member, as an employee of the 8,135
school district under any benefit plan adopted under this 8,136
section. The member shall pay to the school district the amount 8,137
certified for that coverage under division (D)(1) or (2) of this 8,138
section. Payments for such coverage shall be made, in advance, 8,139
in a manner prescribed by the board. The member's exercise of an 8,140
option to be covered under this section shall be in writing, 8,141
announced at a regular public meeting of the board, and recorded 8,142
as a public record in the minutes of the board. 8,143
For the purposes of determining the cost to board members 8,145
under this division: 8,146
(1) In the case of a benefit plan purchased under division 8,148
(A) of this section, the provider of the benefits shall certify 8,149
to the board the provider's charge for coverage under each option 8,150
available to employees under that benefit plan; 8,151
(2) In the case of benefits provided under division (B) or 8,153
(C) of this section, the board of trustees of the jointly 8,154
administered trust fund shall certify to the board of education 8,155
the trustees' charge for coverage under each option available to 8,156
employees under each benefit plan. 8,157
(E) The board may provide the benefits described in this 8,159
section through an individual self-insurance program or a joint 8,160
self-insurance program as provided in section 9.833 of the 8,161
Revised Code. 8,162
Sec. 3375.40. Each board of library trustees appointed 8,171
pursuant to sections 3375.06, 3375.10, 3375.12, 3375.15, 3375.22, 8,172
and 3375.30 of the Revised Code may: 8,173
(A) Hold title to and have the custody of all real and 8,175
personal property of the free public library under its 8,176
jurisdiction; 8,177
(B) Expend for library purposes, and in the exercise of 8,179
the power enumerated in this section, all moneys, whether derived 8,180
from the county library and local government support fund or 8,181
otherwise, credited to the free public library under its 8,182
185
jurisdiction and generally do all things it considers necessary 8,183
for the establishment, maintenance, and improvement of the public 8,184
library under its jurisdiction; 8,185
(C) Purchase, lease, construct, remodel, renovate, or 8,187
otherwise improve, equip, and furnish buildings or parts of 8,188
buildings and other real property, and purchase, lease, or 8,189
otherwise acquire motor vehicles and other personal property, 8,191
necessary for the proper maintenance and operation of the free 8,192
public libraries under its jurisdiction, and pay the costs 8,193
thereof in installments or otherwise. Financing of these costs 8,194
may be provided through the issuance of notes, through an 8,195
installment sale, or through a lease-purchase agreement. Any
such notes shall be issued pursuant to section 3375.404 of the 8,196
Revised Code.
(D) Purchase, lease, lease with an option to purchase, or 8,198
erect buildings or parts of buildings to be used as main 8,199
libraries, branch libraries, or library stations pursuant to 8,200
section 3375.41 of the Revised Code; 8,201
(E) Establish and maintain a main library, branches, 8,203
library stations, and traveling library service within the 8,204
territorial boundaries of the subdivision or district over which 8,205
it has jurisdiction of free public library service; 8,206
(F) Establish and maintain branches, library stations, and 8,208
traveling library service in any school district, outside the 8,209
territorial boundaries of the subdivision or district over which 8,210
it has jurisdiction of free public library service, upon 8,211
application to and approval of the state library board, pursuant 8,212
to section 3375.05 of the Revised Code; provided the board of 8,213
trustees of any free public library maintaining branches, 8,214
stations, or traveling-book service, outside the territorial 8,215
boundaries of the subdivision or district over which it has 8,216
jurisdiction of free public library service, on September 4, 8,217
1947, may continue to maintain and operate such branches, 8,218
stations, and traveling library service without the approval of 8,219
186
the state library board; 8,220
(G) Appoint and fix the compensation of all of the 8,222
employees of the free public library under its jurisdiction; pay 8,223
the reasonable cost of tuition for any of its employees who 8,224
enroll in a course of study the board considers essential to the 8,225
duties of the employee or to the improvement of the employee's 8,226
performance; and reimburse applicants for employment for any 8,227
reasonable expenses they incur by appearing for a personal 8,228
interview; 8,229
(H) Make and publish rules for the proper operation and 8,231
management of the free public library and facilities under its 8,232
jurisdiction, including rules pertaining to the provision of 8,233
library services to individuals, corporations, or institutions 8,234
that are not inhabitants of the county; 8,235
(I) Establish and maintain a museum in connection with and 8,237
as an adjunct to the free public library under its jurisdiction; 8,238
(J) By the adoption of a resolution accept any bequest, 8,240
gift, or endowment upon the conditions connected with such 8,241
bequest, gift, or endowment; provided no such bequest, gift, or 8,242
endowment shall be accepted by such board if the conditions 8,243
thereof remove any portion of the free public library under its 8,244
jurisdiction from the control of such board or if such 8,245
conditions, in any manner, limit the free use of such library or 8,246
any part thereof by the residents of the counties in which such 8,247
library is located; 8,248
(K) At the end of any fiscal year by a two-thirds vote of 8,250
its full membership set aside any unencumbered surplus remaining 8,251
in the general fund of the library under its jurisdiction for any 8,252
purpose including creating or increasing a special building and 8,253
repair fund, or for operating the library or acquiring equipment 8,254
and supplies; 8,255
(L) Procure and pay all or part of the cost of group life, 8,257
hospitalization, surgical, major medical, disability benefit, 8,258
dental care, eye care, hearing aids, or prescription drug 8,259
187
insurance, or a combination of any of the foregoing types of 8,260
insurance or coverage, whether issued by an insurance company, or 8,261
nonprofit medical or dental care A HEALTH INSURING corporation 8,262
duly licensed by the state, covering its employees and in the 8,263
case of hospitalization, surgical, major medical, dental care, 8,264
eye care, hearing aids, or prescription drug insurance, also 8,265
covering the dependents and spouses of such employees, and in the 8,266
case of disability benefits, also covering spouses of such 8,267
employees. With respect to life insurance, coverage for any 8,268
employee shall not exceed the greater of the sum of ten thousand 8,269
dollars or the annual salary of the employee, exclusive of any 8,270
double indemnity clause that is a part of the policy. 8,271
(M) Pay reasonable dues and expenses for the free public 8,273
library and library trustees in library associations. 8,274
Sec. 3381.14. A regional arts and cultural district may 8,283
procure and pay all or any part of the cost of group 8,284
hospitalization, surgical, major medical, or sickness and 8,285
accident insurance or a combination of any of the foregoing for 8,286
the employees of the district and their immediate dependents, 8,287
whether issued by an insurance company, nonprofit medical care OR 8,288
A HEALTH INSURING corporation, or hospital service association 8,289
duly authorized to do business in this state. 8,290
Sec. 3501.141. (A) The board of elections of any county 8,299
may contract, purchase, or otherwise procure and pay all or any 8,300
part of the cost of group insurance policies that may provide 8,301
benefits for hospitalization, surgical care, major medical care, 8,302
disability, dental care, eye care, medical care, hearing aids, or 8,303
prescription drugs, and that may provide sickness and accident 8,304
insurance, or group life insurance, or a combination of any of 8,305
the foregoing types of insurance or coverage for the full-time 8,306
employees of such board and their immediate dependents, whether 8,307
issued by an insurance company, a health or medical care 8,308
corporation, a dental care corporation, or a health maintenance 8,309
organization INSURING CORPORATION, duly authorized to do business 8,310
188
in this state. 8,311
(B) The board of elections of any county may procure and 8,313
pay all or any part of the cost of group hospitalization, 8,314
surgical, major medical, or sickness and accident insurance or a 8,315
combination of any of the foregoing types of insurance or 8,316
coverage for the members appointed to the board of elections 8,317
under section 3501.06 of the Revised Code and their immediate 8,318
dependents when each member's term begins, whether issued by an 8,319
insurance company or a health or medical care INSURING 8,320
corporation, duly authorized to do business in this state. 8,321
Sec. 3701.24. (A) As used in this section and sections 8,330
3701.241 to 3701.249 of the Revised Code: 8,331
(1) "AIDS" means the illness designated as acquired 8,333
immunodeficiency syndrome. 8,334
(2) "HIV" means the human immunodeficiency virus 8,336
identified as the causative agent of AIDS. 8,337
(3) "AIDS-related condition" means symptoms of illness 8,339
related to HIV infection, including AIDS-related complex, that 8,341
are confirmed by a positive HIV test. 8,342
(4) "HIV test" means any test for the antibody or antigen 8,344
to HIV that has been approved by the director of health under 8,345
division (B) of section 3701.241 of the Revised Code. 8,346
(5) "Health care facility" has the same meaning as in 8,348
section 1742.01 1751.01 of the Revised Code. 8,349
(6) "Director" means the director of health or any 8,351
employee of the department of health acting on his THE DIRECTOR'S 8,353
behalf.
(7) "Physician" means a person who holds a current, valid 8,355
certificate issued under Chapter 4731. of the Revised Code 8,356
authorizing the practice of medicine or surgery and osteopathic 8,357
medicine and surgery. 8,358
(8) "Nurse" means a registered nurse or licensed practical 8,360
nurse who holds a license or certificate issued under Chapter 8,361
4723. of the Revised Code. 8,362
189
(9) "Anonymous test" means an HIV test administered so 8,364
that the individual to be tested can give informed consent to the 8,365
test and receive the results by means of a code system that does 8,366
not link his THE identity OF THE INDIVIDUAL TESTED to the request 8,368
for the test or the test results.
(10) "Confidential test" means an HIV test administered so 8,370
that the identity of the individual tested is linked to the test 8,371
but is held in confidence to the extent provided by section 8,372
3701.24 to 3701.248 of the Revised Code. 8,373
(11) "Health care provider" means an individual who 8,375
provides diagnostic, evaluative, or treatment services. Pursuant 8,376
to Chapter 119. of the Revised Code, the public health council 8,377
may adopt rules further defining the scope of the term "health 8,378
care provider." 8,379
(12) "Significant exposure to body fluids" means a 8,381
percutaneous or mucous membrane exposure of an individual to the 8,382
blood, semen, vaginal secretions, or spinal, synovial, pleural, 8,383
peritoneal, pericardial, or amniotic fluid of another individual. 8,384
(13) "Emergency medical services worker" means all of the 8,386
following: 8,387
(a) A peace officer; 8,389
(b) An employee of an emergency medical service 8,391
organization as defined in section 4765.01 of the Revised Code; 8,392
(c) A firefighter employed by a political subdivision; 8,394
(d) A volunteer firefighter, emergency operator, or rescue 8,396
operator; 8,397
(e) An employee of a private organization that renders 8,399
rescue services, emergency medical services, or emergency medical 8,400
transportation to accident victims and persons suffering serious 8,401
illness or injury. 8,402
(14) "Peace officer" has the same meaning as in division 8,404
(A) of section 109.71 of the Revised Code, except that it also 8,405
includes a sheriff and the superintendent and troopers of the 8,406
state highway patrol. 8,407
190
(B) Boards of health, health authorities or officials, and 8,409
physicians in localities in which there are no health authorities 8,410
or officials, shall report promptly to the department of health 8,411
the existence of any one of the following diseases: 8,412
(1) Asiatic cholera; 8,414
(2) Yellow fever; 8,416
(3) Diphtheria; 8,418
(4) Typhus or typhoid fever; 8,420
(5) Any other contagious or infectious diseases that the 8,422
public health council specifies. 8,423
(C) Persons designated by rule adopted by the public 8,425
health council under section 3701.241 of the Revised Code shall 8,426
report promptly every case of AIDS, every AIDS-related condition, 8,428
and every confirmed positive HIV test to the department of health 8,429
on forms and in a manner prescribed by the director. In each 8,430
county the director shall designate the health commissioner of a 8,431
health district in the county to receive the reports. 8,432
Information reported under this division that identifies an 8,434
individual is confidential and may be released only with the 8,435
written consent of the individual except as the director 8,436
determines necessary to ensure the accuracy of the information, 8,437
as necessary to provide treatment to the individual, as ordered 8,438
by a court pursuant to section 3701.243 or 3701.247 of the 8,439
Revised Code, or pursuant to a search warrant or a subpoena 8,440
issued by or at the request of a grand jury, prosecuting 8,441
attorney, city director of law or similar chief legal officer of 8,442
a municipal corporation, or village solicitor, in connection with 8,443
a criminal investigation or prosecution. Information that does 8,444
not identify an individual may be released in summary, 8,445
statistical, or other form. 8,446
Sec. 3701.76. (A) The director of health shall establish 8,455
and maintain a statewide public information campaign on the 8,456
effects of diethylstilbestrol or other nonsteroidal synthetic 8,457
estrogens for the purpose of educating the public concerning the 8,458
191
potential hazards related to exposure to diethylstilbestrol or 8,459
other nonsteroidal synthetic estrogens and encouraging persons 8,460
exposed to diethylstilbestrol or other nonsteroidal synthetic 8,461
estrogens, including those exposed before birth, to seek medical 8,462
attention for the identification and treatment of any conditions 8,463
resulting from this exposure. 8,464
(B) The director shall maintain a registry of hospitals, 8,466
clinics, physicians, or other health care providers to whom he 8,467
THE DIRECTOR shall refer persons who make inquiries to the 8,468
department of health regarding possible exposure to 8,469
diethylstilbestrol or other nonsteroidal synthetic estrogens. In 8,470
order to be eligible for listing in the registry, a health care 8,471
provider shall make an application to the director, and shall 8,472
have the necessary experience, facilities, and equipment to make 8,473
examinations for possible effects of diethylstilbestrol or other 8,474
nonsteroidal synthetic estrogens. 8,475
(C) The director shall maintain a registry of persons who 8,477
have been exposed to diethylstilbestrol or other nonsteroidal 8,478
synthetic estrogens, including persons exposed before birth, for 8,479
the purpose of studying and monitoring conditions caused by 8,480
exposure to diethylstilbestrol or other nonsteroidal synthetic 8,481
estrogen. No person shall be listed in the registry without his 8,482
THE DIRECTOR'S consent. 8,483
(D) The director shall make an annual report to the 8,485
general assembly on the effectiveness of the programs established 8,486
under this section, and shall make recommendations concerning the 8,487
programs and possible legislation relating to them. 8,488
(E) No insurance company doing business under Title XXXIX 8,490
and no HEALTH INSURING corporation holding a certificate of 8,491
authority or license under Chapter 1737., 1738., or 1742. 1751. 8,492
of the Revised Code shall cancel or refuse to renew a policy or 8,494
subscription, contract, CERTIFICATE, OR AGREEMENT or limit 8,495
benefits provided under a policy or subscription, contract, 8,496
CERTIFICATE, OR AGREEMENT solely because a policyholder, 8,497
192
subscriber, or applicant for a policy or subscription, contract, 8,498
CERTIFICATE, OR AGREEMENT has been exposed to diethylstilbestrol 8,499
or other nonsteroidal synthetic estrogens. 8,500
Sec. 3702.51. As used in sections 3702.51 to 3702.62 of 8,509
the Revised Code: 8,510
(A) "Applicant" means any person that submits an 8,512
application for a certificate of need and who is designated in 8,513
the application as the applicant. 8,514
(B) "Person" means any individual, corporation, business 8,516
trust, estate, firm, partnership, association, joint stock 8,517
company, insurance company, government unit, or other entity. 8,518
(C) "Certificate of need" means a written approval granted 8,520
by the director of health to an applicant to authorize conducting 8,521
a reviewable activity. 8,522
(D) "Health service area" means a geographic region 8,524
designated by the director of health under section 3702.58 of the 8,525
Revised Code. 8,526
(E) "Health service" means a clinically related service, 8,528
such as a diagnostic, treatment, rehabilitative, or preventive 8,529
service. 8,530
(F) "Health service agency" means an agency designated to 8,532
serve a health service area in accordance with section 3702.58 of 8,533
the Revised Code. 8,534
(G) "Health care facility" means: 8,536
(1) A hospital registered under section 3701.07 of the 8,538
Revised Code; 8,539
(2) A nursing home licensed under section 3721.02 of the 8,541
Revised Code, or by a political subdivision certified under 8,542
section 3721.09 of the Revised Code; 8,543
(3) A county home or a county nursing home as defined in 8,545
section 5155.31 of the Revised Code that is certified under Title 8,546
XVIII or XIX of the "Social Security Act," 49 Stat. 620 (1935), 8,547
42 U.S.C.A. 301, as amended; 8,548
(4) A freestanding dialysis center; 8,550
193
(5) A freestanding inpatient rehabilitation facility; 8,552
(6) An ambulatory surgical facility; 8,554
(7) A freestanding cardiac catheterization facility; 8,556
(8) A freestanding birthing center; 8,558
(9) A freestanding or mobile diagnostic imaging center; 8,560
(10) A freestanding radiation therapy center. 8,562
A health care facility does not include the offices of 8,564
private physicians and dentists whether for individual or group 8,565
practice, Christian Science sanitoriums operated or listed and 8,566
certified by the First Church of Christ, Scientist, Boston, 8,567
Massachusetts, residential facilities licensed under section 8,568
5123.19 of the Revised Code, or habilitation centers certified by 8,569
the director of mental retardation and developmental disabilities 8,570
under section 5123.041 of the Revised Code. 8,571
(H) "Medical equipment" means a single unit of medical 8,573
equipment or a single system of components with related functions 8,574
that is used to provide health services. 8,575
(I) "Third-party payer" means a medical care corporation 8,577
or health care INSURING corporation licensed under Chapter 1737. 8,579
or 1738. 1751. of the Revised Code, a health maintenance 8,580
organization AS DEFINED IN DIVISION (K) OF THIS SECTION, an 8,581
insurance company that issues sickness and accident insurance in 8,582
conformity with Chapter 3923. of the Revised Code, a 8,583
state-financed health insurance program under Chapter 3701., 8,584
4123., or 5111. of the Revised Code, or any self-insurance plan. 8,585
(J) "Government unit" means the state and any county, 8,587
municipal corporation, township, or other political subdivision 8,588
of the state, or any department, division, board, or other agency 8,589
of the state or a political subdivision. 8,590
(K) "Health maintenance organization" means a public or 8,592
private organization organized under the law of any state that is 8,593
qualified under section 1310(d) of Title XIII of the "Public 8,594
Health Service Act," 87 Stat. 931 (1973), 42 U.S.C. 300e--9 or 8,595
that does all of the following: 8,596
194
(1) Provides or otherwise makes available to enrolled 8,598
participants health care services including at least the 8,599
following basic health care services: usual physician services, 8,600
hospitalization, laboratory, x-ray, emergency and preventive 8,601
services, and out-of-area coverage; 8,602
(2) Is compensated, except for copayments, for the 8,604
provision of basic health care services listed in division (K)(1) 8,605
of this section to enrolled participants by a payment that is 8,606
paid on a periodic basis without regard to the date the health 8,607
care services are provided and that is fixed without regard to 8,608
the frequency, extent, or kind of health service actually 8,609
provided; 8,610
(3) Provides physician services primarily either: 8,612
(a) Directly through physicians who are either employees 8,614
or partners of the organization; 8,615
(b) Through arrangements with individual physicians or one 8,617
or more groups of physicians organized on a group practice or 8,618
individual practice basis. 8,619
(L) "Existing health care facility" means a health care 8,621
facility that is licensed or otherwise approved to practice in 8,622
this state, in accordance with applicable law, is staffed and 8,623
equipped to provide health care services, and actively provides 8,624
health services or has not been actively providing health 8,625
services for less than twelve consecutive months. 8,626
(M) "State" means the state of Ohio, including, but not 8,628
limited to, the general assembly, the supreme court, the offices 8,629
of all elected state officers, and all departments, boards, 8,630
offices, commissions, agencies, institutions, and other 8,631
instrumentalities of the state of Ohio. "State" does not include 8,632
political subdivisions. 8,633
(N) "Political subdivision" means a municipal corporation, 8,635
township, county, school district, and all other bodies corporate 8,636
and politic responsible for governmental activities only in 8,637
geographic areas smaller than that of the state to which the 8,638
195
sovereign immunity of the state attaches. 8,639
(O) "Affected person" means: 8,641
(1) An applicant for a certificate of need, including an 8,643
applicant whose application was reviewed comparatively with the 8,644
application in question; 8,645
(2) The person that requested the reviewability ruling in 8,647
question;
(3) Any person that resides or regularly uses health care 8,649
facilities within the geographic area served or to be served by 8,650
the health care services that would be provided under the 8,651
certificate of need or reviewability ruling in question; 8,652
(4) Any health care facility that is located in the health 8,654
service area where the health care services would be provided 8,655
under the certificate of need or reviewability ruling in 8,656
question;
(5) Third-party payers that reimburse health care 8,658
facilities for services in the health service area where the 8,659
health care services would be provided under the certificate of 8,660
need or reviewability ruling in question; 8,661
(6) Any other person who testified at a public hearing 8,663
held under division (B) of section 3702.52 of the Revised Code or 8,664
submitted written comments in the course of review of the 8,665
certificate of need application in question. 8,666
(P) "Osteopathic hospital" means a hospital registered 8,668
under section 3701.07 of the Revised Code that advocates 8,669
osteopathic principles and the practice and perpetuation of 8,670
osteopathic medicine by doing any of the following: 8,671
(1) Maintaining a department or service of osteopathic 8,673
medicine or a committee on the utilization of osteopathic 8,674
principles and methods, under the supervision of an osteopathic 8,675
physician; 8,676
(2) Maintaining an active medical staff, the majority of 8,678
which is comprised of osteopathic physicians; 8,679
(3) Maintaining a medical staff executive committee that 8,681
196
has osteopathic physicians as a majority of its members. 8,682
(Q) "Ambulatory surgical facility" has the same meaning as 8,684
in section 3702.30 of the Revised Code. 8,685
(R) Except as otherwise provided in division (T) of this 8,687
section, and until the termination date specified in section 8,688
3702.511 of the Revised Code, "reviewable activity" means any of 8,689
the following:
(1) The addition by any person of any of the following 8,692
health services, regardless of the amount of operating costs or 8,693
capital expenditures: 8,694
(a) A heart, heart-lung, lung, liver, kidney, bowel, 8,696
pancreas, or bone marrow transplantation service, a stem cell 8,697
harvesting and reinfusion service, or a service for 8,698
transplantation of any other organ unless transplantation of the 8,699
organ is designated by public health council rule not to be a 8,700
reviewable activity; 8,701
(b) A cardiac catheterization service; 8,703
(c) An open-heart surgery service; 8,705
(d) Any new, experimental medical technology that is 8,708
designated by rule of the public health council.
(2) The acceptance of high-risk patients, as defined in 8,710
rules adopted under section 3702.57 of the Revised Code, by any 8,711
cardiac catheterization service that was initiated without a 8,712
certificate of need pursuant to division (R)(3)(b) of the version 8,714
of this section in effect immediately prior to April 20, 1995; 8,716
(3)(a) The establishment, development, or construction of 8,718
a new health care facility other than a new long-term care 8,719
facility or a new hospital; 8,720
(b) The establishment, development, or construction of a 8,722
new hospital or the relocation of an existing hospital; 8,723
(c) The relocation of hospital beds, other than long-term 8,725
care, perinatal, or pediatric intensive care beds, into or out of 8,726
a rural area. 8,727
(4)(a) The replacement of an existing hospital; 8,729
197
(b) The replacement of an existing hospital obstetric or 8,731
newborn care unit or freestanding birthing center. 8,733
(5)(a) The renovation of a hospital that involves a 8,737
capital expenditure, obligated on or after the effective date of
this amendment, of five million dollars or more, not including 8,739
expenditures for equipment, staffing, or operational costs. For
purposes of division (R)(5)(a) of this section, a capital 8,741
expenditure is obligated:
(i) When a contract enforceable under Ohio law is entered 8,743
into for the construction, acquisition, lease, or financing of a 8,744
capital asset; 8,745
(ii) When the governing body of a hospital takes formal 8,747
action to commit its own funds for a construction project 8,748
undertaken by the hospital as its own contractor; 8,749
(iii) In the case of donated property, on the date the 8,751
gift is completed under applicable Ohio law. 8,752
(b) The renovation of a hospital obstetric or newborn care 8,754
unit or freestanding birthing center that involves a capital 8,756
expenditure of five million dollars or more, not including 8,757
expenditures for equipment, staffing, or operational costs. 8,758
(6) Any change in the health care services, bed capacity, 8,760
or site, or any other failure to conduct the reviewable activity 8,761
in substantial accordance with the approved application for which 8,762
a certificate of need was granted, if the change is made prior to 8,763
the date the activity for which the certificate was issued ceases 8,764
to be a reviewable activity; 8,765
(7) Any of the following changes in perinatal bed capacity 8,767
or pediatric intensive care bed capacity: 8,768
(a) An increase in bed capacity; 8,770
(b) A change in service or service-level designation of 8,773
newborn care beds or obstetric beds in a hospital or freestanding 8,774
birthing center, other than a change of service that is provided
within the service-level designation of newborn care or obstetric 8,775
beds as registered by the department of health; 8,776
198
(c) A relocation of perinatal or pediatric intensive care 8,779
beds from one physical facility or site to another, excluding the 8,780
relocation of beds within a hospital or freestanding birthing 8,781
center or the relocation of beds among buildings of a hospital or 8,783
freestanding birthing center at the same site. 8,784
(8) The expenditure of more than one hundred ten per cent 8,786
of the maximum expenditure specified in a certificate of need; 8,787
(9) Any transfer of a certificate of need issued prior to 8,789
April 20, 1995, from the person to whom it was issued to another 8,791
person before the project that constitutes a reviewable activity 8,792
is completed, any agreement that contemplates the transfer of a 8,793
certificate of need issued prior to that date upon completion of 8,795
the project, and any transfer of the controlling interest in an 8,796
entity that holds a certificate of need issued prior to that
date. However, the transfer of a certificate of need issued 8,797
prior to that date or agreement to transfer such a certificate of 8,799
need from the person to whom the certificate of need was issued 8,800
to an affiliated or related person does not constitute a 8,801
reviewable transfer of a certificate of need for the purposes of 8,802
this division, unless the transfer results in a change in the 8,803
person that holds the ultimate controlling interest in the 8,804
certificate of need.
(10)(a) The acquisition by any person of any of the 8,806
following medical equipment, regardless of the amount of 8,808
operating costs or capital expenditure:
(i) A cobalt radiation therapy unit; 8,810
(ii) A linear accelerator; 8,812
(iii) A gamma knife unit. 8,814
(b) The acquisition by any person of medical equipment 8,816
with a cost of two million dollars or more. The cost of 8,817
acquiring medical equipment includes the sum of the following: 8,818
(i) The greater of its fair market value or the cost of 8,820
its lease or purchase; 8,821
(ii) The cost of installation and any other activities 8,823
199
essential to the acquisition of the equipment and its placement 8,824
into service.
(11) The addition of another cardiac catheterization 8,827
laboratory to an existing cardiac catheterization service. 8,828
(S) Except as provided in division (T) of this section, 8,831
"reviewable activity" also means any of the following activities, 8,833
none of which are subject to a termination date:
(1) The establishment, development, or construction of a 8,835
new long-term care facility; 8,836
(2) The replacement of an existing long-term care 8,838
facility; 8,839
(3) The renovation of a long-term care facility that 8,841
involves a capital expenditure of two million dollars or more, 8,842
not including expenditures for equipment, staffing, or 8,843
operational costs; 8,844
(4) Any of the following changes in long-term care bed 8,846
capacity: 8,847
(a) An increase in bed capacity; 8,849
(b) A relocation of beds from one physical facility or 8,852
site to another, excluding the relocation of beds within a 8,853
long-term care facility or among buildings of a long-term care 8,854
facility at the same site;
(c) A recategorization of hospital beds registered under 8,857
section 3701.07 of the Revised Code from another registration 8,859
category to skilled nursing beds or long-term care beds. 8,860
(5) Any change in the health services, bed capacity, or 8,862
site, or any other failure to conduct the reviewable activity in 8,863
substantial accordance with the approved application for which a 8,864
certificate of need concerning long-term care beds was granted, 8,865
if the change is made within five years after the implementation 8,866
of the reviewable activity for which the certificate was granted; 8,868
(6) The expenditure of more than one hundred ten per cent 8,870
of the maximum expenditure specified in a certificate of need 8,871
concerning long-term care beds; 8,872
200
(7) Any transfer of a certificate of need that concerns 8,874
long-term care beds and was issued prior to April 20, 1995, from 8,876
the person to whom it was issued to another person before the 8,877
project that constitutes a reviewable activity is completed, any 8,878
agreement that contemplates the transfer of such a certificate of 8,879
need upon completion of the project, and any transfer of the 8,880
controlling interest in an entity that holds such a certificate 8,881
of need. However, the transfer of a certificate of need that 8,882
concerns long-term care beds and was issued prior to April 20, 8,884
1995, or agreement to transfer such a certificate of need from 8,885
the person to whom the certificate was issued to an affiliated or 8,886
related person does not constitute a reviewable transfer of a 8,887
certificate of need for purposes of this division, unless the 8,888
transfer results in a change in the person that holds the 8,889
ultimate controlling interest in the certificate of need. 8,890
(T) "Reviewable activity" does not include any of the 8,892
following activities: 8,893
(1) Acquisition of computer hardware or software; 8,895
(2) Acquisition of a telephone system; 8,897
(3) Construction or acquisition of parking facilities; 8,899
(4) Correction of cited deficiencies that are in violation 8,901
of federal, state, or local fire, building, or safety laws and 8,902
rules and that constitute an imminent threat to public health or 8,903
safety; 8,904
(5) Acquisition of an existing health care facility that 8,906
does not involve a change in the number of the beds, by service, 8,907
or in the number or type of health services; 8,908
(6) Correction of cited deficiencies identified by 8,910
accreditation surveys of the joint commission on accreditation of 8,911
healthcare organizations or of the American osteopathic 8,912
association; 8,913
(7) Acquisition of medical equipment to replace the same 8,915
or similar equipment for which a certificate of need has been 8,916
issued if the replaced equipment is removed from service; 8,917
201
(8) Mergers, consolidations, or other corporate 8,919
reorganizations of health care facilities that do not involve a 8,920
change in the number of beds, by service, or in the number or 8,921
type of health services; 8,922
(9) Construction, repair, or renovation of bathroom 8,924
facilities; 8,925
(10) Construction of laundry facilities, waste disposal 8,927
facilities, dietary department projects, heating and air 8,928
conditioning projects, administrative offices, and portions of 8,929
medical office buildings used exclusively for physician services; 8,930
(11) Acquisition of medical equipment to conduct research 8,932
required by the United States food and drug administration or 8,933
clinical trials sponsored by the national institute of health. 8,934
Use of medical equipment that was acquired without a certificate 8,935
of need under division (T)(11) of this section and for which 8,937
premarket approval has been granted by the United States food and 8,938
drug administration to provide services for which patients or 8,939
reimbursement entities will be charged shall be a reviewable 8,940
activity. 8,941
(12) Removal of asbestos from a health care facility. 8,943
Only that portion of a project that meets the requirements 8,945
of division (T) of this section is not a reviewable activity. 8,947
(U) "Small rural hospital" means a hospital that is 8,949
located within a rural area, has fewer than one hundred beds, and 8,951
to which fewer than four thousand persons were admitted during 8,952
the most recent calendar year.
(V) "Children's hospital" means any of the following: 8,954
(1) A hospital registered under section 3701.07 of the 8,956
Revised Code that provides general pediatric medical and surgical 8,957
care, and in which at least seventy-five per cent of annual 8,958
inpatient discharges for the preceding two calendar years were 8,959
individuals less than eighteen years of age; 8,960
(2) A distinct portion of a hospital registered under 8,962
section 3701.07 of the Revised Code that provides general 8,963
202
pediatric medical and surgical care, has a total of at least one 8,964
hundred fifty registered pediatric special care and pediatric 8,965
acute care beds, and in which at least seventy-five per cent of 8,966
annual inpatient discharges for the preceding two calendar years 8,967
were individuals less than eighteen years of age; 8,968
(3) A distinct portion of a hospital, if the hospital is 8,970
registered under section 3701.07 of the Revised Code as a 8,971
children's hospital and the children's hospital meets all the 8,972
requirements of division (V)(1) of this section. 8,973
(W) "Long-term care facility" means any of the following: 8,975
(1) A nursing home licensed under section 3721.02 of the 8,977
Revised Code or by a political subdivision certified under 8,978
section 3721.09 of the Revised Code; 8,979
(2) The portion of any facility, including a county home 8,981
or county nursing home, that is certified as a skilled nursing 8,982
facility or a nursing facility under Title XVIII or XIX of the 8,983
"Social Security Act";
(3) The portion of any hospital that contains beds 8,985
registered under section 3701.07 of the Revised Code as skilled 8,986
nursing beds or long-term care beds. 8,987
(X) "Long-term care bed" means a bed in a long-term care 8,989
facility.
(Y) "Perinatal bed" means a bed in a hospital that is 8,991
registered under section 3701.07 of the Revised Code as a newborn 8,992
care bed or obstetric bed, or a bed in a freestanding birthing 8,993
center.
(Z) "Freestanding birthing center" means any facility in 8,995
which deliveries routinely occur, regardless of whether the 8,997
facility is located on the campus of another health care
facility, and which is not licensed under Chapter 3711. of the 8,999
Revised Code as a level one, two, or three maternity unit or a 9,001
limited maternity unit.
(AA)(1) "Reviewability ruling" means a ruling issued by 9,003
the director of health under division (A) of section 3702.52 of 9,004
203
the Revised Code as to whether a particular proposed project is 9,005
or is not a reviewable activity. 9,006
(2) "Nonreviewability ruling" means a ruling issued under 9,008
that division that a particular proposed project is not a 9,009
reviewable activity. 9,010
(BB)(1) "Metropolitan statistical area" means an area of 9,013
this state designated a metropolitan statistical area or primary 9,014
metropolitan statistical area in United States office of 9,016
management and budget bulletin No. 93-17, June 30, 1993, and its 9,018
attachments. 9,019
(2) "Rural area" means any area of this state not located 9,021
within a metropolitan statistical area. 9,022
Sec. 3702.62. (A) Any action pursuant to section 140.03, 9,031
140.04, 140.05, 307.091, 313.21, 339.01, 339.021, 339.03, 339.06, 9,032
339.08, 339.09, 339.12, 339.14, 339.21, 339.231, 339.24, 339.31, 9,033
339.36, 339.39, 513.05, 513.07, 513.08, 513.081, 513.12, 513.15, 9,034
513.17, 513.171, 749.02, 749.14, 749.16, 749.20, 749.25, 749.28, 9,035
749.35, 1742.06 1751.06, or 3707.29 of the Revised Code shall be 9,036
taken in accordance with sections 3702.51 to 3702.61 of the 9,037
Revised Code.
(B) A nursing home certified as an intermediate care 9,039
facility for the mentally retarded under Title XIX of the "Social 9,040
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, 9,041
that is required to apply for licensure as a residential facility 9,042
under section 5123.19 of the Revised Code is not, with respect to 9,043
the portion of the home certified as an intermediate care
facility for the mentally retarded, subject to sections 3702.51 9,044
to 3702.61 of the Revised Code. 9,045
Sec. 3709.16. The board of health of a city or general 9,054
health district shall determine the duties and fix the salaries 9,055
of its employees. 9,056
No member of the board shall be appointed as health officer 9,058
or ward physician. 9,059
The board of health of any health district may procure and 9,061
204
pay all or any part of the cost of group life, hospitalization, 9,062
surgical, major medical, sickness and accident insurance, or a 9,063
combination of any of the foregoing types of insurance or 9,064
coverage, for the health commissioner, the employees of the 9,065
health district, and their immediate dependents, from the funds 9,066
or budgets from which said health commissioner or employees are 9,067
compensated for services, issued by an insurance company or 9,068
nonprofit medical care A HEALTH INSURING corporation duly 9,069
authorized to do business in this state. 9,070
Notwithstanding section 3917.01 of the Revised Code, the 9,072
board of health of any health district may purchase group life 9,073
insurance authorized by this section by reason of payment of 9,074
premiums therefor by the board from its funds, and such group 9,075
life insurance may be issued and purchased if otherwise 9,076
consistent with sections 3917.01 to 3917.06 of the Revised Code. 9,077
Sec. 3729.12. Not later than a date specified by the 9,087
director of health, the Ohio health care data center shall make 9,088
its first submission of a report containing the health care 9,089
information specified in this section to the governor, the 9,090
speaker of the house of representatives, the president of the 9,091
senate, and the chairpersons of the standing committees of the 9,092
house of representatives and the senate that have primary 9,093
responsibility for the consideration of health legislation. Each 9,094
year thereafter, the data center shall submit a report not later 9,095
than the thirty-first day of December. The report shall contain, 9,096
to the extent possible with the data collected under sections 9,097
3729.15 to 3729.45 of the Revised Code, an analysis of all of the 9,098
following:
(A) The one hundred high priority diagnoses and one 9,100
hundred high priority medical procedures that account for eighty 9,101
per cent of public and private health care costs in this state, 9,102
and diagnoses and medical procedures for which a disproportionate 9,103
share of public and private expenditures are consumed relative to 9,104
the total number of diseases diagnosed and medical procedures 9,105
205
performed; 9,106
(B) The relationship between: 9,108
(1) Health care costs, access, outcomes, continuity of 9,110
care, and professional practice patterns for selected diseases 9,111
and procedures; 9,112
(2) An individual's source of payment, age, geographic 9,114
location, sex, race, and income. 9,115
(C) The differences in administrative expenses for 9,117
delivery of health care in the public sector versus the private 9,118
sector; 9,119
(D)(1) Compared to previous years when appropriate data 9,121
were collected, the increase in expenditures that has occurred in 9,122
the public health care programs in each of the following 9,123
categories: 9,124
(a) Long-term care facilities; 9,126
(b) Hospital inpatient services; 9,128
(c) Hospital outpatient services; 9,130
(d) Home-based health care; 9,132
(e) Physicians' services; 9,134
(f) Allied health services; 9,136
(g) Pharmaceuticals; 9,138
(h) Durable medical equipment and medical and surgical 9,140
products; 9,141
(i) Mental health services; 9,143
(j) Other health services selected by the director of 9,145
health. 9,146
(2) The factors that have contributed to the expenditure 9,148
increases in each of the categories specified by division (D)(1) 9,149
of this section. 9,150
(E) The extent to which physicians and other health care 9,152
providers selected by the director participate in public versus 9,153
private health care programs, and changes in this participation 9,154
from previous years when appropriate data were collected; 9,155
(F) The distribution of emergency medical services among 9,157
206
the population of this state, and the relationship between: 9,158
(1) Access to emergency medical services; 9,160
(2) An individual's source of payment, age, geographic 9,162
location, sex, race, and income. 9,163
(G) The number of residents of this state who are 9,165
uninsured or underinsured with respect to health care, the 9,166
distribution of this population by county, the demographic 9,167
characteristics, including employment status, of this population, 9,168
and the changes in those demographic characteristics from 9,169
previous years when appropriate data were collected; 9,170
(H) The percentage of individuals who seek or register for 9,172
health care services that: 9,173
(1) Are diagnosed or treated; 9,175
(2) Are denied services; 9,177
(3) Receive primary care services from emergency 9,179
facilities. 9,180
(I) The differences between primary care case managed 9,182
systems and other managed health care reimbursement systems in 9,183
health care costs and outcomes for one hundred high priority 9,184
diseases or procedures selected by the director, access to health 9,185
care, and professional practice patterns and variations, and the 9,186
factors that contribute to those differences; 9,187
(J) The relationship between: 9,189
(1) Long-term care facility admission, transfer, and 9,191
length-of-stay; 9,192
(2) An individual's source of payment, age, geographic 9,194
location, sex, race, and income. 9,195
(K) The percentage of hospitals' uncompensated care, 9,197
including uncompensated care provided by group practices as 9,198
defined in section 4731.65 of the Revised Code that have one 9,199
hundred members or more, that is attributable to each of the 9,201
following:
(1) Charity care; 9,203
(2) Courtesy care; 9,205
207
(3) Contractual allowances; 9,207
(4) The medical assistance program; 9,209
(5) The medicare program; 9,211
(6) Bad debts. 9,213
(L) The relationship between the number and type of 9,215
pharmaceutical prescriptions and each of the following: 9,216
(1) An individual's source of payment, age, geographic 9,218
location, and sex; 9,219
(2) Use of a therapeutic formulary by disease category. 9,221
(M) The extent to which physicians and other health care 9,223
providers selected by the director provide primary care services 9,224
to indigent individuals and the type of primary care services 9,225
provided; 9,226
(N) Public or private provider reimbursement strategies 9,228
that have been effective in containing health care costs; 9,229
(O) The effectiveness of quality improvement programs 9,231
introduced by health care organizations, including health 9,232
maintenance organizations INSURING CORPORATIONS and independent 9,233
practice associations, or health care plans in improving the 9,234
general quality of health care in this state; 9,235
(P) The comparison of health care costs, access, outcomes, 9,237
continuity of care, and professional practice patterns in this 9,238
state with other states and countries; 9,239
(Q) State and local statutes, ordinances, or rules that 9,241
may contribute to health care cost increases and suggested 9,242
changes in the regulatory framework to reduce costs without 9,243
adversely affecting quality or access; 9,244
(R) The increase in health care costs that can be 9,246
attributed to increases in malpractice insurance premiums and 9,247
increases in the practice of defensive medicine; 9,248
(S) The total number of visits by medical assistance 9,250
program recipients and medicare beneficiaries to clinics versus 9,251
primary care health care practitioner offices in this state, 9,252
categorized by type of clinic or primary care practitioner and 9,253
208
diagnosis; 9,254
(T) Variations in treatment, costs, and medical outcome of 9,256
a range of diagnoses selected by the director according to 9,257
practitioner specialty versus primary care case management with 9,258
global fees and comparison of individuals' source of payment, 9,259
age, geographic location, sex, race, and income; 9,260
(U) The major components of the cost of long-term care 9,262
facilities and the variations in the costs of the components 9,263
according to diagnosis, the resident's level of functioning, 9,264
facility size and geographic location, and source of payment; 9,265
(V) Factors that account for increases in the utilization 9,267
of long-term care facilities in comparison with home and 9,268
community outpatient care; 9,269
(W) The effect of health care utilization and costs on the 9,271
general health of residents of this state and the effect of 9,272
behaviorial BEHAVIORAL risk factors, including tobacco use, 9,273
alcohol and substance abuse, lack of exercise, being overweight, 9,275
and other factors selected by the director; 9,276
(X) The effect of utilization of preventive health care 9,278
services on health care costs and outcomes, categorized by age, 9,279
occupation, and type of health care coverage; 9,280
(Y) The number of individuals in each county who received 9,282
services the previous calendar year from a public health care 9,283
program administered in whole or in part by the department of 9,284
mental retardation and developmental disabilities or a county 9,285
board of mental retardation and developmental disabilities, 9,286
compared to the number of individuals in each county who applied 9,287
and were found eligible for those services that year but did not 9,288
receive them; 9,289
(Z) The number of individuals in each county that received 9,291
services the previous calendar year from a public health care 9,292
program administered in whole or in part by the department of 9,293
mental health, a community mental health board, or a board of 9,294
alcohol, drug abuse, and mental health services, compared to the 9,295
209
number of individuals in each county who applied and were found 9,296
eligible for those services that year but did not receive them. 9,297
The report must comply with section 3729.46 of the Revised 9,299
Code. 9,300
Sec. 3901.04. (A) As used in this section: 9,309
(1) "Laws of this state relating to insurance" include but 9,311
are not limited to Chapters 1736., 1737., 1738., 1739. 9,312
notwithstanding section 1739.02, 1740., and 1742. CHAPTER 1751. 9,314
notwithstanding section 1742.30 1751.08, Title XXXIX, sections 9,315
5725.18 to 5725.25, and Chapter 5729. of the Revised Code. 9,316
(2) "Person" has the meaning defined in division (A) of 9,318
section 3901.19 of the Revised Code. 9,319
(B) Whenever it appears to the superintendent of 9,321
insurance, from his THE SUPERINTENDENT'S files, upon complaint or 9,323
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 9,324
prohibited by the laws of this state relating to insurance, or 9,325
defined as unfair or deceptive by such laws, or when the 9,326
superintendent believes it to be in the best interest of the 9,327
public and necessary for the protection of the people in this 9,328
state, the superintendent or anyone designated by the 9,329
superintendent under his THE SUPERINTENDENT'S official seal may 9,330
do any one or more of the following:
(1) Require any person to file with the superintendent, on 9,332
a form that is appropriate for review by the superintendent, an 9,333
original or additional statement or report in writing, under oath 9,334
or otherwise, as to any facts or circumstances concerning the 9,335
person's conduct of the business of insurance within this state 9,336
and as to any other information that the superintendent considers 9,337
to be material or relevant to such business; 9,338
(2) Administer oaths, summon and compel by order or 9,340
subpoena the attendance of witnesses to testify in relation to 9,341
any matter which, by the laws of this state relating to 9,342
insurance, is the subject of inquiry and investigation, and 9,343
210
require the production of any book, paper, or document pertaining 9,344
to such matter. A subpoena, notice, or order under this section 9,345
may be served by certified mail, return receipt requested. If 9,346
the subpoena, notice, or order is returned because of inability 9,347
to deliver, or if no return is received within thirty days of the 9,348
date of mailing, the subpoena, notice, or order may be served by 9,349
ordinary mail. If no return of ordinary mail is received within 9,350
thirty days after the date of mailing, service shall be deemed to 9,351
have been made. If the subpoena, notice, or order is returned 9,352
because of inability to deliver, the superintendent may designate 9,353
a person or persons to effect either personal or residence 9,354
service upon the witness. Service of any subpoena, notice, or 9,355
order and return may also be made in any manner authorized under 9,356
the Rules of Civil Procedure. Such service shall be made by an 9,357
employee of the department designated by the superintendent, a 9,358
sheriff, a deputy sheriff, an attorney, or any person authorized 9,359
by the Rules of Civil Procedure to serve process. 9,360
In the case of disobedience of any notice, order, or 9,362
subpoena served on a person or the refusal of a witness to 9,363
testify to a matter regarding which he THE PERSON may lawfully be 9,365
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 9,366
obedience by attachment proceedings for contempt, as in the case 9,367
of disobedience of the requirements of a subpoena issued from 9,368
such court, or a refusal to testify therein. Witnesses shall 9,369
receive the fees and mileage allowed by section 2335.06 of the 9,370
Revised Code. All such fees, upon the presentation of proper 9,371
vouchers approved by the superintendent, shall be paid out of the 9,372
appropriation for the contingent fund of the department of 9,373
insurance. The fees and mileage of witnesses not summoned by the 9,374
superintendent or his THE SUPERINTENDENT'S designee shall not be 9,375
paid by the state. 9,376
(3) In a case in which there is no administrative 9,378
procedure available to the superintendent to resolve a matter at 9,379
211
issue, request the attorney general to commence an action for a 9,380
declaratory judgment under Chapter 2721. of the Revised Code with 9,381
respect to the matter. 9,382
(4) Initiate criminal proceedings by presenting evidence 9,384
of the commission of any criminal offense established under the 9,385
laws of this state relating to insurance to the prosecuting 9,386
attorney of any county in which the offense may be prosecuted. At 9,388
the request of the prosecuting attorney, the attorney general may 9,389
assist in the prosecution of the violation with all the rights, 9,390
privileges, and powers conferred by law on prosecuting attorneys 9,391
including, but not limited to, the power to appear before grand 9,392
juries and to interrogate witnesses before grand juries. 9,393
Sec. 3901.041. The superintendent of insurance shall 9,402
adopt, amend, and rescind rules and make adjudications, necessary 9,403
to discharge his THE SUPERINTENDENT'S duties and exercise his THE 9,404
SUPERINTENDENT'S powers, including, but not limited to, his THE 9,405
SUPERINTENDENT'S duties and powers under Chapters 1737., 1738., 9,406
and 1740. CHAPTER 1751. and Title XXXIX of the Revised Code, 9,408
subject to sections 119.01 to 119.13 CHAPTER 119. of the Revised 9,409
Code.
Sec. 3901.043. The superintendent of insurance may adopt 9,418
rules in accordance with Chapter 119. of the Revised Code to 9,419
establish reasonable fees for any service or transaction 9,420
performed by the department of insurance pursuant to section 9,421
1738.04, 1742.03 1751.03, 3901.321, 3901.341, 3907.09, 3907.10, 9,422
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 9,423
Revised Code or any provision in sections 3913.01 to 3913.23 or 9,424
in Chapter 3905. of the Revised Code, if no fee is otherwise 9,425
provided under Title XVII or XXXIX of the Revised Code for such 9,426
service or transaction. Any fee collected pursuant to those 9,427
rules shall be paid into the state treasury to the credit of the 9,428
department of insurance operating fund.
Sec. 3901.071. All moneys collected by the superintendent 9,437
212
of insurance for expenses incurred by him THE SUPERINTENDENT in 9,438
conducting examinations pursuant to the Revised Code of the 9,439
financial affairs of any insurance company doing business in this 9,440
state, for which the insurance company examined is required to 9,441
pay the costs, shall be paid to the superintendent. The 9,442
superintendent shall deposit the money in the state treasury to 9,443
the credit of the superintendent's examination fund, which is 9,444
hereby established. Any funds expended or obligated therefrom by 9,445
the superintendent shall be expended or obligated solely for 9,446
defrayment of the costs of examinations of the financial affairs 9,447
of insurance companies made by the superintendent pursuant to the 9,448
Revised Code. For purposes of this section, "insurance company" 9,449
means any domestic or foreign stock company, risk retention 9,450
group, mutual company, mutual protective association, fraternal 9,451
benefit society, reciprocal or inter-insurance exchange, 9,452
nonprofit medical care corporation, AND health care INSURING 9,454
corporation, and nonprofit dental care corporation, regardless of 9,455
the type of coverage written, benefits provided, or guarantees 9,456
made by each.
Sec. 3901.16. Any association, company, or corporation, 9,465
INCLUDING A HEALTH INSURING CORPORATION, which violates any law 9,466
relating to the superintendent of insurance, ANY PROVISION OF 9,468
CHAPTER 1751. OF THE REVISED CODE, or any insurance law of this
state, for the violation of which no forfeiture or penalty is 9,469
elsewhere provided in the Revised Code, shall forfeit and pay not 9,470
less than one thousand nor more than ten thousand dollars, to be 9,471
recovered by an action in the name of the state and on collection 9,472
to be paid to the superintendent, who shall pay such sum into the 9,473
state treasury.
Sec. 3901.19. As used in sections 3901.19 to 3901.26 of 9,482
the Revised Code: 9,483
(A) "Person" means any individual, corporation, 9,485
association, partnership, reciprocal exchange, inter-insurer, 9,486
fraternal benefit society, title guarantee and trust company, 9,487
213
prepaid dental plan organization, medical care corporation, 9,488
health care INSURING corporation, dental care corporation, health 9,490
maintenance organization incorporated under Chapter 1735., 1736.,
1737., 1738., 1740., or 1742. of the Revised Code, and any other 9,491
legal entity. 9,492
(B) "Residents" includes any individual, partnership, or 9,494
corporation. 9,495
(C) "Maternity benefits" means those benefits calculated 9,497
to indemnify the insured for hospital and medical expenses fairly 9,498
and reasonably associated with a pregnancy and childbirth. 9,499
(D) "Insurance" includes, but is not limited to, any 9,501
policy or contract offered, issued, sold, or marketed by an 9,502
insurer, corporation, association, organization, or entity 9,503
regulated by the superintendent of insurance or doing business in 9,504
this state. Nothing in any other section of the Revised Code 9,505
shall be construed to exclude single premium deferred annuities 9,506
from the regulation of the superintendent under sections 3901.19 9,507
to 3901.26 of the Revised Code. 9,508
Sec. 3901.31. (A) Every person who is directly or 9,517
indirectly the beneficial owner of more than ten per cent of any 9,518
class of any equity security of a domestic stock insurance 9,519
company which is not a wholly owned subsidiary of an insurance 9,520
holding company system or who is a director or officer of such 9,521
company, shall file with the superintendent of insurance within 9,522
ten days after he THE PERSON becomes such beneficial owner, 9,523
director, or officer, a statement in such form as the 9,525
superintendent of insurance may prescribe, of the amount of all 9,526
equity securities of such company of which he THE PERSON is the 9,527
beneficial owner, and within ten days after the close of each 9,529
calendar month thereafter, if there has been a change in such 9,530
ownership during such month, shall file with the superintendent 9,531
of insurance a statement, in such form as the superintendent of 9,532
insurance may prescribe, indicating his THE PERSON'S ownership at 9,533
the close of the calendar month and such changes in his THE 9,534
214
PERSON'S ownership as have occurred during such calendar month. 9,535
(B) For the purpose of preventing the unfair use of 9,537
information which may have been obtained by such beneficial 9,538
owner, director, or officer by reason of his THE BENEFICIAL 9,539
OWNER'S, DIRECTOR'S, OR OFFICER'S relationship to such company, 9,540
any profit realized by him THE BENEFICIAL OWNER, DIRECTOR, OR 9,541
OFFICER from any purchase and sale, or any sale and purchase, of 9,542
any equity security of such company within any period of less 9,544
than six months, unless such security was acquired in good faith 9,545
in connection with a debt previously contracted, shall inure to 9,546
and be recoverable by the company, irrespective of any intention 9,547
on the part of such beneficial owner, director, or officer in 9,548
entering into such transaction of holding the security purchased 9,549
or of not repurchasing the security sold for a period exceeding 9,550
six months. Suit to recover such profit may be instituted at law 9,551
or in equity in any court of competent jurisdiction by the 9,552
company, or by the owner of any security of the company in the 9,553
name and in behalf of the company if the company fails or refuses 9,554
to bring such suit within sixty days after request or fails 9,555
diligently to prosecute the same thereafter; but no such suit 9,556
shall be brought more than two years after the date such profit 9,557
was realized. Division (B) of this section shall not be 9,558
construed to cover any transaction where such beneficial owner 9,559
was not such both at the time of purchase and sale, or the sale 9,560
and purchase, of the security involved, or any transaction or 9,561
transactions which the superintendent of insurance by rules may 9,562
exempt as not comprehended within the purpose of division (B) of 9,563
this section.
(C) No such beneficial owner, director, or officer, 9,565
directly or indirectly, shall sell any equity security of such 9,566
company if the person selling the security or his THE PERSON'S 9,567
principal does not own the security sold, or if owning the 9,568
security, does not deliver it against such sale within twenty 9,569
days thereafter, or does not within five days after such sale 9,570
215
deposit it in the mails or other usual channels of 9,571
transportation; but no person shall be deemed to have violated 9,572
division (C) of this section if he THE PERSON proves that 9,573
notwithstanding the exercise of good faith he THE PERSON was 9,574
unable to make such delivery or deposit within such time, or that 9,575
to do so would cause undue inconvenience or expense.
(D) A domestic insurance company having at least fifty 9,577
shareholders or any other person soliciting proxies with respect 9,578
to such domestic insurance company shall not solicit voting 9,579
proxies from any shareholder or other person except upon a proxy 9,580
statement and pursuant to a notice of meeting, which statement 9,581
and notice have been submitted to the superintendent of insurance 9,582
at least ten days prior to being mailed to the intended 9,583
recipients. Such proxy statement and notice of meeting shall 9,584
make such disclosures pertinent to the business to be carried on 9,585
at the meeting or meetings with respect to which such proxies are 9,586
solicited and such notices are given as the superintendent by 9,587
rule requires. The superintendent shall retain such proxy 9,588
material for examination by any interested party for at least one 9,589
year. 9,590
(E) Division (B) of this section does not apply to any 9,592
purchase and sale, or sale and purchase, and division (C) of this 9,593
section does not apply to any sale, of an equity security of a 9,594
domestic stock insurance company not then or theretofore held by 9,595
him in an investment account, by a dealer in the ordinary course 9,596
of his THE DEALER'S business and incident to the establishment or 9,598
maintenance by him THE DEALER of a primary or secondary market 9,599
for such security. The superintendent of insurance may, by such 9,600
rules as he THE SUPERINTENDENT considers necessary or appropriate 9,601
in the public interest, describe and define the terms and 9,603
conditions with respect to securities held in an investment 9,604
account and transactions made in the ordinary course of business 9,605
and incident to the establishment or maintenance of a primary or 9,606
secondary market.
216
(F) Divisions (A), (B), and (C) of this section do not 9,608
apply to foreign or domestic arbitrage transactions unless made 9,609
in contravention of such rules as the superintendent of insurance 9,610
may adopt in order to carry out the purposes of this section. 9,611
(G) "Equity security" when used in this section means any 9,613
stock or similar security; or any security convertible, with or 9,614
without consideration, into such a security, or carrying any 9,615
warrant or right to subscribe to or purchase such a security; or 9,616
any such warrant or right; or any other security which the 9,617
superintendent of insurance determines to be of similar nature 9,618
and considers necessary or appropriate, by such rules as he THE 9,619
SUPERINTENDENT may prescribe in the public interest or for the 9,620
protection of investors, to treat as an equity security. 9,621
(H) The superintendent of insurance may adopt, amend, and 9,623
rescind rules, pursuant to Chapter 119. of the Revised Code, 9,624
which will enable him THE SUPERINTENDENT to carry out the duties 9,626
imposed upon him by this section.
(I) THIS SECTION APPLIES TO HEALTH INSURING CORPORATIONS 9,628
IN THE SAME MANNER IN WHICH THIS SECTION APPLIES TO DOMESTIC 9,629
STOCK INSURANCE COMPANIES. 9,630
Sec. 3901.32. As used in sections 3901.32 to 3901.37 of 9,639
the Revised Code: 9,640
(A) "Affiliate of" or "affiliated with" a specific person 9,642
means a person that, directly or indirectly, through one or more 9,643
intermediaries, controls, is controlled by, or is under common 9,644
control with, the person specified. 9,645
(B) "Control," including "controlling," "controlled by," 9,647
and "under common control with," means the possession, direct or 9,648
indirect, of the power to direct or cause the direction of the 9,649
management and policies of a person, whether through the 9,650
ownership of voting securities, by contract other than a 9,651
commercial contract for goods or nonmanagement services, or 9,652
otherwise, unless the power is the result of an official position 9,653
with or corporate office held by the person. Control shall be 9,654
217
presumed to exist if any person, directly or indirectly, owns, 9,655
controls, holds with the power to vote, or holds proxies 9,656
representing, ten per cent or more of the voting securities of 9,657
any other person. This presumption may be rebutted by a showing 9,658
made in the manner provided in division (J) of section 3901.33 of 9,660
the Revised Code that control does not exist in fact. The 9,661
superintendent of insurance may determine, after furnishing all 9,662
persons in interest notice and opportunity to be heard and making 9,663
specific findings of fact to support such determination, that 9,664
control exists in fact, notwithstanding the absence of a 9,665
presumption to that effect. 9,666
(C) "Insurance holding company system" means two or more 9,668
affiliated persons, one or more of which is an insurer. 9,669
(D) "Insurer" means any person engaged in the business of 9,671
insurance, guaranty, or membership, an inter-insurance exchange, 9,672
a mutual or fraternal benefit society, a prepaid dental plan 9,673
organization, a health maintenance organization, a medical care, 9,674
OR A health care, or dental care INSURING corporation, excepting 9,676
any agency, authority, or instrumentality of the United States,
its possessions and territories, the Commonwealth of Puerto Rico, 9,677
the District of Columbia, or a state or political subdivision of 9,678
a state. 9,679
(E) "Person" means an individual, a corporation, a 9,681
partnership, an association, a joint stock company, a trust, an 9,682
unincorporated organization, any similar entity, or any 9,683
combination of the foregoing acting in concert. 9,684
(F) "Subsidiary" of a specified person is an affiliate 9,686
controlled by such person, directly or indirectly, through one or 9,687
more intermediaries. 9,688
(G) "Voting security" includes any security convertible 9,690
into or evidencing a right to acquire a voting security. 9,691
Sec. 3901.38. (A) As used in this section: 9,700
(1) "Beneficiary" means any policyholder, subscriber, 9,702
member, employee, or other person who is eligible for benefits 9,703
218
under a benefits contract. 9,704
(2) "Benefits contract" means a sickness and accident 9,706
insurance policy providing hospital, surgical, or medical expense 9,707
coverage, OR A health maintenance organization INSURING 9,708
CORPORATION contract, preferred provider organization contract, 9,710
or other policy or agreement under which a third-party payer 9,711
agrees to reimburse for covered health care or dental services 9,712
rendered to beneficiaries, up to the limits and exclusions 9,713
contained in the benefits contract.
(3) "Completed claim" means a proof of loss or a claim for 9,715
payment for health care services which has been submitted to the 9,716
appropriate claims processing office of the third-party payer 9,717
accompanied by sufficient documentation for the third-party payer 9,718
to determine proof of loss and reasonably required by the 9,719
third-party payer to accept or reject the claim. 9,720
(4) "Hospital" has the same meaning set forth in section 9,722
3727.01 of the Revised Code. 9,723
(5) "Proof of loss" means a claim for payment for health 9,725
care services which has been submitted to the appropriate claims 9,726
processing office of the third-party payer accompanied by 9,727
sufficient documentation for the third-party payer to determine 9,728
benefits payable under the benefits contract and reasonably 9,729
required by the third-party payer to accept or reject the claim. 9,730
(6) "Provider" means a hospital, nursing home, physician, 9,732
podiatrist, dentist, pharmacist, chiropractor, or other licensed 9,733
health care provider entitled to reimbursement by a third-party 9,734
payer for services rendered to a beneficiary under a benefits 9,735
contract. 9,736
(7) "Reimburse" means indemnify, make payment, or 9,738
otherwise accept responsibility for payment for health care 9,739
services rendered to a beneficiary, or arrange for the provision 9,740
of health care services to a beneficiary. 9,741
(8) "Third-party payer" means any of the following: 9,743
(a) An insurance company; 9,745
219
(b) A health maintenance organization INSURING 9,747
CORPORATION;
(c) A preferred provider organization; 9,749
(d) A labor organization; 9,751
(e) An employer; 9,753
(f) A prepaid dental plan organization AN INTERMEDIARY 9,755
ORGANIZATION, AS DEFINED IN SECTION 1751.01 OF THE REVISED CODE, 9,756
THAT IS NOT A HEALTH DELIVERY NETWORK CONTRACTING SOLELY WITH 9,757
SELF-INSURED EMPLOYERS;
(g) An administrator subject to sections 3959.01 to 9,759
3959.16 of the Revised Code; 9,760
(h) A HEALTH DELIVERY NETWORK, AS DEFINED IN SECTION 9,762
1751.01 OF THE REVISED CODE; 9,763
(i) Any other person that is obligated pursuant to a 9,765
benefits contract to reimburse for covered health care services 9,766
rendered to beneficiaries under such contract. 9,767
(B)(1) Except as provided in division (B)(2) of this 9,769
section, within twenty-four days of the receipt of a completed 9,770
claim from a provider or a beneficiary for reimbursement for 9,771
health care services rendered by the provider to a beneficiary, a 9,772
third-party payer shall, in accordance with division (D) of this 9,773
section, make payment of any amount due on such claim. 9,774
(2) A third-party payer and a provider may, in negotiating 9,776
a reimbursement contract, agree to any time period by which a 9,777
third-party payer shall, subject to division (D) of this section, 9,778
make payment of any amount due on a completed claim. Nothing in 9,779
this division shall be construed as limiting in any manner the 9,780
application of the requirements of this section to any benefits 9,781
or reimbursement contract. 9,782
(3) Any provider or beneficiary aggrieved with respect to 9,784
any act of a third-party payer that such provider or beneficiary 9,785
believes to be a violation of division (B)(1) or (2) of this 9,786
section may file a written complaint with the superintendent of 9,787
insurance. If a series of such complaints is received by the 9,788
220
superintendent with respect to a particular third-party payer and 9,789
if, after investigation, the superintendent finds that such 9,790
third-party payer has engaged in a series of such violations 9,791
which, taken together, constitute a consistent pattern or a 9,792
practice of such third-party payer to violate division (B)(1) or 9,793
(2) of this section, the superintendent shall issue an order 9,794
requiring such third-party payer to cease and desist from 9,795
engaging in such violations and to pay a late payment penalty as 9,796
specified in divisions (B)(4) and (5) of this section with 9,797
respect to the claims the superintendent finds were not timely 9,798
paid. In the order, the superintendent shall specify the reasons 9,799
for his THE SUPERINTENDENT'S finding and order and state that a 9,800
hearing conducted pursuant to Chapter 119. of the Revised Code 9,802
shall be held within fifteen days after requested in writing by 9,803
the third-party payer. The provisions of this division (B)(3) of 9,804
this section are in addition to, and not in lieu of, such other 9,805
remedies as providers and beneficiaries may otherwise have by 9,806
law.
(4)(a) The late payment penalty shall be computed based 9,808
upon the number of days that have elapsed between the date 9,809
payment is due in accordance with division (B)(1) or (2) of this 9,810
section and the date payment is actually sent. 9,811
(b) The interest rate for determining the amount of the 9,813
late payment penalty shall be the rate agreed to by the provider 9,814
and the third-party payer or the rate specified by and determined 9,815
in accordance with division (A) of section 1343.01 of the Revised 9,816
Code. 9,817
(5) A provider and a third-party payer may enter into a 9,819
contractual agreement in which the timing of payments by the 9,820
third-party payer is not directly related to the receipt of a 9,821
completed claim. Such contractual arrangement may include 9,822
periodic interim payment arrangements, capitation payment 9,823
arrangements, or other payment arrangements acceptable to the 9,824
provider and the third-party payer. Except as agreed to under 9,825
221
such contract, this section does not apply to such payment 9,826
arrangements. 9,827
(6) Any late payment penalty due and payable by a 9,829
third-party payer in accordance with this section shall not be 9,830
used to reduce benefits or payments otherwise payable under a 9,831
benefits contract. 9,832
(C) No third-party payer shall refuse to process or pay 9,834
within the time period required under division (B)(1) or (2) of 9,835
this section a completed claim submitted by a provider on the 9,836
ground the beneficiary has not been discharged from the hospital 9,837
or the treatment has not been completed, if the submitted claim 9,838
covers services actually rendered and charges actually incurred 9,839
over at least a thirty-day period. 9,840
(D)(1) Nothwithstanding NOTWITHSTANDING section 1742.10 or 9,842
division (I)(2) of section 3923.04 of the Revised Code, a 9,843
reimbursement contract entered into or renewed on or after the 9,844
effective date of this section JUNE 29, 1988, between a 9,845
third-party payer and a hospital shall provide that reimbursement 9,846
for any service provided by a hospital pursuant to a 9,847
reimbursement contract and covered under a benefits contract 9,848
shall be made directly to the hospital. 9,849
(2) If the third-party payer and the hospital have not 9,851
entered into a contract regarding the provision and reimbursement 9,852
for covered services, the third-party payer shall accept and 9,853
honor a completed and validly executed assignment of benefits 9,854
with a hospital by a beneficiary, except when the third-party 9,855
payer has notified the hospital in writing of the conditions 9,856
under which the third-party payer will not accept and honor an 9,857
assignment of benefits. Such notice shall be made annually. 9,858
(3) A third-party payer may not refuse to accept and honor 9,860
a validly executed assignment of benefits with a hospital 9,861
pursuant to division (D)(2) of this section for medically 9,862
necessary hospital services provided on an emergency basis. 9,863
(E) A series of violations which taken together, 9,865
222
constitute a consistent pattern or a practice of violation of any 9,866
of the provisions of this section is an unfair and deceptive act 9,867
pursuant to sections 3901.19 to 3901.23 of the Revised Code and 9,868
is subject to proceedings pursuant to those sections. 9,869
Sec. 3901.40. No insurance company, medical care 9,878
corporation, health care INSURING corporation, OR self-insurance 9,880
plan, or dental care corporation authorized to do business in 9,882
this state shall include or provide in its policies or subscriber
agreements for benefit payments or reimbursement for services in 9,883
any hospital which is not certified or accredited as provided in 9,884
division (A) of section 3727.02 of the Revised Code. No hospital 9,885
located in this state shall charge any insurance company, medical 9,886
care corporation, health care INSURING corporation, dental care 9,888
corporation, federal, state, or local government agency, or
person for any services rendered unless the hospital is certified 9,890
or accredited as provided in division (A) of section 3727.02 of 9,891
the Revised Code. "Hospital" as used in this section means only 9,892
those institutions included within the definition of that term 9,893
contained in section 3727.01 of the Revised Code, and the 9,894
prohibitions in this section do not apply to facilities excluded
from that definition. 9,895
Sec. 3901.41. (A) An insurance company licensed to 9,904
transact business in this state, OR A HEALTH INSURING CORPORATION 9,906
HOLDING A CERTIFICATE OF AUTHORITY UNDER CHAPTER 1751. OF THE 9,907
REVISED CODE, shall notify the superintendent of insurance and 9,908
deliver a copy of any order or judgment to the superintendent 9,909
within thirty days of the happening in another state of any one 9,910
or more of the following:
(1) Suspension or revocation of its right to transact 9,912
business; 9,913
(2) Receipt of an order to show cause why its license 9,915
should not be suspended or revoked; 9,916
(3) Imposition of a penalty on it for any violation of the 9,918
insurance laws of such other state. 9,919
223
(B) Whenever the superintendent finds that an insurance 9,921
company OR A HEALTH INSURING CORPORATION has failed to notify the 9,922
superintendent and to deliver a copy of any order or judgment to 9,924
him THE SUPERINTENDENT pursuant to division (A) of this section, 9,925
he THE SUPERINTENDENT may order a hearing to be held not less 9,926
than thirty days after the service of notice, to require it to 9,927
show cause why an order should not be made by the superintendent, 9,928
as a result of the violation of division (A) of this section, 9,929
directing the company OR CORPORATION to suspend any transaction 9,930
of business in this state or levying a penalty against the 9,932
company in an amount not to exceed five hundred dollars. All 9,933
such hearings shall be conducted, and may be appealed, in 9,934
accordance with sections 119.01 to 119.13 CHAPTER 119. of the 9,935
Revised Code. 9,936
Sec. 3901.48. (A) The original work papers of a certified 9,945
public accountant performing an audit of an insurance company OR 9,947
HEALTH INSURING CORPORATION doing business in this state that is
required by rule or by any section of the Revised Code to file an 9,949
audited financial report with the superintendent of insurance 9,950
shall remain the property of the certified public accountant. 9,951
Any copies of these work papers voluntarily given to the 9,952
superintendent shall be the property of the superintendent. The 9,953
original work papers or any copies of them, whether in possession 9,954
of the certified public accountant or the department of 9,955
insurance, are confidential and are not a public record as 9,956
defined in section 149.43 of the Revised Code. The original work 9,957
papers and any copies of them are not subject to subpoena and 9,958
shall not be made public by the superintendent or any other 9,959
person. However, the original work papers and any copies of them 9,960
may be released by the superintendent to the insurance regulatory 9,961
authority of any other state if that authority agrees to maintain 9,962
the confidentiality of the work papers or copies and if the work 9,963
papers and copies are not public records under the laws of that 9,964
state. 9,965
224
(B) The work papers of the superintendent or of the person 9,967
appointed by him THE SUPERINTENDENT, resulting from the conduct 9,968
of an examination made pursuant to section 3901.07 of the Revised 9,970
Code, are confidential and are not a public record as defined in 9,971
section 149.43 of the Revised Code. The original work papers and 9,972
any copies of them are not subject to subpoena and shall not be 9,973
made public by the superintendent or any other person. However, 9,974
the original work papers and any copies of them may be released 9,975
by the superintendent to the insurance regulatory authority of 9,976
any other state if that authority agrees to maintain the 9,977
confidentiality of the work papers or copies and if the work 9,978
papers and copies are not public records under the laws of that 9,979
state. 9,980
(C) The work papers of the superintendent or of any person 9,982
appointed by the superintendent, resulting from the conduct of a 9,983
performance regulation examination made pursuant to authority 9,984
granted under section 3901.011 of the Revised Code, are 9,985
confidential and are not a public record as defined in section 9,986
149.43 of the Revised Code. The original work papers and any 9,987
copies of them are not subject to subpoena and shall not be made 9,988
public by the superintendent or any other person. However, the 9,989
original work papers and any copies of them may be released by 9,990
the superintendent to the insurance regulatory authority of any 9,991
other state if that authority agrees to maintain the 9,992
confidentiality of the work papers or copies and if the work 9,993
papers and copies are not public records under the laws of that 9,994
state.
Sec. 3901.72. Any person may advance to a domestic 10,004
insurance company or a health maintenance organization INSURING 10,005
CORPORATION any sum of money necessary for the purpose of the 10,007
insurance company's or health maintenance organization's INSURING 10,008
CORPORATION'S business, or to enable the insurance company or 10,010
health maintenance organization INSURING CORPORATION to comply 10,011
with any law, or as a cash guarantee fund. Such money, and 10,012
225
interest agreed upon, not exceeding ten per cent per annum or the 10,013
total of four hundred basis points plus the rate on United States 10,014
treasury notes or bonds closest in maturity to the final 10,015
repayment date of the money so advanced, whichever is greater, 10,016
shall not be a liability or claim against the insurance company 10,017
or health maintenance organization INSURING CORPORATION, or any 10,018
of its assets, except as provided in this section, and shall be 10,020
repaid only out of the surplus earnings of such insurance company 10,021
or health maintenance organization INSURING CORPORATION. Except 10,022
as ordered by the superintendent of insurance, no part of the 10,024
principal or interest thereof shall be repaid until the surplus 10,025
of the insurance company or health maintenance organization 10,026
INSURING CORPORATION remaining after such repayment is equal in 10,027
amount to the principal of the money so advanced. Such 10,028
advancement and repayment shall be subject to the approval of the 10,029
superintendent, provided that this section shall not affect the 10,030
power to borrow money which any such insurance company or health 10,031
maintenance organization INSURING CORPORATION possesses under 10,032
other laws. No commission or promotion expenses shall be paid by 10,034
the insurance company or health maintenance organization INSURING 10,035
CORPORATION, in connection with the advance of any such money to 10,037
the insurance company or health maintenance organization INSURING 10,038
CORPORATION, and the amount of any such unpaid advance shall be 10,040
reported in each annual statement.
Sec. 3902.01. (A) The purpose of sections 3902.01 to 10,049
3902.08 of the Revised Code is to establish minimum standards for 10,050
language used in policies and certificates of life insurance and 10,051
annuities, credit life insurance and credit disability insurance, 10,052
and sickness and accident insurance, and subscriber POLICIES OR 10,053
certificates of medical care corporations, health care INSURING 10,054
corporations, dental care corporations, and health maintenance 10,055
organizations, delivered or issued for deliver DELIVERY in this 10,057
state, to facilitate ease of reading by insureds and subscribers. 10,059
(B) Sections 3902.01 to 3902.08 of the Revised Code are 10,061
226
not intended to increase the risk assumed by insurance companies 10,062
or other entities subject to sections 3902.01 to 3902.08 of the 10,063
Revised Code or to supersede their obligation to comply with the 10,064
substance of other applicable insurance laws. Sections 3902.01 10,065
to 3902.08 of the Revised Code are not intended to impede
flexibility and innovation in the development of policy forms or 10,066
content, or to lead to the standardization of policy forms or 10,067
content.
Sec. 3902.02. As used in sections 3902.01 to 3902.08 of 10,076
the Revised Code: 10,077
(A) "Policy" or "policy form" means any policy, contract, 10,079
plan or agreement of life insurance and annuities, credit life 10,080
insurance and credit disability insurance, and sickness and 10,081
accident insurance, and subscriber POLICIES, CONTRACTS, 10,082
certificates, AND AGREEMENTS of medical care corporations, health 10,084
care INSURING corporations, dental care corporations, and health 10,086
maintenance organizations, delivered or issued for delivery in 10,087
this state by any company subject to sections 3902.01 to 3902.08 10,088
of the Revised Code; any certificate, contract or policy issued 10,089
by a fraternal benefit society; any certificate issued pursuant 10,090
to a group insurance policy delivered or issued for delivery in 10,091
this state; and any evidence of coverage issued by a health 10,092
maintenance organization INSURING CORPORATION.
(B) "Company" or "insurer" means any entity authorized to 10,094
do the business of life insurance and annuities, sickness and 10,095
accident insurance, credit life insurance, or credit disability 10,096
insurance; a fraternal benefit society; AND a medical care 10,097
corporation; a health care INSURING corporation; a dental care 10,099
corporation; and a health maintenance organization. 10,100
Sec. 3902.11. As used in sections 3902.11 to 3902.14 of 10,109
the Revised Code: 10,110
(A) "Beneficiary" has the same meaning as in division 10,112
(A)(1) of section 3901.38 of the Revised Code. 10,113
(B) "Plan of health coverage" means any of the following 10,115
227
if the policy, contract, or agreement contains a coordination of 10,116
benefits provision: 10,117
(1) An individual or group sickness and accident insurance 10,119
policy or an individual or group contract of a health maintenance 10,120
organization, which policy or contract provides for hospital, 10,121
dental, surgical, or medical services; 10,122
(2) Any individual or group contract that provides dental 10,124
benefits OF A HEALTH INSURING CORPORATION, WHICH CONTRACT 10,125
PROVIDES FOR HOSPITAL, DENTAL, SURGICAL, OR MEDICAL SERVICES; 10,126
(3) Any other individual or group policy or agreement 10,128
under which a third-party payer provides for hospital, dental, 10,129
surgical, or medical services; 10,130
(4) An individual or group contract of a health care 10,132
corporation. 10,133
(C) "Provider" has the same meaning as in division (A)(6) 10,135
of section 3901.38 of the Revised Code. 10,136
(D) "Third-party payer" has the same meaning as in 10,138
division (A)(8) of section 3901.38 of the Revised Code, and 10,139
includes any health care corporation. 10,140
Sec. 3902.13. (A) A plan of health coverage determines 10,149
its order of benefits using the first of the following that 10,150
applies: 10,151
(1) A plan that does not coordinate with other plans is 10,153
always the primary plan. 10,154
(2) The benefits of the plan that covers a person as an 10,156
employee, member, insured, or subscriber, other than a dependent, 10,157
is the primary plan. The plan that covers the person as a 10,158
dependent is the secondary plan. 10,159
(3) When more than one plan covers the same child as a 10,161
dependent of different parents who are not divorced or separated, 10,162
the primary plan is the plan of the parent whose birthday falls 10,163
earlier in the year. The secondary plan is the plan of the 10,164
parent whose birthday falls later in the year. If both parents 10,165
have the same birthday, the benefits of the plan that covered the 10,166
228
parent the longer is the primary plan. The plan that covered the 10,167
parent the shorter time is the secondary plan. If the other 10,168
plan's provision for coordination of benefits does not include 10,169
the rule contained in this division because it is not subject to 10,170
regulation under this division, but instead has a rule based on 10,171
the gender of the parent, and if, as a result, the plans do not 10,172
agree on the order of benefits, the rule of the other plan will 10,173
determine the order of benefits. 10,174
(4)(a) Except as provided in division (A)(4)(b) of this 10,176
section, if more than one plan covers a person as a dependent 10,177
child of divorced or separated parents, benefits for the child 10,178
are determined in the following order: 10,179
(i) The plan of the parent who is the residential parent 10,181
and legal custodian of the child; 10,182
(ii) The plan of the spouse of the parent who is the 10,184
residential parent and legal custodian of the child; 10,185
(iii) The plan of the parent who is not the residential 10,187
parent and legal custodian of the child. 10,188
(b) If the specific terms of a court decree state that one 10,190
parent is responsible for the health care expenses of the child, 10,191
the plan of that parent is the primary plan. A parent 10,192
responsible for the health care pursuant to a court decree must 10,193
notify the insurer or health maintenance organization INSURING 10,194
CORPORATION of the terms of the decree. 10,196
(5) The primary plan is the plan that covers a person as 10,198
an employee who is neither laid off or retired, or that 10,199
employee's dependent. The secondary plan is the plan that covers 10,200
that person as a laid-off or retired employee, or that employee's 10,201
dependent. 10,202
(6) If none of the rules in divisions (A)(1), (2), (3), 10,204
(4), and (5) of this section determines the order of benefits, 10,205
the primary plan is the plan that covered an employee, member, 10,206
insured, or subscriber longer. The secondary plan is the plan 10,207
that covered that person the shorter time. 10,208
229
(B) When a plan of health coverage is determined to be a 10,210
secondary plan it acts to provide benefits in excess of those 10,211
provided by the primary plan. 10,212
(C) The secondary plan shall not be required to make 10,214
payment in an amount which exceeds the amount it would have paid 10,215
if it were the primary plan, but in no event, when combined with 10,216
the amount paid by the primary plan, shall payments by the 10,217
secondary plan exceed one hundred per cent of expenses allowable 10,218
under the provisions of the applicable policies and contracts. 10,219
(D) A third-party payer may require a beneficiary to file 10,221
a claim with the primary plan before it determines the amount of 10,222
its payment obligation, if any, with regard to that claim. 10,223
(E) Nothing in this section shall be construed to require 10,225
a plan to make a payment until it determines whether it is the 10,226
primary plan or the secondary plan and what benefits are payable 10,227
under the primary plan. 10,228
(F) A plan may obtain any facts and information necessary 10,230
to apply the provisions of this section, or supply this 10,231
information to any other third-party payer or provider, or any 10,232
agent of such third-party payer or provider, without the consent 10,233
of the beneficiary. Each person claiming benefits under the plan 10,234
shall provide any information necessary to apply the provisions 10,235
of this section. 10,236
(G) If the amount of payments made by any plan is more 10,238
than should have been paid, the plan may recover the excess from 10,239
whichever party received the excess payment. 10,240
(H) No third-party payer shall administer a plan of health 10,242
coverage delivered, issued for delivery, or renewed on or after 10,243
June 29, 1988, unless such plan complies with this section. 10,244
(I)(1) A third-party payer that is subject to this section 10,246
and has reason to believe payment has been made by another 10,247
third-party payer for the same service may request from that 10,248
third-party payer, and shall be provided by the third-party 10,249
payer, such data as necessary to determine whether duplicate 10,250
230
payment has been made. 10,251
(2) A third-party payer that meets the criteria of a 10,253
secondary payer in accordance with this section may seek 10,254
repayment of any duplicate payment that may have been made from 10,255
the person to whom it made payment. If the person who received 10,256
the duplicate payment is a provider, absent a finding of a court 10,257
of competent jurisdiction that the provider has engaged in civil 10,258
or criminal fraudulent activities, the request for the return of 10,259
any duplicate payment shall be made within three years after the 10,260
close of the provider's fiscal year in which the duplicate 10,261
payment has been made. 10,262
(J) Nothing in this section shall be construed to affect 10,264
the prohibition of section 3923.37 of the Revised Code. 10,265
(K)(1) No third-party payer shall knowingly fail to comply 10,267
with the order of benefits as set forth in division (A) of this 10,268
section. 10,269
(2) No primary plan shall direct or encourage an insured 10,271
to use the benefits of a secondary plan that results in a 10,272
reduction of payment by such primary plan. 10,273
(L) Whoever violates division (K) of this section is 10,275
deemed to have engaged in an unfair and deceptive insurance act 10,276
or practice under sections 3901.19 to 3901.26 of the Revised 10,277
Code, and is subject to proceedings pursuant to those sections. 10,278
Sec. 3904.01. As used in sections 3904.01 to 3904.22 of 10,287
the Revised Code: 10,288
(A)(1) "Adverse underwriting decision" means any of the 10,290
following actions with respect to insurance transactions 10,291
involving life, health, or disability insurance coverage that is 10,292
individually underwritten: 10,293
(a) A declination of insurance coverage; 10,295
(b) A termination of insurance coverage; 10,297
(c) Failure of an agent to apply for insurance coverage 10,299
with a specific insurance institution that the agent represents 10,300
and that is requested by an applicant; 10,301
231
(d) An offer to insure at higher than standard rates. 10,303
(2) Notwithstanding division (A)(1) of this section, none 10,305
of the following actions is an adverse underwriting decision, but 10,306
the insurance institution or agent responsible for their 10,307
occurrence shall nevertheless provide the applicant or 10,308
policyholder with the specific reason or reasons for their 10,309
occurrence: 10,310
(a) The termination of an individual policy form on a 10,312
class or statewide basis; 10,313
(b) A declination of insurance coverage solely because the 10,315
coverage is not available on a class or statewide basis; 10,316
(c) The rescission of a policy. 10,318
(B) "Affiliate" or "affiliated" means a person that 10,320
directly, or indirectly through one or more intermediaries, 10,321
controls, is controlled by, or is under common control with 10,322
another person. 10,323
(C) "Agent" means a person licensed under Chapter 3905. of 10,325
the Revised Code to negotiate or solicit applications for a 10,326
policy or contract of life, health, or disability insurance. 10,327
(D) "Applicant" means any person that seeks to contract 10,329
for life, health, or disability insurance coverage other than a 10,330
person seeking group insurance that is not individually 10,331
underwritten. 10,332
(E) "Consumer report" means any written, oral, or other 10,334
communication of information bearing on a natural person's credit 10,335
worthiness, credit standing, credit capacity, character, general 10,336
reputation, personal characteristics, or mode of living that is 10,337
used or expected to be used in connection with a life, health, or 10,338
disability insurance transaction. 10,339
(F) "Consumer reporting agency" means any person that does 10,341
all of the following: 10,342
(1) Regularly engages, in whole or in part, in the 10,344
practice of assembling or preparing consumer reports for a 10,345
monetary fee; 10,346
232
(2) Obtains information primarily from sources other than 10,348
insurance institutions; 10,349
(3) Furnishes consumer reports to other persons. 10,351
(G) "Control," including the terms "controlled by" or 10,353
"under common control with," means the possession, direct or 10,354
indirect, of the power to direct or cause the direction of the 10,355
management and policies of a person, whether through the 10,356
ownership of voting securities, by contract other than a 10,357
commercial contract for goods or nonmanagement services, or 10,358
otherwise, unless the power is the result of an official position 10,359
with or corporate office held by the person. 10,360
(H) "Declination of insurance coverage" means a denial, in 10,362
whole or in part, by an insurance institution or agent of 10,363
requested insurance coverage. 10,364
(I) "Individual" means any natural person who in 10,366
connection with life, health, or disability insurance: 10,367
(1) Is a past, present, or proposed principal insured or 10,369
certificate holder; 10,370
(2) Is a past, present, or proposed policy owner; 10,372
(3) Is a past or present applicant; 10,374
(4) Is a past or present claimant; 10,376
(5) Derived, derives, or is proposed to derive insurance 10,378
coverage under an insurance policy or certificate subject to 10,379
sections 3904.01 to 3904.22 of the Revised Code. 10,380
(J) "Institutional source" means any person or 10,382
governmental entity that provides information about an individual 10,383
to an agent, insurance institution, or insurance support 10,384
organization, other than any of the following: 10,385
(1) An agent; 10,387
(2) The individual who is the subject of the information; 10,389
(3) A natural person acting in a personal capacity rather 10,391
than in a business or professional capacity. 10,392
(K) "Insurance institution" means any corporation, 10,394
association, partnership, fraternal benefit society, or other 10,395
233
person engaged in the business of life, health, or disability 10,396
insurance, including health maintenance organizations, prepaid 10,397
dental plan organizations, medical care corporations, health care 10,398
INSURING corporations, and dental care corporations. "Insurance 10,400
institution" does not include agents or insurance support 10,401
organizations. 10,402
(L)(1) "Insurance support organization" means any person 10,404
that regularly engages, in whole or in part, in the practice of 10,405
assembling or collecting information about natural persons for 10,406
the primary purpose of providing the information to an insurance 10,407
institution or agent for insurance transactions, including both 10,408
of the following: 10,409
(a) The furnishing of consumer reports or investigative 10,411
consumer reports to an insurance institution or agent for use in 10,412
connection with an insurance transaction; 10,413
(b) The collection of personal information from insurance 10,415
institutions, agents, or other insurance support organizations 10,416
for the purpose of detecting or preventing fraud, material 10,417
misrepresentation, or material nondisclosure in connection with 10,418
insurance underwriting or insurance claim activity. 10,419
(2) Notwithstanding division (L)(1) of this section, 10,421
agents, government institutions, insurance institutions, medical 10,422
care institutions, and medical professionals are not "insurance 10,423
support organizations" for purposes of sections 3904.01 to 10,424
3904.22 of the Revised Code. 10,425
(M) "Insurance transaction" means any transaction 10,427
involving life, health, or disability insurance primarily for 10,428
personal, family, or household needs rather than business or 10,429
professional needs and entailing either the determination of an 10,430
individual's eligibility for a life, health, or disability 10,431
insurance coverage, benefit, or payment, or the servicing of a 10,432
life, health, or disability insurance application, policy, 10,433
contract, or certificate. 10,434
(N) "Investigative consumer report" means a consumer 10,436
234
report or portion thereof in which information about a natural 10,437
person's character, general reputation, personal characteristics, 10,438
or mode of living is obtained through personal interviews with 10,439
the person's neighbors, friends, associates, acquaintances, or 10,440
others who may have knowledge concerning such items of 10,441
information. 10,442
(O) "Medical care institution" means any facility or 10,444
institution that is licensed to provide health care services to 10,445
natural persons, including home-health agencies, hospitals, 10,446
medical clinics, public health agencies, rehabilitation agencies, 10,447
and skilled nursing facilities. 10,448
(P) "Medical professional" means any person licensed or 10,450
certified to provide health care services to natural persons, 10,451
including a chiropractor, clinical dietician, clinical 10,452
psychologist, dentist, nurse, occupational therapist, 10,453
optometrist, pharmacist, physical therapist, physician, 10,454
podiatrist, psychiatric social worker, and speech therapist. 10,455
(Q) "Medical record information" means personal 10,457
information that relates to an individual's physical or mental 10,458
condition, medical history, or medical treatment and that is 10,459
obtained from a medical professional or medical care institution, 10,460
from the individual, or from the individual's spouse, parent, or 10,461
legal guardian. 10,462
(R) "Personal information" means any individually 10,464
identifiable information gathered in connection with an insurance 10,465
transaction from which judgments can be made about an 10,466
individual's character, habits, avocations, finances, occupation, 10,467
general reputation, credit, health, or any other personal 10,468
characteristics. "Personal information" includes an individual's 10,469
name and address and medical record information but does not 10,470
include privileged information. 10,471
(S) "Policyholder" means any person that is a present 10,473
owner of individual life, health, or disability insurance, or a 10,474
present certificate holder under group life, health, or 10,475
235
disability insurance that is individually underwritten. 10,476
(T) "Pretext interview" means an interview whereby a 10,478
person, in an attempt to obtain information about a natural 10,479
person, performs one or more of the following acts: 10,480
(1) Pretends to be someone he THE INTERVIEWER is not; 10,482
(2) Pretends to represent a person he THE INTERVIEWER is 10,484
not in fact representing; 10,486
(3) Misrepresents the true purpose of the interview; 10,488
(4) Refuses to identify himself SELF upon request. 10,490
(U) "Privileged information" means any individually 10,492
identifiable information that relates to a claim for life, 10,493
health, or disability insurance benefits or a civil or criminal 10,494
proceeding involving an individual, and that is collected in 10,495
connection with, or in reasonable anticipation of, a claim for 10,496
life, health, or disability insurance benefits or civil or 10,497
criminal proceeding involving an individual. However, 10,498
information otherwise meeting the requirements of this division 10,499
shall nevertheless be considered personal information if it is 10,500
disclosed in violation of section 3904.13 of the Revised Code. 10,501
(V) "Termination of insurance coverage" or "termination of 10,503
an insurance policy" means either a cancellation or nonrenewal of 10,504
a life, health, or disability insurance policy, in whole or in 10,505
part, for any reason other than the failure to pay a premium as 10,506
required by the policy. 10,507
(W) "Unauthorized insurer" means an insurance institution 10,509
that has not been granted a certificate of authority by the 10,510
superintendent of insurance to transact the business of life, 10,511
health, or disability insurance in this state. 10,512
Sec. 3905.71. As used in sections 3905.71 to 3905.79 of 10,521
the Revised Code: 10,522
(A) "Actuary" means a person who is a member in good 10,524
standing of the American academy of actuaries. 10,525
(B) "Insurer" means any person licensed to do business in 10,527
this state under Chapter 1736., 1737., 1738., 1740., 1742., 1751. 10,529
236
or 1761. of the Revised Code or Title XXXIX of the Revised Code. 10,530
(C) "Laws of this state relating to insurance" has the 10,532
same meaning as in section 3901.04 of the Revised Code. 10,533
(D)(1) "Managing general agent" means any person that does 10,535
all of the following: 10,536
(a) Manages all or part of the insurance business of an 10,538
insurer, including the management of a separate division, 10,539
department, or underwriting office, or negotiates and binds 10,540
ceding reinsurance contracts on behalf of an insurer; 10,541
(b) Acts as an agent for the insurer, whether known as a 10,543
managing general agent, manager, or other similar term; 10,544
(c) With or without the authority of the insurer, 10,546
separately or together with affiliates, does both of the 10,547
following: 10,548
(i) Produces, directly or indirectly, and underwrites an 10,550
amount of gross direct written premium equal to or more than five 10,551
per cent of the policyholder surplus of the insurer as reported 10,552
in the last annual statement of the insurer in any one year; 10,553
(ii) Adjusts or pays claims, or negotiates reinsurance on 10,555
behalf of the insurer. 10,556
(2) "Managing general agent" does not include any of the 10,558
following: 10,559
(a) An employee of the insurer; 10,561
(b) A United States manager of the United States branch of 10,563
an alien insurer; 10,564
(c) An underwriting manager that, pursuant to contract, 10,566
manages all or a part of the insurance operations of the insurer, 10,567
is under common control with the insurer, subject to sections 10,568
3901.32 to 3901.37 of the Revised Code, and whose compensation is 10,569
not based on the volume of premiums written; 10,570
(d) The attorney authorized by and acting for the 10,572
subscribers of a reciprocal insurer or inter-insurance exchange 10,573
under powers of attorney; 10,574
(e) An administrator licensed pursuant to Chapter 3959. of 10,576
237
the Revised Code whose activities on behalf of an insurer are 10,577
limited to administrative services involving underwriting or the 10,578
payment of claims, and do not include the management of all or 10,579
part of the insurance business of the insurer. 10,580
(E) "Underwrite" or "underwriting" means the authority to 10,582
accept or reject risk on behalf of an insurer. 10,583
Sec. 3923.123. (A) As used in this section: 10,592
(1) "Association" means a voluntary unincorporated 10,594
association of insurers formed for the sole purpose of enabling 10,595
cooperative action to provide health coverage in accordance with 10,596
this section. 10,597
(2) "Insurer" includes any insurance company authorized to 10,599
do the business of sickness and accident insurance in this state, 10,600
medical care corporation organized under Chapter 1737. of the 10,601
Revised Code, AND ANY health care INSURING corporation organized 10,603
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 10,604
the Revised Code, dental care corporation organized under Chapter 10,606
1740. of the Revised Code, or hospital maintenance organization 10,607
organized under Chapter 1742. of the Revised Code.
(3) "Insured" means a person covered under a group policy 10,609
or contract issued pursuant to this section. 10,610
(4) "Qualified unemployed person" means one who became 10,612
unemployed while a resident of this state from employment or 10,613
self-employment and has since been continuously unemployed or is 10,614
employed only so that he THE PERSON does not have, or have a 10,615
right to purchase, group health coverage. An individual who is, 10,617
or who becomes, covered by medicare is not a qualified unemployed 10,618
person. A person eligible for coverage under this section, who 10,619
is also eligible for continuation of coverage under section 10,620
1737.30, 1738.26, 1742.34, 1751.53 or 3923.38 of the Revised 10,621
Code, may elect either coverage, but not both. A person who 10,623
elects continuation of coverage under any EITHER of such sections 10,624
may, upon the termination of the continuation of coverage, elect 10,626
any coverage available under this section. 10,627
238
(B) Any insurer may join with one or more other insurers, 10,629
in an association, to offer, sell, and issue to a policyholder or 10,630
subscriber selected by the association a policy or contract of 10,631
group health coverage, covering residents of this state who are 10,632
qualified unemployed persons and the spouses or dependents of 10,633
such residents. The coverage shall be offered, issued, and 10,634
administered in the name of the association. Membership in the 10,635
association shall be open to any insurer and each insurer which 10,636
participates shall be liable for a specified percentage of the 10,637
risks. The policy or contract may be executed on behalf of the 10,638
association by a duly authorized person. 10,639
(C) The persons eligible for coverage under the policy or 10,641
contract shall be all residents of this state who are qualified 10,642
unemployed persons and their spouses and dependents, subject to 10,643
reasonable underwriting restrictions to be set forth in the plan 10,644
of the association. The policy or contract may provide basic 10,645
hospital and surgical coverage, basic medical coverage, major 10,646
medical coverage, and any combination of these; provided that it 10,647
shall not be required as a condition for obtaining major medical 10,648
coverage that any basic coverage be taken. 10,649
(D) The association shall file with the superintendent of 10,651
insurance any policy, contract, certificate, or other evidence of 10,652
coverage, application, or other forms pertaining to such 10,653
insurance together with the premium rates to be charged therefor. 10,654
The superintendent may approve, disapprove, and withdraw approval 10,655
of the forms in accordance with section 3923.02 of the Revised 10,656
Code, or the premium rates if by reasonable assumptions such 10,657
rates are excessive in relation to the benefits provided. In 10,658
determining whether such rates by reasonable assumptions are 10,659
excessive in relation to the benefits provided, the 10,660
superintendent shall give due consideration to past and 10,661
prospective claim experience, within and outside this state, and 10,662
to fluctuations in such claim experience, to a reasonable risk 10,663
charge, to contribution to surplus and contingency funds, to past 10,664
239
and prospective expenses, both within and outside this state, and 10,665
to all other relevant factors within and outside this state, 10,666
including any differing operating methods of the insurers joining 10,667
in the issuance of the policy or contract. In reviewing the 10,668
forms the superintendent shall not be bound by the requirements 10,669
of sections 3923.04 to 3923.07 of the Revised Code with respect 10,670
to standard provisions to be included in sickness and accident 10,671
policies or forms. 10,672
(E) The association may enroll eligible persons for 10,674
coverage under the policy or contract through any person licensed 10,675
by, or authorized under the law of, this state to sell the 10,676
policies or contracts, or to enroll persons in the health plans, 10,677
of any of the insurers participating in the association. 10,678
(F) The association shall file annually with the 10,680
superintendent on such date and in such form as he THE 10,681
SUPERINTENDENT may prescribe, a financial summary of its 10,683
operations.
(G) The association may sue and be sued in its associate 10,685
name and for such purposes only shall be treated as a domestic 10,686
corporation. Service of process against such association made 10,687
upon a managing agent, any member thereof, or any agent 10,688
authorized by appointment to receive service of process, shall 10,689
have the same force and effect as if such service had been made 10,690
upon all members of the association. 10,691
(H) Under any policy issued as provided in this section, 10,693
the policyholder, or such person as the policyholder shall 10,694
designate, shall alone be a member of each domestic mutual 10,695
insurance company joining in the issue of the policy and shall be 10,696
entitled to one vote by virtue of such policy at the meetings of 10,697
each such mutual insurance company. Notice of the annual 10,698
meetings of each such mutual insurance company may be given by 10,699
written notice to the policyholder or as otherwise prescribed in 10,700
said policy. 10,701
Sec. 3923.30. Every person, the state and any of its 10,710
240
instrumentalities, any county, township, school district, or 10,711
other political subdivisions and any of its instrumentalities, 10,712
and any municipal corporation and any of its instrumentalities, 10,713
which provides payment for health care benefits for any of its 10,714
employees resident in this state, which benefits are not provided 10,715
by contract with an insurer qualified to provide sickness and 10,716
accident insurance, or a health maintenance organization INSURING 10,717
CORPORATION, shall include the following benefits in its plan of 10,719
health care benefits commencing on or after January 1, 1979: 10,720
(A) If such plan of health care benefits provides payment 10,722
for the treatment of mental or nervous disorders, then such plan 10,723
shall provide benefits for services on an outpatient basis for 10,724
each eligible employee and dependent for mental or emotional 10,725
disorders, or for evaluations, that are at least equal to the 10,726
following: 10,727
(1) Payments not less than five hundred fifty dollars in a 10,729
twelve-month period, for services legally performed by or under 10,730
the clinical supervision of a licensed physician or a licensed 10,731
psychologist, whether performed in an office, in a hospital, or 10,732
in a community mental health facility so long as the hospital or 10,733
community mental health facility is approved by the joint 10,734
commission on accreditation of hospitals or certified by the 10,735
department of mental health as being in compliance with standards 10,736
established under division (I) of section 5119.01 of the Revised 10,737
Code; 10,738
(2) Such benefit shall be subject to reasonable 10,740
limitations, and may be subject to reasonable deductibles and 10,741
co-insurance costs. 10,742
(3) In order to qualify for participation under this 10,744
division, every facility specified in this division shall have in 10,745
effect a plan for utilization review and a plan for peer review 10,746
and every person specified in this division shall have in effect 10,747
a plan for peer review. Such plans shall have the purpose of 10,748
ensuring high quality patient care and effective and efficient 10,749
241
utilization of available health facilities and services. 10,750
(4) Such payment for benefits shall not be greater than 10,752
usual, customary, and reasonable. 10,753
(5) For purposes of this division, "community mental 10,755
health facility" means a facility as defined in section 3923.28 10,756
of the Revised Code. 10,757
(6)(a) Services performed under the clinical supervision 10,759
of a licensed physician or licensed psychologist, in order to be 10,760
reimbursable under the coverage required in division (A) of this 10,761
section, shall meet both of the following requirements: 10,762
(i) The services shall be performed in accordance with a 10,764
treatment plan that describes the expected duration, frequency, 10,765
and type of services to be performed; 10,766
(ii) The plan shall be reviewed and approved by a licensed 10,768
physician or licensed psychologist every three months. 10,769
(b) Payment of benefits for services reimbursable under 10,771
division (A)(6)(a) of the section shall not be restricted to 10,772
services described in the treatment plan or conditioned upon 10,773
standards of a licensed physician or licensed psychologist, which 10,774
at least equal the requirements of division (A)(6)(a) of this 10,775
section. 10,776
(B) Payment for benefits for alcoholism treatment for 10,778
outpatient, inpatient, and intermediate primary care for each 10,779
eligible employee and dependent that are at least equal to the 10,780
following: 10,781
(1) Payments not less than five hundred fifty dollars in a 10,783
twelve-month period for services legally performed by or under 10,784
the clinical supervision of a licensed physician or licensed 10,785
psychologist, whether performed in an office, or in a hospital or 10,786
a community mental health facility or alcoholism treatment 10,787
facility so long as the hospital, community mental health 10,788
facility, or alcoholism treatment facility is approved by the 10,789
joint commission on accreditation of hospitals or certified by 10,790
the department of health; 10,791
242
(2) The benefits provided under this division shall be 10,793
subject to reasonable limitations and may be subject to 10,794
reasonable deductibles and co-insurance costs. 10,795
(3) A licensed physician or licensed psychologist shall 10,797
every three months certify a patient's need for continued 10,798
services performed by such facilities. 10,799
(4) In order to qualify for participation under this 10,801
division, every facility specified in this division shall have in 10,802
effect a plan for utilization review and a plan for peer review 10,803
and every person specified in this division shall have in effect 10,804
a plan for peer review. Such plans shall have the purpose of 10,805
ensuring high quality patient care and efficient utilization of 10,806
available health facilities and services. Such person or 10,807
facilities shall also have in effect a program of rehabilitation 10,808
or a program of rehabilitation and detoxification. 10,809
(5) Nothing in this section shall be construed to require 10,811
reimbursement for benefits which is greater than usual, 10,812
customary, and reasonable. 10,813
Sec. 3923.301. Every person, the state and any of its 10,822
instrumentalities, any county, township, school district, or 10,823
other political subdivision and any of its instrumentalities, and 10,824
any municipal corporation and any of its instrumentalities that 10,826
provides payment for health care benefits for any of its
employees resident in this state, which benefits are not provided 10,827
by contract with an insurer qualified to provide sickness and 10,828
accident insurance or a health maintenance organization INSURING 10,829
CORPORATION, and THAT includes reimbursement for any service that 10,831
may be legally performed by a certified nurse-midwife who is 10,832
authorized under section 4723.42 of the Revised Code to practice 10,834
nurse-midwifery, shall not deny reimbursement to a certified 10,835
nurse-midwife performing the service if the service is performed 10,837
in collaboration with a licensed physician. The collaborating 10,840
physician shall be identified on the claim form.
The cost of collaboration with a certified nurse-midwife by 10,843
243
a licensed physician as required under section 4723.43 of the 10,844
Revised Code is a reimbursable expense. 10,845
The division of any reimbursement payment for services 10,847
performed by a certified nurse-midwife between the nurse-midwife 10,848
and the nurse-midwife's collaborating physician shall be 10,849
determined and mutually agreed upon by the certified 10,851
nurse-midwife and the physician. The division of fees shall not 10,852
be considered a violation of division (B)(17) of section 4731.22 10,853
of the Revised Code. In no case shall the total fees charged 10,854
exceed the fee the physician would have charged had the physician 10,855
provided the entire service.
Sec. 3923.33. As used in section 3923.33 and sections 10,865
3923.331 to 3923.339 of the Revised Code: 10,866
(A) "Applicant" means: 10,868
(1) In the case of an individual medicare supplement 10,870
policy, the person who seeks to contract for insurance benefits; 10,871
and 10,872
(2) In the case of a group medicare supplement policy, the 10,874
proposed certificate holder. 10,875
(B) "Certificate" means, for purposes of section 3923.33 10,877
and sections 3923.331 to 3923.339 of the Revised Code, any 10,878
certificate delivered or issued for delivery in this state under 10,879
a group medicare supplement policy. 10,880
(C) "Certificate form" means the form on which the 10,882
certificate is delivered or issued for delivery by the issuer. 10,883
(D) "Direct response insurance policy" means a medicare 10,885
supplement policy or certificate marketed without the direct 10,886
involvement of an insurance agent. 10,887
(E) "Issuer" includes insurance companies, fraternal 10,889
benefit societies, health maintenance organizations INSURING 10,890
CORPORATIONS, and any other entities delivering or issuing for 10,892
delivery in this state medicare supplement policies or 10,893
certificates.
(F) "Medicare" means the "Health Insurance for the Aged 10,895
244
Act," Title XVIII of the Social Security Amendments of 1965, 79 10,896
Stat. 291, 42 U.S.C.A. 1395, as then constituted or later 10,897
amended. 10,898
(G) "Medicare supplement policy" means a group or 10,900
individual policy of sickness and accident insurance or a 10,901
subscriber contract of health maintenance organizations INSURING 10,902
CORPORATIONS or any other issuers, other than a policy issued 10,904
pursuant to a contract under section 1876 of the "Social Security 10,905
Act," 49 Stat. 620 (1935), 42 U.S.C.A., 1395mm, as amended, or an 10,906
issued policy under any demonstration project specified in 42 10,907
U.S.C.A. 1395ss(g)(1), which is advertised, marketed, or designed 10,909
primarily as a supplement to reimbursements under medicare for 10,910
the hospital, medical, or surgical expenses of persons eligible 10,911
for medicare.
(H) "Policy form" means the form on which the policy is 10,913
delivered or issued for delivery by the issuer. 10,914
Sec. 3923.333. Medicare supplement policies shall return 10,923
to policyholders benefits that are reasonable in relation to the 10,924
premium charged. The superintendent of insurance shall issue 10,925
reasonable rules to establish minimum standards for loss ratios 10,926
of medicare supplement policies on the basis of incurred claims 10,927
experience, or incurred health care expenses where coverage is
provided by a health maintenance organization INSURING 10,928
CORPORATION on a service rather than reimbursement basis, and 10,930
earned premiums in accordance with accepted actuarial principles 10,931
and practices.
Sec. 3923.38. (A) As used in this section: 10,940
(1) "Group policy" includes any group sickness and 10,942
accident policy or contract delivered, issued for delivery, or 10,943
renewed in this state on or after June 28, 1984, and any private 10,944
or public employer self-insurance plan or other plan that 10,945
provides, or provides payment for, health care benefits for 10,946
employees resident in this state other than through an insurer, 10,947
OR health care INSURING corporation, or health maintenance 10,949
245
organization, to which both of the following apply: 10,951
(a) The policy insures employees for hospital, surgical, 10,953
or major medical insurance on an expense incurred or service 10,954
basis, other than for specified diseases or for accidental 10,955
injuries only. 10,956
(b) The policy is in effect and covers an eligible 10,958
employee at the time the employee's employment is terminated. 10,959
(2) "Eligible employee" includes only an employee to whom 10,961
all of the following apply: 10,962
(a) The employee has been continuously insured under a 10,964
group policy or under the policy and any prior similar group 10,965
coverage replaced by the policy, during the entire three-month 10,966
period preceding the termination of the employee's employment. 10,967
(b) The employee is entitled, at the time of the 10,969
termination of his THE EMPLOYEE'S employment, to unemployment 10,970
compensation benefits under Chapter 4141. of the Revised Code. 10,972
(c) The employee is not, and does not become, covered by 10,974
or eligible for coverage by medicare under Title XVIII of the 10,975
Social Security Act, as amended. 10,976
(d) The employee is not, and does not become, covered by 10,978
or eligible for coverage by any other insured or uninsured 10,979
arrangement that provides hospital, surgical, or medical coverage 10,980
for individuals in a group and under which the person was not 10,981
covered immediately prior to such termination. A person eligible 10,982
for continuation of coverage under this section, who is also 10,983
eligible for coverage under section 3923.123 of the Revised Code, 10,984
may elect either coverage, but not both. A person who elects 10,985
continuation of coverage may elect any coverage available under 10,986
section 3923.123 of the Revised Code upon the termination of the 10,987
continuation of coverage. 10,988
(3) "Group rate" means, in the case of an employer 10,990
self-insurance or other health benefits plan, the average monthly 10,991
cost per employee, over a period of at least twelve months, of 10,992
the operation of the plan that would represent a group insurance 10,993
246
rate if the same coverage had been provided under a group 10,994
sickness and accident insurance policy. 10,995
(B) A group policy shall provide that any eligible 10,997
employee may continue the employee's hospital, surgical, and 10,998
medical insurance under the policy, for the employee and the 10,999
employee's eligible dependents, for a period of six months after 11,000
the date that the insurance coverage would otherwise terminate by 11,001
reason of the termination of his THE EMPLOYEE'S employment. Each 11,003
certificate of coverage, or other notice of coverage, issued to 11,004
employees under the policy shall include a notice of the 11,005
employee's privilege of continuation. 11,006
(C) All of the following apply to the continuation of 11,008
coverage required under division (B) of this section: 11,009
(1) Continuation need not include dental, vision care, 11,011
prescription drug benefits, or any other benefits provided under 11,012
the policy in addition to its hospital, surgical, or major 11,013
medical benefits. 11,014
(2) The employer shall notify the employee of the right of 11,016
continuation at the time the employer notifies the employee of 11,017
the termination of employment. The notice shall inform the 11,018
employee of the amount of contribution required by the employer 11,019
under division (C)(4) of this section. 11,020
(3) The employee shall file a written election of 11,022
continuation with the employer and pay the employer the first 11,023
contribution required under division (C)(4) of this section. The 11,024
request and payment must be received by the employer no later 11,025
than the earlier of any of the following dates: 11,026
(a) Thirty-one days after the date on which the employee's 11,028
coverage would otherwise terminate; 11,029
(b) Ten days after the date on which the employee's 11,031
coverage would otherwise terminate, if the employer has notified 11,032
the employee of the right of continuation prior to such date; 11,033
(c) Ten days after the employer notifies the employee of 11,035
the right of continuation, if the notice is given after the date 11,036
247
on which the employee's coverage would otherwise terminate. 11,037
(4) The employee must pay to the employer, on a monthly 11,039
basis, in advance, the amount of contribution required by the 11,040
employer. The amount required shall not exceed the group rate 11,041
for the insurance being continued under the policy on the due 11,042
date of each payment. 11,043
(5) The employee's privilege to continue coverage and the 11,045
coverage under any continuation ceases if any of the following 11,046
occurs: 11,047
(a) The employee ceases to be an eligible employee under 11,049
division (A)(2)(c) or (d) of this section; 11,050
(b) A period of six months expires after the date that the 11,052
employee's insurance under the policy would otherwise have 11,053
terminated because of the termination of employment; 11,054
(c) The employee fails to make a timely payment of a 11,056
required contribution, in which event the coverage shall cease at 11,057
the end of the coverage for which contributions were made; 11,058
(d) The policy is terminated, or the employer terminates 11,060
participation under the policy, unless the employer replaces the 11,061
coverage by similar coverage under another group policy or other 11,062
group health arrangement. 11,063
If the employer replaces the policy with similar group 11,065
health coverage, all of the following apply: 11,066
(i) The member shall be covered under the replacement 11,068
coverage, for the balance of the period that he THE MEMBER would 11,069
have remained covered under the terminated coverage if it had not 11,071
been terminated. 11,072
(ii) The minimum level of benefits under the replacement 11,074
coverage shall be the applicable level of benefits of the policy 11,075
replaced reduced by any benefits payable under the policy 11,076
replaced. 11,077
(iii) The policy replaced shall continue to provide 11,079
benefits to the extent of its accrued liabilities and extensions 11,080
of benefits as if the replacement had not occurred. 11,081
248
(D) This section does not apply to an employer's 11,083
self-insurance plan if federal law supersedes, preempts, 11,084
prohibits, or otherwise precludes its application to such plans. 11,085
Sec. 3923.382. (A) As used in this section: 11,094
(1) "Eligible person" means any person who, at the time a 11,096
reservist is called or ordered to active duty, is covered under a 11,097
group plan and is either of the following: 11,098
(a) An employee who is a reservist called or ordered to 11,100
active duty; 11,101
(b) The spouse or a dependent child of an employee 11,103
described in division (A)(1)(a) of this section. 11,104
(2) "Group plan" includes any private or public employer 11,106
self-insurance plan that satisfies all of the following: 11,107
(a) The plan is established or modified in this state on 11,109
or after the effective date of this section APRIL 17, 1991. 11,111
(b) The plan provides, or provides payment for, health 11,113
benefits for employees resident in this state other than through 11,114
an insurer, OR health maintenance organization, health care 11,116
INSURING corporation, or medical care corporation. 11,117
(c) The plan is in effect and covers an eligible person at 11,119
the time a reservist is called or ordered to active duty. 11,120
(3) "Group rate" means the average monthly cost per 11,122
employee, over a period of at least twelve months of the 11,123
operation of a group plan, that would represent a group insurance 11,124
rate if the same coverage had been provided under a group 11,125
sickness and accident insurance policy. 11,126
(4) "Reservist" means a member of a reserve component of 11,128
the armed forces of the United States. "Reservist" includes a 11,129
member of the Ohio national guard and the Ohio air national 11,130
guard. 11,131
(B) Every group plan shall provide that any eligible 11,133
person may continue the coverage under the plan for a period of 11,134
eighteen months after the date on which the coverage would 11,135
otherwise terminate because the reservist is called or ordered to 11,136
249
active duty. 11,137
(C)(1) An eligible person may extend the eighteen-month 11,139
period of continuation of coverage to a thirty-six-month period 11,140
of continuation of coverage, if any of the following occurs 11,141
during the eighteen-month period: 11,142
(a) The death of the reservist; 11,144
(b) The divorce or separation of a reservist from the 11,146
reservist's spouse; 11,147
(c) The cessation of dependency of a child pursuant to the 11,149
terms of the plan. 11,150
(2) The thirty-six-month period of continuation of 11,152
coverage is deemed to begin on the date on which the coverage 11,153
would otherwise terminate because the reservist is called or 11,154
ordered to active duty. 11,155
(3) The employer may begin the thirty-six-month period on 11,157
the date of any occurrence described in division (C)(1) of this 11,158
section. 11,159
(D) All of the following apply to any continuation of 11,161
coverage, or the extension of any continuation of coverage, 11,162
provided under division (B) or (C) of this section: 11,163
(1) The continuation of coverage shall provide the same 11,165
benefits as those provided to any similarly situated eligible 11,166
person who is covered under the same group plan and an employee 11,167
who has not been called or ordered to active duty. 11,168
(2) An employer shall notify each employee of the right of 11,170
continuation of coverage at the time of employment. At the time 11,171
the reservist is called or ordered to active duty, the employer 11,172
shall notify each eligible person of the requirements for the 11,173
continuation of coverage. 11,174
(3) Each certificate or other evidence of coverage issued 11,176
by an employer to an employee under the group plan shall include 11,177
a notice of the eligible person's right of continuation of 11,178
coverage. 11,179
(4) An eligible person shall file a written election of 11,181
250
continuation of coverage with the employer and pay the employer 11,182
the first contribution required under division (D)(5) of this 11,183
section. The written election and payment must be received by 11,184
the employer no later than thirty-one days after the date on 11,185
which the eligible person's coverage would otherwise terminate. 11,186
If the employer notifies the eligible person of the right of 11,187
continuation of coverage after the date on which the eligible 11,188
person's coverage would otherwise terminate, the written election 11,189
and payment must be received by the employer no later than 11,190
thirty-one days after the date of the notification. 11,191
(5)(a) Except as provided in division (D)(5)(b) of this 11,193
section, the eligible person shall pay to the employer, on a 11,194
monthly basis and in advance, the amount of contribution required 11,195
by the employer. The amount shall not exceed one hundred two per 11,196
cent of the group rate for the coverage being continued under the 11,197
group plan on the due date of each payment. 11,198
(b) The employer may pay a portion or all of the eligible 11,200
person's contribution. 11,201
(E) The eligible person's right to any continuation of 11,203
coverage, or the extension of any continuation of coverage, 11,204
provided under division (B) or (C) of this section ceases on the 11,205
date on which any of the following occurs: 11,206
(1) The eligible person, whether as an employee or 11,208
otherwise, enrolls in another group plan or other group health 11,209
plan or arrangement that does not contain any exclusion or 11,210
limitation with respect to any preexisting condition of that 11,211
eligible person. For purposes of division (E)(1) of this 11,212
section, a group plan or other group health plan or arrangement 11,213
does not include the civilian health and medical program of the 11,214
uniformed services as defined in Public Law 99-661, 100 Stat. 11,215
3898 (1986), 10 U.S.C.A. 1072. 11,216
(2) The period of either eighteen months provided under 11,218
division (B) of this section or thirty-six months provided under 11,219
division (C) of this section expires. 11,220
251
(3) The eligible person fails to make a timely payment of 11,222
a required contribution, in which case the coverage ceases at the 11,223
end of the period of coverage for which contributions were made. 11,224
(4) The group plan, or participation under the group plan, 11,226
is terminated, unless the employer, in accordance with division 11,227
(F) of this section, replaces the coverage with similar coverage 11,228
under another group plan or other group health plan or 11,229
arrangement. 11,230
(F) If the employer replaces the group plan with similar 11,232
coverage as described in division (E)(4) of this section, both of 11,233
the following apply: 11,234
(1) The eligible person is covered under the replacement 11,236
coverage for the balance of the period that he THE PERSON would 11,237
have remained covered under the terminated coverage if it had not 11,239
been terminated. 11,240
(2) The level of benefits under the replacement coverage 11,242
is the same as the level of benefits provided to any similarly 11,243
situated eligible person who is covered under the group plan and 11,244
an employee who has not been called or ordered to active duty. 11,245
(G) Upon the reservist's release from active duty and his 11,247
THE RESERVIST'S return to employment for the employer by whom he 11,249
THE RESERVIST was employed at the time he THE RESERVIST was 11,251
called or ordered to active duty, both of the following apply: 11,253
(1) Every eligible person is entitled, without any waiting 11,255
period, to coverage under the employer's group plan that is in 11,256
effect at the time of the reservist's return to employment. 11,257
(2) Every eligible person is entitled to all benefits 11,259
under the group plan described in division (G)(1) of this section 11,260
from the date of the original coverage under the plan. 11,261
(H)(1) No employer shall fail to provide for a 11,263
continuation of coverage, or an extension of a continuation of 11,264
coverage, in a group plan as required by and in accordance with 11,265
the terms and conditions set forth under this section. 11,266
(2) No employer shall fail to issue a certificate or other 11,268
252
evidence of coverage in compliance with division (D)(3) of this 11,269
section. 11,270
(3) No employer shall fail to provide an employee or 11,272
eligible person with notice of the right to a continuation of 11,273
coverage under a group plan in accordance with division (D)(2) of 11,274
this section. 11,275
(I) Whoever violates division (H)(1), (2), or (3) of this 11,277
section is deemed to have engaged in an unfair and deceptive act 11,278
or practice in the business of insurance under sections 3901.19 11,279
to 3901.26 of the Revised Code. 11,280
(J) This section does not apply to a group plan under 11,282
either of the following circumstances: 11,283
(1) The group plan is subject to section 5923.051 of the 11,285
Revised Code. 11,286
(2) The application of this section is superseded, 11,288
preempted, prohibited, or otherwise precluded by federal law. 11,289
Sec. 3923.41. As used in sections 3923.41 to 3923.48 of 11,298
the Revised Code: 11,299
(A) "Long-term care insurance" means any insurance policy 11,301
or rider advertised, marketed, offered, or designed to provide 11,302
coverage for not less than one year for each covered person on an 11,303
expense incurred, indemnity, prepaid, or other basis, for one or 11,304
more necessary or medically necessary diagnostic, preventive, 11,305
therapeutic, rehabilitative, maintenance, or personal care 11,306
services, provided in a setting other than an acute care unit of 11,307
a hospital. "Long-term care insurance" includes group and 11,308
individual annuities and life insurance policies or riders that 11,309
provide directly or supplement long-term care benefits, and 11,310
policies or riders that provide for payment of benefits based on 11,311
cognitive impairment or the loss of functional capacity. 11,312
"Long-term care insurance" includes group and individual policies 11,313
or riders whether issued by insurers, fraternal benefit 11,314
societies, OR health and medical care INSURING corporations, 11,316
prepaid health plans, or health maintenance organizations. 11,317
253
"Long-term care insurance" does not include any insurance policy 11,318
that is offered primarily to provide basic medicare supplement 11,319
coverage, basic hospital expense coverage, basic medical-surgical 11,320
expense coverage, hospital confinement indemnity coverage, major 11,321
medical expense coverage, disability income protection coverage, 11,322
accident only coverage, specified disease or specified accident 11,323
coverage, or limited benefit health coverage. 11,324
With regard to life insurance, "long-term care insurance" 11,326
does not include life insurance policies that accelerate the 11,327
death benefits specifically for one or more of the qualifying 11,328
events of terminal illness, medical conditions requiring 11,329
extraordinary medical intervention, or permanent institutional 11,330
confinement; that provide the option of a lump sum payment for 11,331
those benefits; and in which neither the benefits nor the 11,332
eligibility for the benefits is conditioned upon the receipt of 11,333
long-term care. 11,334
Notwithstanding any other provision contained in sections 11,336
3923.41 to 3923.48 of the Revised Code, any product advertised, 11,337
marketed, or offered as long-term care insurance shall be subject 11,338
to sections 3923.41 to 3923.48 of the Revised Code. 11,339
(B) "Applicant" means either of the following: 11,341
(1) In the case of an individual long-term care insurance 11,343
policy, the person who seeks to contract for benefits; 11,344
(2) In the case of a group long-term care insurance 11,346
policy, the proposed certificate holder. 11,347
(C) "Certificate" means any certificate issued under a 11,349
group long-term care insurance policy that has been delivered, 11,350
issued for delivery, or used in or outside this state. 11,351
(D) "Group long-term care insurance" means a form of 11,353
long-term care insurance covering any group of two or more 11,354
employees, members, or other persons, with or without one or more 11,355
of their dependents and members of their immediate families. Such 11,357
insurance may be offered to groups without regard to the purpose 11,358
or type of group or the occupation of the employees, members, and 11,359
254
other persons insured under the policy.
(E) "Policy" means any policy, contract, rider, or 11,361
endorsement delivered, issued for delivery, or used in or outside 11,362
this state by an insurer, fraternal benefit society, OR health or 11,363
medical care INSURING corporation, prepaid health plan, or health 11,365
maintenance organization. 11,366
Sec. 3923.51. (A) As used in this section, "official 11,375
poverty line" means the poverty line as defined by the United 11,376
States office of management and budget and revised by the 11,377
secretary of health and human services under 95 Stat. 511, 42 11,378
U.S.C.A. 9902, as amended. 11,379
(B) Every insurer that is authorized to write sickness and 11,381
accident insurance in this state may offer group contracts of 11,382
sickness and accident insurance to any charitable foundation that 11,383
is certified as exempt from taxation under section 501(c)(3) of 11,384
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 11,385
1, as amended, and that has the sole purpose of issuing 11,386
certificates of coverage under these contracts to persons under 11,387
the age of nineteen who are members of families that have incomes 11,388
that are no greater than three hundred per cent of the official 11,389
poverty line. 11,390
(C) Contracts offered pursuant to division (B) of this 11,392
section are not subject to any of the following: 11,393
(1) Sections 3923.122, 3923.24, and 3923.29 of the Revised 11,395
Code; 11,396
(2) Any other sickness and accident insurance coverage 11,398
required under this chapter on the effective date of this section 11,400
AUGUST 3, 1989. Any requirement of sickness and accident 11,401
insurance coverage enacted after that date applies to this 11,402
section only if the subsequent enactment specifically refers to 11,403
this section.
(3) Chapter 1742. 1751. of the Revised Code. 11,405
Sec. 3923.54. (A) As used in this section, "screening 11,414
mammography" means a radiologic examination utilized to detect 11,415
255
unsuspected breast cancer at an early stage in asymptomatic women 11,416
and includes the x-ray examination of the breast using equipment 11,417
that is dedicated specifically for mammography including, but not 11,418
limited to, the x-ray tube, filter, compression device, screens, 11,419
film, and cassettes, and that has an average radiation exposure 11,420
delivery of less than one rad mid-breast. "Screening 11,421
mammography" includes two views for each breast. The term also 11,423
includes the professional interpretation of the film. 11,424
"Screening mammography" does not include diagnostic 11,426
mammography.
(B) Each employer in this state that provides, in whole or 11,428
in part, health care benefits for its employees under a policy of 11,429
sickness and accident insurance issued in accordance with Chapter 11,430
3923. of the Revised Code shall also provide to its employees 11,431
benefits for the expenses of both of the following: 11,432
(1) Screening mammography to detect the presence of breast 11,434
cancer in adult women; 11,435
(2) Cytologic screening for the presence of cervical 11,437
cancer. 11,438
(C) An employer may comply with division (B) of this 11,440
section in any of the following ways: 11,441
(1) By providing the benefits under a health maintenance 11,443
organization INSURING CORPORATION contract issued in accordance 11,444
with Chapter 1742. 1751. of the Revised Code or a policy of 11,446
sickness and accident insurance issued in accordance with Chapter 11,447
3923. of the Revised Code;
(2) By reimbursing the employee for the direct health care 11,449
provider charges associated with receipt of the covered service; 11,450
(3) By making any other arrangement that provides the 11,452
benefits described in division (B) of this section. 11,453
(D) The benefits provided under division (B)(1) of this 11,455
section shall cover expenses in accordance with all of the 11,456
following: 11,457
(1) If a woman is at least thirty-five years of age but 11,459
256
under forty years of age, one screening mammography; 11,460
(2) If a woman is at least forty years of age but under 11,462
fifty years of age, either of the following: 11,463
(a) One screening mammography every two years; 11,465
(b) If a licensed physician has determined that the woman 11,467
has risk factors to breast cancer, one screening mammography 11,468
every year. 11,469
(3) If a woman is at least fifty years of age but under 11,471
sixty-five years of age, one screening mammography every year. 11,472
(E)(1) The benefits provided under division (B)(1) of this 11,474
section need not exceed eighty-five dollars per year. 11,475
(2) The benefit paid in accordance with division (E)(1) of 11,477
this section shall constitute full payment. No institutional or 11,478
professional health care provider shall seek or receive 11,479
compensation in excess of the payment made in accordance with 11,480
division (E)(1) of this section, except for approved deductibles 11,481
and copayments. 11,482
(F) The benefits provided under division (B)(1) of this 11,484
section shall be provided only for screening mammographies that 11,485
are performed in a facility or mobile mammography screening unit 11,486
that is accredited under the American college of radiology 11,488
mammography accreditation program or in a hospital as defined in 11,489
section 3727.01 of the Revised Code.
(G) The benefits provided under division (B)(2) of this 11,491
section shall be provided only for cytologic screenings that are 11,492
processed and interpreted in a laboratory certified by the 11,493
college of American pathologists or in a hospital as defined in 11,494
section 3727.01 of the Revised Code. 11,495
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 11,504
of the Revised Code: 11,505
(1) "Case characteristics," "eligible employee," "health 11,507
benefit plan," "late enrollee," "MEWA," and "pre-existing 11,508
conditions provision" have the same meanings as in section 11,509
3924.01 of the Revised Code. 11,510
257
(2) "Insurer" means any sickness and accident insurance 11,512
company authorized to issue health benefit plans in this state, 11,513
or MEWA authorized to issue insured health benefit plans in this 11,514
state. "Insurer" does not include any health maintenance 11,515
organization INSURING CORPORATION that is owned or operated by an 11,516
insurer. 11,517
(3) "Small employer" means any person, firm, corporation, 11,519
or partnership actively engaged in business whose total employed 11,520
work force, on at least fifty per cent of its working days during 11,521
the preceding year, consisted of at least two unrelated eligible 11,522
employees but no more than twenty-five eligible employees, the 11,523
majority of whom were employed within this state. In determining 11,524
the number of eligible employees, companies that are affiliated 11,525
companies or that are eligible to file a combined tax return for 11,526
purposes of state taxation shall be considered one employer. In 11,527
determining whether the members of an association are small 11,528
employers, each member of the association shall be considered as 11,529
a separate person, firm, corporation, or partnership. 11,530
(4) "Small employer group" means any group consisting of 11,532
all of the eligible employees of a small employer, except those 11,533
employees who are covered, or are eligible for coverage, under 11,534
any other private or public health benefits arrangement, 11,535
including the medicare program established under Title XVIII of 11,536
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 11,537
as amended, or any other act of congress or law of this or any 11,538
other state of the United States that provides benefits 11,539
comparable to the benefits provided under this section. 11,540
(B) Beginning in January of each year, insurers shall 11,542
accept applicants for open enrollment coverage, as set forth in 11,543
divisions (B)(1) and (2) of this section, in the order in which 11,544
they apply for coverage and subject to the limitation set forth 11,545
in division (G) of this section: 11,546
(1) Insurers in the business of issuing health benefit 11,548
plans to small employer groups shall accept small employer groups 11,549
258
for which coverage is not otherwise available and for whom 11,550
coverage had not been terminated by the employer or by an insurer 11,551
or, health maintenance organization, OR HEALTH INSURING 11,553
CORPORATION during the preceding twelve-month period; 11,556
(2) Insurers in the business of issuing individual 11,558
policies of sickness and accident insurance as contemplated by 11,559
section 3923.021 of the Revised Code, except individual policies 11,560
issued pursuant to section 3923.122 of the Revised Code, shall 11,561
either accept individuals pursuant to the open enrollment 11,562
requirements of section 3941.53 of the Revised Code, if subject 11,563
to that section, or accept for coverage pursuant to this section 11,565
individuals to whom both of the following conditions apply: 11,566
(a) The individual is not applying for coverage as an 11,568
employee of an employer, as a member of an association, or as a 11,569
member of any other group. 11,570
(b) The individual is not covered, and is not eligible for 11,572
coverage, under any other private or public health benefits 11,573
arrangement, including the medicare program established under 11,574
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 11,575
U.S.C.A. 301, as amended, or any other act of congress or law of 11,576
this or any other state of the United States that provides 11,577
benefits comparable to the benefits provided under this section, 11,578
any medicare supplement policy, or any conversion or continuation 11,579
of coverage policy under state or federal law. 11,580
(C) An insurer shall offer to any individual or small 11,582
employer group accepted under this section the small employer 11,583
health care plan established by the board of directors of the 11,584
Ohio small employer health reinsurance program under division (A) 11,585
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 11,586
plan in benefit plan design and scope of covered services. 11,587
An insurer may offer other health benefit plans in addition 11,589
to, but not in lieu of, the plan required to be offered under 11,590
this division. These additional health benefit plans shall 11,591
259
provide, at a minimum, the coverage provided by the small 11,592
employer health care plan or any health benefit plan that is 11,593
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 11,594
For purposes of this division, the superintendent of 11,596
insurance shall determine whether a health benefit plan is 11,597
substantially similar to the small employer health care plan in 11,598
benefit plan design and scope of covered services. 11,599
(D) Health benefit plans issued under this section may 11,601
establish pre-existing conditions provisions that exclude or 11,602
limit coverage for a period of up to twelve months following the 11,603
individual's effective date of coverage and that may relate only 11,604
to conditions during the six months immediately preceding the 11,605
effective date of coverage. However, an insurer may exclude a 11,606
late enrollee for a period of up to eighteen months following the 11,607
individual's date of application for coverage. 11,608
(E) Premiums charged to groups or individuals under this 11,610
section may not exceed an amount that is two and one-half times 11,611
the highest rate charged any other group with similar case 11,612
characteristics or any other individual to which the insurer is 11,613
currently accepting new business, and for which similar 11,614
copayments and deductibles are applied. 11,615
(F) In offering health benefit plans under this section, 11,617
an insurer may require the purchase of health benefit plans that 11,618
condition the reimbursement of health services upon the use of a 11,619
specific network of providers. 11,620
(G)(1) In no event shall an insurer be required to accept 11,622
annually under this section either individuals or small employer 11,623
groups that, in the aggregate, would cause the insurer to have a 11,624
total number of new insureds that is more than one-half per cent 11,625
of its total number of insured individuals in this state per 11,626
year, as contemplated by section 3923.021 of the Revised Code, 11,627
and small group certificate holders of health benefit plans in 11,628
this state per year, calculated as of the immediately preceding 11,630
260
thirty-first day of December and excluding the insurer's medicare 11,631
supplement policies and conversion or continuation of coverage 11,633
policies under state or federal law and any policies described in 11,634
division (N) of this section. If an insurer is subject to, and 11,636
elects to operate under, the individual open enrollment 11,637
requirements of section 3941.53 of the Revised Code, in no event 11,638
shall the insurer be required to accept annually under this 11,639
section small employer groups that would cause the insurer to 11,640
have a total number of new insureds that is more than one-half 11,641
per cent of its total number of small group certificate holders 11,642
calculated as set forth in division (G)(1) of this section. 11,643
(2) An officer of the insurer shall certify to the 11,645
department of insurance when it has met the enrollment limit set 11,646
forth in division (G)(1) of this section. Upon providing such 11,647
certification, the insurer shall be relieved of its open 11,648
enrollment requirement under this section for the remainder of 11,649
the calendar year. 11,650
(H) An insurer shall not be required to accept under this 11,652
section applicants who, at the time of enrollment, are confined 11,653
to a health care facility because of chronic illness, permanent 11,654
injury, or other infirmity that would cause economic impairment 11,655
to the insurer if the applicants were accepted, or to make the 11,656
effective date of benefits for individuals or groups accepted 11,657
under this section earlier than ninety days after the date of 11,658
acceptance. 11,659
(I) The requirements of this section do not apply to any 11,661
insurer that is currently in a state of supervision, insolvency, 11,662
or liquidation. If an insurer demonstrates to the satisfaction 11,663
of the superintendent that the requirements of this section would 11,665
place the insurer in a state of supervision, insolvency, or 11,666
liquidation, the superintendent may waive or modify the 11,667
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 11,669
a period of not more than one year. At the expiration of such 11,670
261
time, a new showing of need for a waiver or modification by the 11,671
insurer shall be made before a new waiver or modification is 11,672
issued or imposed.
(J) No hospital, health care facility, or health care 11,674
practitioner, and no person who employs any health care 11,675
practitioner, shall balance bill any individual or dependent of 11,676
an individual or any eligible employee or dependent of an 11,677
employee for any health care supplies or services provided to the 11,678
individual or dependent or the eligible employee or dependent, 11,679
who is insured under a policy or enrolled under a health benefit 11,681
plan issued under this section. The hospital, health care 11,682
facility, or health care practitioner, or any person that employs 11,683
the health care practitioner, shall accept payments made to it by 11,684
the insurer under the terms of the policy or contract insuring or 11,686
covering such individual as payment in full for such health care 11,687
supplies or services. 11,688
As used in this division, "hospital" has the same meaning 11,690
as in section 3727.01 of the Revised Code; "health care 11,691
practitioner" has the same meaning as in section 4769.01 of the 11,692
Revised Code; and "balance bill" means charging or collecting an 11,693
amount in excess of the amount reimbursable or payable under the 11,694
policy or health care service contract issued to an individual or 11,695
group under this section for such health care supply or service. 11,696
"Balance bill" does not include charging for or collecting 11,697
copayments or deductibles required by the policy or contract. 11,698
(K) An insurer shall pay an agent a commission in the 11,700
amount of five per cent of the premium charged for initial 11,701
placement or for otherwise securing the issuance of a policy or 11,702
contract issued to an individual or small employer group under 11,703
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 11,704
adopt, in accordance with Chapter 119. of the Revised Code, such 11,705
rules as are necessary to enforce this division. 11,706
(L) Except as otherwise provided in this section, sections 11,708
262
3924.01 to 3924.06 of the Revised Code apply to all health 11,709
benefit plans issued under this section. 11,710
(M) Individuals accepted for coverage under this section 11,712
may be issued contracts and certificates subject to the 11,713
requirements of section 3923.12 of the Revised Code. The 11,714
coverage issued to such individuals is not subject to the 11,715
requirements of section 3923.021 of the Revised Code. 11,716
(N) This section does not apply to any policy that 11,718
provides coverage for specific diseases or accidents only, or to 11,720
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 11,722
than six months, or other policy that offers only supplemental 11,723
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 11,732
the Revised Code: 11,733
(A) "Actuarial certification" means a written statement 11,735
prepared by a member of the American academy of actuaries, or by 11,736
any other person acceptable to the superintendent of insurance, 11,737
that states that, based upon the person's examination, a carrier 11,738
offering health benefit plans to small employers is in compliance 11,739
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 11,740
certification" shall include a review of the appropriate records 11,741
of, and the actuarial assumptions and methods used by, the 11,742
carrier relative to establishing premium rates for the health 11,743
benefit plans. 11,744
(B) "Adjusted average market premium price" means the 11,746
average market premium price as determined by the board of 11,748
directors of the Ohio small employer health reinsurance program 11,749
either on the basis of the arithmetic mean of all carriers' 11,750
premium rates for an SEHC plan sold to groups with similar case 11,751
characteristics by all carriers selling SEHC plans in the state, 11,753
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 11,755
plan that is issued by a carrier and that covers at least two but 11,756
263
no more than fifty employees of a small employer, the lowest 11,758
premium rate for a new or existing business prescribed by the 11,759
carrier for the same or similar coverage under a plan or 11,760
arrangement covering any small employer with similar case 11,761
characteristics.
(D) "Carrier" means any sickness and accident insurance 11,763
company or health maintenance organization INSURING CORPORATION 11,764
authorized to issue health benefit plans in this state or a MEWA. 11,766
A sickness and accident insurance company that owns or operates a 11,768
health maintenance organization INSURING CORPORATION, either as a 11,769
separate corporation or as a line of business, shall be 11,771
considered as a separate carrier from that health maintenance 11,772
organization INSURING CORPORATION for purposes of sections 11,774
3924.01 to 3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 11,776
employer, the geographic area in which the employees work; the 11,777
age and sex of the individual employees and their dependents; the 11,778
appropriate industry classification as determined by the carrier; 11,779
the number of employees and dependents; and such other objective 11,780
criteria as may be established by the carrier. "Case 11,781
characteristics" does not include claims experience, health 11,782
status, or duration of coverage from the date of issue. 11,783
(F) "Dependent" means the spouse or child of an eligible 11,785
employee, subject to applicable terms of the health benefits plan 11,786
covering the employee. 11,787
(G) "Eligible employee" means an employee who works a 11,789
normal work week of twenty-five or more hours. "Eligible 11,790
employee" does not include a temporary or substitute employee, or 11,792
a seasonal employee who works only part of the calendar year on 11,793
the basis of natural or suitable times or circumstances. 11,794
(H) "Financially impaired" means a program member that, 11,796
after April 14, 1993, is not insolvent but is determined by the 11,799
superintendent to be potentially unable to fulfill its 11,800
contractual obligations, or is placed under an order of 11,801
264
rehabilitation or conservation by a court of competent 11,802
jurisdiction or under an order of supervision by the 11,803
superintendent.
(I) "Health benefit plan" means any hospital or medical 11,805
expense policy or certificate or any health plan provided by a 11,807
carrier, that is delivered, issued for delivery, renewed, or used 11,809
in this state on or after the date occurring six months after the 11,810
effective date of this amendment NOVEMBER 24, 1995. "Health 11,811
benefit plan" does not include policies covering only accident, 11,813
credit, dental, disability income, long-term care, hospital 11,814
indemnity, medicare supplement, specified disease, or vision 11,815
care; coverage under a one-time-limited-duration policy of no 11,816
longer than six months; coverage issued by a health care 11,817
corporation; coverage issued by a prepaid dental plan 11,819
organization solely or in conjunction with a carrier; coverage 11,820
issued as a supplement to liability insurance; insurance arising 11,821
out of a workers' compensation or similar law; automobile 11,822
medical-payment insurance; or insurance under which benefits are 11,823
payable with or without regard to fault and which is statutorily 11,824
required to be contained in any liability insurance policy or 11,825
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 11,827
period immediately following any service waiting period 11,828
established by an employer. 11,829
(K) "Late enrollee" means an eligible employee or 11,831
dependent who requests enrollment in a small employer's health 11,832
benefit plan following the initial enrollment period provided 11,833
under the terms of the first plan for which the employee or 11,834
dependent was eligible through the small employer, unless any of 11,835
the following apply: 11,836
(1) The individual: 11,838
(a) Was covered under another health benefit plan at the 11,841
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 11,843
265
coverage under another health benefit plan was the reason for 11,846
declining enrollment;
(c) Has lost coverage under another health benefit plan as 11,849
a result of the termination of employment, a reduction of hours 11,850
worked per week, the termination of the other plan's coverage, 11,851
death of a spouse, or divorce; and 11,852
(d) Requests enrollment within thirty days after the 11,854
termination of coverage under another health benefit plan. 11,855
(2) The individual is employed by an employer who offers 11,857
multiple health benefit plans and the individual elects a 11,858
different health benefit plan during an open enrollment period. 11,859
(3) A court has ordered coverage to be provided for a 11,861
spouse or minor child under a covered employee's plan and a 11,862
request for enrollment is made within thirty days after issuance 11,863
of the court order. 11,864
(L) "MEWA" means any "multiple employer welfare 11,866
arrangement" as defined in section 3 of the "Federal Employee 11,867
Retirement Income Security Act of 1974," 88 Stat. 832, 29 11,868
U.S.C.A. 1001, as amended, except for any arrangement which is 11,869
fully insured as defined in division (b)(6)(D) of section 514 of 11,870
that act. 11,871
(M) "Midpoint rate" means, for small employers with 11,873
similar case characteristics and plan designs and as determined 11,874
by the applicable carrier for a rating period, the arithmetic 11,875
average of the applicable base premium rate and the corresponding 11,876
highest premium rate. 11,877
(N) "Pre-existing conditions provision" means a policy 11,879
provision that excludes or limits coverage for charges or 11,880
expenses incurred during a specified period following the 11,881
insured's effective date of coverage as to a condition which, 11,882
during a specified period immediately preceding the effective 11,883
date of coverage, had manifested itself in such a manner as would 11,884
cause an ordinarily prudent person to seek medical advice, 11,885
diagnosis, care, or treatment or for which medical advice, 11,886
266
diagnosis, care, or treatment was recommended or received, or a 11,887
pregnancy existing on the effective date of coverage. 11,888
(O) "Service waiting period" means the period of time 11,890
after employment begins before an eligible employee may enroll in 11,891
any applicable health benefit plan offered by the small employer. 11,892
(P)(1) "Small employer" means any person, firm, 11,895
corporation, partnership, or association actively engaged in 11,896
business whose total employed work force consisted of, on at 11,897
least fifty per cent of its working days during the preceding 11,898
year, at least two but no more than fifty eligible employees, the 11,899
majority of whom were employed within the state. 11,900
(2) In determining the number of eligible employees for 11,902
purposes of division (P)(1) of this section, companies which are 11,903
affiliated companies or which are eligible to file a combined tax 11,904
return for purposes of state taxation shall be considered one 11,905
employer. Except as otherwise specifically provided, provisions 11,906
of sections 3924.01 to 3924.14 of the Revised Code that apply to 11,907
a small employer that has a health benefit plan shall continue to 11,908
apply until the plan anniversary following the date the employer 11,909
no longer meets the requirements of this division. 11,910
(Q) "SEHC plan" means an Ohio small employer health care 11,913
plan, which is a health benefit plan for small employers
established by the board in accordance with section 3924.10 of 11,914
the Revised Code. 11,915
Sec. 3924.02. (A) An individual or group health benefit 11,924
plan is subject to sections 3924.01 to 3924.14 of the Revised 11,925
Code if it provides health care benefits covering at least two 11,927
but no more than fifty employees of a small employer, and if it 11,928
meets either of the following conditions: 11,929
(1) Any portion of the premium or benefits is paid by a 11,931
small employer, or any covered individual is reimbursed, whether 11,932
through wage adjustments or otherwise, by a small employer for 11,933
any portion of the premium. 11,934
(2) The health benefit plan is treated by the employer or 11,936
267
any of the covered individuals as part of a plan or program for 11,937
purposes of section 106 or 162 of the "Internal Revenue Code of 11,938
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 11,939
(B) Notwithstanding division (A) of this section, 11,941
divisions (G) to (J) of section 3924.03 of the Revised Code and 11,943
section 3924.04 of the Revised Code do not apply to health 11,944
benefit policies that are not sold to owners of small businesses 11,945
as an employment benefit plan. Such policies shall clearly state 11,946
that they are not being sold as an employment benefit plan and 11,947
that the owner of the business is not responsible, either 11,948
directly or indirectly, for paying the premium or benefits. 11,949
(C) Every health benefit plan offered or delivered by a 11,951
carrier, other than a health maintenance organization INSURING 11,952
CORPORATION, to a small employer is subject to sections 3923.23, 11,954
3923.231, 3923.232, 3923.233, and 3923.234 of the Revised Code 11,955
and any other provision of the Revised Code that requires the 11,956
reimbursement, utilization, or consideration of a specific 11,957
category of a licensed or certified health care practitioner. 11,958
(D) Except as expressly provided in sections 3924.01 to 11,960
3924.14 of the Revised Code, no health benefit plan offered to a 11,961
small employer is subject to any of the following: 11,962
(1) Any law that would inhibit any carrier from 11,964
contracting with providers or groups of providers with respect to 11,965
health care services or benefits; 11,966
(2) Any law that would impose any restriction on the 11,968
ability to negotiate with providers regarding the level or method 11,969
of reimbursing care or services provided under the health benefit 11,970
plan; 11,971
(3) Any law that would require any carrier to either 11,973
include a specific provider or class of provider when contracting 11,974
for health care services or benefits, or to exclude any class of 11,975
provider that is generally authorized by statute to provide such 11,976
care. 11,977
Sec. 3924.08. (A) The board of directors of the Ohio 11,986
268
small employer health reinsurance program shall consist of nine 11,987
appointed members who shall serve staggered terms as determined 11,988
by the initial board for its members and by the plan of operation 11,989
of the program for members of subsequent boards. Within thirty 11,990
days after April 14, 1993, the members of the board shall be 11,991
appointed, as follows: 11,992
(1) The chairperson of the senate committee having 11,994
jurisdiction over insurance shall appoint the following members: 11,995
(a) Two member carriers that are small employer carriers; 11,997
(b) One member carrier that is a health maintenance 11,999
organization INSURING CORPORATION predominantly in the small 12,000
employer market; 12,001
(c) One representative of providers of health care. 12,003
(2) The chairperson of the committee in the house of 12,005
representatives having jurisdiction over insurance shall appoint 12,006
the following members: 12,007
(a) One member carrier that is a small employer carrier; 12,009
(b) One member carrier whose principal health insurance 12,011
business is in the large employer market; 12,012
(c) One representative of an employer with fifty or fewer 12,014
employees; 12,015
(d) One representative of consumers in this state. 12,017
(3) The superintendent shall appoint a representative of a 12,019
member carrier operating in the small employer market who is a 12,020
fellow of the society of actuaries. 12,021
The superintendent, a member of the house of 12,023
representatives appointed by the speaker of the house of 12,024
representatives, and a member of the senate appointed by the 12,025
president of the senate, shall be ex-officio members of the 12,026
board. The membership of all boards subsequent to the initial 12,027
board shall reflect the distribution described in division (A) of 12,029
this section.
The chairperson of the initial board and each subsequent 12,031
board shall represent a small employer member carrier and shall 12,032
269
be elected by a majority of the voting members of the board. 12,033
Each chairperson shall serve for the maximum duration established 12,034
in the plan of operation. 12,035
(B) Within one hundred eighty days after the appointment 12,037
of the initial board, the board shall establish a plan of 12,038
operation and, thereafter, any amendments to the plan that are 12,039
necessary or suitable, to assure the fair, reasonable, and 12,040
equitable administration of the program. The board shall, 12,041
immediately upon adoption, provide to the superintendent copies 12,042
of the plan of operation and all subsequent amendments to it. 12,043
(C) The plan of operation shall establish rules, 12,045
conditions, and procedures for all of the following: 12,046
(1) The handling and accounting of assets and moneys of 12,048
the program and for an annual fiscal reporting to the 12,049
superintendent; 12,050
(2) Filling vacancies on the board; 12,052
(3) Selecting an administering insurer, which shall be a 12,054
carrier as defined in section 3924.01 of the Revised Code, and 12,055
setting forth the powers and duties of the administering insurer; 12,056
(4) Reinsuring risks in accordance with sections 3924.07 12,058
to 3924.14 of the Revised Code; 12,059
(5) Collecting assessments subject to section 3924.13 of 12,061
the Revised Code from all members to provide for claims reinsured 12,062
by the program and for administrative expenses incurred or 12,063
estimated to be incurred during the period for which the 12,064
assessment is made; 12,065
(6) Providing protection for carriers from the financial 12,067
risk associated with small employers that present poor credit 12,068
risks; 12,069
(7) Establishing standards for the coverage of small 12,071
employers that have a high turnover of employees; 12,072
(8) Establishing an appeals process for carriers to seek 12,074
relief when a carrier has experienced an unfair share of 12,075
administrative and credit risks; 12,076
270
(9) Establishing the adjusted average market premium 12,078
prices for use by the SEHC plan for groups of two to twenty-five 12,079
employees and for groups of twenty-six to fifty employees that 12,080
are offered in the state; 12,081
(10) Establishing participation standards at issue and 12,083
renewal for reinsured cases; 12,084
(11) Reinsuring risks and collecting assessments in 12,086
accordance with division (G) of section 3924.11 of the Revised 12,087
Code; 12,088
(12) Any additional matters as determined by the board. 12,090
Sec. 3924.10. (A) The board of directors of the Ohio 12,099
small employer health reinsurance program shall design the SEHC 12,100
plan which, when offered by a carrier, is eligible for 12,101
reinsurance under the program. The board shall establish the 12,102
form and level of coverage to be made available by carriers in 12,103
their SEHC plan. In designing the plan the board shall also 12,105
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 12,106
of coverage established by the board shall specify which 12,107
components of a health benefit plan offered by a small employer 12,108
carrier may be reinsured. The SEHC plan is subject to division 12,110
(C) of section 3924.02 of the Revised Code and to the provisions 12,111
in Chapters 1742. 1751., 3923., and any other chapter of the 12,113
Revised Code that require coverage or the offer of coverage of a 12,114
health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 12,117
eighty days after its appointment. The plan may include cost 12,118
containment features including any of the following:
(1) Utilization review of health care services, including 12,120
review of the medical necessity of hospital and physician 12,121
services; 12,122
(2) Case management benefit alternatives; 12,124
(3) Selective contracting with hospitals, physicians, and 12,126
other health care providers; 12,127
271
(4) Reasonable benefit differentials applicable to 12,129
participating and nonparticipating providers; 12,130
(5) Employee assistance program options that provide 12,132
preventive and early intervention mental health and substance 12,133
abuse services; 12,134
(6) Other provisions for the cost-effective management of 12,136
the plan. 12,137
(C) An SEHC plan established for use by health maintenance 12,140
organizations INSURING CORPORATIONS shall be consistent with the 12,141
basic method of operation of such organizations CORPORATIONS. 12,142
(D) Each carrier shall certify to the superintendent of 12,144
insurance, in the form and manner prescribed by the 12,145
superintendent, that the SEHC plan filed by the carrier is in 12,147
substantial compliance with the provisions of the board SEHC 12,148
plan. Upon receipt by the superintendent of the certification, 12,149
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 12,151
date that the program becomes operational and as a condition of 12,152
transacting business in this state, renew coverage provided to 12,153
any individual or group under its SEHC plan. 12,154
(F) A carrier shall not be required to renew coverage 12,156
where the superintendent finds that renewal of coverage would 12,157
place the carrier in a financially impaired condition. The 12,158
superintendent shall determine when the carrier is no longer 12,159
financially impaired and is, therefore, subject to the guaranteed 12,160
renewability requirements. 12,161
Sec. 3924.12. (A) Except as provided in division (B) of 12,170
this section, premium rates charged for coverage reinsured by the 12,171
Ohio small employer health reinsurance program shall be 12,172
established as follows: 12,173
(1) For whole group reinsurance coverage, one and one-half 12,175
times the adjusted average market premium price established by 12,176
the program for that classification or group with similar 12,177
characteristics and coverage, with respect to the eligible 12,178
272
employees of a small employer and their dependents, all of whose 12,179
coverage is reinsured with the program, minus a ceding expense 12,180
factor determined by the board of directors of the program; 12,181
(2) For individual reinsurance coverage, five times the 12,183
adjusted average market premium price established by the program 12,184
for an individual in that classification or group with similar 12,185
characteristics and coverage, with respect to an eligible 12,186
employee or his THE EMPLOYEE'S dependents, minus a ceding expense 12,188
factor determined by the board. 12,189
(B) Premium rates charged for reinsurance by the program 12,191
to a health maintenance organization INSURING CORPORATION that is 12,193
approved by the secretary of health and human services as a 12,194
federally qualified health maintenance organization pursuant to 12,195
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 12,196
as amended, and as such is subject to requirements that limit the 12,197
amount of risk that may be ceded to the program, may be modified 12,198
to reflect the portion of risk that may be ceded to the program. 12,199
Sec. 3924.13. (A) Following the close of each calendar 12,208
year, the administering insurer of the Ohio small employer health 12,209
reinsurance program shall determine the net premiums, the program 12,210
expenses for administration, and the incurred losses, if any, for 12,211
the year, taking into account investment income and other 12,212
appropriate gains and losses. For purposes of this section, 12,213
health benefit plan premiums earned by MEWAs shall be established 12,214
by adding paid claim losses and administrative expenses of the 12,215
MEWA. Health benefit plan premiums and benefits paid by a 12,217
carrier that are less than an amount determined by the board of 12,218
directors of the program to justify the cost of collection shall 12,219
not be considered for purposes of determining assessments. For 12,220
purposes of this division, "net premiums" means health benefit 12,221
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 12,223
assessments of carriers in accordance with this division. 12,224
Assessments shall be apportioned by the board among all carriers 12,225
273
participating in the program in proportion to their respective 12,226
shares of the total premiums, net of reinsurance premiums paid 12,227
for coverage under this program earned in the state from health 12,228
benefit plans covering small employers that are issued by 12,229
participating members during the calendar year coinciding with or 12,230
ending during the fiscal year of the program, or on any other 12,231
equitable basis reflecting coverage of small employers as may be 12,232
provided in the plan of operation. An assessment shall be made 12,233
pursuant to this division against a health maintenance 12,234
organization INSURING CORPORATION that is approved by the 12,235
secretary of health and human services as a federally qualified 12,237
health maintenance organization pursuant to the "Social Security 12,238
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, subject 12,239
to an assessment adjustment formula adopted by the board for such 12,240
health maintenance organizations INSURING CORPORATIONS that 12,241
recognizes the restrictions imposed on the organizations ENTITIES 12,243
by federal law. The adjustment formula shall be adopted by the 12,245
board prior to the first anniversary of the program's operation. 12,246
In no event shall the assessment made pursuant to this division 12,247
exceed, on an annual basis, one per cent of the carrier's Ohio 12,249
small employer group premium as reported on its most recent 12,250
annual statement filed with the superintendent of insurance. If 12,251
an excess is actuarially projected, the superintendent may take 12,252
any action necessary to lower the assessment to the maximum level 12,253
of one per cent.
(C) If assessments exceed actual losses and administrative 12,255
expenses of the program, the excess shall be held at interest and 12,256
used by the board to offset future losses or to reduce program 12,257
premiums. As used in this division, "future losses" includes 12,258
reserves for incurred but not reported claims. 12,259
(D) Each carrier's proportion of participation in the 12,261
program shall be determined annually by the board based on annual 12,263
statements and other reports deemed necessary by the board and 12,264
filed by the carrier with the board. MEWAs shall report to the 12,265
274
board claims payments made and administrative expenses incurred 12,266
in this state on an annual basis on a form prescribed by the 12,267
superintendent.
(E) Provision shall be made in the plan of operation for 12,269
the imposition of an interest penalty for late payment of 12,270
assessments. 12,271
(F) A carrier may seek from the superintendent a 12,273
deferment, in whole or in part, from any assessment issued by the 12,274
board. The superintendent may defer, in whole or in part, the 12,275
assessment of a carrier if, in the opinion of the superintendent, 12,276
payment of the assessment would endanger the carrier's ability to 12,277
fulfill its contractual obligations. 12,278
(G) In the event an assessment against a carrier is 12,280
deferred in whole or in part, the amount by which the assessment 12,281
is deferred may be assessed against the other carriers in a 12,282
manner consistent with the basis for assessments set forth in 12,283
this section. In such event, the other carriers assessed shall 12,284
have a claim in the amount of the assessment against the carrier 12,285
receiving the deferment. The carrier receiving the deferment 12,286
shall remain liable to the program for the amount deferred. The 12,287
superintendent may attach appropriate conditions to any 12,288
deferment. 12,289
Sec. 3924.41. (A) As used in sections 3924.41 and 3924.42 12,298
of the Revised Code, "health insurer" means any sickness and 12,299
accident insurer, health maintenance organization, preferred 12,300
provider organization, OR health care INSURING corporation, 12,302
medical care corporation, dental care corporation, or prepaid 12,303
dental plan organization. "Health insurer" also includes any 12,304
group health plan as defined in section 607 of the federal 12,305
"Employee Retirement Income Security Act of 1974," 88 Stat. 832, 12,306
29 U.S.C.A. 1167. 12,307
(B) Notwithstanding any other provision of the Revised 12,309
Code, no health insurer shall take into consideration the 12,310
availability of, or eligibility for, medical assistance in this 12,311
275
state under Chapter 5111. of the Revised Code or in any other 12,312
state pursuant to Title XIX of the "Social Security Act," 49 12,313
Stat. 620 (1935), 42 U.S.C.A. 301, as amended, when determining 12,314
an individual's eligibility for coverage or when making payments 12,315
to or on behalf of an enrollee, subscriber, policyholder, or 12,316
certificate holder. 12,317
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 12,326
the Revised Code: 12,327
(A) "Account holder" means the natural person who opens a 12,330
medical savings account or on whose behalf a medical savings 12,331
account is opened.
(B) "Eligible medical expense" means any expense for a 12,334
service rendered by a licensed health care provider or a 12,335
christian science CHRISTIAN SCIENCE practitioner, or for an 12,336
article, device, or drug prescribed by a licensed health care 12,337
provider or provided by a christian science CHRISTIAN SCIENCE 12,339
practitioner, when intended for use in the mitigation, treatment, 12,341
or prevention of disease; or premiums paid for comprehensive 12,342
sickness and accident insurance, coverage under a health care 12,343
plan of a health maintenance organization INSURING CORPORATION 12,344
organized under Chapter 1742. 1751. of the Revised Code, 12,346
long-term care insurance as defined in section 3923.41 of the
Revised Code, Medicare supplemental coverage as defined in 12,347
section 3923.33 of the Revised Code, or payments made pursuant to 12,349
cost sharing agreements under comprehensive sickness and accident 12,350
plans. An "eligible medical expense" does not include expenses 12,351
otherwise paid or reimbursed, including medical expenses paid or 12,352
reimbursed under an automobile or motor vehicle insurance policy, 12,353
a workers' compensation insurance policy or plan, or an
employer-sponsored health coverage policy, plan, or contract. 12,354
(C) "Qualified dependent" means a child of an account 12,357
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 12,360
twenty-three years of age and a full-time student at an
276
accredited college or university; 12,361
(2) The child is not self-sufficient due to physical or 12,363
mental disorders or impairments; 12,364
(3) The child is legally entitled to the provision of 12,366
proper or necessary subsistence, education, medical care, or 12,367
other care necessary for the child's health, guidance, or 12,368
well-being and is not otherwise emancipated, self-supporting, 12,369
married, or a member of the armed forces of the United States. 12,371
Sec. 3924.62. (A) A medical savings account may be opened 12,380
by or on behalf of any natural person, to pay the person's 12,381
eligible medical expenses and the eligible medical expenses of 12,382
that person's spouse or qualified dependent. A medical savings 12,383
account may be opened by or on behalf of a person only if that 12,385
person participates in a sickness or accident insurance plan, a 12,386
plan offered by a health maintenance organization INSURING
CORPORATION organized under Chapter 1742. 1751. of the Revised 12,388
Code, or a self-funded, employer-sponsored health benefit plan
established pursuant to the "Employee Retirement Income Security 12,389
Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. While 12,390
the medical savings account is open, the account holder shall 12,391
continue to participate in such a plan.
(B) A person who refuses to participate in a policy, plan, 12,394
or contract of health coverage that is funded by the person's 12,395
employer, and who receives additional monetary compensation by 12,396
virtue of refusing that coverage, may not open a medical savings 12,397
account unless the medical savings account also is sponsored by 12,398
the person's employer. 12,399
Sec. 3924.64. (A) At the time a medical savings account 12,409
is opened, an administrator for the account shall be designated. 12,410
If an employer opens an account for an employee, the employer may 12,411
designate the administrator. If an account is opened by any 12,412
person other than an employer, or if an employer chooses not to 12,413
designate an administrator for an account opened for an employee, 12,414
the account holder shall designate the administrator. The 12,415
277
administrator shall manage the account in a fiduciary capacity 12,416
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 12,419
of the following:
(1) A federally or state-chartered bank, savings and loan 12,422
association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary; 12,424
(3) An insurer authorized under Title XXXIX of the Revised 12,427
Code to engage in the business of sickness and accident 12,428
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 12,431
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 12,434
Revised Code;
(6) A certified public accountant; 12,436
(7) An employer that administers an employee benefit plan 12,439
subject to regulation under the "Employee Retirement Income 12,440
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 12,442
amended, or that maintains medical savings accounts for its 12,443
employees;
(8) Health maintenance organizations INSURING CORPORATIONS 12,445
organized under Chapter 1742. 1751. of the Revised Code. 12,446
(C) Each administrator shall send to the account holder, 12,449
at least annually, a statement setting forth the balance 12,450
remaining in the account holder's account and detailing the 12,451
activity in the account since the last statement was issued. 12,452
Upon an administrator's receipt of a written request from an 12,453
account holder for a current statement, the administrator shall 12,454
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 12,457
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 12,458
account holder, the account holder's spouse, or qualified 12,459
dependents, the administrator shall reimburse the account holder 12,460
278
for, or shall pay for, the eligible medical expense with funds 12,461
from the account holder's account, if sufficient funds are 12,462
available in the account holder's account. If there are not 12,463
sufficient funds in the account to fully reimburse the account 12,464
holder or pay the expenses, the administrator shall reimburse the 12,466
account holder or pay the expenses using whatever funds are in 12,467
the account. The reimbursement or payment shall be made within 12,468
thirty days of the administrator's receipt of the documentation. 12,469
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 12,470
expense does not count toward meeting the deductible or other 12,471
obligation for the receipt of benefits that is required by the 12,472
insurer or other third-party payer providing health coverage to 12,473
the account holder. The administrator shall keep a record of the 12,474
amounts disbursed from the account for documented eligible 12,475
medical expenses and of the dates on which the expenses were 12,476
incurred. This record shall be made available to any sickness 12,477
and accident insurer or other third-party payer providing health 12,478
coverage to the account holder, for use by the insurer or 12,479
third-party payer in determining whether the account holder has 12,480
met the deductible or other obligation required for the receipt 12,481
of benefits from the insurer or third-party payer. 12,482
(E) When an account is opened, the administrator shall 12,485
give written notice to the account holder of the date of the last 12,486
business day of the administrator's business year. 12,487
Sec. 3924.73. (A) As used in this section: 12,496
(1) "Health care insurer" means any person legally engaged 12,498
in the business of providing sickness and accident insurance 12,499
contracts in this state, a health maintenance organization 12,500
INSURING CORPORATION organized under Chapter 1742. 1751. of the 12,501
Revised Code, or any legal entity that is self-insured and 12,502
provides health care benefits to its employees or members. 12,503
(2) "Small employer" has the same meaning as in division 12,505
(P) of section 3924.01 of the Revised Code. 12,506
279
(B)(1) Subject to division (B)(2) of this section, nothing 12,509
in sections 3924.61 to 3924.74 of the Revised Code shall be 12,510
construed to limit the rights, privileges, or protections of 12,511
employees or small employers under sections 3924.01 to 3924.14 of 12,512
the Revised Code. 12,513
(2) If any account holder enrolls or applies to enroll in 12,515
a policy or contract offered by a health care insurer providing 12,516
sickness and accident coverage that is more comprehensive than, 12,517
and has a deductible amount that is less than, the coverage and 12,518
deductible amount of the policy under which the account holder 12,519
currently is enrolled, the health care insurer to which the 12,520
account holder applies may subject the account holder to the same 12,522
medical review, waiting periods, and underwriting requirements to 12,523
which the health care insurer generally subjects other enrollees 12,524
or applicants, unless the account holder enrolls or applies to 12,525
enroll during a designated period of open enrollment. 12,526
Sec. 3929.77. The joint underwriting association shall be 12,535
governed by a board of governors consisting of nine members seven 12,536
of whom shall be selected from the members of the joint 12,537
underwriting association and appointed by the superintendent of 12,538
insurance. Five members shall be selected from insurers and
corporations domiciled in this state. Two members shall be 12,539
selected from insurers and corporations domiciled outside this 12,540
state. One member shall be an insurance agent licensed and 12,541
writing insurance in this state. One member shall represent the 12,542
interests of consumers and shall neither be a member of, or 12,543
associated with, a health care provider or profession nor
associated with an insurance company or an association organized 12,544
A HEALTH INSURING CORPORATION HOLDING A CERTIFICATE OF AUTHORITY 12,545
under Chapter 1737., 1738., or 1740. 1751. of the Revised Code. 12,546
The directors of the stabilization reserve fund shall serve as ex 12,548
officio members of the board of governors.
Sec. 3956.01. As used in this chapter: 12,557
(A) "Account" means either of the two accounts created 12,559
280
under section 3956.06 of the Revised Code. 12,560
(B) "Contractual obligation" means any obligation under a 12,562
policy, contract, or certificate under a group policy or 12,563
contract, or portion of the policy or contract, for which 12,564
coverage is provided under section 3956.04 of the Revised Code. 12,565
(C) "Covered policy or contract" means any policy, 12,567
contract, or group certificate within the scope of section 12,568
3956.04 of the Revised Code. 12,569
(D) "Impaired insurer" means a member insurer that, after 12,571
the effective date of this section NOVEMBER 20, 1989, is not an 12,573
insolvent insurer, and to which either of the following applies: 12,574
(1) The insurer is considered by the superintendent to be 12,576
potentially unable to fulfill its contractual obligations; 12,577
(2) The insurer is placed under an order of rehabilitation 12,579
or conservation by a court of competent jurisdiction. 12,580
(E) "Insolvent insurer" means a member insurer that, after 12,582
the effective date of this section NOVEMBER 20, 1989, is placed 12,584
under an order of liquidation by a court of competent 12,585
jurisdiction with a finding of insolvency. 12,586
(F)(1) "Member insurer" means any insurer that holds a 12,588
certificate of authority or is licensed to transact in this state 12,589
any kind of insurance for which coverage is provided under 12,590
section 3956.04 of the Revised Code, and includes any insurer 12,591
whose certificate of authority or license in this state may have 12,592
been suspended, revoked, not renewed, or voluntarily withdrawn 12,593
after the effective date of this section NOVEMBER 20, 1989. 12,595
(2) "Member insurer" does not include any of the 12,597
following: 12,598
(a) A medical care corporation; 12,600
(b) A health care corporation; 12,602
(c) A dental care corporation; 12,604
(d) A prepaid dental plan; 12,606
(e) A health maintenance organization INSURING 12,609
CORPORATION;
281
(f) A preferred provider organization; 12,611
(g)(b) A fraternal benefit society; 12,613
(h)(c) A self-insurance or joint self-insurance pool or 12,615
plan of the state or any political subdivision of the state; 12,616
(i)(d) A mutual protective association; 12,618
(j)(e) An insurance exchange; 12,620
(k)(f) Any person who qualifies as a "member insurer" 12,622
under section 3955.01 of the Revised Code and who does not 12,624
receive premiums on covered policies or contracts;
(l)(g) Any entity similar to any of those described in 12,626
divisions (F)(2)(a) to (k)(f) of this section. 12,627
(3) "Member insurer" includes any insurer that operates 12,629
any of the entities described in division (F)(2) of this section 12,630
as a line of business, and not as a separate, affiliated legal 12,631
entity, and otherwise qualifies as a member insurer. 12,632
(G) "Premiums" means amounts received on covered policies 12,634
or contracts, less premiums, considerations, and deposits 12,635
returned on the policies or contracts, and less dividends and 12,636
experience credits on the policies and contracts. "Premiums" 12,637
does not include either of the following: 12,638
(1) Any amounts in excess of one million dollars received 12,640
on any unallocated annuity contract not issued under a 12,641
governmental retirement plan established under Section 401, 12,642
403(b), or 457 of the "Internal Revenue Code of 1986," 100 Stat. 12,643
2085, 26 U.S.C.A. 1, as amended; 12,644
(2) Any amounts received for any policies or contracts or 12,646
for the portions of any policies or contracts for which coverage 12,647
is not provided under section 3956.04 of the Revised Code. 12,648
Division (G)(2) of this section shall not be construed to require 12,649
the exclusion, from assessable premiums, of premiums paid for 12,650
coverages in excess of the interest limitations specified in 12,651
division (B)(2)(c) of section 3956.04 of the Revised Code or of 12,652
premiums paid for coverages in excess of the limitations with 12,653
respect to any one individual, any one participant, or any one 12,654
282
contract holder specified in division (C)(2) of section 3956.04 12,655
of the Revised Code. 12,656
(H) "Resident" means any person who resides in this state 12,658
at the time a member insurer is determined to be an impaired or 12,659
insolvent insurer and to whom a contractual obligation is owed. 12,660
A person may be a resident of only one state, which, in the case 12,661
of a person other than a natural person, shall be its principal 12,662
place of business. 12,663
(I) "Subaccount" means any of the three subaccounts 12,665
created under division (A) of section 3956.06 of the Revised 12,666
Code. 12,667
(J) "Supplemental contract" means any agreement entered 12,669
into for the distribution of policy or contract proceeds. 12,670
(K) "Unallocated annuity contract" means any annuity 12,672
contract or group annuity certificate that is not issued to and 12,673
owned by an individual, except to the extent of any annuity 12,674
benefits guaranteed to an individual by an insurer under that 12,675
contract or certificate. 12,676
Sec. 3959.01. (A) "Administration fees" means any amount 12,685
charged a covered person for services rendered. "Administration 12,686
fees" includes commissions earned or paid by any person relative 12,687
to services performed by an administrator. 12,688
(B) "Administrator" means any person who adjusts or 12,690
settles claims on, residents of this state in connection with 12,691
life, dental, health, or disability insurance or self-insurance 12,692
programs. "Administrator" does not include any of the following: 12,693
(1) An insurance agent or solicitor licensed in this state 12,695
whose activities are limited exclusively to the sale of insurance 12,696
and who does not provide any administrative services; 12,697
(2) Any person who administers or operates the workers' 12,699
compensation program of a self-insuring employer under Chapter 12,700
4123. of the Revised Code; 12,701
(3) Any person who administers pension plans for the 12,703
benefit of the person's own members or employees or administers 12,705
283
pension plans for the benefit of the members or employees of any 12,706
other person; 12,707
(4) Any person that administers an insured plan or a 12,709
self-insured plan that provides life, dental, health, or 12,710
disability benefits exclusively for the person's own members or 12,711
employees; 12,712
(5) Any medical care corporation organized under Chapter 12,714
1737. of the Revised Code, prepaid dental plan organization 12,715
organized under Chapter 1736. of the Revised Code, health care 12,716
INSURING corporation organized HOLDING A CERTIFICATE OF AUTHORITY 12,718
under Chapter 1738. 1751. of the Revised Code, dental care 12,720
corporation organized under Chapter 1740. of the Revised Code, 12,721
health maintenance organization organized under Chapter 1742. of 12,722
the Revised Code, or an insurance company that is authorized to 12,723
write life or sickness and accident insurance in this state. 12,724
(C) "Aggregate excess insurance" means that type of 12,726
coverage whereby the insurer agrees to reimburse the insured 12,727
employer or trust for all benefits or claims paid during an 12,728
agreement period on behalf of all covered persons under the plan 12,729
or trust which exceed a stated deductible amount and subject to a 12,730
stated maximum. 12,731
(D) "Contributions" means any amount collected from a 12,733
covered person to fund the self-insured portion of any plan in 12,734
accordance with the plan's provisions, summary plan descriptions, 12,735
and contracts of insurance. 12,736
(E) "Fiduciary" has the meaning set forth in section 12,738
1002(21)(A) of the "Employee Retirement Income Security Act of 12,739
1974," 88 Stat. 829, 29 U.S.C. 1001, as amended. 12,740
(F) "Fiscal year" means the twelve-month accounting period 12,742
commencing on the date the plan is established and ending twelve 12,743
months following that date, and each corresponding twelve-month 12,744
accounting period thereafter as provided for in the summary plan 12,745
description. 12,746
(G) "Plan" means any arrangement in written form for the 12,748
284
payment of life, dental, health, or disability benefits to 12,749
covered persons defined by the summary plan description. 12,750
(H) "Plan sponsor" means the person who establishes the 12,752
plan. 12,753
(I) "Self-insurance program" means a program whereby an 12,755
employer provides a plan of benefits for its employees without 12,756
involving an intermediate insurance carrier to assume risk or pay 12,757
claims. "Self-insurance program" includes but is not limited to 12,758
employer programs that pay claims up to a prearranged limit 12,759
beyond which they purchase insurance coverage to protect against 12,760
unpredictable or catastrophic losses. 12,761
(J) "Specific excess insurance" means that type of 12,763
coverage whereby the insurer agrees to reimburse the insured 12,764
employer or trust for all benefits or claims paid during an 12,765
agreement period on behalf of a covered person in excess of a 12,766
stated deductible amount and subject to a stated maximum. 12,767
(K) "Summary plan description" means the written document 12,769
adopted by the plan sponsor which outlines the plan of benefits, 12,770
conditions, limitations, exclusions, and other pertinent details 12,771
relative to the benefits provided to covered persons thereunder. 12,772
Sec. 3999.32. (A) As used in this section: 12,782
(1) "Certificate holder" means any person whose employment 12,784
or retirement status is the basis of eligibility for coverage 12,785
under a group policy of sickness and accident insurance or for 12,786
enrollment under a group contract of a prepaid dental plan 12,787
organization, medical care corporation, health care INSURING 12,788
corporation, dental care corporation, or health maintenance 12,790
organization.
(2) "Health insurer" means any sickness and accident 12,792
insurer, prepaid dental plan organization, medical care 12,793
corporation, OR health care INSURING corporation, dental care, 12,795
corporation, or health maintenance organization. 12,796
(B) Each person to whom a group policy or contract of 12,798
sickness and accident insurance or other health care coverage has 12,799
285
been delivered or issued for delivery in this state by a health 12,800
insurer shall make a reasonable effort to notify every 12,801
certificate holder, or his CERTIFICATE HOLDER'S designee, who is 12,803
covered under that policy or contract whenever the person fails 12,804
to make a required premium payment or contribution on behalf of 12,805
the certificate holder and that failure results in the 12,806
termination of coverage. The person shall mail or present the 12,807
notice to the certificate holder or his CERTIFICATE HOLDER'S 12,808
designee no later than five days after the date on which the 12,810
person receives the notice from the health insurer as required 12,811
under division (D) of this section. If a person other than the 12,812
policyholder or contract holder is obligated to make the required 12,813
premium payment or contribution on behalf of the certificate 12,814
holder, that person shall mail or present the notice as required 12,815
by this section.
(C) The notice required by division (B) of this section 12,817
shall be in writing and shall clearly state that the person 12,818
failed to make the required premium payment or contribution, the 12,819
reasons for the failure, and the effect of the failure on the 12,820
coverage of the certificate holder under the policy or contract. 12,821
(D) If a person described in division (B) of this section 12,823
fails to make a required premium payment or contribution on 12,824
behalf of a certificate holder and that failure results in the 12,825
termination of the coverage, the health insurer providing the 12,826
coverage shall notify the person in writing of that person's 12,827
duties as described in divisions (B) and (C) of this section. If 12,828
a person other than the policyholder or contract holder if IS 12,829
obligated to make the required premium payment or contribution on 12,830
behalf of the certificate holder, the insurer shall notify the 12,831
person in writing of that person's duties as described in 12,832
divisions (B) and (C) of this section. 12,833
(E) A certificate holder may designate any person to 12,835
receive on his THE CERTIFICATE HOLDER'S behalf the notice 12,836
required by division (B) of this section. The certificate holder 12,838
286
shall furnish the name and address of the person so designated to 12,839
the person to whom the group policy or contract has been 12,840
delivered or issued for delivery. 12,841
(F) No person shall knowingly fail to comply with division 12,843
(B) or (C) of this section. 12,844
Sec. 3999.36. (A) As used in this section and sections 12,854
3999.37 and 3999.38 of the Revised Code: 12,855
(1) "Insurer" means any person that is authorized to 12,857
engage in the business of insurance in this state under title 12,859
TITLE XXXIX of the Revised Code;, any prepaid dental plan 12,860
organization, medical care corporation, health care INSURING 12,861
corporation, dental care corporation, or health maintenance 12,863
organization; or any other person engaging either directly or 12,864
indirectly in this state in the business of insurance or entering 12,865
into contracts substantially amounting to insurance under section 12,866
3905.42 of the Revised Code. 12,867
(2) "Impaired" or "impairment" means a financial situation 12,869
in which the insurer's assets are less than the sum of the 12,870
insurer's minimum required capital, minimum required surplus, and 12,871
all liabilities, as determined in accordance with the 12,872
requirements for the preparation and filing of the insurer's 12,873
annual financial statement. 12,874
(3) "Chief executive officer" means the person, 12,876
irrespective of his THE PERSON'S title, designated by the board 12,877
of directors or trustees of an insurer as the person charged with 12,879
the responsibility of administering and implementing the 12,880
insurer's policies and procedures. 12,881
(B) Whenever a chief executive officer of an insurer knows 12,883
or has reason to know that the insurer is impaired, he THE CHIEF 12,884
EXECUTIVE OFFICER shall provide written notice of the impairment 12,886
to the superintendent of insurance and to each member of the 12,887
board of directors or trustees of the insurer. The chief 12,888
executive officer shall provide the notice as soon as reasonably 12,889
possible, but no later than thirty days after he THE CHIEF 12,890
287
EXECUTIVE OFFICER knows or has reason to know of the impairment. 12,892
No chief executive officer shall fail to provide notice in 12,893
compliance with this division.
(C) The notice received by the superintendent under 12,895
division (B) of this section is not a public record under section 12,896
149.43 of the Revised Code. 12,897
Sec. 4582.041. (A) Any port authority created under 12,906
section 4582.02 of the Revised Code may procure and pay all or 12,907
any part of the cost of group hospitalization, surgical, major 12,908
medical, sickness and accident insurance, or group life 12,909
insurance, or a combination of any of the foregoing types of 12,910
insurance or coverage for full-time employees and their immediate 12,911
dependents, whether issued by an insurance company or a medical 12,912
care corporation, duly authorized to do business in this state. 12,913
(B) Any port authority also may procure and pay all or any 12,915
part of the cost of a plan of group hospitalization, surgical, or 12,916
major medical insurance with a health care INSURING corporation 12,917
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,919
1751. of the Revised Code, provided that each full-time employee 12,921
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,923
insurance company or medical care corporation as provided in 12,924
division (A) of this section and such a plan offered by a health 12,925
care INSURING corporation under this division, on the condition 12,926
that the full-time employee shall pay any amount by which the 12,928
cost of the plan offered in this division exceeds the cost of the 12,929
plan offered under division (A) of this section; and 12,930
(2) Change from one of the two plans to the other at a 12,932
time each year as determined by the port authority. 12,933
Sec. 4582.29. (A) Any port authority created under 12,942
section 4582.22 of the Revised Code may procure and pay all or 12,943
any part of the cost of group hospitalization, surgical, major 12,944
medical, sickness and accident insurance, or group life 12,945
insurance, or a combination of any of the foregoing types of 12,946
288
insurance or coverage for full-time employees and their immediate 12,947
dependents, whether issued by an insurance company or a medical 12,948
care corporation, duly authorized to do business in this state. 12,949
(B) Any port authority also may procure and pay all or any 12,951
part of the cost of a plan of group hospitalization, surgical, or 12,952
major medical insurance with a health care INSURING corporation 12,953
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,955
1751. of the Revised Code, provided that each full-time employee 12,957
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,959
insurance company, hospital service association, or medical care 12,960
corporation as provided in division (A) of this section and a 12,961
plan offered by a health care INSURING corporation under this 12,962
division, on the condition that the full-time employee shall pay 12,964
any amount by which the cost of the plan offered in this division 12,965
exceeds the cost of the plan offered under division (A) of this 12,966
section; and
(2) Change from one of the two plans to the other at a 12,968
time each year as determined by the port authority. 12,969
Sec. 4715.02. The governor, with the advice and consent of 12,978
the senate, shall appoint a state dental board consisting of 12,979
seven persons, five of whom shall be graduates of a reputable 12,980
dental college, a citizen CITIZENS of the United States, and 12,981
shall have been in the legal and reputable practice of dentistry 12,982
in the state at least five years next preceding his THEIR 12,983
appointment; one of whom shall be a graduate of a reputable 12,984
school of dental hygiene, a citizen of the United States, and 12,985
shall have been in the legal and reputable practice of dental 12,986
hygiene in the state at least five years next preceding his THE 12,987
PERSON'S appointment; and one of whom shall be a member of the 12,989
public at large who is not associated with or financially 12,990
interested in the practice of dentistry. Terms of office shall 12,991
be for five years, commencing on the seventh day of April and 12,992
ending on the sixth day of April, except that upon expiration of 12,993
289
the term ending April 25, 1978, the new term which succeeds it 12,994
shall commence on April 26, 1978 and end on April 6, 1983; upon 12,995
expiration of the term ending July 23, 1974, the new term which 12,996
succeeds it shall commence on July 24, 1974 and end on April 6, 12,997
1979; and upon expiration of the term ending June 24, 1975, the 12,998
new term which succeeds it shall commence on June 25, 1975 and 12,999
end on April 6, 1980. Each member shall hold office from the 13,000
date of his THE MEMBER'S appointment until the end of the term 13,002
for which he THE MEMBER was appointed. Any member appointed to 13,004
fill a vacancy occurring prior to the expiration of the term for 13,005
which his THE MEMBER'S predecessor was appointed shall hold 13,007
office for the remainder of such term. Any member shall continue 13,008
in office subsequent to the expiration date of his THE MEMBER'S 13,009
term until his THE MEMBER'S successor takes office, or until a 13,010
period of sixty days has elapsed, whichever occurs first. No 13,012
person so appointed shall serve to exceed two terms. The Ohio 13,013
dental association may submit to the governor the names of five 13,014
nominees for each position to be filled by a dentist and from the 13,015
names so submitted or from others, at his THE GOVERNOR'S 13,016
discretion, the governor shall make such appointments; provided 13,018
that all such appointees shall possess the required 13,019
qualifications. The Ohio dental hygienists association, inc. 13,020
may submit to the governor the names of five nominees for each 13,021
position to be filled by a dental hygienist and from the names so 13,022
submitted or from others, at his THE GOVERNOR'S discretion, the 13,024
governor shall make such appointments; provided that all such
appointees shall possess the required qualifications. No person 13,025
shall be appointed to the state dental board who is employed by 13,026
or practices in a partnership, association, or corporation 13,027
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1740. 13,029
1751. of the Revised Code with a person who is a member of the 13,030
board.
Sec. 4719.01. (A) As used in sections 4719.01 to 4719.18 13,039
of the Revised Code: 13,040
290
(1) "Affiliate" means a business entity that is owned by, 13,042
operated by, controlled by, or under common control with another 13,043
business entity.
(2) "Communication" means a written or oral notification 13,045
or advertisement that meets both of the following criteria, as 13,046
applicable:
(a) The notification or advertisement is transmitted by or 13,048
on behalf of the seller of goods or services and by or through 13,049
any printed, audio, video, cinematic, telephonic, or electronic 13,050
means.
(b) In the case of a notification or advertisement other 13,052
than by telephone, either of the following conditions is met: 13,053
(i) The notification or advertisement is followed by a 13,055
telephone call from a telephone solicitor or salesperson. 13,056
(ii) The notification or advertisement invites a response 13,058
by telephone, and, during the course of that response, a 13,059
telephone solicitor or salesperson attempts to make or makes a 13,060
sale of goods or services. As used in division (A)(2)(b)(ii) of 13,061
this section, "invites a response by telephone" excludes the mere 13,062
listing or inclusion of a telephone number in a notification or 13,063
advertisement.
(3) "Gift, award, or prize" means anything of value that 13,066
is offered or purportedly offered, or given or purportedly given 13,067
by chance, at no cost to the receiver and with no obligation to 13,068
purchase goods or services. As used in this division, "chance"
includes a situation in which a person is guaranteed to receive 13,070
an item and, at the time of the offer or purported offer, the 13,071
telephone solicitor does not identify the specific item that the
person will receive. 13,072
(4) "Goods or services" means any real property or any 13,075
tangible or intangible personal property, or services of any kind 13,076
provided or offered to a person. "Goods or services" includes,
but is not limited to, advertising; labor performed for the 13,077
benefit of a person; personal property intended to be attached to 13,078
291
or installed in any real property, regardless of whether it is so 13,079
attached or installed; timeshare estates or licenses; and 13,080
extended service contracts.
(5) "Purchaser" means a person that is solicited to become 13,083
or does become financially obligated as a result of a telephone 13,084
solicitation.
(6) "Salesperson" means an individual who is employed, 13,086
appointed, or authorized by a telephone solicitor to make 13,088
telephone solicitations but does not mean any of the following:
(a) An individual who comes within one of the exemptions 13,090
in division (B) of this section; 13,091
(b) An individual employed, appointed, or authorized by a 13,093
person who comes within one of the exemptions in division (B) of 13,094
this section; 13,095
(c) An individual under a written contract with a person 13,097
who comes within one of the exemptions in division (B) of this 13,098
section, if liability for all transactions with purchasers is 13,099
assumed by the person so exempted. 13,100
(7) "Telephone solicitation" means a communication to a 13,102
person that meets both of the following criteria: 13,103
(a) The communication is initiated by or on behalf of a 13,105
telephone solicitor or by a salesperson. 13,106
(b) The communication either represents a price or the 13,108
quality or availability of goods or services or is used to induce 13,109
the person to purchase goods or services, including, but not 13,110
limited to, inducement through the offering of a gift, award, or 13,111
prize.
(8) "Telephone solicitor" means a person that engages in 13,113
telephone solicitation directly or through one or more 13,114
salespersons either from a location in this state or from a 13,115
location outside this state to persons in this state. "Telephone 13,116
solicitor" includes, but is not limited to, any such person that 13,117
is an owner, operator, officer, or director of, partner in, or 13,118
other individual engaged in the management activities of, a 13,119
292
business.
(B) A telephone solicitor is exempt from the provisions of 13,122
sections 4719.02 to 4719.18 and section 4719.99 of the Revised
Code if the telephone solicitor is any one of the following: 13,123
(1) A person engaging in a telephone solicitation that is 13,125
a one-time or infrequent transaction not done in the course of a 13,126
pattern of repeated transactions of a like nature; 13,127
(2) A person engaged in telephone solicitation solely for 13,129
religious or political purposes; a charitable organization, 13,130
fund-raising counsel, or professional solicitor in compliance 13,131
with the registration and reporting requirements of Chapter 1716. 13,132
of the Revised Code; or any person or other entity exempt under 13,133
section 1716.03 of the Revised Code from filing a registration 13,134
statement under section 1716.02 of the Revised Code; 13,136
(3) A person, making a telephone solicitation involving a 13,138
home solicitation sale as defined in section 1345.21 of the 13,139
Revised Code, that makes the sales presentation and completes the 13,140
sale at a later, face-to-face meeting between the seller and the 13,142
purchaser rather than during the telephone solicitation. 13,143
However, if the person, following the telephone solicitation, 13,144
causes another person to collect the payment of any money, this 13,145
exemption does not apply.
(4) A licensed securities, commodities, or investment 13,147
broker, dealer, investment advisor, or associated person when 13,148
making a telephone solicitation within the scope of the person's 13,149
license. As used in division (B)(4) of this section, "licensed 13,150
securities, commodities, or investment broker, dealer, investment 13,151
advisor, or associated person" means a person subject to 13,152
licensure or registration as such by the securities and exchange 13,153
commission; the National Association of Securities Dealers or 13,154
other self-regulatory organization, as defined by 15 U.S.C.A. 13,155
78c; by the division of securities under Chapter 1707. Revised 13,156
Code; or by an official or agency of any other state of the 13,157
United States.
293
(5)(a) A person primarily engaged in soliciting the sale 13,159
of a newspaper of general circulation; 13,160
(b) As used in division (B)(5)(a) of this section, 13,162
"newspaper of general circulation" includes, but is not limited 13,163
to, both of the following:
(i) A newspaper that is a daily law journal designated as 13,165
an official publisher of court calendars pursuant to section 13,166
2701.09 of the Revised Code;
(ii) A newspaper or publication that has at least 13,168
twenty-five per cent editorial, non-advertising content, 13,169
exclusive of inserts, measured relative to total publication 13,170
space, and an audited circulation to at least fifty per cent of 13,171
the households in the newspaper's retail trade zone as defined by
the audit. 13,172
(6)(a) An issuer, or its subsidiary, that has a class of 13,174
securities to which all of the following apply: 13,175
(i) The class of securities is subject to section 12 of 13,177
the "Securities Exchange Act of 1934," 15 U.S.C.A. 78l, and is 13,178
registered or is exempt from registration under 15 U.S.C.A. 13,180
78l(g)(2)(A), (B), (C), (E), (F), (G), or (H);
(ii) The class of securities is listed on the New York 13,183
stock exchange, the American stock exchange, or the NASDAQ 13,184
national market system;
(iii) The class of securities is a reported security as 13,186
defined in 17 C.F.R. 240.11Aa3-1(a)(4). 13,187
(b) An issuer, or its subsidiary, that formerly had a 13,189
class of securities that met the criteria set forth in division 13,190
(B)(6)(a) of this section if the issuer, or its subsidiary, has a 13,192
net worth in excess of one hundred million dollars, files or its 13,193
parent files with the securities and exchange commission an 13,194
S.E.C. form 10-K, and has continued in substantially the same 13,195
business since it had a class of securities that met the criteria
in division (B)(6)(a) of this section. As used in division 13,196
(B)(6)(b) of this section, "issuer" and "subsidiary" include the 13,197
294
successor to an issuer or subsidiary. 13,199
(7) A person soliciting a transaction regulated by the 13,201
commodity futures trading commission, if the person is registered 13,202
or temporarily registered for that activity with the commission 13,203
under 7 U.S.C.A. 1 et. seq. and the registration or temporary 13,204
registration has not expired or been suspended or revoked; 13,205
(8) A person soliciting the sale of any book, record, 13,207
audio tape, compact disc, or video, if the person allows the 13,208
purchaser to review the merchandise for at least seven days and 13,210
provides a full refund within thirty days to a purchaser who 13,211
returns the merchandise or if the person solicits the sale on 13,212
behalf of a membership club operating in compliance with 13,213
regulations adopted by the federal trade commission in 16 C.F.R. 13,214
425;
(9) A supervised financial institution or its subsidiary. 13,216
As used in division (B)(9) of this section, "supervised financial 13,218
institution" means a bank, trust company, savings and loan 13,219
association, savings bank, credit union, industrial loan company,
consumer finance lender, commercial finance lender, or 13,220
institution described in section 2(c)(2)(F) of the "Bank Holding 13,221
Company Act of 1956," 12 U.S.C.A. 1841(c)(2)(F), as amended, 13,222
supervised by an official or agency of the United States, this 13,223
state, or any other state of the United States; or a licensee or 13,224
registrant under sections 1321.01 to 1321.19, 1321.51 to 1321.60, 13,225
or 1321.71 to 1321.83 of the Revised Code. 13,226
(10)(a) An insurance company, association, or other 13,228
organization that is licensed or authorized to conduct business 13,229
in this state by the superintendent of insurance pursuant to 13,230
Title XXXIX of the Revised Code or Chapter 1736., 1737., 1738., 13,231
1739., 1740., or 1742. 1751. of the Revised Code, when soliciting 13,232
within the scope of its license or authorization. 13,233
(b) A licensed insurance broker, agent, or solicitor when 13,236
soliciting within the scope of the person's license. As used in 13,237
division (B)(10)(b) of this section, "licensed insurance broker, 13,238
295
agent, or solicitor" means any person licensed as an insurance 13,239
broker, agent, or solicitor by the superintendent of insurance 13,240
pursuant to Title XXXIX of the Revised Code.
(11) A person soliciting the sale of services provided by 13,242
a cable television system operating under authority of a 13,243
governmental franchise or permit; 13,244
(12) A person soliciting a business-to-business sale under 13,246
which any of the following conditions are met: 13,247
(a) The telephone solicitor has been operating 13,249
continuously for at least three years under the same business 13,250
name under which it solicits purchasers, and at least fifty-one 13,251
per cent of its gross dollar volume of sales consists of repeat 13,252
sales to existing customers to whom it has made sales under the 13,253
same business name.
(b) The purchaser business intends to resell the goods 13,256
purchased.
(c) The purchaser business intends to use the goods or 13,259
services purchased in a recycling, reuse, manufacturing, or
remanufacturing process. 13,260
(d) The telephone solicitor is a publisher of a periodical 13,262
or of magazineS distributed as controlled circulation 13,263
publicationS as defined in division (CC) of section 5739.01 of 13,264
the Revised Code and is soliciting sales of advertising, 13,265
subscriptions, reprints, lists, information databases, conference 13,266
participation or sponsorships, trade shows or media products 13,267
related to the periodical or magazine, or other publishing
services provided by the controlled circulation publication. 13,268
(13) A person that, not less often than once each year, 13,270
publishes and delivers to potential purchasers a catalog that 13,271
complies with both of the following: 13,272
(a) It includes all of the following: 13,274
(i) The business address of the seller; 13,276
(ii) A written description or illustration of each good or 13,279
service offered for sale;
296
(iii) A clear and conspicuous disclosure of the sale price 13,281
of each good or service; shipping, handling, and other charges; 13,283
and return policy;
(b) One of the following applies: 13,285
(i) The catalog includes at least twenty-four pages of 13,287
written material and illustrations, is distributed in more than 13,288
one state, and has an annual postage-paid mail circulation of not 13,289
less than two hundred fifty thousand households; 13,290
(ii) The catalog includes at least ten pages of written 13,292
material or an equivalent amount of material in electronic form 13,293
on the internet or an on-line computer service, the person does 13,294
not solicit customers by telephone but solely receives telephone 13,295
calls made in response to the catalog, and during the calls the 13,297
person takes orders but does not engage in further solicitation
of the purchaser. As used in division (B)(13)(b)(ii) of this 13,298
section, "further solicitation" does not include providing the 13,299
purchaser with information about, or attempting to sell, any 13,300
other item in the catalog that prompted the purchaser's call or 13,301
in a substantially similar catalog issued by the seller. 13,302
(14) A political subdivision or instrumentality of the 13,304
United States, this state, or any state of the United States; 13,306
(15) A college or university or any other public or 13,308
private institution of higher education in this state; 13,309
(16) A public utility, as defined in section 4905.02 of 13,311
the Revised Code, that is subject to regulation by the public 13,312
utilities commission, or its affiliate; 13,313
(17) A travel agency or tour promoter that is registered 13,315
in compliance with section 1333.96 of the Revised Code when 13,316
soliciting within the scope of the agency's or promoter's 13,317
registration;
(18) A person that solicits sales through a television 13,319
program or advertisement that is presented in the same market 13,320
area no fewer than twenty days per month or offers for sale no 13,321
fewer than ten distinct items of goods or services; and offers to 13,322
297
the purchaser an unconditional right to return any good or 13,323
service purchased within a period of at least seven days and to 13,324
receive a full refund within thirty days after the purchaser
returns the good or cancels the service; 13,325
(19)(a) A person that, for at least one year, has been 13,327
operating a retail business under the same name as that used in 13,328
connection with telephone solicitation and both of the following 13,329
occur on a continuing basis: 13,330
(i) The person either displays goods and offers them for 13,332
retail sale at the person's business premises or offers services 13,333
for sale and provides them at the person's business premises. 13,334
(ii) At least fifty-one per cent of the person's gross 13,337
dollar volume of retail sales involves purchases of goods or
services at the person's business premises. 13,338
(b) An affiliate of a person that meets the requirements 13,340
in division (B)(19)(a) of this section if the affiliate meets all 13,342
of the following requirements:
(i) The affiliate has operated a retail business for a 13,344
period of less than one year; 13,345
(ii) The affiliate either displays goods and offers them 13,347
for retail sale at the affiliate's business premises or offers 13,348
services for sale and provides them at the affiliate's business 13,349
premises;
(iii) At least fifty-one per cent of the affiliate's gross 13,351
dollar volume of retail sales involves purchases of goods or 13,352
services at the affiliate's business premises. 13,353
(c) A person that, for a period of less than one year, has 13,355
been operating a retail business in this state under the same 13,356
name as that used in connection with telephone solicitation, as 13,357
long as all of the following requirements are met: 13,358
(i) The person either displays goods and offers them for 13,360
retail sale at the person's business premises or offers services 13,361
for sale and provides them at the person's business premises; 13,362
(ii) The goods or services that are the subject of 13,364
298
telephone solicitation are sold at the person's business 13,365
premises, and at least sixty-five per cent of the person's gross 13,366
dollar volume of retail sales involves purchases of goods or 13,367
services at the person's business premises;
(iii) The person conducts all telephone solicitation 13,369
activities according to sections 310.3, 310.4, and 310.5 of the 13,370
telemarketing sales rule adopted by the federal trade commission 13,371
in 16 C.F.R. part 310.
(20) A person who performs telephone solicitation sales 13,373
services on behalf of other persons and to whom one of the 13,374
following applies:
(a) The person has operated under the same ownership, 13,376
control, and business name for at least five years, and the 13,377
person receives at least seventy-five per cent of its gross 13,378
revenues from written telephone solicitation contracts with 13,379
persons who come within one of the exemptions in division (B) of
this section. 13,380
(b) The person is an affiliate of one or more exempt 13,382
persons and makes telephone solicitations on behalf of only the 13,383
exempt persons of which it is an affiliate. 13,384
(c) The person makes telephone solicitations on behalf of 13,386
only exempt persons, the person and each exempt person on whose 13,387
behalf telephone solicitations are made have entered into a 13,388
written contract that specifies the manner in which the telephone 13,389
solicitations are to be conducted and that at a minimum requires 13,390
compliance with the telemarketing sales rule adopted by the
federal trade commission in 16 C.F.R. part 310, and the person 13,392
conducts the telephone solicitations in the manner specified in 13,393
the written contract.
(d) The person performs telephone solicitation for 13,395
religious or political purposes, a charitable organization, a 13,396
fund-raising council, or a professional solicitor in compliance 13,397
with the registration and reporting requirements of Chapter 1716. 13,398
of the Revised Code; and meets all of the following requirements: 13,399
299
(i) The person has operated under the same ownership, 13,401
control, and business name for at least five years, and the 13,402
person receives at least fifty-one per cent of its gross revenues 13,403
from written telephone solicitation contracts with persons who 13,404
come within the exemption in division (B)(2) of this section; 13,405
(ii) The person does not conduct a prize promotion or 13,407
offer the sale of an investment opportunity; and 13,408
(iii) The person conducts all telephone solicitation 13,410
activities according to sections 310.3, 310.4, and 310.5 of the 13,411
telemarketing sales rules adopted by the federal trade commission 13,412
in 16 C.F.R. part 310. 13,413
(21) A person that is a licensed real estate salesperson 13,415
or broker under Chapter 4735. of the Revised Code when soliciting 13,416
within the scope of the person's license; 13,417
(22) A publisher that solicits the sale of the publisher's 13,419
periodical or magazine of general, paid circulation, or a person 13,420
that solicits a sale of that nature on behalf of a publisher 13,421
under a written agreement directly between the publisher and the 13,422
person. As used in division (B)(22) of this section, "periodical 13,423
or magazine of general, paid circulation" excludes a periodical 13,424
or magazine circulated only as part of a membership package or 13,425
given as a free gift or prize from the publisher or person. 13,426
(23) A person that solicits the sale of food, as defined 13,428
in section 3715.01 of the Revised Code, or the sale of products 13,429
of horticulture, as defined in section 5739.01 of the Revised 13,430
Code, if the person does not intend the solicitation to result 13,431
in, or the solicitation actually does not result in, a sale that 13,432
costs the purchaser an amount greater than five hundred dollars.
(24) A funeral director licensed pursuant to Chapter 4717. 13,434
of the Revised Code when soliciting within the scope of that 13,435
license, if both of the following apply: 13,436
(a) The solicitation and sale are conducted in compliance 13,438
with 16 C.F.R. part 453, as adopted by the federal trade 13,439
commission, and with sections 1107.33 and 1345.21 to 1345.28 of 13,440
300
the Revised Code;
(b) The person provides to the purchaser of any preneed 13,442
funeral contract a notice that clearly and conspicuously sets 13,443
forth the cancellation rights specified in division (G) of 13,444
section 1107.33 of the Revised Code, and retains a copy of the 13,445
that notice signed by the purchaser.
(25) A person, or affiliate thereof, licensed to sell or 13,447
issue Ohio instruments designated as travelers checks pursuant to 13,448
sections 1315.01 to 1315.11 of the Revised Code. 13,449
(26) A person that solicits sales from its previous 13,451
purchasers and meets all of the following requirements: 13,452
(a) The solicitation is made under the same business name 13,454
that was previously used to sell goods or services to the 13,455
purchaser;
(b) The person has, for a period of not less than three 13,457
years, operated a business under the same business name as that 13,458
used in connection with telephone solicitation; 13,459
(c) The person does not conduct a prize promotion or offer 13,461
the sale of an investment opportunity; 13,462
(d) The person conducts all telephone solicitation 13,464
activities according to sections 310.3, 310.4, and 310.5 of the 13,465
telemarketing sales rules adopted by the federal trade commission 13,466
in 16 C.F.R. part 310;
(e) Neither the person nor any of its principals has been 13,468
convicted of, pleaded guilty to, or has entered a plea of no 13,469
contest for a felony or a theft offense as defined in sections 13,470
2901.02 and 2913.01 of the Revised Code or similar law of another 13,471
state or of the United States;
(f) Neither the person nor any of its principals has had 13,473
entered against them an injunction or a final judgment or order, 13,474
including an agreed judgment or order, an assurance of voluntary 13,475
compliance, or any similar instrument, in any civil or 13,476
administrative action involving engaging in a pattern of corrupt 13,477
practices, fraud, theft, embezzlement, fraudulent conversion, or 13,478
301
misappropriation of property; the use of any untrue, deceptive,
or misleading representation; or the use of any unfair, unlawful, 13,479
deceptive, or unconscionable trade act or practice. 13,480
(27) An institution defined as a home health agency in 13,482
section 3701.88 of the Revised Code, that conducts all telephone 13,483
solicitation activities according to sections 310.3, 310.4, and 13,484
310.5 of the telemarketing sales rules adopted by the federal 13,485
trade commission in 16 C.F.R. part 310, and engages in telephone 13,486
solicitation only within the scope of the institution's 13,487
certification, accreditation, contract with the department of
aging, or status as a home health agency; and that meets one of 13,488
the following requirements: 13,489
(a) The institution is certified as a provider of home 13,491
health services under Title XVIII of the Social Security Act, 49 13,493
Stat. 620, 42 U.S.C. 301, as amended; and is registered with the 13,494
department of health pursuant to division (B) of section 3701.88 13,495
of the Revised Code; 13,496
(b) The institution is accredited by either the joint 13,498
commission on accreditation of health care organizations or the 13,499
community health accreditation program; 13,500
(c) The institution is providing PASSPORT services under 13,503
the direction of the Ohio department of aging under section
173.40 of the Revised Code; 13,504
(d) An affiliate of an institution that meets the 13,506
requirements of division (B)(27)(a), (b), or (c) of this section 13,508
when offering for sale substantially the same goods and services 13,509
as those that are offered by the institution that meets the
requirements of division (B)(27)(a), (b), or (c) of this section. 13,511
(28) A person licensed to provide a hospice care program 13,513
by the department of health pursuant to section 3712.04 of the 13,514
Revised Code when conducting telephone solicitations within the 13,515
scope of the person's license and according to sections 310.3, 13,516
310.4, and 310.5 of the telemarketing sales rules adopted by the 13,517
federal trade commission in 16 C.F.R. part 310.
302
Sec. 4729.381. No licensed pharmacist shall be liable for 13,526
civil damages or in any criminal prosecution arising from the 13,527
dispensing of a drug based upon a formulary established by a 13,528
practitioner in a hospital, health maintenance organization 13,529
INSURING CORPORATION, or long-term care facility and requiring 13,530
the pharmacist to dispense the particular drug. 13,531
Sec. 4731.67. Section 4731.66 of the Revised Code does not 13,540
apply to any of the following referrals by the holder of a 13,541
certificate under this chapter: 13,542
(A) Referrals for physicians' services that are performed 13,544
by or under the personal supervision of a physician in the same 13,545
group practice as the referring physician; 13,546
(B) Referrals for clinical laboratory services by a 13,548
certificate holder specializing in the practice of pathology if 13,549
those services are provided by or under the supervision of the 13,550
pathologist pursuant to a consultation requested by another 13,551
physician; 13,552
(C) Referrals for in-office ancillary services to which 13,554
all of the following apply: 13,555
(1) The services are furnished by the referring physician, 13,557
a physician in the same group practice as the referring 13,558
physician, or individuals who are employed by the referring 13,559
physician or the group practice and who are supervised by the 13,560
referring physician or a physician in the group practice, and are 13,561
furnished either: 13,562
(a) In a building in which the referring physician, or 13,564
another physician in the same group practice as the referring 13,565
physician, furnishes physicians' services unrelated to the 13,566
furnishing of designated health services; 13,567
(b) In another building used by the referring physician's 13,569
group practice for the centralized provision of the group's 13,570
designated health services. 13,571
(2) The services are billed by the physician performing or 13,573
supervising the services, the physician's group practice, or an 13,574
303
entity wholly owned by the group practice. 13,575
(3) The physician's ownership or investment interest in 13,577
the services described in this division meets any other 13,578
requirements that the state medical board applies in rules 13,579
adopted under section 4731.70 of the Revised Code. 13,580
(D) "Referrals for in-office ancillary services if the 13,582
third-party payer is aware of and has agreed in writing to 13,583
reimburse the services notwithstanding the financial arrangement 13,584
between the physician and the provider of such ancillary 13,585
services. 13,586
(E) Referrals for services furnished by a health 13,588
maintenance organization INSURING CORPORATION to an enrollee of 13,589
the organization CORPORATION; 13,590
(F) Referrals to a hospital for designated health 13,593
services, if all of the following apply:
(1) The financial arrangement between the referring 13,595
physician or immediate family member and the hospital consists of 13,596
an ownership or investment interest described in division (A)(1) 13,597
of section 4731.66 of the Revised Code and not a compensation 13,598
arrangement described in division (A)(2) of that section. 13,599
(2) The referring physician is authorized to perform 13,601
services at the hospital. 13,602
(3) The ownership or investment interest is in the 13,604
hospital itself and not merely in a subdivision of the hospital. 13,605
(G) Referrals to a hospital with which the certificate 13,607
holder's or immediate family member's financial relationship does 13,608
not relate to the provision of designated health services; 13,610
(H) Referrals to a laboratory located in a rural area as 13,612
defined in section 1886(d)(2)(D) of the "Social Security Act," 49 13,613
Stat. 620 (1935), 42 U.S.C.A. 1395ww(d)(2)(D), as amended, if the 13,614
financial relationship consists of an ownership or investment 13,615
interest described in division (A)(1) of section 4731.66 of the 13,616
Revised Code, and not a compensation arrangement described in 13,617
division (A)(2) of that section; 13,618
304
(I) Any other referrals in which the financial 13,620
relationship between the certificate holder or immediate family 13,621
member and the person furnishing services has been specified in 13,622
rules adopted by the state medical board under section 4731.70 of 13,623
the Revised Code. 13,624
Sec. 5111.02. (A) Under the medical assistance program: 13,633
(1) Reimbursement by the department of human services to a 13,635
medical provider for any medical service rendered under the 13,636
program shall not exceed the authorized reimbursement level for 13,637
the same service under the medicare program established under 13,638
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 13,639
U.S.C.A. 301, as amended. 13,640
(2) Reimbursement for freestanding medical laboratory 13,642
charges shall not exceed the customary and usual fee for 13,643
laboratory profiles. 13,644
(3) The department may deduct from payments for services 13,646
rendered by a medicaid provider under the medical assistance 13,647
program any amounts the provider owes the state as the result of 13,648
incorrect medical assistance payments the department has made to 13,649
the provider. 13,650
(4) The department may conduct final fiscal audits in 13,652
accordance with the applicable requirements set forth in federal 13,653
laws and regulations and determine any amounts the provider may 13,654
owe the state. When conducting final fiscal audits, the 13,655
department shall consider generally accepted auditing standards, 13,656
which include the use of statistical sampling. 13,657
(5) To the maximum extent that federal laws and 13,659
regulations permit the implementation of such a policy, the 13,660
department may institute a copayment program for all services 13,661
provided under the medical assistance program. The program shall 13,662
be administered in accordance with the applicable requirements 13,663
set forth in federal laws and regulations. 13,664
(6) The number of days of inpatient hospital care for 13,666
which reimbursement is made on behalf of a recipient of medical 13,667
305
assistance to a hospital that is not paid under a 13,668
diagnostic-related-group prospective payment system shall not 13,669
exceed thirty days during a period beginning on the day of the 13,670
recipient's admission to the hospital and ending sixty days after 13,671
the termination of that hospital stay, except that the department 13,672
may make exceptions to this limitation. The limitation does not 13,673
apply to children participating in the program for medically 13,674
handicapped children established under section 3701.023 of the 13,675
Revised Code. 13,676
(B) The director of human services may adopt, amend, or 13,678
rescind rules under Chapter 119. of the Revised Code establishing 13,679
the amount, duration, and scope of medical services to be 13,680
included in the medical assistance program. Such rules shall 13,681
establish the conditions under which services are covered and 13,682
reimbursed, the method of reimbursement applicable to each 13,683
covered service, and the amount of reimbursement or, in lieu of 13,684
such amounts, methods by which such amounts are to be determined 13,685
for each covered service. Any rules that pertain to nursing 13,686
facilities or intermediate care facilities for the mentally 13,687
retarded shall be consistent with sections 5111.20 to 5111.33 of 13,688
the Revised Code. 13,689
(C) No health maintenance organization INSURING 13,691
CORPORATION that has a contract to provide health care services 13,693
to recipients of medical assistance shall restrict the 13,694
availability to its enrollees of any prescription drugs included 13,695
in the Ohio medicaid drug formulary as established under rules of 13,696
the department.
(D) The division of any reimbursement between a 13,698
collaborating physician or podiatrist and a clinical nurse 13,699
specialist, certified nurse-midwife, or certified nurse 13,700
practitioner for services performed by the nurse shall be 13,701
determined and agreed on by the nurse and collaborating physician 13,702
or podiatrist. In no case shall reimbursement exceed the payment
that the physician or podiatrist would have received had the 13,703
306
physician or podiatrist provided the entire service. 13,705
Sec. 5111.17. (A) As used in this section, 13,714
"community-based clinic" means a clinic that provides prenatal, 13,715
family planning, well child, or primary care services and is 13,716
funded in whole or in part by the state or federal government. 13,717
(B) On receipt of a waiver from the United States 13,719
department of health and human services of any federal 13,720
requirement that would otherwise be violated, the department of 13,721
human services shall establish in Franklin, Hamilton, and Lucas 13,722
counties a managed care system under which designated recipients 13,723
of medical assistance are required to obtain medical services 13,724
from providers designated by the department. The department may 13,725
stagger implementation of the managed care system, but the system 13,726
shall be implemented in at least one county not later than 13,727
January 1, 1995, and in all three counties not later than July 1, 13,728
1996.
(B)(C) The department, by rule adopted under this section, 13,730
may require any recipients in any other county to receive all or 13,731
some of their care through managed care organizations that 13,732
contract with the department and are paid by the department 13,733
pursuant to a capitation or other risk-based methodology 13,734
prescribed in the rules, and to receive their care only from 13,735
providers designated by the organizations.
(C)(D) In accordance with rules adopted under division 13,738
(E)(G) of this section, the department may issue requests for 13,739
proposals from managed care organizations interested in 13,740
contracting with the department to provide managed care to
participating medical assistance recipients. 13,741
(E) A health maintenance organization INSURING CORPORATION 13,744
under contract with the department under this section may enter 13,746
into an agreement with any community-based clinic for the 13,747
provision of medical services to medical assistance recipients
participating in the managed care system if the clinic is willing 13,748
to accept the terms, conditions, and payment procedures 13,749
307
established by the health maintenance organization INSURING 13,750
CORPORATION.
(D)(F) For the purpose of determining the amount the 13,752
department pays hospitals under section 5112.08 of the Revised 13,754
Code and the amount of disproportionate share hospital payments 13,755
paid by the medicare program established under Title XVIII of the 13,756
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 13,757
amended, each managed care organization under contract with the 13,758
department to provide managed care to participating medical
assistance recipients shall keep detailed records for each 13,759
hospital with which it contracts about the cost to the hospital 13,760
of providing the care, payments made by the organization to the 13,761
hospital for the care, utilization of hospital services by 13,762
medical assistance recipients participating in managed care, and
other utilization data required by the department. 13,763
(E)(G) The department shall adopt rules in accordance with 13,765
Chapter 119. of the Revised Code to implement this section. The 13,767
rules shall include all of the following: 13,768
(1) A monthly capitation or other risk-based payment rate 13,770
system for managed care organizations under contract to provide 13,771
managed care to participating medical assistance recipients; 13,773
(2) The method by which the department will issue requests 13,775
for proposals from managed care organizations interested in 13,776
providing managed care to participating medical assistance 13,777
recipients, including all of the following: 13,778
(a) Public notice of the department's intent to issue a 13,780
request for proposals within a county; 13,781
(b) The process for managed care organizations to submit 13,783
letters of interest;
(c) The procurement, selection, and implementation 13,785
timetable within each county; 13,786
(d) The time by which the department will furnish 13,788
interested managed care organizations with demographic, cost, and 13,789
utilization data about medical assistance recipients required or 13,790
308
permitted to enroll in a managed care organization in a county. 13,791
(3) Performance standards of managed care organizations 13,793
under contract with the department governing all of the 13,794
following:
(a) Scope of coverage and benefits; 13,796
(b) Quality assurance performance indicators for services 13,798
including prenatal care, immunizations, screenings that are part 13,799
of the early and periodic screening, diagnostic, and treatment 13,800
program, and any other service specified by the department; 13,801
(c) Service delivery system capacity; 13,803
(d) Reporting requirements; 13,805
(e) Grievance and complaint procedures; 13,807
(f) Enrollment and disenrollment procedures; 13,809
(g) Stop-loss arrangements; 13,811
(h) Marketing; 13,813
(i) Consumer and provider advisory councils; 13,815
(j) Any other requirement established by the department. 13,817
(4) A review process for any managed care organization 13,819
that has submitted a proposal to have the department reconsider 13,820
the denial of a contract under this section or termination of a 13,821
contract entered into under this section;
(5) Any other procedures or requirements the department 13,823
considers necessary to implement managed care. 13,824
Sec. 5111.171. On receipt of a waiver from the United 13,833
States department of health and human services of any federal 13,834
requirement that would be violated by implementation of this 13,835
section, the department shall establish a case management system 13,836
to ensure that recipients of medical assistance under this 13,837
chapter whose medical treatment and care is exceptionally 13,838
expensive receive medical services in a cost-effective manner. 13,839
Recipients identified by the department as being subject to this 13,840
division shall comply with the requirements of the case 13,841
management system as a condition of continued eligibility for 13,842
medical assistance. The department shall reimburse a hospital 13,843
309
under the medical assistance program for emergency services 13,844
covered by the medical assistance program provided to a medical 13,845
assistance recipient pursuant to section 1867 of the "Social 13,846
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 1395dd, as 13,847
amended, regardless of whether the hospital is participating in 13,848
the case management system. 13,849
A hospital's participation in the case management system 13,851
does not prevent its participation in the hospital care assurance 13,852
program established by sections 5112.01 to 5112.21 of the Revised 13,853
Code unless the hospital is operated by a health maintenance 13,854
organization INSURING CORPORATION. 13,855
Sec. 5111.19. The department of human services shall adopt 13,864
rules governing the calculation and payment of graduate medical 13,865
education costs associated with services rendered to recipients 13,866
of the medical assistance program after June 30, 1994. The rules 13,867
shall provide for reimbursement of graduate medical education 13,868
costs associated with services rendered to medical assistance 13,869
recipients, including recipients enrolled in health maintenance 13,870
organizations INSURING CORPORATIONS, that the department 13,871
determines are allowable and reasonable. 13,873
If the department requires a health maintenance 13,875
organization INSURING CORPORATION to pay a provider for graduate 13,876
medical education costs associated with the delivery of services 13,878
to medical assistance recipients enrolled in the organization 13,879
CORPORATION, the department shall include in its payment to the 13,881
organization CORPORATION an amount sufficient for the 13,883
organization CORPORATION to pay such costs. If the department 13,885
does not include in its payments to the organization HEALTH 13,886
INSURING CORPORATION amounts for graduate medical education costs 13,887
of providers, all of the following apply: 13,888
(A) The department shall pay the provider for graduate 13,890
medical education costs associated with the delivery of services 13,891
to medical assistance recipients enrolled in the organization 13,892
CORPORATION; 13,893
310
(B) No provider shall seek reimbursement from the 13,895
organization CORPORATION for such costs; 13,896
(C) The organization CORPORATION is not required to pay 13,898
providers for such costs. 13,900
Sec. 5111.74. (A) Not later than July 1, 1995, the 13,909
department of human services shall establish a fair share 13,910
demonstration project in Butler county for two years. The 13,911
demonstration project shall be administered by the Butler county 13,912
health care management board created under division (B) of this 13,913
section. In establishing the project, the department shall enter 13,914
into an agreement with the board, which shall provide that 13,915
medical assistance services be given to designated medical 13,916
assistance recipients who elect or are required by the department 13,917
to receive their services from or through the board or at least 13,918
one other managed care arrangement designated and approved by the 13,919
department.
The demonstration project shall demonstrate the viability 13,921
of delivering health care services to Butler county medical 13,922
assistance recipients through a cooperative health care 13,923
purchasing plan involving the organization of a managed care 13,924
network by physicians practicing medicine in Butler county and 13,925
hospitals located there. The demonstration project shall 13,926
restructure the medical assistance delivery system to improve the 13,927
delivery of cost effective, quality health care with an emphasis 13,928
on primary and preventive care, and shall prevent cost shifting 13,929
to the private sector. The demonstration project shall 13,930
demonstrate all of the following: 13,931
(1) A cost savings through prevention, the use of 13,933
appropriate levels of care, reduced administrative costs, and 13,934
utilization of the demonstration project through primary provider 13,935
reimbursement policies that encourage the delivery of primary and 13,936
preventive care; 13,937
(2) The effectiveness of local collaboration and autonomy 13,939
in managing medical assistance expenditures in Butler county; 13,940
311
(3) Improved access to quality health care for Butler 13,942
county's medical assistance recipients, while containing health 13,943
care costs. 13,944
The department shall make a grant of two hundred fifty 13,946
thousand dollars to the board on its establishment for operating 13,947
and project expenses. These funds shall be transferred from the 13,948
department's medical assistance account. 13,949
(B)(1) There is hereby created the Butler county health 13,951
care management board to administer the fair share demonstration 13,952
project in that county. The board shall consist of the county 13,953
director of human services and the following members: 13,954
(a) One representative of each hospital system located in 13,956
Butler county, selected by the hospital; 13,957
(b) Two physicians who specialize in pediatrics; two 13,959
family practice physicians; a physician who specializes in 13,960
obstetrics; an emergency department physician; a primary care 13,961
physician; a physician who is a medical specialist; a physician 13,962
who is a surgical specialist; a psychiatrist; and one physician 13,963
selected at large. The physicians shall be selected by the 13,964
county medical society or a similar organization of physicians in 13,965
the county. 13,966
(c) A chiropractor selected by an association of 13,968
chiropractors in the county; 13,969
(d) A licensed registered nurse who is an advanced 13,971
practice nurse selected by an organization of nurses in the 13,972
county; 13,973
(e) A dentist selected by an organization of dentists in 13,975
the county; 13,976
(f) An optometrist selected by an organization of 13,978
optometrists in the county; 13,979
(g) A psychologist selected by an organization of 13,981
psychologists in the county; 13,982
(h) A representative of child and family health services 13,984
clinics selected by the child health service consortium of Butler 13,985
312
county; 13,986
(i) A podiatrist selected by an organization of 13,988
podiatrists in the county. 13,989
(2) All members of the board shall be selected on the 13,991
basis of their experience with the delivery of health care 13,992
services to medical assistance recipients. If more than one 13,993
physician is to be selected from a specialty area, the order of 13,994
preference for determining board membership shall first be those 13,995
physicians that have significant experience in providing health 13,996
care services to medical assistance recipients. 13,997
(3) Each member of the board shall serve for the duration 13,999
of the demonstration project. In the event of a vacancy on the 14,000
board, a member shall be selected in the same manner as the 14,001
member he replaces REPLACED. Members shall not be compensated, 14,003
but may be reimbursed by the board for their actual and necessary 14,004
expenses. A majority of the members constitutes a quorum, and 14,005
the board may take official action only by affirmative vote of a 14,006
quorum.
(4) Not later than thirty days after July 1, 1993, the 14,008
representatives of the hospital systems in Butler county shall 14,010
select a temporary chairman CHAIRPERSON, who shall convene the 14,012
board not later than ninety days after July 1, 1993. Once
convened, the board shall elect a chairman CHAIRPERSON by a 14,014
majority vote from among its members, and all further meetings 14,016
shall be convened by the chairman CHAIRPERSON. The board may 14,018
elect officers and shall establish rules and procedures for its 14,019
governance and a schedule of meetings. The board may establish 14,020
an executive committee and such other subcommittees as it 14,021
determines necessary to act on behalf of the board. The county 14,022
department shall provide the board with any clerical,
professional, or technical assistance it requests. 14,023
(C) The Butler county health care management board shall 14,025
develop and implement a plan for the fair share demonstration 14,026
project. The board shall establish educational and case 14,027
313
management programs as it determines necessary to facilitate 14,028
access to and encourage appropriate utilization of essential 14,029
preventive medicine and primary care services. The board shall 14,030
have limited immunity from antitrust actions in developing and 14,031
implementing the project. The board shall apply for a 14,032
certificate of authority to establish and operate a health 14,033
maintenance organization INSURING CORPORATION under Chapter 1742. 14,035
1751. of the Revised Code. On application of the board, the 14,036
superintendent of insurance shall issue a certificate of 14,037
authority to the board for a two-year period, notwithstanding the 14,038
fact that the board may not meet the requirements of Chapter 14,039
1742. 1751. of the Revised Code. The certificate of authority 14,041
shall be void if the agreement with the department is not 14,042
executed. The superintendent shall retain powers and duties 14,043
under Chapter 3903. of the Revised Code with regard to the Butler 14,044
county health care management board and the demonstration 14,045
project.
The board may do any of the following: 14,047
(1) Enter into contracts with any person organized to do 14,049
business in this state on behalf of the board; 14,050
(2) Accept and spend donations, grants, and other funds 14,052
received by the board; 14,053
(3) Employ personnel and professionals that may be needed 14,055
to assess the feasibility and to develop the demonstration 14,056
project; 14,057
(4) Establish provider agreements in Butler county that 14,059
will organize a managed health care delivery system for medical 14,060
assistance recipients and will establish provider reimbursement 14,061
policies to encourage the delivery of primary health care 14,062
services; 14,063
(5) Monitor the quality of health care delivered to 14,065
medical assistance recipients in Butler county; 14,066
(6) Establish provider agreements with physicians and 14,068
other health care practitioners that set forth the terms, 14,069
314
conditions, and payment procedures for the provision of health 14,070
care services to medical assistance recipients. Any provider 14,071
willing to accept such terms and conditions shall be eligible for 14,072
participation in the project. 14,073
(7) Establish, in cooperation with the county medical 14,075
society, voluntary participation guidelines for the project for 14,076
physicians in Butler county to ensure that they provide health 14,077
care services to their fair share of medical assistance 14,078
recipients in the county. Such guidelines shall be communicated 14,079
to all medical providers providing services in Butler county. 14,080
(8) Require that all medical assistance recipients, other 14,082
than those described in division (A)(2) of section 5111.01 of the 14,083
Revised Code, who elect or are required by the department to 14,084
receive their medical assistance services through the board 14,085
choose a physician who is participating in the demonstration 14,087
project to provide all health care services to the recipient, and 14,088
adopt standards for changing physicians, including disenrollment 14,089
as provided by federal law;
(9) So long as it is consistent with federal law, 14,091
establish a co-pay system for the following: 14,092
(a) Provision of medical services under the demonstration 14,094
project; 14,095
(b) Inappropriate utilization of medical services; 14,097
(c) Over-utilization of medical services; 14,099
(d) Failure of a medical assistance recipient to appear 14,101
for a scheduled medical appointment. 14,102
(10) Enter into agreements with the board of nursing 14,104
authorizing advanced practice nurses, certified nurse 14,106
practitioners, clinical nurse specialists, and certified 14,107
nurse-midwives in Butler county to have prescription powers and 14,109
perform primary care services in collaboration with or under the
supervision of a physician or podiatrist in accordance with 14,111
division (D) of this section; 14,113
(11) Enter into agreements with the state medical board 14,115
315
authorizing physician assistants in Butler county to have 14,116
prescription powers and perform primary care services under the 14,117
general supervision and authority of a physician in accordance 14,118
with division (D) of this section.
(12) Assign medical assistance recipients, other than 14,120
those described in division (A)(2) of section 5111.01 of the 14,121
Revised Code, who elect or are required by the department to 14,122
receive their medical assistance services through the board, to 14,123
providers who have entered into provider agreements with the 14,125
board.
(D) The Butler county health care management board shall 14,127
pass a resolution by a majority vote establishing the terms and 14,128
conditions under which the scope of practice of advanced practice 14,129
nurses, certified nurse practitioners, clinical nurse 14,130
specialists, certified nurse-midwives, and physician assistants 14,131
in Butler county may be expanded. The expansion of practice for 14,133
advanced practice nurses shall comply with section 4723.56 of the 14,134
Revised Code. The expansion of practice for certified nurse 14,136
practitioners, clinical nurse specialists, and certified
nurse-midwives shall comply with Chapter 4723. of the Revised 14,137
Code. The expansion of practice for physician assistants shall 14,139
comply with sections 4730.06 and 4730.07 of the Revised Code. 14,140
The resolution shall be sent to the board of nursing and the Ohio 14,141
state medical board with a request that the scope of practice of 14,142
the practitioners be amended in accordance with the resolution. 14,143
On receipt of the resolution and request, the board of nursing 14,144
and the Ohio state medical board shall, without amendment, adopt 14,145
rules establishing the terms and conditions for expansion of the 14,146
scope of practice of advanced practice nurses, certified nurse 14,147
practitioners, clinical nurse specialists, certified 14,148
nurse-midwives, and physician assistants in Butler county in 14,150
accordance with the resolution. Such rules shall apply only to 14,151
such practitioners performing their duties in Butler county in 14,152
conjunction with and in accordance with the fair share 14,153
316
demonstration project.
(E) The department of human services may negotiate and 14,155
enter into an agreement with the board establishing a 14,156
comprehensive capitated fee for purposes of delivering health 14,157
care services to persons receiving benefits under Chapter 5107. 14,158
and section 5111.013 of the Revised Code, if the department 14,159
obtains a waiver from the secretary of the United States 14,160
department of health and human services of any federal regulation 14,161
that would prohibit or restrict the use of federal funds. The 14,162
department may include those persons described in division (A)(2) 14,163
of section 5111.01 of the Revised Code in the project as it 14,164
considers necessary. The capitated fee shall be based on 14,165
historic and expected utilization of the medical assistance 14,166
program by the Butler county medical assistance population, 14,167
adjusted by the current inflation rate, and shall be sufficient 14,168
to ensure that all Butler county primary care physicians 14,169
participating in the demonstration project are reimbursed for 14,170
office visits at a rate of not less than thirty dollars per 14,171
patient during the first year of the project, and not less than 14,172
thirty-five dollars per patient for the second year of the 14,173
project. Any savings of state funds the department of human 14,174
services receives as the result of the demonstration project 14,175
shall be distributed as follows: 14,176
(1) One-third of the savings to Butler county for 14,178
children's health programs; 14,179
(2) One-third of the savings to the department of human 14,181
services; 14,182
(3) One-third of the savings to providers participating in 14,184
the demonstration project. 14,185
(F) All provider agreements or any contracts entered into 14,187
or negotiated by the board shall be exempt from any contract 14,188
provision contained in a contract between medical providers and 14,189
health insurers or indemnity insurers licensed to do business in 14,190
this state that provides for a lower payment for the services. 14,192
317
(G) The Butler county health care management board shall, 14,194
at the end of each year of the demonstration project, issue a 14,195
report listing every medical provider practicing in Butler 14,196
county, the degree to which such provider has participated in the 14,197
demonstration project, and the extent to which such provider has 14,198
met the voluntary guidelines adopted by the board under division 14,199
(C)(7) of this section. 14,200
(H) The department of human services shall apply for any 14,202
federal waiver needed to implement the Butler county fair share 14,203
demonstration project. 14,204
Sec. 5115.10. (A) The disability assistance medical 14,213
assistance program shall consist of a system of managed primary 14,214
care. Until July 1, 1992, the program shall also include limited 14,215
hospital services, except that if prior to that date hospitals 14,216
are required by section 5112.17 of the Revised Code to provide 14,217
medical services without charge to persons specified in that 14,218
section, the program shall cease to include hospital services at 14,219
the time the requirement of section 5112.17 of the Revised Code 14,220
takes effect. 14,221
The state department of human services may require 14,223
disability assistance medical assistance recipients to enroll in 14,224
health maintenance organizations, preferred provider 14,226
organizations, INSURING CORPORATIONS or other managed care 14,227
programs, or may limit the number or type of health care 14,229
providers from which a recipient may receive services. 14,230
The state department shall adopt rules governing the 14,232
disability assistance medical assistance program established 14,233
under this division. The rules shall specify all of the 14,234
following: 14,235
(1) Services that will be provided under the system of 14,237
managed primary care; 14,238
(2) Hospital services that will be provided during the 14,240
period that hospital services are provided under the program; 14,241
(3) The maximum authorized amount, scope, duration, or 14,243
318
limit of payment for services. 14,244
(B) The director of human services shall designate medical 14,246
services providers for the disability assistance medical 14,247
assistance program. The first such designation shall be made not 14,248
later than September 30, 1991. Services under the program shall 14,249
be provided only by providers designated by the director. The 14,250
director may require that, as a condition of being designated a 14,251
disability assistance medical assistance provider, a provider 14,252
enter into a provider agreement with the state department. 14,253
(C) As long as the disability assistance medical 14,255
assistance program continues to include hospital services, the 14,256
state department or a county director of human services may, 14,257
pursuant to rules adopted by the state department under this 14,258
section, approve an application for disability assistance medical 14,259
assistance for emergency inpatient hospital services when care 14,260
has been given to a person who had not completed a sworn 14,261
application for disability assistance at the time the care was 14,262
rendered, if all of the following apply: 14,263
(1) The person files an application for disability 14,265
assistance within sixty days after being discharged from the 14,266
hospital or, if the conditions of division (D) of this section 14,267
are met, while in the hospital; 14,268
(2) The person met all eligibility requirements for 14,270
disability assistance at the time the care was rendered; 14,271
(3) The care given to the person was a medical service 14,273
within the scope of disability assistance medical assistance as 14,274
established under rules adopted by the department of human 14,275
services. 14,276
(D) If a person files an application for disability 14,278
assistance medical assistance for emergency inpatient hospital 14,279
services while in the hospital, a face-to-face interview shall be 14,280
conducted with the applicant while he THE APPLICANT is in the 14,281
hospital to determine whether he THE APPLICANT is eligible for 14,283
the assistance. If the hospital agrees to reimburse the county 14,285
319
department of human services for all actual costs incurred by the 14,286
department in conducting the interview, the interview shall be 14,287
conducted by an employee of the county department. If, at the 14,288
request of the hospital, the county department designates an 14,289
employee of the hospital to conduct the interview, the interview 14,290
shall be conducted by the hospital employee. 14,291
(E) The state department of human services may assume 14,293
responsibility for peer review of expenditures for disability 14,294
assistance medical assistance. 14,295
Sec. 5119.01. The director of mental health is the chief 14,308
executive and administrative officer of the department of mental 14,309
health. The director may establish procedures for the governance 14,310
of the department, conduct of its employees and officers, 14,311
performance of its business, and custody, use, and preservation 14,312
of departmental records, papers, books, documents, and property. 14,313
Whenever the Revised Code imposes a duty upon or requires an 14,314
action of the department or any of its institutions, the director 14,315
shall perform the action or duty in the name of the department, 14,316
except that the medical director appointed pursuant to section 14,317
5119.07 of the Revised Code shall be responsible for decisions 14,318
relating to medical diagnosis, treatment, rehabilitation, quality 14,319
assurance, and the clinical aspects of the following: licensure 14,320
of hospitals and residential facilities, research, community 14,321
mental health plans, and delivery of mental health services. 14,322
The director shall: 14,324
(A) Adopt rules for the proper execution of the powers and 14,326
duties of the department with respect to the institutions under 14,327
its control, and require the performance of additional duties by 14,328
the officers of the institutions as necessary to fully meet the 14,329
requirements, intents, and purposes of this chapter. In case of 14,330
an apparent conflict between the powers conferred upon any 14,331
managing officer and those conferred by such sections upon the 14,332
department, the presumption shall be conclusive in favor of the 14,333
department. 14,334
320
(B) Adopt rules for the nonpartisan management of the 14,336
institutions under the department's control. An officer or 14,337
employee of the department or any officer or employee of any 14,339
institution under its control who, by solicitation or otherwise, 14,340
exerts influence directly or indirectly to induce any other 14,341
officer or employee of the department or any of its institutions 14,342
to adopt the exerting officer's or employee's political views or 14,343
to favor any particular person, issue, or candidate for office 14,345
shall be removed from the exerting officer's or employee's office 14,346
or position, by the department in case of an officer or employee, 14,347
and by the governor in case of the director. 14,348
(C) Appoint such employees, including the medical 14,350
director, as are necessary for the efficient conduct of the 14,351
department, and prescribe their titles and duties; 14,352
(D) Prescribe the forms of affidavits, applications, 14,354
medical certificates, orders of hospitalization and release, and 14,355
all other forms, reports, and records that are required in the 14,356
hospitalization or admission and release of all persons to the 14,357
institutions under the control of the department, or are 14,358
otherwise required under this chapter or Chapter 5122. of the 14,359
Revised Code; 14,360
(E) Contract with hospitals licensed by the department 14,362
under section 5119.20 of the Revised Code for the care and 14,363
treatment of mentally ill patients, or with persons, 14,364
organizations, or agencies for the custody, supervision, care, or 14,365
treatment of mentally ill persons receiving services elsewhere 14,366
than within the enclosure of a hospital operated under section 14,367
5119.02 of the Revised Code; 14,368
(F) Exercise the powers and perform the duties relating to 14,370
community mental health facilities and services that are assigned 14,371
to the director under this chapter and Chapter 340. of the 14,372
Revised Code; 14,373
(G) Adopt rules under Chapter 119. of the Revised Code for 14,375
the establishment of minimum standards, including standards for 14,376
321
use of seclusion and restraint, of mental health services that 14,377
are not inconsistent with nationally recognized applicable 14,378
standards and that facilitate participation in federal assistance 14,379
programs; 14,380
(H) Develop and implement clinical evaluation and 14,382
monitoring of services that are operated by the department; 14,383
(I) At the director's discretion, adopt rules establishing 14,385
standards for the adequacy of services provided by community 14,387
mental health facilities, and certify the compliance of such 14,388
facilities with the standards for the purpose of authorizing 14,389
their participation in the health care plans of medical care 14,390
corporations under Chapter 1737., health care INSURING 14,391
corporations under Chapter 1738., 1751. and sickness and accident 14,393
insurance policies issued under Chapter 3923. of the Revised 14,394
Code;
(J) Adopt rules establishing standards for the performance 14,396
of evaluations by a forensic center or other psychiatric program 14,397
or facility of the mental condition of defendants ordered by the 14,398
court under section 2919.271, or 2945.371 of the Revised Code, 14,400
and for the treatment of defendants who have been found 14,401
incompetent to stand trial and ordered by the court under section 14,402
2945.38, 2945.39, 2945.401, or 2945.402 of the Revised Code to
receive treatment in facilities; 14,403
(K) On behalf of the department, have the authority and 14,405
responsibility for entering into contracts and other agreements; 14,406
(L) Prepare and publish regularly a state mental health 14,408
plan that describes the department's philosophy, current 14,409
activities, and long-term and short-term goals and activities. 14,410
(M) Adopt rules in accordance with Chapter 119. of the 14,412
Revised Code specifying the supplemental services that may be 14,413
provided through a trust authorized by section 1339.51 of the 14,414
Revised Code; 14,415
(N) Adopt rules in accordance with Chapter 119. of the 14,417
Revised Code establishing standards for the maintenance and 14,418
322
distribution to a beneficiary of assets of a trust authorized by 14,419
section 1339.51 of the Revised Code; 14,420
(O) As used in division (I) of this section: 14,422
(1) "Community mental health facility" means a facility 14,424
that provides community mental health services and is included in 14,426
the community mental health plan for the alcohol, drug addiction, 14,427
and mental health service district in which it is located. 14,428
(2) "Community mental health service" means services, 14,430
other than inpatient services, provided by a community mental 14,431
health facility. 14,432
Sec. 5119.202. No third-party payer shall directly or 14,442
indirectly reimburse, nor shall any person be obligated to pay 14,443
any hospital for psychiatric services for which a license is 14,444
required under section 5119.20 of the Revised Code unless the 14,445
hospital is licensed by the department of mental health.
As used in this section, "third-party payer" means a 14,447
medical care corporation licensed under Chapter 1737. of the 14,449
Revised Code, a health care INSURING corporation licensed under 14,451
Chapter 1738. 1751. of the Revised Code, an insurance company 14,452
that issues sickness and accident insurance in conformity with 14,453
Chapter 3923. of the Revised Code, a state-financed health 14,454
insurance program under Chapter 3701., 4123., or 5101. of the 14,455
Revised Code, or any self-insurance plan.
Sec. 5505.28. (A) The state highway patrol retirement 14,464
board may enter into an agreement with insurance companies, 14,465
medical or health care INSURING corporations, health maintenance 14,467
organizations, or government agencies authorized to do business 14,468
in the state for issuance of a policy or contract of health, 14,469
medical, hospital, or surgical benefits, or any combination 14,470
thereof, for those persons receiving pensions and subscribing to 14,472
the plan. Notwithstanding any other provision of this chapter, 14,473
the policy or contract may also include coverage for any eligible 14,474
individual's spouse and dependent children and for any of the 14,476
individual's sponsored dependents as the board considers 14,477
323
appropriate.
If all or any portion of the policy or contract premium is 14,479
to be paid by any individual receiving a service, disability, or 14,481
survivor pension or benefit, the individual shall, by written 14,483
authorization, instruct the board to deduct from the individual's 14,485
pension or benefit the premium agreed to be paid by the 14,486
individual to the company, corporation, or agency. 14,488
The board may contract for coverage on the basis of part or 14,491
all of the cost of the coverage to be paid from appropriate funds 14,492
of the state highway patrol retirement system. The cost paid 14,493
from the funds of the system shall be included in the employer's 14,495
contribution rate as provided by section 5505.15 of the Revised 14,496
Code.
(B) If the board provides health, medical, hospital, or 14,498
surgical benefits through any means other than a health 14,499
maintenance organization INSURING CORPORATION, it shall offer to 14,500
each individual eligible for the benefits the alternative of 14,503
receiving benefits through enrollment in a health maintenance 14,505
organization INSURING CORPORATION, if all of the following apply: 14,507
(1) The health maintenance organization INSURING 14,509
CORPORATION provides HEALTH CARE services in the geographical 14,511
area in which the individual lives; 14,512
(2) The eligible individual was receiving health care 14,514
benefits through a health maintenance organization OR A HEALTH 14,516
INSURING CORPORATION before retirement; 14,517
(3) The rate and coverage provided by the health 14,519
maintenance organization INSURING CORPORATION to eligible 14,520
individuals is comparable to that currently provided by the board 14,523
under division (A) of this section. If the rate or coverage 14,524
provided by the health maintenance organization INSURING 14,525
CORPORATION is not comparable to that currently provided by the 14,527
board under division (A) of this section, the board may deduct 14,528
the additional cost from the eligible individual's monthly 14,530
benefit.
324
The health maintenance organization INSURING CORPORATION 14,532
shall accept as an enrollee any eligible individual who requests 14,534
enrollment.
The board shall permit each eligible individual to change 14,536
from one plan to another at least once a year at a time 14,538
determined by the board. 14,539
(C) The board shall, beginning the month following receipt 14,541
of satisfactory evidence of the payment for coverage, pay monthly 14,542
to each recipient of a pension under the state highway patrol 14,544
retirement system who is eligible for medical insurance coverage 14,545
under part B of "The Social Security Amendments of 1965," 79 14,546
Stat. 301, 42 U.S.C.A. 1395j, as amended, the lesser of an 14,547
amount equal to the basic premium for such coverage or an amount 14,549
equal to the basic premium for such coverage in effect on January 14,551
1, 1994.
(D) The board shall establish by rule requirements for the 14,553
coordination of any coverage, payment, or benefit provided under 14,555
this section with any similar coverage, payment, or benefit made 14,556
available to the same individual by the public employees 14,557
retirement system, police and firemen's disability and pension 14,558
fund, state teachers retirement system, or school employees 14,559
retirement system. 14,560
(E) The board shall make all other necessary rules 14,562
pursuant to the purpose and intent of this section. 14,563
Sec. 5505.33. (A) As used in this section: 14,572
(1) "Long-term care insurance" has the same meaning as in 14,574
section 3923.41 of the Revised Code. 14,575
(2) "Retirement systems" has the same meaning as in 14,577
division (A) of section 145.581 of the Revised Code. 14,578
(B) The state highway patrol retirement board shall 14,580
establish a program under which members of the retirement system, 14,581
employers on behalf of members, and persons receiving service or 14,582
disability pensions or survivor benefits are permitted to 14,583
participate in contracts for long-term care insurance. 14,584
325
Participation may include dependents and family members. If a 14,585
participant in a contract for long-term care insurance leaves his 14,586
employment, he THE PERSON and his THE PERSON'S dependents and 14,588
family members may, at their election, continue to participate in 14,589
a program established under this section in the same manner as if 14,590
he THE PERSON had not left his employment, except that no part of 14,592
the cost of the insurance shall be paid by his THE PERSON'S 14,593
former employer. Such program may be established independently 14,595
or jointly with one or more of the retirement systems. 14,596
(C) The board may enter into an agreement with insurance 14,598
companies, medical or health care INSURING corporations, health 14,600
maintenance organizations, or government agencies authorized to 14,601
do business in the state for issuance of a long-term care 14,602
insurance policy or contract. However, prior to entering into 14,603
such an agreement with an insurance company, medical or health 14,604
care INSURING corporation, or health maintenance organization, 14,606
the board shall request the superintendent of insurance to 14,607
certify the financial condition of the company, OR corporation, 14,608
or organization. The board shall not enter into the agreement 14,610
if, according to that certification, the company, OR corporation, 14,611
or organization is insolvent, is determined by the superintendent 14,613
to be potentially unable to fulfill its contractual obligations, 14,614
or is placed under an order of rehabilitation or conservation by 14,615
a court of competent jurisdiction or under an order of 14,616
supervision by the superintendent. 14,617
(D) The board shall adopt rules in accordance with section 14,619
111.15 of the Revised Code governing the program. The rules 14,620
shall establish methods of payment for participation under this 14,621
section, which may include establishment of a payroll deduction 14,622
plan under section 5505.203 of the Revised Code, deduction of the 14,623
full premium charged from a person's service or disability 14,624
pension or survivor benefit, or any other method of payment 14,625
considered appropriate by the board. If the program is 14,626
established jointly with one or more of the other retirement 14,627
326
systems, the rules also shall establish the terms and conditions 14,628
of such joint participation. 14,629
Sec. 5923.051. Notwithstanding any collective bargaining 14,638
agreement or other agreement or law to the contrary, the state 14,639
and any agency, authority, commission, or board thereof, shall, 14,640
at the request of any person employed by the entity who is called 14,641
to active duty as specified in division (B) of section 5923.05 of 14,642
the Revised Code, or at the request of the spouse or dependent of 14,643
that person, continue or reactivate the health, medical, 14,644
hospital, dental, vision, and surgical benefits coverage, whether 14,645
provided by an insurance company, medical care corporation, 14,646
health care INSURING corporation, health maintenance 14,647
organization, or other health plan or entity, of that person for 14,649
the duration of the time the person is on active duty as 14,650
described in that division. The person or the spouse or 14,651
dependent thereof who requests the continuation or reactivation 14,652
of the coverage and the employing state or agency, authority, 14,653
commission, or board thereof, each are liable for payment of the 14,654
same costs for the coverage as if the person were not on a leave 14,655
of absence.
Section 2. That existing sections 101.271, 124.81, 124.82, 14,657
124.822, 124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 14,658
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 14,659
1319.12, 1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 14,660
1901.312, 2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 14,661
3307.74, 3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 14,662
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 14,663
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 14,664
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 14,665
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 14,666
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 14,667
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 14,668
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 14,670
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 14,671
327
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 14,673
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, 14,674
1736.12, 1736.13, 1736.14, 1736.15, 1736.16, 1736.17, 1736.18, 14,675
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 1736.24, 1736.25, 14,676
1736.26, 1736.27, 1736.28, 1737.01, 1737.02, 1737.03, 1737.04, 14,677
1737.05, 1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 1737.11, 14,678
1737.12, 1737.13, 1737.14, 1737.15, 1737.16, 1737.17, 1737.18, 14,679
1737.19, 1737.20, 1737.21, 1737.22, 1737.23, 1737.24, 1737.25, 14,680
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 1737.301, 1737.31, 14,681
1737.32, 1737.99, 1738.01, 1738.02, 1738.03, 1738.04, 1738.05, 14,682
1738.06, 1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 1738.12, 14,683
1738.13, 1738.14, 1738.15, 1738.16, 1738.17, 1738.18, 1738.19, 14,684
1738.20, 1738.21, 1738.22, 1738.23, 1738.24, 1738.25, 1738.26, 14,685
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 1738.99, 1740.01, 14,686
1740.02, 1740.03, 1740.04, 1740.05, 1740.06, 1740.07, 1740.08, 14,687
1740.09, 1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 1740.15, 14,688
1740.16, 1740.17, 1740.18, 1740.19, 1740.20, 1740.21, 1740.22, 14,689
1740.23, 1740.24, 1740.25, 1740.26, 1740.99, 1742.01, 1742.02, 14,690
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 1742.08, 1742.09, 14,691
1742.10, 1742.11, 1742.12, 1742.13, 1742.131, 1742.14, 1742.141, 14,692
1742.15, 1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 1742.19, 14,693
1742.20, 1742.21, 1742.22, 1742.23, 1742.24, 1742.25, 1742.26, 14,694
1742.27, 1742.28, 1742.29, 1742.30, 1742.301, 1742.31, 1742.32, 14,695
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 1742.37, 1742.38, 14,696
1742.39, 1742.40, 1742.41, 1742.42, 1742.43, 1742.44, and 1742.45 14,697
of the Revised Code are hereby repealed. 14,698
Section 3. (A) The certificate of authority of every 14,700
prepaid dental plan organization, health care corporation, dental 14,701
care corporation, and health maintenance organization licensed to 14,703
operate under Chapter 1736., 1738., 1740., or 1742. of the 14,705
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 14,708
328
Chapter 1751. of the Revised Code. All assets and liabilities of 14,709
the prepaid dental plan organization, health care corporation, 14,710
dental care corporation, or health maintenance organization, 14,711
including all obligations under subscriber contracts delivered, 14,712
issued for delivery, or renewed prior to the effective date of 14,713
this section, shall be assumed by the successor entity. Except 14,714
as otherwise provided in division (B) of this section, such 14,715
entity shall, no later than January 1, 1998, comply with Chapter 14,716
1751. of the Revised Code. 14,717
(B)(1) Each entity described in division (A) of this 14,719
section shall do both of the following: 14,720
(a) Comply with sections 1751.19 and 1751.26 of the 14,723
Revised Code no later than six months after the effective date of
this section. 14,724
(b) Comply with section 1751.28 of the Revised Code by 14,727
making annual deposits with the Superintendent of Insurance, no 14,728
later than the first day of January of each year, for up to three 14,729
years, beginning the first day of January immediately following 14,730
the effective date of this section. 14,731
(2) Every contract delivered, issued for delivery, or 14,733
renewed by an entity described in division (A) of this section 14,734
prior to the effective date of this section shall comply with 14,735
section 1751.13 of the Revised Code no later than the contract's 14,737
first renewal date after the first day of January immediately 14,738
following the effective date of this section. 14,740
(3) Every contract delivered, issued for delivery, or 14,743
renewed by an entity described in division (A) of this section 14,744
prior to the effective date of this section shall comply with 14,745
section 1751.31 of the Revised Code no later than three months 14,746
after the effective date of this section. 14,747
(4) An entity described in division (A) of this section 14,749
may comply with section 1751.27 of the Revised Code by making 14,750
annual deposits with the Superintendent of Insurance, not later 14,751
than the first day of January of each year, for up to three years 14,752
329
beginning the first day of January immediately following the 14,753
effective date of this section. An equal amount shall be 14,754
deposited each year until the total amount required under section 14,755
1751.27 of the Revised Code has been deposited. 14,756
Section 4. On and after the effective date of this 14,758
section, the Department of Insurance shall no longer accept new 14,759
applications for certificates of authority to operate under 14,760
Chapter 1736., 1737., 1738., 1740., or 1742. of the Revised Code, 14,761
and shall not issue any such certificates of authority. Any such 14,762
application received by the Department of Insurance that is 14,763
pending on the effective date of this section shall be considered 14,764
an application for a certificate of authority to operate under 14,765
Chapter 1751. of the Revised Code, and the review period for that 14,766
application shall begin to run on the effective date of this 14,767
section.
Section 5. The member of the Board of Directors of the 14,769
Ohio Small Employer Health Reinsurance Program who, on the 14,770
effective date of this section, is serving pursuant to section 14,771
3924.08 of the Revised Code as the member carrier that is a 14,772
health maintenance organization predominantly in the small 14,773
employer market, shall continue in office until the end of the 14,774
term for which the member was appointed. Thereafter, that 14,775
appointment shall be filled by a member carrier that is a health 14,776
insuring corporation predominantly in the small employer market. 14,777
Section 6. Section 1751.64 of the Revised Code is hereby 14,779
repealed, effective February 9, 2004. The repeal of that section 14,781
shall apply only to contracts that are delivered, issued for 14,782
delivery, or renewed in this state on or after that date.
Section 7. Every provision for mandated health benefits, 14,784
as defined in section 3901.71 of the Revised Code, that is 14,785
contained in Chapter 1751. of the Revised Code, shall be applied 14,787
to every policy, contract, certificate, or agreement of a health 14,788
insuring corporation on the effective date of the section in 14,789
which the provision is contained, notwithstanding section 3901.71 14,790
330
of the Revised Code.
Section 8. Section 5119.01 of the Revised Code is 14,792
presented in this act as a composite of the section as amended by 14,793
both Sub. H.B. 670 and Am. Sub. S.B. 285 of the 121st General 14,794
Assembly, with the new language of neither of the acts shown in 14,796
capital letters. This is in recognition of the principle stated 14,797
in division (B) of section 1.52 of the Revised Code that such 14,798
amendments are to be harmonized where not substantively 14,799
irreconcilable and constitutes a legislative finding that such is 14,800
the resulting version in effect prior to the effective date of 14,801
this act.