As Passed by the House 1
122nd General Assembly 4
Regular Session Am. Sub. S. B. No. 67 5
1997-1998 6
SENATORS GILLMOR-ZALESKI-HOWARD-OELSLAGER-WATTS-LATELL-RAY- 8
LATTA-DRAKE-REPRESENTATIVES VAN VYVEN-REID-MOTTLEY-METELSKY- 9
LEWIS-GARCIA-HAINES-BRADING-MILLER-VESPER-JERSE-O'BRIEN- 10
WINKLER-OPFER-ROBERTS-PATTON-GRENDELL-PERZ-THOMPSON 11
13
A B I L L
To amend sections 101.271, 124.81, 124.82, 124.822, 15
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 16
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 17
742.45, 742.53, 1319.12, 1337.16, 1545.071, 18
1731.01, 1731.06, 1739.05, 1901.111, 1901.312,
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 19
3113.217, 3307.74, 3307.741, 3309.69, 3309.691, 20
3313.202, 3375.40, 3381.14, 3501.141, 3701.24, 21
3701.76, 3702.51, 3702.62, 3709.16, 3729.12,
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 22
3901.19, 3901.31, 3901.32, 3901.38, 3901.40, 24
3901.41, 3901.48, 3901.72, 3902.01, 3902.02,
3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 25
3923.30, 3923.301, 3923.33, 3923.333, 3923.38, 27
3923.382, 3923.41, 3923.51, 3923.54, 3923.58,
3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 29
3924.13, 3924.41, 3924.61, 3924.62, 3924.64,
3924.73, 3929.77, 3956.01, 3959.01, 3999.32, 30
3999.36, 4582.041, 4582.29, 4715.02, 4719.01, 31
4729.381, 4731.67, 5111.02, 5111.17, 5111.171,
5111.19, 5111.74, 5115.10, 5119.01, 5119.202, 33
5505.28, 5505.33, and 5923.051; to enact sections 34
1751.01 to 1751.08, 1751.11 to 1751.21, 1751.25 35
to 1751.28, 1751.31 to 1751.36, 1751.38, 1751.40,
1751.42, 1751.44 to 1751.48, 1751.51 to 1751.56, 36
2
1751.59 to 1751.67, 1751.70, and 1751.71; and to 38
repeal sections 1736.01, 1736.02, 1736.03,
1736.04, 1736.05, 1736.06, 1736.07, 1736.08, 40
1736.09, 1736.10, 1736.11, 1736.12, 1736.13, 41
1736.14, 1736.15, 1736.16, 1736.17, 1736.18,
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 42
1736.24, 1736.25, 1736.26, 1736.27, 1736.28, 44
1737.01, 1737.02, 1737.03, 1737.04, 1737.05,
1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 45
1737.11, 1737.12, 1737.13, 1737.14, 1737.15, 47
1737.16, 1737.17, 1737.18, 1737.19, 1737.20, 48
1737.21, 1737.22, 1737.23, 1737.24, 1737.25,
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 49
1737.301, 1737.31, 1737.32, 1737.99, 1738.01, 51
1738.02, 1738.03, 1738.04, 1738.05, 1738.06,
1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 52
1738.12, 1738.13, 1738.14, 1738.15, 1738.16, 54
1738.17, 1738.18, 1738.19, 1738.20, 1738.21, 55
1738.22, 1738.23, 1738.24, 1738.25, 1738.26,
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 56
1738.99, 1740.01, 1740.02, 1740.03, 1740.04, 58
1740.05, 1740.06, 1740.07, 1740.08, 1740.09,
1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 59
1740.15, 1740.16, 1740.17, 1740.18, 1740.19, 61
1740.20, 1740.21, 1740.22, 1740.23, 1740.24, 62
1740.25, 1740.26, 1740.99, 1742.01, 1742.02,
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 63
1742.08, 1742.09, 1742.10, 1742.11, 1742.12, 64
1742.13, 1742.131, 1742.14, 1742.141, 1742.15,
1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 65
1742.19, 1742.20, 1742.21, 1742.22, 1742.23, 66
1742.24, 1742.25, 1742.26, 1742.27, 1742.28, 67
1742.29, 1742.30, 1742.301, 1742.31, 1742.32,
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 68
3
1742.37, 1742.38, 1742.39, 1742.40, 1742.41, 69
1742.42, 1742.43, 1742.44, and 1742.45 of the
Revised Code to provide for the establishment, 70
operation, and regulation of health insuring 71
corporations; to repeal the laws governing
prepaid dental plan organizations, medical care 72
corporations, health care corporations, dental 73
care corporations, and health maintenance 74
organizations; to eliminate certain provisions of 75
this act on and after February 9, 2004, by
repealing section 1751.64 of the Revised Code on 76
that date; and to declare an emergency. 77
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 79
Section 1. That sections 101.271, 124.81, 124.82, 124.822, 81
124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 305.171, 82
306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 1319.12, 83
1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 1901.312, 84
2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 3307.74, 85
3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 86
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 87
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 88
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 89
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 90
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 91
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 92
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 94
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 95
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 97
5923.051 be amended and sections 1751.01, 1751.02, 1751.03, 98
1751.04, 1751.05, 1751.06, 1751.07, 1751.08, 1751.11, 1751.12, 99
1751.13, 1751.14, 1751.15, 1751.16, 1751.17, 1751.18, 1751.19, 100
1751.20, 1751.21, 1751.25, 1751.26, 1751.27, 1751.28, 1751.31, 102
4
1751.32, 1751.33, 1751.34, 1751.35, 1751.36, 1751.38, 1751.40, 103
1751.42, 1751.44, 1751.45, 1751.46, 1751.47, 1751.48, 1751.51, 104
1751.52, 1751.53, 1751.54, 1751.55, 1751.56, 1751.59, 1751.60, 105
1751.61, 1751.62, 1751.63, 1751.64, 1751.65, 1751.66, 1751.67, 106
1751.70, and 1751.71 of the Revised Code be enacted to read as 108
follows:
Sec. 101.271. (A) As used in this section, "medical 117
insurance premium" means any premium payment made under a 118
contract with an insurance company, nonprofit health plan, health 119
care INSURING corporation, health maintenance organization, or 121
any combination of such organizations, pursuant to section 124.82 122
of the Revised Code. 123
(B) After the general election in each even-numbered year, 125
the clerk of the senate, with the assistance of the department of 126
administrative services, shall estimate the cost of the medical 127
insurance premiums that will be necessary to provide coverage, on 128
the same basis as for a similarly situated state employee, for 129
each person who is elected to a term as senator at such election, 130
or appointed to fill the unexpired portion of any such term, and 131
any of his THE SENATOR'S dependents qualified for coverage at the 133
time he THE SENATOR assumes office. Using this estimate, the 134
clerk shall determine a fixed amount to be paid by the state in 135
equal monthly installments on behalf of the senator each year of 136
his THE SENATOR'S term as a medical insurance premium, but in no 137
event in an amount to exceed the total premium required in any 139
month by the contract of the state by the carrier. Any amount 140
not paid in such a case shall be placed in reserve and applied 141
against any subsequent month's premium up to the full amount 142
thereof until the entire amount has been paid along with the 143
original estimate for each month. This fixed amount shall be 144
such that, as nearly as can be predicted, the sum of the monthly 145
premiums paid for the senator during his THE SENATOR'S term shall 147
equal the total amount of medical insurance premiums that will be 148
paid for such an employee, as required by section 124.82 of the 149
5
Revised Code, during that term. The senator shall pay the 150
difference between the amount so fixed and the total premium 151
required by the contract of the state with the carrier.
(C) After the general election in each even-numbered year, 153
the executive secretary of the house of representatives, with the 154
assistance of the department of administrative services, shall 155
estimate the cost of the medical insurance premiums that will be 156
necessary to provide coverage, on the same basis as for a 157
similarly situated state employee, for each person who is elected 158
to a term as representative at such election, or appointed to 159
fill the unexpired portion of any such term, and any of his THE 160
REPRESENTATIVE'S dependents qualified for coverage at the time he 161
THE REPRESENTATIVE assumes office. Using this estimate, the 162
executive secretary shall determine a fixed amount to be paid by 163
the state in equal monthly installments on behalf of the 165
representative each year of his THE REPRESENTATIVE'S term as a 167
medical insurance premium, but in no event in an amount to exceed 168
the total premium required in any month by the contract of the 169
state with the carrier. Any amount not paid in such a case shall 170
be placed in reserve and applied against any subsequent month's 171
premium up to the full amount thereof until the entire reserve 172
has been paid along with the original estimate for each month. 173
This fixed amount shall be such that, as nearly as can be 174
predicted, the sum of the monthly premiums paid for the
representative during his THE REPRESENTATIVE'S term shall equal 175
the total amount of medical insurance premiums that will be paid 177
for such an employee, as required by section 124.82 of the 178
Revised Code, during that term. The representative shall pay the 179
difference between the amount so fixed and the total premium 180
required by the contract of the state with the carrier. 181
Sec. 124.81. (A) Except as provided in division (E) of 190
this section, the department of administrative services in 191
consultation with the superintendent of insurance shall negotiate 192
with and, in accordance with the competitive selection procedures 193
6
of Chapter 125. of the Revised Code, contract with one or more 194
insurance companies authorized to do business in this state, for 195
the issuance of one of the following: 196
(1) A policy of group life insurance covering all state 198
employees who are paid directly by warrant of the state auditor, 199
including elected state officials; 200
(2) A combined policy, or coordinated policies of one or 202
more insurance companies, medical care corporations, health care 203
corporations, dental care corporations, or health maintenance 204
INSURING corporations in combination with one or more insurance 205
companies providing group life and health, medical, hospital, 207
dental, or surgical insurance, or any combination thereof, 208
covering all such employees; 209
(3) A policy that may include, but is not limited to, 211
hospitalization, surgical, major medical, dental, vision, and 212
medical care, disability, hearing aids, prescription drugs, group 213
life, life, sickness, and accident insurance, group legal 214
services, or a combination of the above benefits for some or all 215
of the employees paid in accordance with section 124.152 of the 216
Revised Code and for some or all of the employees listed in 217
divisions (B)(2) and (4) of section 124.14 of the Revised Code, 218
and their immediate dependents. 219
(B) If a state employee uses all accumulated sick leave 222
and then goes on an extended medical disability, the policyholder 223
shall continue at no cost to the employee the coverage of the 224
group life insurance for such employee for the period of such 225
extended leave, but not beyond three years.
(C) If a state employee insured under a group life 228
insurance policy as provided in division (A) of this section is 229
laid off pursuant to section 124.32 of the Revised Code, such
employee by request to the policyholder, made no later than the 230
effective date of the layoff, may elect to continue the 231
employee's group life insurance for the one-year period through 232
which the employee may be considered to be on laid-off status by 233
7
paying the policyholder through payroll deduction or otherwise 235
twelve times the monthly premium computed at the existing average 236
rate for the group life case for the amount of the employee's 237
insurance thereunder at the time of the employee's layoff. The 239
policyholder shall pay the premiums to the insurance company at 241
the time of the next regular monthly premium payment for the 242
actively insured employees and furnish the company appropriate 243
data as to such laid-off employees. At the time an employee 244
receives written notice of a layoff, the policyholder shall also 245
give such employee written notice of the opportunity to continue 246
group life insurance in accordance with this division. When such 248
laid-off employee is reinstated for active work before the end of 249
the one-year period, the employee shall be reclassified as 251
insured again as an active employee under the group and 252
appropriate refunds for the number of full months of unearned 253
premium payment shall be made by the policyholder.
(D) This section does not affect the conversion rights of 255
an insured employee when the employee's group insurance 256
terminates under the policy. 257
(E) Notwithstanding division (A) of this section, the 259
department may provide benefits equivalent to those that may be 260
paid under a policy issued by an insurance company, or the 261
department may, to comply with a collectively bargained contract, 262
enter into an agreement with a jointly administered trust fund 263
which receives contributions pursuant to a collective bargaining 264
agreement entered into between this state, or any of its 265
political subdivisions, and any collective bargaining 266
representative of the employees of this state or any political 267
subdivision for the purpose of providing for self-insurance of 268
all risk in the provision of fringe benefits similar to those 269
that may be paid pursuant to division (A) of this section, and 270
the jointly administered trust fund may provide through the 271
self-insurance method specific fringe benefits as authorized by 272
the rules of the board of trustees of the jointly administered 273
8
trust fund. Amounts from the fund may be used to pay direct and 274
indirect costs that are attributable to consultants or a 275
third-party administrator and that are necessary to administer 276
this section. Benefits provided under this section include, but 277
are not limited to, hospitalization, surgical care, major medical 278
care, disability, dental care, vision care, medical care, hearing 279
aids, prescription drugs, group life insurance, sickness and 280
accident insurance, group legal services, or a combination of the 281
above benefits, for the employees and their immediate dependents. 282
(F) Notwithstanding any other provision of the Revised 284
Code, any public employer, including the state, and any of its 285
political subdivisions, including, but not limited to, any 286
county, county hospital, municipal corporation, township, park 287
district, school district, state institution of higher education, 288
public or special district, state agency, authority, commission, 289
or board, or any other branch of public employment, and any 290
collective bargaining representative of employees of the state or 291
any political subdivision may agree in a collective bargaining 292
agreement that any mutually agreed fringe benefit including, but 293
not limited to, hospitalization, surgical care, major medical 294
care, disability, dental care, vision care, medical care, hearing 295
aids, prescription drugs, group life insurance, sickness and 296
accident insurance, group legal services, or a combination 297
thereof, for employees and their dependents be provided through a 298
mutually agreed upon contribution to a jointly administered trust 299
fund. Amounts from the fund may be used to pay direct and 300
indirect costs that are attributable to consultants or a 301
third-party administrator and that are necessary to administer 302
this section. The amount, type, and structure of fringe benefits 304
provided under this division is subject to the determination of 305
the board of trustees of the jointly administered trust fund. 306
Notwithstanding any other provision of the Revised Code, 307
competitive bidding does not apply to the purchase of fringe 308
benefits for employees under this division through a jointly 309
9
administered trust fund. 310
Sec. 124.82. (A) Except as provided in division (D) of 319
this section, the department of administrative services, in 320
consultation with the superintendent of insurance, shall, in 321
accordance with competitive selection procedures of Chapter 125. 322
of the Revised Code, contract with an insurance company or a 324
nonprofit health plan in combination with an insurance company, 325
authorized to do business in this state, for the issuance of a 326
policy or contract of health, medical, hospital, dental, or 327
surgical benefits, or any combination thereof, covering state 328
employees who are paid directly by warrant of the auditor of 329
state, including elected state officials. The department may 330
fulfill its obligation under this division by exercising its 331
authority under division (A)(2) of section 124.81 of the Revised 332
Code.
(B) The department may, in addition, in consultation with 334
the superintendent of insurance, negotiate and contract with 335
health care INSURING corporations organized HOLDING A CERTIFICATE 337
OF AUTHORITY under Chapter 1738. 1751. of the Revised Code, in 338
their APPROVED service areas only, for issuance of any policy or 339
policies or contract or contracts of health, medical, hospital, 340
dental, or surgical benefits, or any combination thereof, or with 341
health maintenance organizations organized under Chapter 1742. of 342
the Revised Code, in their service areas only, for issuance of a 343
contract or contracts of health care services, covering state 344
employees who are paid directly by warrant of the auditor of 345
state, including elected state officials. Except for health care 346
corporation and health maintenance organization plans INSURING 347
CORPORATIONS, no more than one insurance carrier or nonprofit 348
health plan, shall be contracted with to provide the same plan of 350
benefits, provided that:
(1) The amount of the premium or cost for such coverage 352
contributed by the state, for an individual or for an individual 353
and his THE INDIVIDUAL'S family, does not exceed that same amount 355
10
of the premium or cost contributed by the state under division 356
(A) of this section; 357
(2) The employee be permitted to exercise his THE option 359
as to which plan he THE EMPLOYEE will select under division (A) 360
or (B) of this section, at a set time each year, which time shall 362
be determined by the department; 363
(3) The health care INSURING corporations or the health 365
maintenance organizations do not refuse to accept the employee, 366
or the employee and his THE EMPLOYEE'S family, if he THE EMPLOYEE 368
exercises the option to select care provided by the corporations 369
or organizations;
(4) The employee may choose participation in only one of 371
the plans sponsored by the department; 372
(5) The director of health examines and certifies to the 374
department that the quality and adequacy of care rendered by the 375
health care INSURING corporations or the health maintenance 376
organizations meet at least the standards of care provided by 377
hospitals and physicians in that employee's community, who would 378
be providing such care as would be covered by a contract awarded 379
under division (A) of this section. 380
(C) All or any portion of the cost, premium, or charge for 382
the coverage in divisions (A) and (B) of this section may be paid 383
in such manner or combination of manners as the department 384
determines and may include the proration of health care costs, 385
premiums, or charges for part-time employees. 386
(D) Notwithstanding division (A) of this section, the 388
department may provide benefits equivalent to those that may be 389
paid under a policy or contract issued by an insurance company or 390
a nonprofit health plan pursuant to division (A) of this section. 391
(E) This section does not prohibit the state office of 393
collective bargaining from entering into an agreement with an 394
employee representative for the purposes of providing fringe 395
benefits including, but not limited to, hospitalization, surgical 396
care, major medical care, disability, dental care, vision care, 397
11
medical care, hearing aids, prescription drugs, group life 398
insurance, sickness and accident insurance, group legal services 399
or other benefits, or any combination thereof, to employees paid 400
directly by warrant of the auditor of state through a jointly 401
administered trust fund. The employer's contribution for the 402
cost of the benefit care shall be mutually agreed to in the 403
collectively bargained agreement. The amount, type, and 404
structure of fringe benefits provided under this division is 405
subject to the determination of the board of trustees of the 406
jointly administered trust fund. Notwithstanding any other 407
provision of the Revised Code, competitive bidding does not apply 408
to the purchase of fringe benefits for employees under this 409
division when such benefits are provided through a jointly 410
administered trust fund. 411
Sec. 124.822. (A) The department of administrative 421
services shall require, as a condition of entering into a 422
contract with a health maintenance organization INSURING 423
CORPORATION that desires to provide health care services to state 425
employees, including elected public officials, who are paid 426
directly by warrant of the auditor of state and who reside within 427
its APPROVED service area, that the health maintenance 428
organization INSURING CORPORATION enroll at least five hundred of 429
such eligible state employees, or at least five per cent of such 430
eligible state employees, whichever is less. 431
(B) Division (A) of this section applies only to contracts 433
that are entered into or renewed on or after the effective date 434
of this section JULY 16, 1991. 435
Sec. 124.84. (A) The department of administrative 444
services, in consultation with the superintendent of insurance 445
and subject to division (D) of this section, shall negotiate and 446
contract with, one or more insurance companies, medical or health 448
care INSURING corporations, or health maintenance organizations 450
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 452
12
state employees who are paid directly by warrant of the auditor 453
of state, including elected state officials. Any policy 454
purchased under this division shall be negotiated and entered 455
into in accordance with the competitive selection procedures 456
specified in Chapter 125. of the Revised Code. As used in this 457
section, "long-term care insurance" has the same meaning as in 458
section 3923.41 of the Revised Code. 459
(B) Any elected state official or state employee paid 461
directly by warrant of the auditor of state may elect to 462
participate in any long-term care insurance policy purchased 463
under division (A) of this section and any official or employee 464
who does so shall be responsible for paying the entire premium 465
charged, which shall be deducted from the official's or 466
employee's salary or wage and be remitted by the auditor of state 468
directly to the insurance company, medical or health care 469
INSURING corporation, or health maintenance organization. 470
Participation in the policy may include the dependents and family 471
members of the elected state official or state employee. 472
If a participant in a long-term care insurance policy 474
leaves employment, the participant and the participant's 476
dependents and family members may, at their election, continue to 477
participate in a policy established under this section in the 478
same manner as if the participant had not left employment. 479
(C) Any long-term care insurance policy purchased under 481
this section or section 124.841 or 145.581 of the Revised Code 482
shall provide for all of the following with respect to the 483
premiums charged for the policy: 484
(1) They shall be set at the entry age of the official or 486
employee when first covered by the policy and shall not increase 487
except as a class during coverage under the policy. 488
(2) They shall be based on the class of all officials or 490
employees covered by the policy. 491
(3) They shall continue, pursuant to section 145.581 of 493
the Revised Code, after the retirement of the official or 494
13
employee who is covered under the policy, at the rate in effect 495
on the date of the official's or employee's retirement. 496
(D) Prior to entering into a contract with an insurance 498
company, medical or health care INSURING corporation, or health 500
maintenance organization for the purchase of a long-term care
insurance policy under this section, the department shall request 501
the superintendent of insurance to certify the financial 502
condition of the company, OR corporation, or organization. The 504
department shall not enter into the contract if, according to 505
that certification, the company, OR corporation, or organization 507
is insolvent, is determined by the superintendent to be
potentially unable to fulfill its contractual obligations, or is 509
placed under an order of rehabilitation or conservation by a 510
court of competent jurisdiction or under an order of supervision 511
by the superintendent. 512
(E) The department shall adopt rules in accordance with 514
section 111.15 of the Revised Code governing long-term care 515
insurance purchased under this section. The rules shall 516
establish methods of payment for participation under this 517
section, which may include establishment of a payroll deduction 518
plan. 519
Sec. 124.841. (A) As used in this section: 528
(1) "Long-term care insurance" has the same meaning as in 530
section 3923.41 of the Revised Code. 531
(2) "Political subdivision" has the same meaning as in 533
section 9.833 of the Revised Code. 534
(B) Any political subdivision may negotiate with and may 536
contract with, one or more insurance companies, medical or health 538
care INSURING corporations, or health maintenance organizations 539
authorized to operate or do business in this state for the
purchase of a policy of long-term care insurance covering all 540
elected officials and employees of the political subdivision. 542
The contract may be entered into without competitive bidding. 543
Any elected official or employee of a political subdivision may 544
14
elect to participate in any long-term care insurance policy that 545
the political subdivision purchases under this division and any 546
official or employee who does so shall be responsible for paying 547
the entire premium charged, which shall be deducted from his THE 548
OFFICIAL'S OR EMPLOYEE'S salary or wage and be remitted directly 549
to the insurance company, medical or health care INSURING 550
corporation, or health maintenance organization. 551
(C) Any long-term care insurance policy entered into under 553
this section is subject to division (C) of section 124.84 of the 554
Revised Code. 555
Sec. 124.92. If the superintendent of insurance has 564
approved all or a portion of a service area expansion of a health 565
maintenance organization INSURING CORPORATION into an additional 566
county or counties, the department of administrative services 567
shall authorize the organization CORPORATION, at the next open 568
enrollment period conducted by the department, to participate in 569
the open enrollment for state employees who reside in the 570
expanded service area, if both of the following apply:
(A) The open enrollment is conducted in accordance with 572
section 1742.12 1751.15 of the Revised Code; 573
(B) Prior to the expansion of the service area, fewer than 575
two health maintenance organizations INSURING CORPORATIONS were 576
available to state employees in the county or counties into which 578
the organization CORPORATION expanded.
Sec. 124.93. (A) As used in this section, "physician" 587
means any person who holds a valid certificate to practice 588
medicine and surgery or osteopathic medicine and surgery issued 589
under Chapter 4731. of the Revised Code. 590
(B) No health maintenace organization INSURING CORPORATION 592
that, on or after the effective date of this section JULY 1, 595
1993, enters into or renews a contract with the department of 596
administrative services under section 124.82 of the Revised Code 597
shall, because of a physician's race, color, religion, sex, 598
national origin, handicap, age, or ancestry, refuse to contract 599
15
with that physician for the provision of health care services 600
under that section. 601
Any health maintenance organization INSURING CORPORATION 603
that violates this division is deemed to have engaged in an 604
unlawful discriminatory practice as defined in section 4112.02 of 605
the Revised Code and is subject to Chapter 4112. of the Revised 606
Code.
(C) Each health maintenance organization INSURING 608
CORPORATION that, on or after the efective date of this section 610
JULY 1, 1993, enters into or renews a contract with the 612
department of administrative services under section 124.82 of the 613
Revised Code and that refuses to contract with a physician for 614
the provision of health care services under that section shall 615
provide that physician with a written notice that clearly 616
explains the reason or reasons for the refusal. The notice shall 617
be sent to the physician by regular mail within thirty days after 618
the refusal.
Any health maintenance organization INSURING CORPORATION 620
that fails to provide notice in compliance with this division is 621
deemed to have engaged in an unfair and deceptive act or practice 622
in the business of insurance as defined in section 3901.21 of the 623
Revised Code and is subject to sections 3901.19 to 3901.26 of the 624
Revised Code.
Sec. 145.58. (A) As used in this section, "ineligible 633
individual" means all of the following: 634
(1) A former member receiving benefits pursuant to section 636
145.32, 145.33, 145.331, 145.34, or 145.46 of the Revised Code 637
for whom eligibility is established more than five years after 638
June 13, 1981, and who, at the time of establishing eligibility, 639
has accrued less than ten years' service credit, exclusive of 640
credit obtained pursuant to section 145.297 or 145.298 of the 641
Revised Code, credit obtained after January 29, 1981, pursuant to 642
section 145.293 or 145.301 of the Revised Code, and credit 643
obtained after May 4, 1992, pursuant to section 145.28 of the 644
16
Revised Code; 645
(2) The spouse of the former member; 647
(3) The beneficiary of the former member receiving 649
benefits pursuant to section 145.46 of the Revised Code. 650
(B) The public employees retirement board may enter into 652
agreements with insurance companies, medical or health care 653
INSURING corporations, health maintenance organizations, or 655
government agencies authorized to do business in the state for 656
issuance of a policy or contract of health, medical, hospital, or 657
surgical benefits, or any combination thereof, for those 658
individuals receiving age and service retirement or a disability 660
or survivor benefit subscribing to the plan, or for PERS 661
retirants employed under section 145.38 of the Revised Code, for 662
coverage of benefits in accordance with division (D)(4)(b) of 663
section 145.38 of the Revised Code. Notwithstanding any other 664
provision of this chapter, the policy or contract may also 665
include coverage for any eligible individual's spouse and 666
dependent children and for any of the individual's sponsored 667
dependents as the board determines appropriate. If all or any 669
portion of the policy or contract premium is to be paid by any 670
individual receiving age and service retirement or a disability 671
or survivor benefit, the individual shall, by written 672
authorization, instruct the board to deduct the premium agreed to 674
be paid by the individual to the company, corporation, or agency. 676
The board may contract for coverage on the basis of part or 679
all of the cost of the coverage to be paid from appropriate funds 680
of the public employees retirement system. The cost paid from 681
the funds of the system shall be included in the employer's 683
contribution rate provided by sections 145.48 and 145.51 of the 684
Revised Code. The board may by rule provide coverage to 685
ineligible individuals if the coverage is provided at no cost to 686
the retirement system. The board shall not pay or reimburse the 687
cost for coverage under this section or section 145.325 of the 688
Revised Code for any ineligible individual.
17
The board may provide for self-insurance of risk or level 690
of risk as set forth in the contract with the companies, 691
corporations, or agencies, and may provide through the 692
self-insurance method specific benefits as authorized by rules of 693
the board. 694
(C) If the board provides health, medical, hospital, or 696
surgical benefits through any means other than a health 697
maintenance organization INSURING CORPORATION, it shall offer to 698
each individual eligible for the benefits the alternative of 701
receiving benefits through enrollment in a health maintenance 703
organization INSURING CORPORATION, if all of the following apply: 705
(1) The health maintenance organization INSURING 707
CORPORATION provides services in the geographical area in which 709
the individual lives; 710
(2) The eligible individual was receiving health care 712
benefits through a health maintenance organization OR A HEALTH 714
INSURING CORPORATION before retirement; 715
(3) The rate and coverage provided by the health 717
maintenance organization INSURING CORPORATION to eligible 718
individuals is comparable to that currently provided by the board 721
under division (B) of this section. If the rate or coverage 722
provided by the health maintenance organization INSURING 723
CORPORATION is not comparable to that currently provided by the 725
board under division (B) of this section, the board may deduct 726
the additional cost from the eligible individual's monthly 727
benefit.
The health maintenance organization INSURING CORPORATION 729
shall accept as an enrollee any eligible individual who requests 731
enrollment.
The board shall permit each eligible individual to change 733
from one plan to another at least once a year at a time 735
determined by the board. 736
(D) The board shall, beginning the month following receipt 738
of satisfactory evidence of the payment for coverage, pay monthly 739
18
to each recipient of service retirement, or a disability or 740
survivor benefit under the public employees retirement system who 741
is eligible for medical insurance coverage under part B of Title 742
XVIII of "The Social Security Act," 79 Stat. 301 (1965), 42 743
U.S.C.A. 1395j, as amended, an amount equal to the basic premium 744
for such coverage, except that the board shall make no such 746
payment to any ineligible individual.
(E) The board shall establish by rule requirements for the 748
coordination of any coverage, payment, or benefit provided under 750
this section or section 145.325 of the Revised Code with any 751
similar coverage, payment, or benefit made available to the same 752
individual by the police and firemen's disability and pension
fund, state teachers retirement system, school employees 753
retirement system, or state highway patrol retirement system. 754
(F) The board shall make all other necessary rules 758
pursuant to the purpose and intent of this section. 759
Sec. 145.581. (A) As used in this section: 768
(1) "Long-term care insurance" has the same meaning as in 770
section 3923.41 of the Revised Code. 771
(2) "Retirement systems" means the public employees 773
retirement system, the police and firemen's disability and 775
pension fund, the state teachers retirement system, the school 776
employees retirement system, and the state highway patrol 777
retirement system. 778
(B) The public employees retirement board shall establish 780
a long-term care insurance program consisting of the programs 781
authorized by divisions (C) and (D) of this section. Such 782
program may be established independently or jointly with one or 783
more of the other retirement systems. If the program is 784
established jointly, the board shall adopt rules in accordance 785
with section 111.15 of the Revised Code to establish the terms 786
and conditions of such joint participation. 787
(C) The board shall establish a program under which it 789
makes long-term care insurance available to any person who 790
19
participated in a policy of long-term care insurance for which 791
the state or a political subdivision contracted under section 792
124.84 or 124.841 of the Revised Code and is the recipient of a 793
pension, benefit, or allowance from the system. To implement the 794
program under this division, the board, subject to division (E) 795
of this section, may enter into an agreement with the insurance 796
company, medical or health care INSURING corporation, health 798
maintenance organization, or government agency that provided the
insurance. The board shall, under any such agreement, deduct the 799
full premium charged from the person's benefit, pension, or 800
allowance notwithstanding any employer agreement to the contrary. 801
Any long-term care insurance policy entered into under this 803
division is subject to division (C) of section 124.84 of the 804
Revised Code. 805
(D)(1) The board, subject to division (E) of this section, 807
shall establish a program under which a recipient of a pension, 808
benefit, or allowance from the system who is not eligible for 809
such insurance under division (C) of this section may participate 810
in a contract for long-term care insurance. Participation may 811
include the recipient's dependents and family members. 812
(2) The board shall adopt rules in accordance with section 814
111.15 of the Revised Code governing the program. The rules 815
shall establish methods of payment for participation under this 816
section, which may include deduction of the full premium charged 817
from a recipient's pension, benefit, or allowance, or any other 818
method of payment considered appropriate by the board. 819
(E) Prior to entering into any agreement or contract with 821
an insurance company, medical or health care INSURING 823
corporation, or health maintenance organization for the purchase
of, or participation in, a long-term care insurance policy under 824
this section, the board shall request the superintendent of 825
insurance to certify the financial condition of the company, OR 826
corporation, or organization. The board shall not enter into the 827
agreement or contract if, according to that certification, the 829
20
company, OR corporation, or organization is insolvent, is 830
determined by the superintendent to be potentially unable to 831
fulfill its contractual obligations, or is placed under an order 832
of rehabilitation or conservation by a court of competent 833
jurisdiction or under an order of supervision by the 834
superintendent. 835
Sec. 305.171. (A) The board of county commissioners of 844
any county may contract for, purchase, or otherwise procure and 845
pay all or any part of the cost of group insurance policies that 846
may provide benefits including, but not limited to, 847
hospitalization, surgical care, major medical care, disability, 848
dental care, eye care, medical care, hearing aids, or 849
prescription drugs, and that may provide sickness and accident 850
insurance, group legal services, or group life insurance, or a 851
combination of any of the foregoing types of insurance or 852
coverage for county officers and employees and their immediate 853
dependents from the funds or budgets from which the officers or 854
employees are compensated for services, issued by an insurance 855
company, a medical care corporation organized under Chapter 1737. 856
of the Revised Code, or a dental care corporation organized under 857
Chapter 1740. of the Revised Code. 858
(B) The board also may negotiate and contract for any plan 860
or plans of group insurance or health care services with health 861
care INSURING corporations organized HOLDING A CERTIFICATE OF 863
AUTHORITY under Chapter 1738. 1751. of the Revised Code and 864
health maintenance organizations organized under Chapter 1742. of 865
the Revised Code, provided that each officer or employee shall be 866
permitted to do both of the following:
(1) Exercise an option between a plan offered by an 868
insurance company, medical care corporation, or dental care 869
corporation, and such plan or plans offered by health care 870
INSURING corporations or health maintenance organizations under 871
this division, on the condition that the officer or employee 872
shall pay any amount by which the cost of the plan chosen by such 873
21
officer or employee pursuant to this division exceeds the cost of 874
the plan offered under division (A) of this section; 875
(2) Change from one of the plans to another at a time each 877
year as determined by the board. 878
(C) Section 307.86 of the Revised Code does not apply to 880
the purchase of benefits for county officers or employees under 881
divisions (A) and (B) of this section when those benefits are 882
provided through a jointly administered health and welfare trust 883
fund in which the county or contracting authority and a 884
collective bargaining representative of the county employees or 885
contracting authority agree to participate. 886
(D) The board of trustees of a jointly administered trust 888
fund that receives contributions pursuant to collective 889
bargaining agreements entered into between the board of county 890
commissioners of any county and a collective bargaining 891
representative of the employees of the county may provide for 892
self-insurance of all risk in the provision of fringe benefits, 893
and may provide through the self-insurance method specific fringe 894
benefits as authorized by the rules of the board of trustees of 895
the jointly administered trust fund. The fringe benefits may 896
include, but are not limited to, hospitalization, surgical care, 897
major medical care, disability, dental care, vision care, medical 898
care, hearing aids, prescription drugs, group life insurance, 899
sickness and accident insurance, group legal services, or a 900
combination of any of the foregoing types of insurance or 901
coverage, for employees and their dependents. 902
(E) The board of county commissioners may provide the 904
benefits described in divisions (A) to (D) of this section 905
through an individual self-insurance program or a joint 906
self-insurance program as provided in section 9.833 of the 907
Revised Code. 908
(F) When a board of county commissioners offers health 910
benefits authorized under this section to an officer or employee 911
of the county, the board may offer the benefits through a 912
22
cafeteria plan meeting the requirements of section 125 of the 913
"Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 125, 914
as amended, and, as part of that plan, may offer the officer or
employee the option of receiving a cash payment in any form 915
permissible under such cafeteria plans. A cash payment made to 916
an officer or employee under this division shall not exceed 917
twenty-five per cent of the cost of premiums or payments that 918
otherwise would be paid by the board for benefits for the officer 919
or employee under a policy or plan.
(G) The board of county commissioners may establish a 921
policy authorizing any county appointing authority to make a cash 922
payment to any officer or employee in lieu of providing a benefit 923
authorized under this section if the officer or employee elects 924
to take the cash payment instead of the offered benefit. A cash 925
payment made to an officer or employee under this division shall
not exceed twenty-five per cent of the cost of premiums or 926
payments that otherwise would be paid by the board for benefits 927
for the officer or employee under an offered policy or plan. 928
(H) No cash payment in lieu of a health benefit shall be 930
made to a county officer or employee under division (F) or (G) of 931
this section unless the officer or employee signs a statement 932
affirming that he THE OFFICER OR EMPLOYEE is covered under 933
another health insurance or health care policy, contract, or 934
plan, and setting forth the name of the employer, if any, that 935
sponsors the coverage, the name of the carrier that provides the
coverage, and the identifying number of the policy, contract, or 936
plan.
(I)(1) As used in this division: 938
(a) "County-operated municipal court" and "legislative 940
authority" have the same meanings as in section 1901.03 of the 941
Revised Code. 942
(b) "Health care coverage" has the same meaning as in 944
section 1901.111 of the Revised Code. 945
(2) The legislative authority of a county-operated 947
23
municipal court, after consultation with the judges, or the clerk 948
and deputy clerks, of the municipal court, shall negotiate and 949
contract for, purchase, or otherwise procure, and pay the costs, 950
premiums, or charges for, group health care coverage for the 951
judges, and group health care coverage for the clerk and deputy 952
clerks, in accordance with section 1901.111 or 1901.312 of the 953
Revised Code. 954
Sec. 306.48. A regional transit authority may procure and 963
pay all or any part of the cost of group hospitalization, 964
surgical, major medical, or sickness and accident insurance or a 965
combination of any of the foregoing for the officers and 966
employees of the regional transit authority and their immediate
dependents, whether issued by an insurance company, or nonprofit 967
medical care A HEALTH INSURING corporation duly authorized to do 968
business in this state. 969
Sec. 307.86. Anything to be purchased, leased, leased with 978
an option or agreement to purchase, or constructed, including, 979
but not limited to, any product, structure, construction, 980
reconstruction, improvement, maintenance, repair, or service, 981
except the services of an accountant, architect, attorney at law, 982
physician, professional engineer, construction project manager, 983
consultant, surveyor, or appraiser by or on behalf of the county 984
or contracting authority, as defined in section 307.92 of the 985
Revised Code, at a cost in excess of fifteen thousand dollars, 986
except as otherwise provided in division (D) of section 713.23 987
and in sections 125.04, 307.022, 307.041, 307.861, 339.05, 988
340.03, 340.033, 4115.31 to 4115.35, 5119.16, 5513.01, 5543.19, 989
5713.01, and 6137.05 of the Revised Code, shall be obtained 990
through competitive bidding. However, competitive bidding is not 991
required when: 992
(A) The board of county commissioners, by a unanimous vote 994
of its members, makes a determination that a real and present 995
emergency exists and such determination and the reasons therefor 996
are entered in the minutes of the proceedings of the board, when: 997
24
(1) The estimated cost is less than fifty thousand 999
dollars; or 1,000
(2) There is actual physical disaster to structures, radio 1,002
communications equipment, or computers. 1,003
Whenever a contract of purchase, lease, or construction is 1,005
exempted from competitive bidding under division (A)(1) of this 1,006
section because the estimated cost is less than fifty thousand 1,007
dollars, but the estimated cost is fifteen thousand dollars or 1,008
more, the county or contracting authority shall solicit informal 1,009
estimates from no fewer than three persons who could perform the 1,010
contract, before awarding the contract. With regard to each such 1,011
contract, the county or contracting authority shall maintain a 1,012
record of such estimates, including the name of each person from 1,013
whom an estimate is solicited, for no less than one year after 1,014
the contract is awarded. 1,015
(B) The purchase consists of supplies or a replacement or 1,017
supplemental part or parts for a product or equipment owned or 1,018
leased by the county and the only source of supply for such 1,019
supplies, part, or parts is limited to a single supplier. 1,020
(C) The purchase is from the federal government, state, 1,022
another county or contracting authority thereof, a board of 1,023
education, township, or municipal corporation. 1,024
(D) Public social services are purchased for provision by 1,026
the county department of human services under section 329.04 of 1,027
the Revised Code or program services, such as direct and 1,028
ancillary client services, child day-care, case management 1,029
services, residential services, and family resource services, are 1,030
purchased for provision by a county board of mental retardation 1,031
and developmental disabilities under section 5126.05 of the 1,032
Revised Code. 1,033
(E) The purchase consists of human and social services by 1,035
the board of county commissioners from nonprofit corporations or 1,036
associations under programs which are funded entirely by the 1,037
federal government. 1,038
25
(F) The purchase consists of any form of an insurance 1,040
policy or contract authorized to be issued under Title XXXIX of 1,041
the Revised Code or any form of health care contract or plan 1,042
authorized to be issued under Chapter 1736., 1737., 1740., or 1,043
1742. 1751. of the Revised Code, or any combination of such 1,044
policies, contracts, or plans that the contracting authority is 1,045
authorized to purchase, and the contracting authority does all of 1,046
the following: 1,047
(1) Determines that compliance with the requirements of 1,049
this section would increase, rather than decrease, the cost of 1,050
such purchase; 1,051
(2) Employs a competent consultant to assist the 1,053
contracting authority in procuring appropriate coverages at the 1,054
best and lowest prices; 1,055
(3) Requests issuers of such policies, contracts, or plans 1,057
to submit proposals to the contracting authority, in a form 1,058
prescribed by the contracting authority, setting forth the 1,059
coverage and cost of such policies, contracts, or plans as the 1,060
contracting authority desires to purchase; 1,061
(4) Negotiates with such issuers for the purpose of 1,063
purchasing such policies, contracts, or plans at the best and 1,064
lowest price reasonably possible. 1,065
(G) The purchase consists of computer hardware, software, 1,067
or consulting services that are necessary to implement a 1,068
computerized case management automation project administered by 1,069
the Ohio prosecuting attorneys association and funded by a grant 1,070
from the federal government. 1,071
(H) Child day-care services are purchased for provision to 1,073
county employees. 1,074
(I)(1) Property, including land, buildings, and other real 1,076
property, is leased for offices, storage, parking, or other 1,077
purposes and all of the following apply: 1,078
(a) The contracting authority is authorized by the Revised 1,080
Code to lease the property; 1,081
26
(b) The contracting authority develops requests for 1,083
proposals for leasing the property, specifying the criteria that 1,084
will be considered prior to leasing the property, including the 1,085
desired size and geographic location of the property; 1,086
(c) The contracting authority receives responses from 1,088
prospective lessors with property meeting the criteria specified 1,089
in the requests for proposals by giving notice in a manner 1,090
substantially similar to the procedures established for giving 1,091
notice under section 307.87 of the Revised Code; 1,092
(d) The contracting authority negotiates with the 1,094
prospective lessors to obtain a lease at the best and lowest 1,095
price reasonably possible considering the fair market value of 1,096
the property and any relocation and operational costs that may be 1,097
incurred during the period the lease is in effect. 1,099
(2) The contracting authority may use the services of a 1,101
real estate appraiser to obtain advice, consultations, or other 1,102
recommendations regarding the lease of property under this 1,103
division. 1,104
Any issuer of policies, contracts, or plans listed in 1,106
division (F) of this section and any prospective lessor under 1,107
division (I) of this section may have his THE ISSUER'S OR 1,108
PROSPECTIVE LESSOR'S name and address, or the name and address of 1,110
an agent, placed on a special notification list to be kept by the 1,111
contracting authority, by sending the contracting authority such 1,112
name and address. The contracting authority shall send notice to 1,113
all persons listed on the special notification list. Notices 1,114
shall state the deadline and place for submitting proposals. The 1,115
contracting authority shall mail the notices at least six weeks 1,116
prior to the deadline set by the contracting authority for 1,117
submitting such proposals. Every five years the contracting 1,118
authority may review this list and remove any person from the 1,119
list after mailing the person notification of such action. 1,120
Any contracting authority that negotiates a contract under 1,122
division (F) of this section shall request proposals and 1,123
27
renegotiate with issuers in accordance with that division at 1,124
least every three years from the date of the signing of such a 1,125
contract. 1,126
Any consultant employed pursuant to division (F) of this 1,128
section and any real estate appraiser employed pursuant to 1,129
division (I) of this section shall disclose any fees or 1,130
compensation received from any source in connection with that 1,131
employment.
Sec. 339.16. A board of trustees of any county hospital, 1,140
or of any county or district tuberculosis hospital, may contract 1,141
for, purchase, or otherwise procure on behalf of any or all of 1,142
its employees or such employees and their immediate dependents 1,143
the following types of fringe benefits: 1,144
(A) Group or individual insurance contracts which may 1,146
include life, sickness, accident, disability, annuities, 1,147
endowment, health, medical expense, hospital, dental, surgical 1,148
and related coverage or any combination thereof; 1,149
(B) Group or individual contracts with medical care 1,151
corporations, health care INSURING corporations, dental care 1,153
corporations, or other providers of professional services, care, 1,154
or benefits duly authorized to do business in this state.
A board of trustees of any county hospital, or of any 1,156
county or district tuberculosis hospital, may contract for, 1,157
purchase, or otherwise procure insurance contracts which provide 1,158
protection for the trustees and employees against liability, 1,159
including professional liability, provided that this section or 1,160
any insurance contract issued pursuant to this section shall not 1,161
be construed as a waiver of or in any manner affect the immunity 1,162
of the hospital or county. 1,163
All or any portion of the cost, premium, fees, or charges 1,165
therefor may be paid in such manner or combination of manners as 1,166
the board of trustees may determine, including direct payment by 1,167
the employee, and, if authorized in writing by the employee, by 1,168
the board of trustees with moneys made available by deduction 1,169
28
from or reduction in salary or wages or by the foregoing of a 1,170
salary or wage increase. 1,171
Notwithstanding sections 3917.01 and 3917.06 of the Revised 1,173
Code, the board of trustees may purchase group life insurance 1,174
authorized by this section by reason of payment of premiums 1,175
therefor by the board of trustees from its funds, and such group 1,176
life insurance may be issued and purchased if otherwise 1,177
consistent with sections 3917.01 to 3917.06 of the Revised Code. 1,178
Sec. 351.08. (A) A convention facilities authority may 1,187
procure and pay any or all of the cost of group hospitalization, 1,188
surgical, major medical, sickness and accident insurance, or 1,189
group life insurance, or a combination of any of the foregoing 1,190
types of insurance or coverage for full-time employees and their 1,191
dependents, whether issued by an insurance company or a medical 1,192
care corporation, duly authorized to do business in this state. 1,193
(B) A convention facilities authority also may procure and 1,195
pay any or all of the cost of a plan of group hospitalization, 1,196
surgical, or major medical insurance with a health care INSURING 1,197
corporation with a certificate of authority or license issued 1,198
under Chapter 1738. 1751. of the Revised Code, provided that each 1,200
full-time employee shall be permitted to:
(1) Exercise an option between a plan offered by an 1,202
insurance company or medical care corporation as provided in 1,203
division (A) of this section and a plan offered by a health care 1,204
INSURING corporation under this division, on the condition that 1,205
the full-time employee shall pay the amount by which the cost of 1,206
the plan offered in this division exceeds the cost of the plan 1,207
offered under division (A) of this section; and 1,208
(2) Change from one of the two plans to the other at a 1,210
time each year as determined by the convention facilities 1,211
authority. 1,212
Sec. 505.60. (A) The board of township trustees of any 1,221
township may procure and pay all or any part of the cost of 1,222
insurance policies that may provide benefits for hospitalization, 1,223
29
surgical care, major medical care, disability, dental care, eye 1,224
care, medical care, hearing aids, prescription drugs, or sickness 1,225
and accident insurance, or a combination of any of the foregoing 1,226
types of insurance for township officers and employees. If the 1,227
board so procures any such insurance policies, the board shall 1,228
provide uniform coverage under these policies for township 1,229
officers and full-time township employees and their immediate 1,230
dependents and may provide coverage under these policies for 1,231
part-time township employees and their immediate dependents, from 1,232
the funds or budgets from which the officers or employees are 1,233
compensated for services, whether such policies are TO BE issued 1,235
by an insurance company, a medical care corporation organized
under Chapter 1737. of the Revised Code, or a dental care 1,236
corporation organized under Chapter 1740. of the Revised Code 1,237
duly authorized to do business in this state. Any township 1,238
officer or employee may refuse to accept the insurance coverage 1,239
without affecting the availability of such insurance coverage to 1,240
other township officers and employees. 1,241
The board may also contract for group insurance or health 1,243
care services with health care INSURING corporations organized 1,245
HOLDING CERTIFICATES OF AUTHORITY under Chapter 1738. 1751. of 1,246
the Revised Code and health maintenance organizations organized 1,247
under Chapter 1742. of the Revised Code for township officers and 1,248
employees. If the board so contracts, it shall provide uniform 1,249
coverage under any such contracts for township officers and 1,250
full-time township employees and their immediate dependents and 1,251
may provide coverage under such contracts for part-time township 1,252
employees and their immediate dependents, provided that each 1,253
officer and employee so covered is permitted to: 1,254
(1) Choose between a plan offered by an insurance company, 1,256
medical care corporation, or dental care corporation and a plan 1,257
offered by a health care INSURING corporation or health 1,258
maintenance organization, and provided further that the officer 1,259
or employee pays any amount by which the cost of the plan chosen 1,261
30
by him exceeds the cost of the plan offered by the board under 1,262
this section; 1,263
(2) Change his THE choice MADE under division (A) of this 1,266
section at a time each year as determined in advance by the 1,267
board.
An addition of a class or change of definition of coverage 1,269
to the plan offered by the board may be made at any time that it 1,270
is determined by the board to be in the best interest of the 1,271
township. If the total cost to the township of the revised plan 1,272
for any trustee's coverage does not exceed that cost under the 1,273
plan in effect during the prior policy year, the revision of the 1,274
plan does not cause an increase in that trustee's compensation. 1,275
The board may provide the benefits authorized under this 1,277
section, without competitive bidding, by contributing to a health 1,278
and welfare trust fund administered through or in conjunction 1,279
with a collective bargaining representative of the township 1,280
employees. 1,281
The board may also provide the benefits described in this 1,283
section through an individual self-insurance program or a joint 1,284
self-insurance program as provided in section 9.833 of the 1,285
Revised Code. 1,286
(B) A board of township trustees may procure and pay all 1,288
or any part of the cost of group life insurance to insure the 1,289
lives of officers and full-time employees of the township. The 1,290
amount of group life insurance coverage provided by the board to 1,291
insure the lives of officers of the township shall not exceed 1,292
fifty thousand dollars per officer. 1,293
(C) If a board of township trustees fails to pay one or 1,295
more premiums for a policy, contract, or plan of insurance or 1,296
health care services authorized by division (A) of this section 1,297
and the failure causes a lapse, cancellation, or other 1,298
termination of coverage under the policy, contract, or plan, it 1,299
may reimburse a township officer or employee for, or pay on 1,300
behalf of the officer or employee, any expenses incurred that 1,301
31
would have been covered under the policy, contract, or plan. 1,302
(D) As used in this section, "part-time township employee" 1,304
means a township employee who is hired with the expectation that 1,305
the employee will work not more than one thousand five hundred 1,306
hours in any year. 1,307
Sec. 742.45. (A) The board of trustees of the police and 1,316
firemen's disability and pension fund may enter into an agreement 1,318
with insurance companies, medical or health care INSURING 1,319
corporations, health maintenance organizations, or government 1,321
agencies authorized to do business in the state for issuance of a 1,322
policy or contract of health, medical, hospital, or surgical 1,323
benefits, or any combination thereof, for those individuals 1,324
receiving service or disability pensions or survivor benefits 1,326
subscribing to the plan. Notwithstanding any other provision of 1,327
this chapter, the policy or contract may also include coverage 1,328
for any eligible individual's spouse and dependent children and 1,329
for any of the eligible individual's sponsored dependents as the 1,331
board considers appropriate. 1,332
If all or any portion of the policy or contract premium is 1,334
to be paid by any individual receiving a service, disability, or 1,336
survivor pension or benefit, the individual shall, by written 1,338
authorization, instruct the board to deduct from the individual's 1,340
benefit the premium agreed to be paid by the individual to the 1,341
company, corporation, or agency. 1,343
The board may contract for coverage on the basis of part or 1,346
all of the cost of the coverage to be paid from appropriate funds 1,347
of the police and firemen's disability and pension fund. The 1,348
cost paid from the funds of the police and firemen's disability 1,349
and pension fund shall be included in the employer's contribution 1,350
rates provided by sections 742.33 and 742.34 of the Revised Code. 1,352
The board may provide for self-insurance of risk or level 1,354
of risk as set forth in the contract with the companies, 1,355
corporations, or agencies, and may provide through the 1,356
self-insurance method specific benefits as authorized by the 1,357
32
rules of the board. 1,358
(B) If the board provides health, medical, hospital, or 1,360
surgical benefits through any means other than a health 1,361
maintenance organization INSURING CORPORATION, it shall offer to 1,362
each individual eligible for the benefits the alternative of 1,365
receiving benefits through enrollment in a health maintenance 1,366
organization INSURING CORPORATION, if all of the following apply: 1,368
(1) The health maintenance organization INSURING 1,370
CORPORATION provides HEALTH CARE services in the geographical 1,372
area in which the individual lives; 1,373
(2) The eligible individual was receiving health care 1,375
benefits through a health maintenance organization OR A HEALTH 1,377
INSURING CORPORATION before retirement; 1,378
(3) The rate and coverage provided by the health 1,380
maintenance organization INSURING CORPORATION to eligible 1,381
individuals is comparable to that currently provided by the board 1,384
under division (A) of this section. If the rate or coverage 1,385
provided by the health maintenance organization INSURING 1,386
CORPORATION is not comparable to that currently provided by the 1,388
board under division (A) of this section, the board may deduct 1,389
the additional cost from the eligible individual's monthly 1,390
benefit.
The health maintenance organization INSURING CORPORATION 1,392
shall accept as an enrollee any eligible individual who requests 1,394
enrollment.
The board shall permit each eligible individual to change 1,396
from one plan to another at least once a year at a time 1,398
determined by the board. 1,399
(C) The board shall, beginning the month following receipt 1,401
of satisfactory evidence of the payment for coverage, pay monthly 1,402
to each recipient of service, disability, or survivor benefits 1,404
under the police and firemen's disability and pension fund who is 1,405
eligible for medical insurance coverage under part B of "The 1,406
Social Security Amendments of 1965," 79 Stat. 301, 42 U.S.C.A. 1,407
33
1395j, as amended, an amount equal to the basic premiums for such 1,408
coverage.
(D) The board shall establish by rule requirements for the 1,410
coordination of any coverage, payment, or benefit provided under 1,411
this section with any similar coverage, payment, or benefit made 1,412
available to the same individual by the public employees 1,414
retirement system, state teachers retirement system, school
employees retirement system, or state highway patrol retirement 1,415
system.
(E) The board shall make all other necessary rules 1,417
pursuant to the purpose and intent of this section. 1,418
Sec. 742.53. (A) As used in this section: 1,427
(1) "Long-term care insurance" has the same meaning as in 1,429
section 3923.41 of the Revised Code. 1,430
(2) "Retirement systems" has the same meaning as in 1,432
division (A) of section 145.581 of the Revised Code. 1,433
(B) The board of trustees of the police and firemen's 1,435
disability and pension fund shall establish a program under which 1,436
members of the fund, employers on behalf of members, and persons 1,437
receiving service or disability pensions or survivor benefits are 1,438
permitted to participate in contracts for long-term care 1,439
insurance. Participation may include dependents and family 1,440
members. If a participant in a contract for long-term care 1,441
insurance leaves his employment, he THE PARTICIPANT and his THE 1,443
PARTICIPANT'S dependents and family members may, at their 1,444
election, continue to participate in a program established under 1,445
this section in the same manner as if he THE PARTICIPANT had not 1,446
left his employment, except that no part of the cost of the 1,448
insurance shall be paid by his THE PARTICIPANT'S former employer. 1,449
Such program may be established independently or jointly 1,451
with one or more of the other retirement systems. 1,452
(C) The fund may enter into an agreement with insurance 1,454
companies, medical or health care INSURING corporations, health 1,456
maintenance organizations, or government agencies authorized to
34
do business in the state for issuance of a long-term care 1,457
insurance policy or contract. However, prior to entering into 1,458
such an agreement with an insurance company, medical or health 1,459
care INSURING corporation, or health maintenance organization, 1,461
the fund shall request the superintendent of insurance to certify 1,462
the financial condition of the company, OR corporation, or 1,463
organization. The fund shall not enter into the agreement if, 1,464
according to that certification, the company, OR corporation, or 1,465
organization is insolvent, is determined by the superintendent to 1,467
be potentially unable to fulfill its contractual obligations, or 1,468
is placed under an order of rehabilitation or conservation by a 1,469
court of competent jurisdiction or under an order of supervision 1,470
by the superintendent. 1,471
(D) The board shall adopt rules in accordance with section 1,473
111.15 of the Revised Code governing the program. The rules 1,474
shall establish methods of payment for participation under this 1,475
section, which may include establishment of a payroll deduction 1,476
plan under section 742.56 of the Revised Code, deduction of the 1,477
full premium charged from a person's service or disability 1,478
pension or survivor benefit, or any other method of payment 1,479
considered appropriate by the board. If the program is 1,480
established jointly with one or more of the other retirement 1,481
systems, the rules also shall establish the terms and conditions 1,482
of such joint participation. 1,483
Sec. 1319.12. (A)(1) As used in this section, "collection 1,493
agency" means any person who, for compensation, contingent or 1,494
otherwise, or for other valuable consideration, offers services 1,495
to collect an alleged debt asserted to be owed to another. 1,496
(2) "Collection agency" does not mean a person whose 1,498
collection activities are confined to and directly related to the 1,500
operation of another business, including, but not limited to, the 1,501
following:
(a) Any bank, including the trust department of a bank, 1,504
trust company, savings and loan association, savings bank, credit 1,505
35
union, or fiduciary as defined in section 1339.03 of the Revised 1,507
Code, except those that own or operate a collection agency; 1,509
(b) Any real estate broker, real estate salesperson, 1,512
limited real estate broker, or limited real estate salesperson, 1,513
as these persons are defined in section 4735.01 of the Revised 1,514
Code;
(c) Any retail seller collecting its own accounts; 1,517
(d) Any insurance company authorized to do business in 1,519
this state under Title XXXIX of the Revised Code or a health 1,520
maintenance organization INSURING CORPORATION authorized to 1,521
operate in this state under Chapter 1742. 1751. of the Revised 1,522
Code;
(e) Any public officer or judicial officer acting under 1,524
order of a court;
(f) Any licensee as defined either in section 1321.01 or 1,526
1321.71 of the Revised Code, or any registrant as defined in 1,527
section 1321.51 of the Revised Code; 1,528
(g) Any public utility. 1,530
(B) A collection agency with a place of business in this 1,533
state may take assignment of another person's accounts, bills, or 1,535
other evidences of indebtedness in its own name for the purpose 1,536
of billing, collecting, or filing suit in its own name as the 1,537
real party in interest.
(C) No collection agency shall commence litigation for the 1,540
collection of an assigned account, bill, or other evidence of 1,541
indebtedness unless it has taken the assignment in accordance 1,542
with all of the following requirements: 1,543
(1) The assignment was voluntary, properly executed, and 1,545
acknowledged by the person transferring title to the collection 1,546
agency. 1,547
(2) The collection agency did not require the assignment 1,549
as a condition to listing the account, bill, or other evidence of 1,551
indebtedness with the collection agency for collection.
(3) The assignment was manifested by a written agreement 1,553
36
separate from and in addition to any document intended for the 1,554
purpose of listing the account, bill, or other evidence of 1,555
indebtedness with the collection agency. The written agreement 1,556
must state the effective date of the assignment and the 1,557
consideration paid or given, if any, for the assignment, and must 1,559
expressly authorize the collection agency to refer the assigned 1,560
account, bill, or other evidence of indebtedness to an attorney 1,561
admitted to the practice of law in this state for the
commencement of litigation. The written agreement must also 1,562
disclose that the collection agency may, for purposes of filing 1,563
an action, consolidate the assigned account, bill, or other 1,564
evidence of indebtedness with those of other creditors against an 1,565
individual debtor or co-debtors.
(4) Upon the effective date of the assignment to the 1,567
collection agency, the creditor's account maintained by the 1,568
collection agency in connection with the assigned account, bill, 1,569
or other evidence of indebtedness was canceled. 1,570
(D) A collection agency shall commence litigation for the 1,573
collection of an assigned account, bill, or other evidence of 1,574
indebtedness in a court of competent jurisdiction located in the 1,575
county in which the debtor resides, or in the case of co-debtors, 1,576
a county in which at least one of the co-debtors resides. 1,577
(E) No collection agency shall commence any litigation 1,580
authorized by this section unless the agency appears by an 1,581
attorney admitted to the practice of law in this state. 1,582
(F) This section does not affect the powers and duties of 1,584
any person described in division (A)(2) of this section. 1,585
(G) Nothing in this section relieves a collection agency 1,587
from complying with the "Fair Debt Collection Practices Act," 91 1,588
Stat. 874 (1977), 15 U.S.C. 1692, as amended, or deprives any 1,589
debtor of the right to assert defenses as provided in section 1,590
1317.031 of the Revised Code and 16 C.F.R. 433, as amended. 1,591
(H) For purposes of filing an action, a collection agency 1,594
that has taken an assignment or assignments pursuant to this 1,595
37
section may consolidate the assigned accounts, bills, or other 1,596
evidences of indebtedness of one or more creditors against an 1,597
individual debtor or co-debtors. Each separate assigned account, 1,598
bill, or evidence of indebtedness must be separately identified 1,599
and pled in any consolidated action authorized by this section. 1,600
If a debtor or co-debtor raises a good faith dispute concerning 1,601
any account, bill, or other evidence of indebtedness, the court 1,602
shall separate each disputed account, bill, or other evidence of 1,603
indebtedness from the action and hear the disputed account, bill, 1,605
or other evidence of indebtedness on its own merits in a separate 1,606
action. The court shall charge the filing fee of the separate 1,607
action to the losing party.
Sec. 1337.16. (A) No physician, health care facility, 1,616
other health care provider, person authorized to engage in the 1,617
business of insurance in this state under Title XXXIX of the 1,618
Revised Code, medical care corporation, health care INSURING 1,620
corporation, health maintenance organization, other health care 1,621
plan, or legal entity that is self-insured and provides benefits 1,622
to its employees or members shall require an individual to create 1,623
or refrain from creating a durable power of attorney for health 1,624
care, or shall require an individual to revoke or refrain from 1,625
revoking a durable power of attorney for health care, as a 1,626
condition of being admitted to a health care facility, being 1,627
provided health care, being insured, or being the recipient of 1,628
benefits. 1,629
(B)(1) Subject to division (B)(2) of this section, an 1,631
attending physician of a principal or a health care facility in 1,632
which a principal is confined may refuse to comply or allow 1,633
compliance with the instructions of an attorney in fact under a 1,634
durable power of attorney for health care on the basis of a 1,635
matter of conscience or on another basis. An employee or agent 1,636
of an attending physician of a principal or of a health care 1,637
facility in which a principal is confined may refuse to comply 1,638
with the instructions of an attorney in fact under a durable 1,639
38
power of attorney for health care on the basis of a matter of 1,640
conscience. 1,641
(2)(a) An attending physician of a principal who, or 1,643
health care facility in which a principal is confined that, is 1,644
not willing or not able to comply or allow compliance with the 1,645
instructions of an attorney in fact under a durable power of 1,646
attorney for health care to use or continue, or to withhold or 1,647
withdraw, health care that were given under division (A) of 1,648
section 1337.13 of the Revised Code, or with any probate court 1,649
reevaluation order issued pursuant to division (D)(6) of this 1,650
section, shall not prevent or attempt to prevent, or unreasonably 1,651
delay or attempt to unreasonably delay, the transfer of the 1,652
principal to the care of a physician who, or a health care 1,653
facility that, is willing and able to so comply or allow 1,654
compliance. 1,655
(b) If the instruction of an attorney in fact under a 1,657
durable power of attorney for health care that is given under 1,658
division (A) of section 1337.13 of the Revised Code is to use or 1,659
continue life-sustaining treatment in connection with a principal 1,660
who is in a terminal condition or in a permanently unconscious 1,661
state, the attending physician of the principal who, or the 1,662
health care facility in which the principal is confined that, is 1,663
not willing or not able to comply or allow compliance with that 1,664
instruction shall use or continue the life-sustaining treatment 1,665
or cause it to be used or continued until a transfer as described 1,666
in division (B)(2)(a) of this section is made. 1,667
(C) Sections 1337.11 to 1337.17 of the Revised Code and a 1,669
durable power of attorney for health care created under section 1,670
1337.12 of the Revised Code do not affect or limit the authority 1,671
of a physician or a health care facility to provide or not to 1,672
provide health care to a person in accordance with reasonable 1,673
medical standards applicable in an emergency situation. 1,674
(D)(1) If the attending physician of a principal and one 1,676
other physician who examines the principal determine that he THE 1,677
39
PRINCIPAL is in a terminal condition or in a permanently 1,679
unconscious state, if the attending physician additionally 1,680
determines that the principal has lost the capacity to make 1,681
informed health care decisions for himself THE PRINCIPAL and that 1,682
there is no reasonable possibility that the principal will regain 1,684
the capacity to make informed health care decisions for himself 1,685
THE PRINCIPAL, and if the attorney in fact under the principal's 1,687
durable power of attorney for health care makes a health care 1,688
decision pertaining to the use or continuation, or the 1,689
withholding or withdrawal, of life-sustaining treatment, the 1,690
attending physician shall do all of the following: 1,691
(a) Record the determinations and health care decision in 1,693
the principal's medical record; 1,694
(b) Make a good faith effort, and use reasonable 1,696
diligence, to notify the appropriate individual or individuals, 1,697
in accordance with the following descending order of priority, of 1,698
the determinations and health care decision: 1,699
(i) If any, the guardian of the principal. This division 1,701
does not permit or require the appointment of a guardian for the 1,702
principal. 1,703
(ii) The principal's spouse; 1,705
(iii) The principal's adult children who are available 1,707
within a reasonable period of time for consultation with the 1,708
principal's attending physician; 1,709
(iv) The principal's parents; 1,711
(v) An adult sibling of the principal or, if there is more 1,713
than one adult sibling, a majority of the principal's adult 1,714
siblings who are available within a reasonable period of time for 1,715
such consultation. 1,716
(c) Record in the principal's medical record the names of 1,717
the individual or individuals notified pursuant to division 1,718
(D)(1)(b) of this section and the manner of notification; 1,719
(d) Afford time for the individual or individuals notified 1,721
pursuant to division (D)(1)(b) of this section to object in the 1,722
40
manner described in division (D)(3)(a) of this section. 1,723
(2)(a) If, despite making a good faith effort, and despite 1,725
using reasonable diligence, to notify the appropriate individual 1,726
or individuals described in division (D)(1)(b) of this section, 1,727
the attending physician cannot notify the individual or 1,728
individuals of the determinations and health care decision 1,729
because the individual or individuals are deceased, cannot be 1,730
located, or cannot be notified for some other reason, the 1,731
requirements of divisions (D)(1)(b), (c), and (d) of this section 1,732
and, except as provided in division (D)(3)(b) of this section, 1,733
the provisions of divisions (D)(3) to (6) of this section shall 1,734
not apply in connection with the principal. However, the 1,735
attending physician shall record in the principal's medical 1,736
record information pertaining to the reason for the failure to 1,737
provide the requisite notices and information pertaining to the 1,738
nature of the good faith effort and reasonable diligence used. 1,739
(b) The requirements of divisions (D)(1)(b), (c), and (d) 1,741
of this section and, except as provided in division (D)(3)(b) of 1,742
this section, the provisions of divisions (D)(3) to (6) of this 1,743
section shall not apply in connection with the principal if only 1,744
one individual would have to be notified pursuant to division 1,745
(D)(1)(b) of this section and that individual is the attorney in 1,746
fact under the durable power of attorney for health care. 1,747
However, the attending physician of the principal shall record in 1,748
the principal's medical record information indicating that no 1,749
notice was given pursuant to division (D)(1)(b) of this section 1,750
because of the provisions of division (D)(2)(b) of this section. 1,751
(3)(a) Within forty-eight hours after receipt of a notice 1,753
pursuant to division (D)(1) of this section, any individual so 1,754
notified shall advise the attending physician of the principal 1,755
whether he THE INDIVIDUAL objects on a basis specified in 1,756
division (D)(4)(c) of this section. If an objection as described 1,758
in that division is communicated to the attending physician, 1,759
then, within two business days after the communication, the 1,760
41
individual shall file a complaint as described in division (D)(4) 1,761
of this section in the probate court of the county in which the 1,762
principal is located. If the individual fails to so file a 1,763
complaint, his THE INDIVIDUAL'S objections as described in 1,765
division (D)(4)(c) of this section shall be considered to be 1,766
void.
(b) Within forty-eight hours after the priority individual 1,768
or any member of a priority class of individuals receives a 1,769
notice pursuant to division (D)(1) of this section or within 1,770
forty-eight hours after information pertaining to an unnotified 1,771
priority individual or unnotified priority class of individuals 1,772
is recorded in a principal's medical record pursuant to division 1,773
(D)(2)(a) or (b) of this section, the individual or a majority of 1,774
the individuals in the next class of individuals that pertains to 1,775
the principal in the descending order of priority set forth in 1,776
divisions (D)(1)(b)(i) to (v) of this section shall advise the 1,777
attending physician of the principal whether he THE INDIVIDUAL or 1,779
they MAJORITY object on a basis specified in division (D)(4)(c) 1,780
of this section. If an objection as described in that division 1,781
is communicated to the attending physician, then, within two 1,782
business days after the communication, the objecting individual 1,783
or majority shall file a complaint as described in division 1,784
(D)(4) of this section in the probate court of the county in 1,785
which the principal is located. If the objecting individual or 1,786
majority fails to file a complaint, his or their THE objections 1,787
as described in division (D)(4)(c) of this section shall be 1,788
considered to be void.
(4) A complaint of an individual that is filed in 1,790
accordance with division (D)(3)(a) of this section or of an 1,791
individual or majority of individuals that is filed in accordance 1,792
with division (D)(3)(b) of this section shall satisfy all of the 1,793
following: 1,794
(a) Name any health care facility in which the principal 1,796
is confined; 1,797
42
(b) Name the principal, his THE PRINCIPAL'S attending 1,799
physician, and the consulting physician associated with the 1,801
determination that the principal is in a terminal condition or in 1,802
a permanently unconscious state; 1,803
(c) Indicate whether the plaintiff or plaintiffs object on 1,805
one or more of the following bases: 1,806
(i) To the attending physician's determination that the 1,808
principal has lost the capacity to make informed health care 1,809
decisions for himself THE PRINCIPAL; 1,810
(ii) To the attending physician's determination that there 1,812
is no reasonable possibility that the principal will regain the 1,813
capacity to make informed health care decisions for himself THE 1,814
PRINCIPAL; 1,815
(iii) That, in exercising his THE ATTORNEY IN FACT'S 1,817
authority, the attorney in fact is not acting consistently with 1,819
the desires of the principal or, if the desires of the principal 1,820
are unknown, in the best interest of the principal; 1,821
(iv) That the durable power of attorney for health care 1,823
has expired or otherwise is no longer effective; 1,824
(v) To the attending physician's and consulting 1,826
physician's determinations that the principal is in a terminal 1,827
condition or in a permanently unconscious state; 1,828
(vi) That the attorney in fact's health care decision 1,830
pertaining to the use or continuation, or the withholding or 1,831
withdrawal, of life-sustaining treatment is not authorized by the 1,832
durable power of attorney for health care or is prohibited under 1,833
section 1337.13 of the Revised Code; 1,834
(vii) That the durable power of attorney for health care 1,836
was executed when the principal was not of sound mind or was 1,837
under or subject to duress, fraud, or undue influence; 1,838
(viii) That the durable power of attorney for health care 1,840
otherwise does not substantially comply with section 1337.12 of 1,841
the Revised Code. 1,842
(d) Request the probate court to issue one or more of the 1,844
43
following types of orders: 1,845
(i) An order to the attending physician to reevaluate, in 1,847
light of the court proceedings, the determination that the 1,848
principal has lost the capacity to make informed health care 1,849
decisions for himself THE PRINCIPAL, the determination that the 1,850
principal is in a terminal condition or in a permanently 1,852
unconscious state, or the determination that there is no 1,853
reasonable possibility that the principal will regain the 1,854
capacity to make informed health care decisions for himself THE 1,855
PRINCIPAL;
(ii) An order to the attorney in fact to act consistently 1,857
with the desires of the principal or, if the desires of the 1,858
principal are unknown, in the best interest of the principal in 1,859
exercising his THE ATTORNEY IN FACT'S authority, or to make only 1,860
health care decisions pertaining to life-sustaining treatment 1,862
that are authorized by the durable power of attorney for health 1,863
care and that are not prohibited under section 1337.13 of the 1,864
Revised Code;
(iii) An order invalidating the durable power of attorney 1,866
for health care because it has expired or otherwise is no longer 1,867
effective, it was executed when the principal was not of sound 1,868
mind or was under or subject to duress, fraud, or undue 1,869
influence, or it otherwise does not substantially comply with 1,870
section 1337.12 of the Revised Code. 1,871
(e) Be accompanied by an affidavit of the plaintiff or 1,872
plaintiffs that includes averments relative to whether he THE 1,873
PLAINTIFF is an individual or they THE PLAINTIFFS are individuals 1,875
as described in division (D)(1)(b)(i), (ii), (iii), (iv), or (v) 1,877
of this section and to the factual basis for his THE PLAINTIFF'S 1,878
or their THE PLAINTIFFS' objections; 1,879
(f) Name any individuals who were notified by the 1,881
attending physician in accordance with division (D)(1)(b) of this 1,882
section and who are not joining in the complaint as plaintiffs; 1,883
(g) Name, in the caption of the complaint, as defendants 1,885
44
the attending physician of the principal, the attorney in fact 1,886
under the durable power of attorney for health care, the 1,887
consulting physician associated with the determination that the 1,888
principal is in a terminal condition or in a permanently 1,889
unconscious state, any health care facility in which the 1,890
principal is confined, and any individuals who were notified by 1,891
the attending physician in accordance with division (D)(1)(b) of 1,892
this section and who are not joining in the complaint as 1,893
plaintiffs. 1,894
(5) Notwithstanding any contrary provision of the Revised 1,896
Code or of the Rules of Civil Procedure, the state and persons 1,897
other than an objecting individual as described in division 1,898
(D)(3)(a) of this section, other than an objecting individual or 1,899
majority of individuals as described in division (D)(3)(b) of 1,900
this section, and other than persons described in division 1,901
(D)(4)(g) of this section are prohibited from commencing a civil 1,902
action under division (D) of this section and from joining or 1,903
being joined as parties to an action commenced under division (D) 1,904
of this section, including joining by way of intervention. 1,905
(6)(a) A probate court in which a complaint as described 1,907
in division (D)(4) of this section is filed within the period 1,908
specified in division (D)(3)(a) or (b) of this section shall 1,909
conduct a hearing on the complaint after a copy of it and a 1,910
notice of the hearing have been served upon the defendants. The 1,911
clerk of the probate court in which the complaint is filed shall 1,912
cause the complaint and the notice of the hearing to be so served 1,913
in accordance with the Rules of Civil Procedure, which service 1,914
shall be made, if possible, within three days after the filing of 1,915
the complaint. The hearing shall be conducted at the earliest 1,916
possible time, but no later than the third business day after 1,917
such service has been completed. Immediately following the 1,918
hearing, the court shall enter on its journal its determination 1,919
whether a requested order will be issued. 1,920
(b) If the health care decision of the attorney in fact 1,922
45
authorized the use or continuation of life-sustaining treatment 1,923
and if the plaintiff or plaintiffs requested a reevaluation order 1,924
to the attending physician of the principal or an order to the 1,925
attorney in fact as described in division (D)(4)(d)(i) or (ii) of 1,926
this section, the court shall issue the requested order only if 1,927
it finds that the plaintiff or plaintiffs have established a 1,928
factual basis for the objection or objections involved by clear 1,929
and convincing evidence and, if applicable, to a reasonable 1,930
degree of medical certainty and in accordance with reasonable 1,931
medical standards. 1,932
(c) If the health care decision of the attorney in fact 1,934
authorized the withholding or withdrawal of life-sustaining 1,935
treatment and if the plaintiff or plaintiffs requested a 1,936
reevaluation order to the attending physician of the principal or 1,937
an order to the attorney in fact as described in division 1,938
(D)(4)(d)(i) or (ii) of this section, the court shall issue the 1,939
requested order only if it finds that the plaintiff or plaintiffs 1,940
have established a factual basis for the objection or objections 1,941
involved by a preponderance of the evidence and, if applicable, 1,942
to a reasonable degree of medical certainty and in accordance 1,943
with reasonable medical standards. 1,944
(d) If the plaintiff or plaintiffs requested an 1,946
invalidation order as described in division (D)(4)(d)(iii) of 1,947
this section, the court shall issue the order only if it finds 1,948
that the plaintiff or plaintiffs have established a factual basis 1,949
for the objection or objections involved by clear and convincing 1,950
evidence. 1,951
(e) If the court issues a reevaluation order to the 1,953
principal's attending physician pursuant to division (D)(6)(b) or 1,954
(c) of this section, the attending physician shall make the 1,955
requisite reevaluation. If, after doing so, the attending 1,956
physician again determines that the principal has lost the 1,957
capacity to make informed health care decisions for himself THE 1,958
PRINCIPAL, that the principal is in a terminal condition or in a 1,960
46
permanently unconscious state, or that there is no reasonable 1,961
possibility that the principal will regain the capacity to make 1,962
informed health care decisions for himself THE PRINCIPAL, the 1,963
attending physician shall notify the court in writing of the 1,966
determination and comply with division (B)(2) of this section. 1,967
(E)(1) In connection with the provision of comfort care in 1,969
a manner consistent with divisions (C) and (E) of section 1337.13 1,970
of the Revised Code to a principal who is in a terminal condition 1,971
or in a permanently unconscious state, nothing in sections 1,972
1337.11 to 1337.17 of the Revised Code precludes the attending 1,973
physician of the principal who carries out the responsibility to
provide comfort care to the principal in good faith and while 1,974
acting within the scope of his THE ATTENDING PHYSICIAN'S 1,975
authority from prescribing, dispensing, administering, or causing 1,977
to be administered any particular medical procedure, treatment,
intervention, or other measure to the principal, including, but 1,978
not limited to, prescribing, dispensing, administering, or 1,979
causing to be administered by judicious titration or in another 1,980
manner any form of medication, for the purpose of diminishing his 1,981
THE PRINCIPAL'S pain or discomfort and not for the purpose of 1,983
postponing or causing his THE PRINCIPAL'S death, even though the 1,984
medical procedure, treatment, intervention, or other measure may 1,986
appear to hasten or increase the risk of the principal's death. 1,987
In connection with the provision of comfort care in a manner 1,988
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 1,989
a permanently unconscious state, nothing in sections 1337.11 to 1,990
1337.17 of the Revised Code precludes health care personnel 1,991
acting under the direction of the principal's attending physician 1,992
who carry out the responsibility to provide comfort care to the 1,993
principal in good faith and while acting within the scope of
their authority from dispensing, administering, or causing to be 1,994
administered any particular medical procedure, treatment, 1,995
intervention, or other measure to the principal, including, but 1,996
47
not limited to, dispensing, administering, or causing to be 1,997
administered by judicious titration or in another manner any form 1,998
of medication, for the purpose of diminishing his THE PRINCIPAL'S 1,999
pain or discomfort and not for the purpose of postponing or 2,000
causing his THE PRINCIPAL'S death, even though the medical 2,002
procedure, treatment, intervention, or other measure may appear
to hasten or increase the risk of the principal's death. 2,003
(2) If, at any time, a priority individual or any member 2,005
of a priority class of individuals under division (D)(1)(b) of 2,006
this section or if, at any time, the individual or a majority of 2,008
the individuals in the next class of individuals that pertains to 2,009
the principal in the descending order of priority set forth in 2,010
that division, believes in good faith that both of the following 2,011
circumstances apply, the priority individual, the member of the 2,013
priority class of individuals, or the individual or majority of 2,014
individuals in the next class of individuals that pertains to the 2,015
principal may commence an action in the probate court of the
county in which a principal who is in a terminal condition or 2,016
permanently unconscious state is located for the issuance of an 2,017
order mandating the use or continuation of comfort care in 2,018
connection with the principal in a manner that is consistent with 2,019
sections 1337.11 to 1337.17 of the Revised Code: 2,020
(a) Comfort care is not being used or continued in 2,022
connection with the principal. 2,023
(b) The withholding or withdrawal of the comfort care is 2,025
contrary to sections 1337.11 to 1337.17 of the Revised Code. 2,026
(F) Except as provided in divisions (D) and (E) of this 2,028
section in connection with principals who are in a terminal 2,029
condition or in a permanently unconscious state, sections 1337.11 2,030
to 1337.17 of the Revised Code do not authorize the commencement 2,031
of any civil action in a probate court or court of common pleas 2,033
for the purpose of obtaining an order relative to a health care 2,034
decision made by an attorney in fact under a durable power of 2,035
attorney for health care. 2,036
48
(G) A durable power of attorney for health care, or other 2,038
document, that is similar to a durable power of attorney for 2,039
health care authorized by sections 1337.11 to 1337.17 of the 2,040
Revised Code, that is or has been executed under the law of 2,041
another state prior to, on, or after October 10, 1991, and that 2,042
substantially complies with that law or with sections 1337.11 to 2,044
1337.17 of the Revised Code shall be considered to be valid for 2,045
purposes of those sections.
Sec. 1545.071. The board of park commissioners of any park 2,054
district may procure and pay all or any part of the cost of group 2,055
insurance policies that may provide benefits for hospitalization, 2,056
surgical care, major medical care, disability, dental care, eye 2,057
care, medical care, hearing aids, or prescription drugs, or 2,058
sickness and accident insurance or a combination of any of the 2,059
foregoing types of insurance or coverage for park district 2,060
officers and employees and their immediate dependents issued by 2,061
an insurance company, a medical care corporation organized under 2,062
Chapter 1737. of the Revised Code, or a dental care corporation 2,063
organized under Chapter 1740. of the Revised Code duly authorized 2,064
to do business in this state. 2,065
The board may procure and pay all or any part of the cost 2,067
of group life insurance to insure the lives of park district 2,068
employees. 2,069
The board also may contract for group insurance or health 2,071
care services with health care INSURING corporations organized 2,073
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 2,074
the Revised Code and health maintenance organizations organized 2,075
under Chapter 1742. of the Revised Code provided that each 2,076
officer or employee is permitted to:
(A) Choose between a plan offered by an insurance company, 2,078
medical care corporation, or dental care corporation and a plan 2,079
offered by a health care INSURING corporation or health 2,080
maintenance organization and provided further that the officer or 2,082
employee pays any amount by which the cost of the plan chosen by 2,083
49
him THE OFFICER OR EMPLOYEE exceeds the cost of the plan offered 2,084
by the board under this section; 2,086
(B) Change his THE choice MADE under division (A) of this 2,089
section at a time each year as determined in advance by the
board.
Any appointed member of the board of park commissioners and 2,091
the spouse and dependent children of the member may be covered, 2,092
at the option and expense of the member, as a noncompensated 2,093
employee of the park district under any benefit plan described in 2,094
division (A) of this section. The member shall pay to the park 2,095
district the amount certified to it by the benefit provider as 2,096
the provider's charge for the coverage the member has chosen 2,097
under division (A) of this section. Payments for coverage shall 2,098
be made, in advance, in a manner prescribed by the board. The 2,099
member's exercise of an option to be covered under this section 2,100
shall be in writing, announced at a regular public meeting of the 2,101
board, and recorded as a public record in the minutes of the 2,102
board. 2,103
The board may provide the benefits authorized in this 2,105
section by contributing to a health and welfare trust fund 2,106
administered through or in conjunction with a collective 2,107
bargaining representative of the park district employees. 2,108
The board may provide the benefits described in this 2,110
section through an individual self-insurance program or a joint 2,111
self-insurance program as provided in section 9.833 of the 2,112
Revised Code. 2,113
Sec. 1731.01. As used in this chapter: 2,122
(A) "Alliance" or "small employer health care alliance" 2,124
means an existing or newly created organization that has been 2,125
granted a certificate of authority by the superintendent of 2,126
insurance under section 1731.021 of the Revised Code and that is 2,127
either of the following: 2,128
(1) A chamber of commerce, trade association, professional 2,130
organization, or any other organization that has all of the 2,131
50
following characteristics: 2,132
(a) Is a nonprofit corporation or association; 2,134
(b) Has members that include or are exclusively small 2,136
employers; 2,137
(c) Sponsors or is part of a program to assist such small 2,139
employer members to obtain coverage for their employees under one 2,140
or more health benefit plans; 2,141
(d) Is not directly or indirectly controlled, through 2,143
voting membership, representation on its governing board, or 2,144
otherwise, by any insurance company, person, firm, or corporation 2,145
that sells insurance, any provider, or by persons who are 2,146
officers, trustees, or directors of such enterprises, or by any 2,147
combination of such enterprises or persons. 2,148
(2) A nonprofit corporation controlled by one or more 2,150
organizations described in division (A)(1) of this section. 2,151
(B) "Alliance program" or "alliance health care program" 2,153
means a program sponsored by a small employer health care 2,154
alliance that assists small employer members of such small 2,155
employer health care alliance or any other small employer health 2,156
care alliance to obtain coverage for their employees under one or 2,157
more health benefit plans, and that includes at least one 2,158
agreement between a small employer health care alliance and an 2,159
insurer that contains the insurer's agreement to offer and sell 2,160
one or more health benefit plans to such small employers and 2,161
contains all of the other features required under section 1731.04 2,162
of the Revised Code. 2,163
(C) "Eligible employees, retirees, their dependents, and 2,165
members of their families," as used together or separately, means 2,166
the active employees of a small employer, or retired former 2,167
employees of a small employer or predecessor firm or 2,168
organization, their dependents or members of their families, who 2,169
are eligible for coverage under the terms of the applicable 2,170
alliance program. 2,171
(D) "Enrolled small employer" or "enrolled employer" means 2,173
51
a small employer that has obtained coverage for its eligible 2,174
employees from an insurer under an alliance program. 2,175
(E) "Health benefit plan" means any hospital or medical 2,177
expense policy of insurance or A health care plan provided by an 2,178
insurer, including a health maintenance organization INSURING 2,179
CORPORATION plan and a preferred provider organization plan, 2,180
provided by or through an insurer, or any combination thereof. 2,182
"Health benefit plan" does not include any of the following: 2,183
(1) A policy covering only accident, credit, dental, 2,185
disability income, long-term care, hospital indemnity, medicare 2,186
supplement, specified disease, OR vision care, or coverage issued 2,187
by a health care corporation, except where any of the foregoing 2,188
is offered as an addition, indorsement, or rider to a health 2,189
benefit plan; 2,190
(2) Coverage issued as a supplement to liability 2,192
insurance, insurance arising out of a workers' compensation or 2,193
similar law, automobile medical-payment insurance, or insurance 2,194
under which benefits are payable with or without regard to fault 2,195
and which is statutorily required to be contained in any 2,196
liability insurance policy or equivalent self-insurance; 2,197
(3) COVERAGE ISSUED BY A HEALTH INSURING CORPORATION 2,199
AUTHORIZED TO OFFER SUPPLEMENTAL HEALTH CARE SERVICES ONLY. 2,200
(F) "Insurer" means an insurance company authorized to do 2,202
the business of sickness and accident insurance in this state or, 2,203
for the purposes of this chapter, a health maintenance 2,204
organization INSURING CORPORATION authorized to issue health 2,205
benefit CARE plans in this state. 2,206
(G) "Participants" or "beneficiaries" means those eligible 2,208
employees, retirees, their dependents, and members of their 2,209
families who are covered by health benefit plans provided by an 2,210
insurer to enrolled small employers under an alliance program. 2,211
(H) "Provider" means a hospital, urgent care facility, 2,213
nursing home, physician, podiatrist, dentist, pharmacist, 2,214
chiropractor, certified registered nurse anesthetist, dietitian, 2,215
52
health maintenance organization, or other health care provider 2,216
licensed by this state, or group of such health care providers. 2,217
(I) "Qualified alliance program" means an alliance program 2,219
under which health care benefits are provided to two thousand 2,220
five hundred or more participants. 2,221
(J) "Small employer," regardless of its definition in any 2,223
other chapter of the Revised Code, in this chapter means an 2,224
employer that employs no more than one hundred fifty full-time 2,225
employees, at least a majority of whom are employed at locations 2,226
within this state. 2,227
(1) For this purpose: 2,229
(a) Each entity that is controlled by, controls, or is 2,231
under common control with, one or more other entities shall, 2,232
together with such other entities, be considered to be a single 2,233
employer. 2,234
(b) "Full-time employee" means a person who normally works 2,236
at least twenty-five hours per week and at least forty weeks per 2,237
year for the employer. 2,238
(c) An employer will be treated as having one hundred 2,240
fifty or fewer full-time employees on any day if, during the 2,241
prior calendar year or any twelve consecutive months during the 2,242
twenty-four full months immediately preceding that day, the mean 2,243
number of full-time employees employed by the employer does not 2,244
exceed one hundred fifty. 2,245
(2) An employer that qualifies as a small employer for 2,247
purposes of becoming an enrolled small employer continues to be 2,248
treated as a small employer for purposes of this chapter until 2,249
such time as it fails to meet the conditions described in 2,250
division (J)(1) of this section for any period of thirty-six 2,251
consecutive months after first becoming an enrolled small 2,252
employer, unless earlier disqualified under the terms of the 2,253
alliance program. 2,254
Sec. 1731.06. (A) No health benefit plan offered or 2,263
provided by an insurer to a small employer under a qualified 2,264
53
alliance program is subject to any law that does any of the 2,265
following: 2,266
(1) Inhibits the insurer from selectively contracting with 2,268
providers or groups of providers with respect to health care 2,269
service or benefits; 2,270
(2) Imposes any restrictions on the ability of the insurer 2,272
to negotiate with providers regarding the level or method of 2,273
reimbursing for care or services; 2,274
(3) Requires the insurer either to include a specific 2,276
provider or class of providers, or to exclude any class of 2,277
providers that are generally authorized by law to provide such 2,278
care, in connection with health care services or benefits under 2,279
such health benefit plan; 2,280
(4) Limits the financial incentives that a health benefit 2,282
plan may require a beneficiary to pay when a nonplan provider is 2,283
used on a nonemergency basis; 2,284
(5) Prohibits utilization review of any or all treatments 2,286
and conditions; 2,287
(6) Requires the use of specified standards of health care 2,289
practice in such reviews or requires the disclosure of the 2,290
specific criteria used in such reviews; 2,291
(7) Requires payments to providers for the expenses of 2,293
responding to utilization review requests; 2,294
(8) Imposes liability for delays in performing such 2,296
review. 2,297
(B) Notwithstanding division (A) of this section, every 2,299
health benefit plan offered or provided by an insurer, other than 2,300
a health maintenance organization INSURING CORPORATION, to a 2,301
small employer under a qualified alliance program is subject to 2,303
sections 3923.23, 3923.231, 3923.232, 3923.233, and 3923.234 of 2,304
the Revised Code and any other provision of the Revised Code that 2,305
requires the reimbursement, utilization, or consideration of a 2,306
specific category of licensed or certified health care 2,307
practitioner.
54
Sec. 1739.05. (A) A multiple employer welfare arrangement 2,316
that is created pursuant to sections 1739.01 to 1739.22 of the 2,317
Revised Code and that operates a group self-insurance program may 2,318
be established only if any of the following applies: 2,319
(1) The arrangement has and maintains a minimum enrollment 2,321
of three hundred employees of two or more employers. 2,322
(2) The arrangement has and maintains a minimum enrollment 2,324
of three hundred self-employed individuals. 2,325
(3) The arrangement has and maintains a minimum enrollment 2,327
of three hundred employees or self-employed individuals in any 2,328
combination of divisions (A)(1) and (2) of this section. 2,329
(B) A multiple employer welfare arrangement that is 2,331
created pursuant to sections 1739.01 to 1739.22 of the Revised 2,332
Code and that operates a group self-insurance program shall 2,333
comply with all laws applicable to self-funded programs in this 2,334
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26, 2,335
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30, 2,336
3923.301, and 3923.38 of the Revised Code. 2,337
(C) A multiple employer welfare arrangement created 2,339
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,340
solicit enrollments only through agents or solicitors licensed 2,341
pursuant to Chapter 3905. of the Revised Code to sell or solicit 2,342
sickness and accident insurance. 2,343
(D) A multiple employer welfare arrangement created 2,345
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall 2,346
provide benefits only to individuals who are members, employees 2,347
of members, or the dependents of members or employees, or are 2,348
eligible for continuation of coverage under section 1742.34 2,349
1751.53 or 3923.38 of the Revised Code or under Title X of the 2,350
"Consolidated Omnibus Budget Reconciliation Act of 1985," 100 2,351
Stat. 227, 29 U.S.C.A. 1161, as amended. 2,352
Sec. 1751.01. AS USED IN THIS CHAPTER: 2,354
(A) "BASIC HEALTH CARE SERVICES" MEANS THE FOLLOWING 2,357
SERVICES WHEN MEDICALLY NECESSARY: 2,358
55
(1) PHYSICIAN'S SERVICES, EXCEPT WHEN SUCH SERVICES ARE 2,360
SUPPLEMENTAL UNDER DIVISION (B) OF THIS SECTION; 2,362
(2) INPATIENT HOSPITAL SERVICES; 2,364
(3) OUTPATIENT MEDICAL SERVICES; 2,366
(4) EMERGENCY HEALTH SERVICES; 2,368
(5) URGENT CARE SERVICES; 2,370
(6) DIAGNOSTIC LABORATORY SERVICES AND DIAGNOSTIC AND 2,372
THERAPEUTIC RADIOLOGIC SERVICES; 2,373
(7) PREVENTIVE HEALTH CARE SERVICES, INCLUDING, BUT NOT 2,375
LIMITED TO, VOLUNTARY FAMILY PLANNING SERVICES, INFERTILITY 2,376
SERVICES, PERIODIC PHYSICAL EXAMINATIONS, PRENATAL OBSTETRICAL 2,377
CARE, AND WELL-CHILD CARE. 2,378
"BASIC HEALTH CARE SERVICES" DOES NOT INCLUDE EXPERIMENTAL 2,380
PROCEDURES. 2,381
A HEALTH INSURING CORPORATION SHALL NOT OFFER COVERAGE FOR 2,383
A HEALTH CARE SERVICE, DEFINED AS A BASIC HEALTH CARE SERVICE BY 2,384
THIS DIVISION, UNLESS IT OFFERS COVERAGE FOR ALL LISTED BASIC 2,385
HEALTH CARE SERVICES. HOWEVER, THIS REQUIREMENT DOES NOT APPLY 2,387
TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XVIII OF THE 2,388
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 2,390
AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR MEDICARE COST 2,391
CONTRACT, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN THE 2,392
FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 2,394
8905, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE XIX 2,395
OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,397
301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR 2,398
MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER 2,399
CHAPTER 5111. OF THE REVISED CODE, OR TO THE COVERAGE OF 2,401
BENEFICIARIES UNDER ANY FEDERAL HEALTH CARE PROGRAM REGULATED BY 2,402
A FEDERAL REGULATORY BODY.
(B) "SUPPLEMENTAL HEALTH CARE SERVICES" MEANS ANY HEALTH 2,405
CARE SERVICES OTHER THAN BASIC HEALTH CARE SERVICES THAT A HEALTH 2,406
INSURING CORPORATION MAY OFFER, ALONE OR IN COMBINATION WITH 2,407
EITHER BASIC HEALTH CARE SERVICES OR OTHER SUPPLEMENTAL HEALTH 2,408
56
CARE SERVICES, AND INCLUDES:
(1) SERVICES OF FACILITIES FOR INTERMEDIATE OR LONG-TERM 2,410
CARE, OR BOTH; 2,411
(2) DENTAL CARE SERVICES; 2,413
(3) VISION CARE AND OPTOMETRIC SERVICES INCLUDING LENSES 2,415
AND FRAMES; 2,416
(4) PODIATRIC CARE OR FOOT CARE SERVICES; 2,418
(5) MENTAL HEALTH SERVICES INCLUDING PSYCHOLOGICAL 2,420
SERVICES; 2,421
(6) SHORT-TERM OUTPATIENT EVALUATIVE AND 2,423
CRISIS-INTERVENTION MENTAL HEALTH SERVICES; 2,424
(7) MEDICAL OR PSYCHOLOGICAL TREATMENT AND REFERRAL 2,426
SERVICES FOR ALCOHOL AND DRUG ABUSE OR ADDICTION; 2,427
(8) HOME HEALTH SERVICES; 2,429
(9) PRESCRIPTION DRUG SERVICES; 2,431
(10) NURSING SERVICES; 2,433
(11) SERVICES OF A DIETITIAN LICENSED UNDER CHAPTER 4759. 2,436
OF THE REVISED CODE;
(12) PHYSICAL THERAPY SERVICES; 2,438
(13) CHIROPRACTIC SERVICES; 2,440
(14) ANY OTHER CATEGORY OF SERVICES APPROVED BY THE 2,442
SUPERINTENDENT OF INSURANCE. 2,443
(C) "SPECIALTY HEALTH CARE SERVICES" MEANS ONE OF THE 2,445
SUPPLEMENTAL HEALTH CARE SERVICES LISTED IN DIVISION (B)(1) TO 2,447
(13) OF THIS SECTION, WHEN PROVIDED BY A HEALTH INSURING 2,448
CORPORATION ON AN OUTPATIENT-ONLY BASIS AND NOT IN COMBINATION 2,449
WITH OTHER SUPPLEMENTAL HEALTH CARE SERVICES.
(D) "CLOSED PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,452
REQUIRES ENROLLEES TO USE PARTICIPATING PROVIDERS. 2,453
(E) "COMPENSATION" MEANS REMUNERATION FOR THE PROVISION OF 2,456
HEALTH CARE SERVICES, DETERMINED ON OTHER THAN A FEE-FOR-SERVICE 2,457
OR DISCOUNTED-FEE-FOR-SERVICE BASIS.
(F) "CONTRACTUAL PERIODIC PREPAYMENT" MEANS THE FORMULA 2,460
FOR DETERMINING THE PREMIUM RATE FOR ALL SUBSCRIBERS OF A HEALTH 2,461
57
INSURING CORPORATION. 2,462
(G) "CORPORATION" MEANS A CORPORATION FORMED UNDER CHAPTER 2,465
1701. OR 1702. OF THE REVISED CODE OR THE SIMILAR LAWS OF ANOTHER 2,467
STATE.
(H) "EMERGENCY HEALTH SERVICES" MEANS THOSE HEALTH CARE 2,470
SERVICES THAT MUST BE AVAILABLE ON A SEVEN-DAYS-PER-WEEK, 2,471
TWENTY-FOUR-HOURS-PER-DAY BASIS IN ORDER TO PREVENT JEOPARDY TO 2,472
AN ENROLLEE'S HEALTH STATUS THAT WOULD OCCUR IF SUCH SERVICES 2,473
WERE NOT RECEIVED AS SOON AS POSSIBLE, AND INCLUDES, WHERE 2,474
APPROPRIATE, PROVISIONS FOR TRANSPORTATION AND INDEMNITY PAYMENTS 2,475
OR SERVICE AGREEMENTS FOR OUT-OF-AREA COVERAGE. 2,476
(I) "ENROLLEE" MEANS ANY NATURAL PERSON WHO IS ENTITLED TO 2,479
RECEIVE HEALTH CARE BENEFITS PROVIDED BY A HEALTH INSURING 2,480
CORPORATION.
(J) "EVIDENCE OF COVERAGE" MEANS ANY CERTIFICATE, 2,483
AGREEMENT, POLICY, OR CONTRACT ISSUED TO A SUBSCRIBER THAT SETS 2,484
OUT THE COVERAGE AND OTHER RIGHTS TO WHICH SUCH PERSON IS 2,485
ENTITLED UNDER A HEALTH CARE PLAN. 2,486
(K) "HEALTH CARE FACILITY" MEANS ANY FACILITY, EXCEPT A 2,489
HEALTH CARE PRACTITIONER'S OFFICE, THAT PROVIDES PREVENTIVE, 2,490
DIAGNOSTIC, THERAPEUTIC, ACUTE CONVALESCENT, REHABILITATION, 2,491
MENTAL HEALTH, MENTAL RETARDATION, INTERMEDIATE CARE, OR SKILLED 2,492
NURSING SERVICES. 2,493
(L) "HEALTH CARE SERVICES" MEANS ANY SERVICES INVOLVED IN 2,496
OR INCIDENT TO THE FURNISHING OF PREVENTIVE, DIAGNOSTIC, 2,497
THERAPEUTIC, OR REHABILITATIVE CARE. 2,498
(M) "HEALTH DELIVERY NETWORK" MEANS ANY GROUP OF PROVIDERS 2,501
OR HEALTH CARE FACILITIES, OR BOTH, OR ANY REPRESENTATIVE 2,502
THEREOF, THAT HAVE ENTERED INTO AN AGREEMENT TO OFFER HEALTH CARE 2,504
SERVICES IN A PANEL RATHER THAN ON AN INDIVIDUAL BASIS. 2,505
(N) "HEALTH INSURING CORPORATION" MEANS A CORPORATION, AS 2,508
DEFINED IN DIVISION (G) OF THIS SECTION, THAT, PURSUANT TO A 2,509
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT, PAYS FOR, 2,510
REIMBURSES, OR PROVIDES, DELIVERS, ARRANGES FOR, OR OTHERWISE 2,511
58
MAKES AVAILABLE, BASIC HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH 2,512
CARE SERVICES, OR SPECIALTY HEALTH CARE SERVICES, OR A 2,513
COMBINATION OF BASIC HEALTH CARE SERVICES AND EITHER SUPPLEMENTAL 2,514
HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE SERVICES, THROUGH 2,516
EITHER AN OPEN PANEL PLAN OR A CLOSED PANEL PLAN. 2,517
"HEALTH INSURING CORPORATION" DOES NOT INCLUDE A LIMITED 2,520
LIABILITY COMPANY FORMED PURSUANT TO CHAPTER 1705. OF THE REVISED 2,522
CODE, A CORPORATION FORMED BY OR ON BEHALF OF A POLITICAL 2,524
SUBDIVISION OR A DEPARTMENT, OFFICE, OR INSTITUTION OF THE STATE, 2,525
OR A PUBLIC ENTITY FORMED BY OR ON BEHALF OF A BOARD OF COUNTY 2,526
COMMISSIONERS, A COUNTY BOARD OF MENTAL RETARDATION AND 2,527
DEVELOPMENTAL DISABILITIES, AN ALCOHOL AND DRUG ADDICTION 2,530
SERVICES BOARD, A BOARD OF ALCOHOL, DRUG ADDICTION, AND MENTAL 2,531
HEALTH SERVICES, OR A COMMUNITY MENTAL HEALTH BOARD, AS THOSE 2,532
TERMS ARE USED IN CHAPTERS 340. AND 5126. OF THE REVISED CODE. 2,533
EXCEPT AS PROVIDED BY DIVISION (D) OF SECTION 1751.02 OF THE 2,536
REVISED CODE, OR AS OTHERWISE PROVIDED BY LAW, NO BOARD, 2,539
COMMISSION, AGENCY, OR OTHER ENTITY UNDER THE CONTROL OF A 2,540
POLITICAL SUBDIVISION MAY ACCEPT INSURANCE RISK IN PROVIDING FOR 2,541
HEALTH CARE SERVICES. HOWEVER, NOTHING IN THIS DIVISION SHALL BE 2,542
CONSTRUED AS PROHIBITING SUCH ENTITIES FROM PURCHASING THE 2,543
SERVICES OF A HEALTH INSURING CORPORATION OR A THIRD-PARTY 2,544
ADMINISTRATOR LICENSED UNDER CHAPTER 3959. OF THE REVISED CODE. 2,546
(O) "INTERMEDIARY ORGANIZATION" MEANS A HEALTH DELIVERY 2,549
NETWORK OR OTHER ENTITY THAT CONTRACTS WITH LICENSED HEALTH 2,550
INSURING CORPORATIONS OR SELF-INSURED EMPLOYERS, OR BOTH, TO 2,551
PROVIDE HEALTH CARE SERVICES, AND THAT ENTERS INTO CONTRACTUAL 2,553
ARRANGEMENTS WITH OTHER ENTITIES FOR THE PROVISION OF HEALTH CARE 2,554
SERVICES FOR THE PURPOSE OF FULFILLING THE TERMS OF ITS CONTRACTS 2,555
WITH THE HEALTH INSURING CORPORATIONS AND SELF-INSURED EMPLOYERS. 2,556
(P) "INTERMEDIATE CARE" MEANS RESIDENTIAL CARE ABOVE THE 2,559
LEVEL OF ROOM AND BOARD FOR PATIENTS WHO REQUIRE PERSONAL 2,560
ASSISTANCE AND HEALTH-RELATED SERVICES, BUT WHO DO NOT REQUIRE 2,561
SKILLED NURSING CARE.
59
(Q) "MEDICAL RECORD" MEANS THE PERSONAL INFORMATION THAT 2,564
RELATES TO AN INDIVIDUAL'S PHYSICAL OR MENTAL CONDITION, MEDICAL 2,565
HISTORY, OR MEDICAL TREATMENT. 2,566
(R)(1) "OPEN PANEL PLAN" MEANS A HEALTH CARE PLAN THAT 2,568
PROVIDES INCENTIVES FOR ENROLLEES TO USE PARTICIPATING PROVIDERS 2,569
AND THAT ALSO ALLOWS ENROLLEES TO USE PROVIDERS THAT ARE NOT 2,570
PARTICIPATING PROVIDERS.
(2) NO HEALTH INSURING CORPORATION MAY OFFER AN OPEN PANEL 2,573
PLAN, UNLESS THE HEALTH INSURING CORPORATION IS ALSO LICENSED AS 2,574
AN INSURER UNDER TITLE XXXIX OF THE REVISED CODE, THE HEALTH 2,575
INSURING CORPORATION, ON THE EFFECTIVE DATE OF THIS SECTION, 2,576
HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO OPERATE UNDER 2,577
CHAPTER 1736. OR 1740. OF THE REVISED CODE, OR AN INSURER 2,578
LICENSED UNDER TITLE XXXIX OF THE REVISED CODE IS RESPONSIBLE FOR 2,580
THE OUT-OF-NETWORK RISK AS EVIDENCED BY BOTH AN EVIDENCE OF
COVERAGE FILING UNDER SECTION 1751.11 OF THE REVISED CODE AND A 2,582
POLICY AND CERTIFICATE FILING UNDER SECTION 3923.02 OF THE 2,584
REVISED CODE.
(S) "PERSON" HAS THE SAME MEANING AS IN SECTION 1.59 OF 2,586
THE REVISED CODE, AND, UNLESS THE CONTEXT OTHERWISE REQUIRES, 2,587
INCLUDES ANY INSURANCE COMPANY HOLDING A CERTIFICATE OF AUTHORITY 2,588
UNDER TITLE XXXIX OF THE REVISED CODE, ANY SUBSIDIARY AND 2,590
AFFILIATE OF AN INSURANCE COMPANY, AND ANY GOVERNMENT AGENCY. 2,591
(T) "PREMIUM RATE" MEANS ANY SET FEE REGULARLY PAID BY A 2,594
SUBSCRIBER TO A HEALTH INSURING CORPORATION. A "PREMIUM RATE" 2,595
DOES NOT INCLUDE A ONE-TIME MEMBERSHIP FEE, AN ANNUAL
ADMINISTRATIVE FEE, OR A NOMINAL ACCESS FEE, PAID TO A MANAGED 2,596
HEALTH CARE SYSTEM UNDER WHICH THE RECIPIENT OF HEALTH CARE 2,597
SERVICES REMAINS SOLELY RESPONSIBLE FOR ANY CHARGES ACCESSED FOR 2,598
THOSE SERVICES BY THE PROVIDER OR HEALTH CARE FACILITY. 2,599
(U) "PRIMARY CARE PROVIDER" MEANS A PROVIDER THAT IS 2,602
DESIGNATED BY A HEALTH INSURING CORPORATION TO SUPERVISE, 2,603
COORDINATE, OR PROVIDE INITIAL CARE OR CONTINUING CARE TO AN 2,604
ENROLLEE, AND THAT MAY BE REQUIRED BY THE HEALTH INSURING 2,605
60
CORPORATION TO INITIATE A REFERRAL FOR SPECIALTY CARE AND TO 2,606
MAINTAIN SUPERVISION OF THE HEALTH CARE SERVICES RENDERED TO THE 2,607
ENROLLEE.
(V) "PROVIDER" MEANS ANY NATURAL PERSON OR PARTNERSHIP OF 2,610
NATURAL PERSONS WHO ARE LICENSED, CERTIFIED, ACCREDITED, OR 2,611
OTHERWISE AUTHORIZED IN THIS STATE TO FURNISH HEALTH CARE 2,612
SERVICES, OR ANY PROFESSIONAL ASSOCIATION ORGANIZED UNDER CHAPTER 2,613
1785. OF THE REVISED CODE, PROVIDED THAT NOTHING IN THIS CHAPTER 2,615
OR OTHER PROVISIONS OF LAW SHALL BE CONSTRUED TO PRECLUDE A 2,616
HEALTH INSURING CORPORATION, HEALTH CARE PRACTITIONER, OR 2,617
ORGANIZED HEALTH CARE GROUP ASSOCIATED WITH A HEALTH INSURING 2,618
CORPORATION FROM EMPLOYING NURSE PRACTITIONERS, DIETITIANS, 2,619
PHYSICIANS' ASSISTANTS, DENTAL ASSISTANTS, DENTAL HYGIENISTS, 2,620
OPTOMETRIC TECHNICIANS, OR OTHER ALLIED HEALTH PERSONNEL WHO ARE 2,621
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THIS 2,622
STATE TO FURNISH HEALTH CARE SERVICES.
(W) "PROVIDER SPONSORED ORGANIZATION" MEANS A CORPORATION, 2,625
AS DEFINED IN DIVISION (G) OF THIS SECTION, THAT IS AT LEAST 2,626
EIGHTY PER CENT OWNED OR CONTROLLED BY ONE OR MORE HOSPITALS, AS 2,628
DEFINED IN SECTION 3727.01 OF THE REVISED CODE, OR ONE OR MORE 2,629
PHYSICIANS LICENSED TO PRACTICE MEDICINE OR SURGERY OR 2,630
OSTEOPATHIC MEDICINE AND SURGERY UNDER CHAPTER 4731. OF THE 2,631
REVISED CODE, OR ANY COMBINATION OF SUCH PHYSICIANS AND 2,632
HOSPITALS. SUCH CONTROL IS PRESUMED TO EXIST IF AT LEAST EIGHTY 2,633
PER CENT OF THE VOTING RIGHTS OR GOVERNANCE RIGHTS OF A PROVIDER 2,634
SPONSORED ORGANIZATION ARE DIRECTLY OR INDIRECTLY OWNED, 2,635
CONTROLLED, OR OTHERWISE HELD BY ANY COMBINATION OF THE 2,636
PHYSICIANS AND HOSPITALS DESCRIBED IN THIS DIVISION. 2,637
(X) "SOLICITATION DOCUMENT" MEANS THE WRITTEN MATERIALS 2,639
PROVIDED TO PROSPECTIVE SUBSCRIBERS OR ENROLLEES, OR BOTH, AND 2,640
USED FOR ADVERTISING AND MARKETING TO INDUCE ENROLLMENT IN THE 2,641
HEALTH CARE PLANS OF A HEALTH INSURING CORPORATION. 2,642
(Y) "SUBSCRIBER" MEANS A PERSON WHO IS RESPONSIBLE FOR 2,645
MAKING PAYMENTS TO A HEALTH INSURING CORPORATION FOR 2,646
61
PARTICIPATION IN A HEALTH CARE PLAN, OR AN ENROLLEE WHOSE 2,647
EMPLOYMENT OR OTHER STATUS IS THE BASIS OF ELIGIBILITY FOR 2,648
ENROLLMENT IN A HEALTH INSURING CORPORATION.
(Z) "URGENT CARE SERVICES" MEANS THOSE HEALTH CARE 2,651
SERVICES THAT ARE APPROPRIATELY PROVIDED FOR AN UNFORESEEN 2,652
CONDITION OF A KIND THAT USUALLY REQUIRES MEDICAL ATTENTION 2,653
WITHOUT DELAY BUT THAT DOES NOT POSE A THREAT TO THE LIFE, LIMB, 2,654
OR PERMANENT HEALTH OF THE INJURED OR ILL PERSON, AND MAY INCLUDE 2,656
SUCH HEALTH CARE SERVICES PROVIDED OUT OF THE HEALTH INSURING 2,657
CORPORATION'S APPROVED SERVICE AREA PURSUANT TO INDEMNITY 2,658
PAYMENTS OR SERVICE AGREEMENTS.
Sec. 1751.02. (A) NOTWITHSTANDING ANY LAW IN THIS STATE 2,660
TO THE CONTRARY, ANY CORPORATION, AS DEFINED IN SECTION 1751.01 2,662
OF THE REVISED CODE, MAY APPLY TO THE SUPERINTENDENT OF INSURANCE 2,664
FOR A CERTIFICATE OF AUTHORITY TO ESTABLISH AND OPERATE A HEALTH 2,665
INSURING CORPORATION. IF THE CORPORATION APPLYING FOR A 2,666
CERTIFICATE OF AUTHORITY IS A FOREIGN CORPORATION DOMICILED IN A 2,667
STATE WITHOUT LAWS SIMILAR TO THOSE OF THIS CHAPTER, THE 2,669
CORPORATION MUST FORM A DOMESTIC CORPORATION TO APPLY FOR,
OBTAIN, AND MAINTAIN A CERTIFICATE OF AUTHORITY UNDER THIS 2,670
CHAPTER.
(B) NO PERSON SHALL ESTABLISH, OPERATE, OR PERFORM THE 2,673
SERVICES OF A HEALTH INSURING CORPORATION IN THIS STATE WITHOUT 2,675
OBTAINING A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. 2,676
(C) EXCEPT AS PROVIDED BY DIVISION (D) OF THIS SECTION, NO 2,679
POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR INSTITUTION OF 2,680
THIS STATE, OR CORPORATION FORMED BY OR ON BEHALF OF ANY
POLITICAL SUBDIVISION OR DEPARTMENT, OFFICE, OR INSTITUTION OF 2,681
THIS STATE, SHALL ESTABLISH, OPERATE, OR PERFORM THE SERVICES OF 2,682
A HEALTH INSURING CORPORATION. NOTHING IN THIS SECTION SHALL BE 2,685
CONSTRUED TO PRECLUDE A BOARD OF COUNTY COMMISSIONERS, A COUNTY 2,686
BOARD OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES, AN 2,687
ALCOHOL AND DRUG ADDICTION SERVICES BOARD, A BOARD OF ALCOHOL, 2,688
DRUG ADDICTION, AND MENTAL HEALTH SERVICES, OR A COMMUNITY MENTAL 2,689
62
HEALTH BOARD, OR A PUBLIC ENTITY FORMED BY OR ON BEHALF OF ANY OF 2,690
THESE BOARDS, FROM USING MANAGED CARE TECHNIQUES IN CARRYING OUT 2,691
THE BOARD'S OR PUBLIC ENTITY'S DUTIES PURSUANT TO THE 2,692
REQUIREMENTS OF CHAPTERS 307., 329., 340., AND 5126. OF THE 2,694
REVISED CODE. HOWEVER, NO SUCH BOARD OR PUBLIC ENTITY MAY 2,696
OPERATE SO AS TO COMPETE IN THE PRIVATE SECTOR WITH HEALTH 2,697
INSURING CORPORATIONS HOLDING CERTIFICATES OF AUTHORITY UNDER 2,698
THIS CHAPTER.
(D) A CORPORATION FORMED BY OR ON BEHALF OF A PUBLICLY 2,700
OWNED, OPERATED, OR FUNDED HOSPITAL OR HEALTH CARE FACILITY MAY 2,701
APPLY TO THE SUPERINTENDENT FOR A CERTIFICATE OF AUTHORITY UNDER 2,703
DIVISION (A) OF THIS SECTION TO ESTABLISH AND OPERATE A HEALTH 2,704
INSURING CORPORATION.
(E) A HEALTH INSURING CORPORATION SHALL OPERATE IN THIS 2,707
STATE IN COMPLIANCE WITH THIS CHAPTER AND WITH SECTIONS 3702.51 2,708
TO 3702.62 OF THE REVISED CODE, AND SHALL OPERATE IN CONFORMITY 2,711
WITH ITS FILINGS WITH THE SUPERINTENDENT UNDER THIS CHAPTER, 2,712
INCLUDING FILINGS MADE PURSUANT TO SECTIONS 1751.03, 1751.11, 2,713
1751.12, AND 1751.31 OF THE REVISED CODE. 2,715
(F) AN INSURER LICENSED UNDER TITLE XXXIX OF THE REVISED 2,719
CODE NEED NOT OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,720
INSURING CORPORATION TO OFFER AN OPEN PANEL PLAN AS LONG AS THE 2,721
PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE OPEN 2,722
PANEL PLAN RECEIVE THEIR COMPENSATION DIRECTLY FROM THE INSURER. 2,723
IF THE PROVIDERS AND HEALTH CARE FACILITIES PARTICIPATING IN THE 2,724
OPEN PANEL PLAN RECEIVE THEIR COMPENSATION FROM ANY PERSON OTHER 2,725
THAN THE INSURER, OR IF THE INSURER OFFERS A CLOSED PANEL PLAN, 2,726
THE INSURER MUST OBTAIN A CERTIFICATE OF AUTHORITY AS A HEALTH 2,727
INSURING CORPORATION.
(G) AN INTERMEDIARY ORGANIZATION NEED NOT OBTAIN A 2,730
CERTIFICATE OF AUTHORITY AS A HEALTH INSURING CORPORATION, 2,731
REGARDLESS OF THE METHOD OF REIMBURSEMENT TO THE INTERMEDIARY 2,732
ORGANIZATION, AS LONG AS A HEALTH INSURING CORPORATION OR A 2,734
SELF-INSURED EMPLOYER MAINTAINS THE ULTIMATE RESPONSIBILITY TO 2,735
63
ASSURE DELIVERY OF ALL HEALTH CARE SERVICES REQUIRED BY THE
CONTRACT BETWEEN THE HEALTH INSURING CORPORATION AND THE 2,736
SUBSCRIBER AND THE LAWS OF THIS STATE OR BETWEEN THE SELF-INSURED 2,737
EMPLOYER AND ITS EMPLOYEES. 2,738
NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE ANY 2,740
HEALTH CARE FACILITY, PROVIDER, HEALTH DELIVERY NETWORK, OR 2,741
INTERMEDIARY ORGANIZATION THAT CONTRACTS WITH A HEALTH INSURING 2,742
CORPORATION OR SELF-INSURED EMPLOYER, REGARDLESS OF THE METHOD OF 2,744
REIMBURSEMENT TO THE HEALTH CARE FACILITY, PROVIDER, HEALTH
DELIVERY NETWORK, OR INTERMEDIARY ORGANIZATION, TO OBTAIN A 2,745
CERTIFICATE OF AUTHORITY AS A HEALTH INSURING CORPORATION UNDER 2,746
THIS CHAPTER, UNLESS OTHERWISE PROVIDED, IN THE CASE OF CONTRACTS 2,748
WITH A SELF-INSURED EMPLOYER, BY OPERATION OF THE "EMPLOYEE 2,750
RETIREMENT INCOME SECURITY ACT OF 1974," 88 STAT. 829, 29 2,755
U.S.C.A. 1001, AS AMENDED. 2,756
(H) ANY HEALTH DELIVERY NETWORK DOING BUSINESS IN THIS 2,759
STATE THAT IS NOT REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY 2,760
UNDER THIS CHAPTER SHALL CERTIFY TO THE SUPERINTENDENT ANNUALLY, 2,761
NOT LATER THAN THE FIRST DAY OF JULY, AND SHALL PROVIDE A 2,763
STATEMENT SIGNED BY THE HIGHEST RANKING OFFICIAL WHICH INCLUDES 2,764
THE FOLLOWING INFORMATION:
(1) THE HEALTH DELIVERY NETWORK'S FULL NAME AND THE 2,766
ADDRESS OF ITS PRINCIPAL PLACE OF BUSINESS; 2,767
(2) A STATEMENT THAT THE HEALTH DELIVERY NETWORK IS NOT 2,769
REQUIRED TO OBTAIN A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 2,770
TO CONDUCT ITS BUSINESS. 2,771
(I) THE SUPERINTENDENT SHALL NOT ISSUE A CERTIFICATE OF 2,774
AUTHORITY TO A HEALTH INSURING CORPORATION THAT IS A PROVIDER 2,775
SPONSORED ORGANIZATION UNLESS ALL HEALTH CARE PLANS TO BE OFFERED 2,776
BY THE HEALTH INSURING CORPORATION PROVIDE BASIC HEALTH CARE 2,777
SERVICES. SUBSTANTIALLY ALL OF THE PHYSICIANS AND HOSPITALS WITH 2,778
OWNERSHIP OR CONTROL OF THE PROVIDER SPONSORED ORGANIZATION, AS 2,779
DEFINED IN DIVISION (W) OF SECTION 1751.01 OF THE REVISED CODE, 2,782
SHALL ALSO BE PARTICIPATING PROVIDERS FOR THE PROVISION OF BASIC 2,783
64
HEALTH CARE SERVICES FOR HEALTH CARE PLANS OFFERED BY THE 2,784
PROVIDER SPONSORED ORGANIZATION. IF A HEALTH INSURING 2,785
CORPORATION THAT IS A PROVIDER SPONSORED ORGANIZATION OFFERS 2,786
HEALTH CARE PLANS THAT DO NOT PROVIDE BASIC HEALTH CARE SERVICES, 2,787
THE HEALTH INSURING CORPORATION SHALL BE DEEMED, FOR PURPOSES OF 2,788
SECTION 1751.35 OF THE REVISED CODE, TO HAVE FAILED TO 2,789
SUBSTANTIALLY COMPLY WITH THIS CHAPTER. 2,790
EXCEPT AS SPECIFICALLY PROVIDED IN THIS DIVISION AND IN 2,792
DIVISION (C) OF SECTION 1751.28 OF THE REVISED CODE, THE 2,794
PROVISIONS OF THIS CHAPTER SHALL APPLY TO ALL HEALTH INSURING
CORPORATIONS THAT ARE PROVIDER SPONSORED ORGANIZATIONS IN THE 2,795
SAME MANNER THAT THESE PROVISIONS APPLY TO ALL HEALTH INSURING 2,796
CORPORATIONS THAT ARE NOT PROVIDER SPONSORED ORGANIZATIONS. 2,797
(J) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO APPLY TO 2,799
ANY MULTIPLE EMPLOYER WELFARE ARRANGEMENT OPERATING PURSUANT TO 2,800
CHAPTER 1739. OF THE REVISED CODE. 2,801
(K) ANY PERSON WHO VIOLATES DIVISION (B) OF THIS SECTION, 2,805
AND ANY HEALTH DELIVERY NETWORK THAT FAILS TO COMPLY WITH 2,806
DIVISION (H) OF THIS SECTION, IS SUBJECT TO THE PENALTIES SET 2,807
FORTH IN SECTION 1751.45 OF THE REVISED CODE. 2,809
Sec. 1751.03. (A) EACH APPLICATION FOR A CERTIFICATE OF 2,812
AUTHORITY UNDER THIS CHAPTER SHALL BE VERIFIED BY AN OFFICER OR 2,813
AUTHORIZED REPRESENTATIVE OF THE APPLICANT, SHALL BE IN A FORMAT 2,814
PRESCRIBED BY THE SUPERINTENDENT OF INSURANCE, AND SHALL SET 2,815
FORTH OR BE ACCOMPANIED BY THE FOLLOWING: 2,816
(1) A CERTIFIED COPY OF THE APPLICANT'S ARTICLES OF 2,818
INCORPORATION AND ALL AMENDMENTS TO THE ARTICLES OF 2,819
INCORPORATION; 2,820
(2) A COPY OF ANY REGULATIONS ADOPTED FOR THE GOVERNMENT 2,822
OF THE CORPORATION, ANY BYLAWS, AND ANY SIMILAR DOCUMENTS, AND A 2,823
COPY OF ALL AMENDMENTS TO THESE REGULATIONS, BYLAWS, AND 2,824
DOCUMENTS. THE CORPORATE SECRETARY SHALL CERTIFY THAT THESE 2,825
REGULATIONS, BYLAWS, DOCUMENTS, AND AMENDMENTS HAVE BEEN PROPERLY 2,827
ADOPTED OR APPROVED.
65
(3) A LIST OF THE NAMES, ADDRESSES, AND OFFICIAL POSITIONS 2,830
OF THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE APPLICANT, 2,831
INCLUDING ALL MEMBERS OF THE BOARD, THE PRINCIPAL OFFICERS, AND 2,832
THE PERSON RESPONSIBLE FOR COMPLETING OR FILING FINANCIAL 2,833
STATEMENTS WITH THE DEPARTMENT OF INSURANCE, ACCOMPANIED BY A 2,834
COMPLETED ORIGINAL BIOGRAPHICAL AFFIDAVIT AND RELEASE OF 2,835
INFORMATION FOR EACH OF THESE PERSONS ON FORMS ACCEPTABLE TO THE 2,836
DEPARTMENT;
(4) A FULL AND COMPLETE DISCLOSURE OF THE EXTENT AND 2,838
NATURE OF ANY CONTRACTUAL OR OTHER FINANCIAL ARRANGEMENT BETWEEN 2,839
THE APPLICANT AND ANY PROVIDER OR A PERSON LISTED IN DIVISION 2,841
(A)(3) OF THIS SECTION, INCLUDING, BUT NOT LIMITED TO, A FULL AND 2,842
COMPLETE DISCLOSURE OF THE FINANCIAL INTEREST HELD BY ANY SUCH 2,843
PROVIDER OR PERSON IN ANY HEALTH CARE FACILITY, PROVIDER, OR 2,844
INSURER THAT HAS ENTERED INTO A FINANCIAL RELATIONSHIP WITH THE 2,845
HEALTH INSURING CORPORATION; 2,846
(5) A DESCRIPTION OF THE APPLICANT, ITS FACILITIES, AND 2,848
ITS PERSONNEL, INCLUDING, BUT NOT LIMITED TO, THE LOCATION, HOURS 2,850
OF OPERATION, AND TELEPHONE NUMBERS OF ALL CONTRACTED FACILITIES; 2,851
(6) THE APPLICANT'S PROJECTED ANNUAL ENROLLEE POPULATION 2,853
OVER A THREE-YEAR PERIOD; 2,854
(7) A CLEAR AND SPECIFIC DESCRIPTION OF THE HEALTH CARE 2,856
PLAN OR PLANS TO BE USED BY THE APPLICANT, INCLUDING A 2,857
DESCRIPTION OF THE PROPOSED PROVIDERS, PROCEDURES FOR ACCESSING 2,858
CARE, AND THE FORM OF ALL PROPOSED AND EXISTING CONTRACTS 2,859
RELATING TO THE ADMINISTRATION, DELIVERY, OR FINANCING OF HEALTH 2,860
CARE SERVICES; 2,861
(8) A COPY OF EACH TYPE OF EVIDENCE OF COVERAGE AND 2,863
IDENTIFICATION CARD OR SIMILAR DOCUMENT TO BE ISSUED TO 2,864
SUBSCRIBERS; 2,865
(9) A COPY OF EACH TYPE OF INDIVIDUAL OR GROUP POLICY, 2,867
CONTRACT, OR AGREEMENT TO BE USED; 2,868
(10) THE SCHEDULE OF THE PROPOSED CONTRACTUAL PERIODIC 2,870
PREPAYMENTS OR PREMIUM RATES, OR BOTH, ACCOMPANIED BY APPROPRIATE 2,871
66
SUPPORTING DATA; 2,872
(11) A FINANCIAL PLAN WHICH PROVIDES A THREE-YEAR 2,874
PROJECTION OF OPERATING RESULTS, INCLUDING THE PROJECTED 2,875
EXPENSES, INCOME, AND SOURCES OF WORKING CAPITAL; 2,876
(12) THE ENROLLEE COMPLAINT PROCEDURE TO BE UTILIZED AS 2,878
REQUIRED UNDER SECTION 1751.19 OF THE REVISED CODE; 2,881
(13) A DESCRIPTION OF THE PROCEDURES AND PROGRAMS TO BE 2,883
IMPLEMENTED ON AN ONGOING BASIS TO ASSURE THE QUALITY OF HEALTH 2,884
CARE SERVICES DELIVERED TO ENROLLEES; 2,885
(14) A STATEMENT DESCRIBING THE GEOGRAPHIC AREA OR AREAS 2,887
TO BE SERVED, BY COUNTY; 2,888
(15) A COPY OF ALL SOLICITATION DOCUMENTS; 2,890
(16) A BALANCE SHEET AND OTHER FINANCIAL STATEMENTS 2,892
SHOWING THE APPLICANT'S ASSETS, LIABILITIES, INCOME, AND OTHER 2,893
SOURCES OF FINANCIAL SUPPORT; 2,894
(17) A DESCRIPTION OF THE NATURE AND EXTENT OF ANY 2,896
REINSURANCE PROGRAM TO BE IMPLEMENTED, AND A DEMONSTRATION THAT 2,897
ERRORS AND OMISSION INSURANCE AND, IF APPROPRIATE, FIDELITY 2,898
INSURANCE, WILL BE IN PLACE UPON THE APPLICANT'S RECEIPT OF A 2,899
CERTIFICATE OF AUTHORITY; 2,900
(18) COPIES OF ALL PROPOSED OR IN FORCE RELATED-PARTY OR 2,902
INTERCOMPANY AGREEMENTS WITH AN EXPLANATION OF THE FINANCIAL 2,903
IMPACT OF THESE AGREEMENTS ON THE APPLICANT. IF THE APPLICANT 2,904
INTENDS TO ENTER INTO A CONTRACT FOR MANAGERIAL OR ADMINISTRATIVE 2,906
SERVICES, WITH EITHER AN AFFILIATED OR AN UNAFFILIATED PERSON,
THE APPLICANT SHALL PROVIDE A COPY OF THE CONTRACT AND A DETAILED 2,907
DESCRIPTION OF THE PERSON TO PROVIDE THESE SERVICES. THE 2,909
DESCRIPTION SHALL INCLUDE THAT PERSON'S EXPERIENCE IN MANAGING OR 2,910
ADMINISTERING HEALTH CARE PLANS, A COPY OF THAT PERSON'S MOST 2,911
RECENT AUDITED FINANCIAL STATEMENT, AND A COMPLETED BIOGRAPHICAL 2,912
AFFIDAVIT ON A FORM ACCEPTABLE TO THE SUPERINTENDENT FOR EACH OF 2,913
THAT PERSON'S PRINCIPAL OFFICERS AND BOARD MEMBERS AND FOR ANY 2,914
ADDITIONAL EMPLOYEE TO BE DIRECTLY INVOLVED IN PROVIDING 2,915
MANAGERIAL OR ADMINISTRATIVE SERVICES TO THE HEALTH INSURING 2,916
67
CORPORATION. IF THE PERSON TO PROVIDE MANAGERIAL OR 2,917
ADMINISTRATIVE SERVICES IS AFFILIATED WITH THE HEALTH INSURING 2,918
CORPORATION, THE CONTRACT MUST PROVIDE FOR PAYMENT FOR SERVICES 2,919
BASED ON ACTUAL COSTS.
(19) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,921
ADMITTED ASSETS OF THE APPLICANT HAVE NOT BEEN AND WILL NOT BE 2,922
PLEDGED OR HYPOTHECATED; 2,923
(20) A STATEMENT FROM THE APPLICANT'S BOARD THAT THE 2,925
APPLICANT WILL SUBMIT MONTHLY FINANCIAL STATEMENTS DURING THE 2,926
FIRST YEAR OF OPERATIONS; 2,927
(21) THE NAME AND ADDRESS OF THE APPLICANT'S OHIO 2,930
STATUTORY AGENT FOR SERVICE OF PROCESS, NOTICE, OR DEMAND; 2,931
(22) COPIES OF ALL DOCUMENTS THE APPLICANT FILED WITH THE 2,933
SECRETARY OF STATE; 2,934
(23) THE LOCATION OF THOSE BOOKS AND RECORDS OF THE 2,936
APPLICANT THAT MUST BE MAINTAINED IN OHIO; 2,937
(24) THE APPLICANT'S FEDERAL IDENTIFICATION NUMBER, 2,939
CORPORATE ADDRESS, AND MAILING ADDRESS; 2,940
(25) AN INTERNAL AND EXTERNAL ORGANIZATIONAL CHART; 2,943
(26) A LIST OF THE ASSETS REPRESENTING THE INITIAL NET 2,945
WORTH OF THE APPLICANT; 2,946
(27) IF THE APPLICANT HAS A PARENT COMPANY, THE PARENT 2,948
COMPANY'S GUARANTY, ON A FORM ACCEPTABLE TO THE SUPERINTENDENT, 2,949
THAT THE APPLICANT WILL MAINTAIN OHIO'S MINIMUM NET WORTH. IF NO 2,952
PARENT COMPANY EXISTS, A STATEMENT REGARDING THE AVAILABILITY OF 2,953
FUTURE FUNDS IF NEEDED.
(28) THE NAMES AND ADDRESSES OF THE APPLICANT'S ACTUARY 2,955
AND EXTERNAL AUDITORS; 2,956
(29) IF THE APPLICANT IS A FOREIGN CORPORATION, A COPY OF 2,958
THE MOST RECENT FINANCIAL STATEMENTS FILED WITH THE INSURANCE 2,959
REGULATORY AGENCY IN THE APPLICANT'S STATE OF DOMICILE; 2,960
(30) IF THE APPLICANT IS A FOREIGN CORPORATION, A 2,962
STATEMENT FROM THE INSURANCE REGULATORY AGENCY OF THE APPLICANT'S 2,963
STATE OF DOMICILE STATING THAT THE REGULATORY AGENCY HAS NO 2,964
68
OBJECTION TO THE APPLICANT APPLYING FOR AN OHIO LICENSE AND THAT 2,965
THE APPLICANT IS IN GOOD STANDING IN THE APPLICANT'S STATE OF 2,966
DOMICILE; 2,967
(31) ANY OTHER INFORMATION THAT THE SUPERINTENDENT MAY 2,969
REQUIRE. 2,970
(B)(1) A HEALTH INSURING CORPORATION, UNLESS OTHERWISE 2,973
PROVIDED FOR IN THIS CHAPTER, SHALL FILE A TIMELY NOTICE WITH THE 2,974
SUPERINTENDENT DESCRIBING ANY CHANGE TO THE CORPORATION'S 2,975
ARTICLES OF INCORPORATION OR REGULATIONS, OR ANY MAJOR 2,976
MODIFICATION TO ITS OPERATIONS AS SET OUT IN THE INFORMATION 2,977
REQUIRED BY DIVISION (A) OF THIS SECTION THAT AFFECTS ANY OF THE 2,979
FOLLOWING:
(a) THE SOLVENCY OF THE HEALTH INSURING CORPORATION; 2,982
(b) THE HEALTH INSURING CORPORATION'S CONTINUED PROVISION 2,985
OF SERVICES THAT IT HAS CONTRACTED TO PROVIDE; 2,986
(c) THE MANNER IN WHICH THE HEALTH INSURING CORPORATION 2,989
CONDUCTS ITS BUSINESS.
(2) IF THE CHANGE OR MODIFICATION IS TO BE THE RESULT OF 2,991
AN ACTION TO BE TAKEN BY THE HEALTH INSURING CORPORATION, THE 2,992
NOTICE SHALL BE FILED WITH THE SUPERINTENDENT PRIOR TO THE HEALTH 2,993
INSURING CORPORATION TAKING THE ACTION. THE ACTION SHALL BE 2,995
DEEMED APPROVED IF THE SUPERINTENDENT DOES NOT DISAPPROVE IT 2,996
WITHIN SIXTY DAYS OF FILING. 2,997
(C)(1) NO HEALTH INSURING CORPORATION SHALL EXPAND ITS 3,000
APPROVED SERVICE AREA UNTIL A COPY OF THE REQUEST FOR EXPANSION, 3,001
ACCOMPANIED BY DOCUMENTATION OF THE NETWORK OF PROVIDERS, 3,002
ENROLLMENT PROJECTIONS, PLAN OF OPERATION, AND ANY OTHER CHANGES 3,003
HAVE BEEN FILED WITH THE SUPERINTENDENT. 3,004
(2) WITHIN TEN CALENDAR DAYS AFTER RECEIPT OF A COMPLETE 3,006
FILING UNDER DIVISION (C)(1) OF THIS SECTION, THE SUPERINTENDENT 3,008
SHALL REFER THE APPROPRIATE JURISDICTIONAL ISSUES TO THE DIRECTOR 3,009
OF HEALTH PURSUANT TO SECTION 1751.04 OF THE REVISED CODE. 3,011
(3) WITHIN SEVENTY-FIVE DAYS AFTER THE SUPERINTENDENT'S 3,013
RECEIPT OF A COMPLETE FILING UNDER DIVISION (C)(1) OF THIS 3,015
69
SECTION, THE SUPERINTENDENT SHALL DETERMINE WHETHER THE PLAN FOR 3,016
EXPANSION IS LAWFUL, FAIR, AND REASONABLE. THE SUPERINTENDENT 3,017
MAY NOT MAKE A DETERMINATION UNTIL THE SUPERINTENDENT HAS 3,018
RECEIVED THE DIRECTOR'S CERTIFICATION OF COMPLIANCE, WHICH THE 3,019
DIRECTOR SHALL FURNISH WITHIN FORTY-FIVE DAYS AFTER REFERRAL 3,020
UNDER DIVISION (C)(2) OF THIS SECTION. THE DIRECTOR SHALL NOT 3,022
CERTIFY THAT THE REQUIREMENTS OF SECTION 1751.04 OF THE REVISED 3,024
CODE ARE NOT MET, UNLESS THE APPLICANT HAS BEEN GIVEN AN 3,025
OPPORTUNITY FOR A HEARING AS PROVIDED IN DIVISION (D) OF SECTION 3,027
1751.04 OF THE REVISED CODE. THE FORTY-FIVE-DAY AND 3,028
SEVENTY-FIVE-DAY REVIEW PERIODS PROVIDED FOR IN DIVISION (C)(3) 3,030
OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON WHICH THE 3,031
NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS MAILED 3,032
AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A FINAL 3,033
CERTIFICATION. 3,034
(4) IF THE SUPERINTENDENT HAS NOT APPROVED OR DISAPPROVED 3,036
ALL OR A PORTION OF A SERVICE AREA EXPANSION WITHIN THE 3,037
SEVENTY-FIVE-DAY PERIOD PROVIDED FOR IN DIVISION (C)(3) OF THIS 3,039
SECTION, THE FILING SHALL BE DEEMED APPROVED. 3,040
(5) DISAPPROVAL OF ALL OR A PORTION OF THE FILING SHALL BE 3,043
EFFECTED BY WRITTEN NOTICE, WHICH SHALL STATE THE GROUNDS FOR THE 3,044
ORDER OF DISAPPROVAL AND SHALL BE GIVEN IN ACCORDANCE WITH 3,045
CHAPTER 119. OF THE REVISED CODE.
Sec. 1751.04. (A) UPON THE RECEIPT BY THE SUPERINTENDENT 3,048
OF INSURANCE OF A COMPLETE APPLICATION FOR A CERTIFICATE OF 3,049
AUTHORITY TO ESTABLISH OR OPERATE A HEALTH INSURING CORPORATION, 3,050
WHICH APPLICATION SETS FORTH OR IS ACCOMPANIED BY THE INFORMATION 3,051
AND DOCUMENTS REQUIRED BY DIVISION (A) OF SECTION 1751.03 OF THE 3,053
REVISED CODE, THE SUPERINTENDENT SHALL TRANSMIT COPIES OF THE 3,055
APPLICATION AND ACCOMPANYING DOCUMENTS TO THE DIRECTOR OF HEALTH. 3,056
(B) THE DIRECTOR SHALL REVIEW THE APPLICATION AND 3,059
ACCOMPANYING DOCUMENTS AND MAKE FINDINGS AS TO WHETHER THE 3,060
APPLICANT FOR A CERTIFICATE OF AUTHORITY HAS DONE ALL OF THE 3,061
FOLLOWING WITH RESPECT TO ANY BASIC HEALTH CARE SERVICES AND 3,062
70
SUPPLEMENTAL HEALTH CARE SERVICES TO BE FURNISHED: 3,063
(1) DEMONSTRATED THE WILLINGNESS AND POTENTIAL ABILITY TO 3,065
ENSURE THAT ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL 3,066
HEALTH CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE WILL 3,068
BE PROVIDED TO ALL ITS ENROLLEES AS PROMPTLY AS IS APPROPRIATE 3,069
AND IN A MANNER THAT ASSURES CONTINUITY; 3,070
(2) MADE EFFECTIVE ARRANGEMENTS TO ENSURE THAT ITS 3,072
ENROLLEES HAVE RELIABLE ACCESS TO QUALIFIED PROVIDERS IN THOSE 3,073
SPECIALTIES THAT ARE GENERALLY AVAILABLE IN THE GEOGRAPHIC AREA 3,074
OR AREAS TO BE SERVED BY THE APPLICANT AND THAT ARE NECESSARY TO 3,075
PROVIDE ALL BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 3,076
CARE SERVICES DESCRIBED IN THE EVIDENCE OF COVERAGE; 3,078
(3) MADE APPROPRIATE ARRANGEMENTS FOR THE AVAILABILITY OF 3,080
SHORT-TERM HEALTH CARE SERVICES IN EMERGENCIES WITHIN THE 3,081
GEOGRAPHIC AREA OR AREAS TO BE SERVED BY THE APPLICANT, 3,082
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK, AND FOR THE 3,083
PROVISION OF ADEQUATE COVERAGE WHENEVER AN OUT-OF-AREA EMERGENCY 3,084
ARISES; 3,085
(4) MADE APPROPRIATE ARRANGEMENTS FOR AN ONGOING 3,087
EVALUATION AND ASSURANCE OF THE QUALITY OF HEALTH CARE SERVICES 3,088
PROVIDED TO ENROLLEES AND THE ADEQUACY OF THE PERSONNEL, 3,089
FACILITIES, AND EQUIPMENT BY OR THROUGH WHICH THE SERVICES ARE 3,090
RENDERED;
(5) DEVELOPED A PROCEDURE TO GATHER AND REPORT STATISTICS 3,092
RELATING TO THE COST AND EFFECTIVENESS OF ITS OPERATIONS, THE 3,093
PATTERN OF UTILIZATION OF ITS SERVICES, AND THE QUALITY, 3,094
AVAILABILITY, AND ACCESSIBILITY OF ITS SERVICES. 3,095
(C) WITHIN NINETY DAYS OF THE DIRECTOR'S RECEIPT OF THE 3,097
APPLICATION FOR ISSUANCE OF A CERTIFICATE OF AUTHORITY, THE 3,099
DIRECTOR SHALL CERTIFY TO THE SUPERINTENDENT WHETHER OR NOT THE 3,100
APPLICANT MEETS THE REQUIREMENTS OF DIVISION (B) OF THIS SECTION 3,101
AND SECTIONS 3702.51 TO 3702.62 OF THE REVISED CODE. IF THE 3,102
DIRECTOR CERTIFIES THAT THE APPLICANT DOES NOT MEET THESE 3,103
REQUIREMENTS, THE DIRECTOR SHALL SPECIFY IN WHAT RESPECTS IT IS 3,104
71
DEFICIENT. HOWEVER, THE DIRECTOR SHALL NOT CERTIFY THAT THE 3,105
REQUIREMENTS OF THIS SECTION ARE NOT MET UNLESS THE APPLICANT HAS 3,106
BEEN GIVEN AN OPPORTUNITY FOR A HEARING. 3,107
(D) IF THE APPLICANT REQUESTS A HEARING, THE DIRECTOR 3,110
SHALL HOLD A HEARING BEFORE CERTIFYING THAT THE APPLICANT DOES 3,111
NOT MEET THE REQUIREMENTS OF THIS SECTION. THE HEARING SHALL BE 3,112
HELD IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,114
(E) THE NINETY-DAY REVIEW PERIOD PROVIDED FOR UNDER 3,117
DIVISION (C) OF THIS SECTION SHALL CEASE TO RUN AS OF THE DATE ON 3,119
WHICH THE NOTICE OF THE APPLICANT'S RIGHT TO REQUEST A HEARING IS 3,120
MAILED AND SHALL REMAIN SUSPENDED UNTIL THE DIRECTOR ISSUES A 3,121
FINAL CERTIFICATION ORDER.
Sec. 1751.05. (A) THE SUPERINTENDENT OF INSURANCE SHALL 3,124
ISSUE OR DENY A CERTIFICATE OF AUTHORITY TO ESTABLISH OR OPERATE 3,125
A HEALTH INSURING CORPORATION TO ANY CORPORATION FILING AN 3,126
APPLICATION PURSUANT TO SECTION 1751.03 OF THE REVISED CODE 3,128
WITHIN FORTY-FIVE DAYS OF THE SUPERINTENDENT'S RECEIPT OF THE 3,129
CERTIFICATION FROM THE DIRECTOR OF HEALTH UNDER DIVISION (C) OF 3,130
SECTION 1751.04 OF THE REVISED CODE. A CERTIFICATE OF AUTHORITY 3,131
SHALL BE ISSUED UPON PAYMENT OF THE APPLICATION FEE PRESCRIBED IN 3,132
SECTION 1751.44 OF THE REVISED CODE IF THE SUPERINTENDENT IS 3,133
SATISFIED THAT THE FOLLOWING CONDITIONS ARE MET: 3,134
(1) THE PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS 3,137
OF THE APPLICANT ARE COMPETENT, TRUSTWORTHY, AND POSSESS GOOD 3,138
REPUTATIONS.
(2) THE DIRECTOR CERTIFIES, IN ACCORDANCE WITH DIVISION 3,140
(C) OF SECTION 1751.04 OF THE REVISED CODE, THAT THE 3,141
ORGANIZATION'S PROPOSED PLAN OF OPERATION MEETS THE REQUIREMENTS 3,142
OF DIVISION (B) OF THAT SECTION AND SECTIONS 3702.51 TO 3702.62 3,144
OF THE REVISED CODE. IF, AFTER THE DIRECTOR HAS CERTIFIED 3,145
COMPLIANCE, THE APPLICATION IS AMENDED IN A MANNER THAT AFFECTS 3,146
ITS APPROVAL UNDER SECTION 1751.04 OF THE REVISED CODE, THE 3,147
SUPERINTENDENT SHALL REQUEST THE DIRECTOR TO REVIEW AND RECERTIFY 3,148
THE AMENDED PLAN OF OPERATION. WITHIN FORTY-FIVE DAYS OF RECEIPT 3,149
72
OF THE AMENDED PLAN FROM THE SUPERINTENDENT, THE DIRECTOR SHALL 3,150
CERTIFY TO THE SUPERINTENDENT, PURSUANT TO SECTION 1751.04 OF THE 3,151
REVISED CODE, WHETHER OR NOT THE AMENDED PLAN MEETS THE 3,153
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. THE 3,154
SUPERINTENDENT'S FORTY-FIVE-DAY REVIEW PERIOD SHALL CEASE TO RUN 3,155
AS OF THE DATE ON WHICH THE AMENDED PLAN IS TRANSMITTED TO THE 3,156
DIRECTOR AND SHALL REMAIN SUSPENDED UNTIL THE SUPERINTENDENT 3,157
RECEIVES A NEW CERTIFICATION FROM THE DIRECTOR.
(3) THE APPLICANT CONSTITUTES AN APPROPRIATE MECHANISM TO 3,159
EFFECTIVELY PROVIDE OR ARRANGE FOR THE PROVISION OF THE BASIC 3,160
HEALTH CARE SERVICES, SUPPLEMENTAL HEALTH CARE SERVICES, OR 3,161
SPECIALTY HEALTH CARE SERVICES TO BE PROVIDED TO ENROLLEES. 3,162
(4) THE APPLICANT IS FINANCIALLY RESPONSIBLE, COMPLIES 3,164
WITH SECTION 1751.28 OF THE REVISED CODE, AND MAY REASONABLY BE 3,166
EXPECTED TO MEET ITS OBLIGATIONS TO ENROLLEES AND PROSPECTIVE 3,167
ENROLLEES. IN MAKING THIS DETERMINATION, THE SUPERINTENDENT MAY 3,168
CONSIDER: 3,169
(a) THE FINANCIAL SOUNDNESS OF THE APPLICANT'S 3,171
ARRANGEMENTS FOR HEALTH CARE SERVICES, INCLUDING THE APPLICANT'S 3,172
PROPOSED CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUMS AND THE USE 3,173
OF COPAYMENTS OR DEDUCTIBLES; 3,174
(b) THE ADEQUACY OF WORKING CAPITAL; 3,176
(c) ANY AGREEMENT WITH AN INSURER, A GOVERNMENT, OR ANY 3,179
OTHER PERSON FOR INSURING THE PAYMENT OF THE COST OF HEALTH CARE 3,180
SERVICES OR PROVIDING FOR AUTOMATIC APPLICABILITY OF AN 3,181
ALTERNATIVE COVERAGE IN THE EVENT OF DISCONTINUANCE OF THE HEALTH 3,182
INSURING CORPORATION'S OPERATIONS; 3,183
(d) ANY AGREEMENT WITH PROVIDERS OR HEALTH CARE FACILITIES 3,185
FOR THE PROVISION OF HEALTH CARE SERVICES; 3,186
(e) ANY DEPOSIT OF SECURITIES SUBMITTED IN ACCORDANCE WITH 3,189
SECTION 1751.27 OF THE REVISED CODE AS A GUARANTEE THAT THE 3,190
OBLIGATIONS WILL BE PERFORMED. 3,191
(5) THE APPLICANT HAS SUBMITTED DOCUMENTATION OF AN 3,193
ARRANGEMENT TO PROVIDE HEALTH CARE SERVICES TO ITS ENROLLEES 3,194
73
UNTIL THE EXPIRATION OF THE ENROLLEES' CONTRACTS WITH THE 3,195
APPLICANT IF A HEALTH CARE PLAN OR THE OPERATIONS OF THE HEALTH 3,196
INSURING CORPORATION ARE DISCONTINUED PRIOR TO THE EXPIRATION OF 3,197
THE ENROLLEES' CONTRACTS. AN ARRANGEMENT TO PROVIDE HEALTH CARE 3,198
SERVICES MAY BE MADE BY USING ANY ONE, OR ANY COMBINATION, OF THE 3,200
FOLLOWING METHODS:
(a) THE MAINTENANCE OF INSOLVENCY INSURANCE; 3,202
(b) A PROVISION IN CONTRACTS WITH PROVIDERS AND HEALTH 3,205
CARE FACILITIES, BUT NO HEALTH INSURING CORPORATION SHALL RELY 3,206
SOLELY ON SUCH A PROVISION FOR MORE THAN THIRTY DAYS; 3,207
(c) AN AGREEMENT WITH OTHER HEALTH INSURING CORPORATIONS 3,210
OR INSURERS, PROVIDING ENROLLEES WITH AUTOMATIC CONVERSION RIGHTS 3,211
UPON THE DISCONTINUATION OF A HEALTH CARE PLAN OR THE HEALTH 3,212
INSURING CORPORATION'S OPERATIONS; 3,213
(d) SUCH OTHER METHODS AS APPROVED BY THE SUPERINTENDENT. 3,215
(6) NOTHING IN THE APPLICANT'S PROPOSED METHOD OF 3,217
OPERATION, AS SHOWN BY THE INFORMATION SUBMITTED PURSUANT TO 3,218
SECTION 1751.03 OF THE REVISED CODE OR BY INDEPENDENT 3,220
INVESTIGATION, WILL CAUSE HARM TO AN ENROLLEE OR TO THE PUBLIC AT 3,222
LARGE, AS DETERMINED BY THE SUPERINTENDENT.
(7) ANY DEFICIENCIES CERTIFIED BY THE DIRECTOR HAVE BEEN 3,224
CORRECTED. 3,225
(8) THE APPLICANT HAS DEPOSITED SECURITIES AS SET FORTH IN 3,228
SECTION 1751.27 OF THE REVISED CODE.
(B) IF AN APPLICANT ELECTS TO FULFILL THE REQUIREMENTS OF 3,231
DIVISION (A)(5) OF THIS SECTION THROUGH AN AGREEMENT WITH OTHER 3,233
HEALTH INSURING CORPORATIONS OR INSURERS, THE AGREEMENT SHALL 3,234
REQUIRE THOSE HEALTH INSURING CORPORATIONS OR INSURERS TO GIVE 3,235
THIRTY DAYS' NOTICE TO THE SUPERINTENDENT PRIOR TO CANCELLATION 3,236
OR DISCONTINUATION OF THE AGREEMENT FOR ANY REASON. 3,237
(C) A CERTIFICATE OF AUTHORITY SHALL BE DENIED ONLY AFTER 3,240
COMPLIANCE WITH THE REQUIREMENTS OF SECTION 1751.36 OF THE 3,241
REVISED CODE.
Sec. 1751.06. UPON OBTAINING A CERTIFICATE OF AUTHORITY AS 3,243
74
REQUIRED UNDER THIS CHAPTER, A HEALTH INSURING CORPORATION MAY DO 3,245
ALL OF THE FOLLOWING:
(A) ENROLL INDIVIDUALS AND THEIR DEPENDENTS IN EITHER OF 3,248
THE FOLLOWING CIRCUMSTANCES: 3,249
(1) THE INDIVIDUAL RESIDES IN THE APPROVED SERVICE AREA. 3,252
(2) THE INDIVIDUAL'S PLACE OF EMPLOYMENT IS LOCATED IN THE 3,255
APPROVED SERVICE AREA AND THE INDIVIDUAL HAS AGREED TO RECEIVE 3,256
HEALTH CARE SERVICES IN ACCORDANCE WITH THE EVIDENCE OF COVERAGE. 3,257
(B) CONTRACT WITH PROVIDERS AND HEALTH CARE FACILITIES FOR 3,260
THE HEALTH CARE SERVICES TO WHICH ENROLLEES ARE ENTITLED UNDER 3,261
THE TERMS OF THE HEALTH INSURING CORPORATION'S HEALTH CARE 3,262
CONTRACTS;
(C) CONTRACT WITH INSURANCE COMPANIES AUTHORIZED TO DO 3,265
BUSINESS IN THIS STATE FOR INSURANCE, INDEMNITY, OR REIMBURSEMENT 3,266
AGAINST THE COST OF PROVIDING EMERGENCY AND NONEMERGENCY HEALTH 3,267
CARE SERVICES FOR ENROLLEES, SUBJECT TO THE PROVISIONS SET FORTH 3,268
IN THIS CHAPTER AND THE LIMITATIONS SET FORTH IN THE REVISED 3,270
CODE;
(D) CONTRACT WITH ANY PERSON PURSUANT TO THE REQUIREMENTS 3,273
OF DIVISION (A)(18) OF SECTION 1751.03 OF THE REVISED CODE FOR 3,275
MANAGERIAL OR ADMINISTRATIVE SERVICES, OR FOR DATA PROCESSING, 3,276
ACTUARIAL ANALYSIS, BILLING SERVICES, OR ANY OTHER SERVICES 3,277
AUTHORIZED BY THE SUPERINTENDENT OF INSURANCE. HOWEVER, A HEALTH 3,279
INSURING CORPORATION SHALL NOT ENTER INTO A CONTRACT FOR ANY OF 3,280
THE SERVICES LISTED IN THIS DIVISION WITH AN INSURANCE COMPANY 3,281
THAT IS NOT AUTHORIZED TO ENGAGE IN THE BUSINESS OF INSURANCE IN 3,282
THIS STATE.
(E) ACCEPT FROM GOVERNMENTAL AGENCIES, PRIVATE AGENCIES, 3,285
CORPORATIONS, ASSOCIATIONS, GROUPS, INDIVIDUALS, OR OTHER 3,286
PERSONS, PAYMENTS COVERING ALL OR PART OF THE COSTS OF PLANNING, 3,287
DEVELOPMENT, CONSTRUCTION, AND THE PROVISION OF HEALTH CARE 3,288
SERVICES;
(F) PURCHASE, LEASE, CONSTRUCT, RENOVATE, OPERATE, OR 3,291
MAINTAIN HEALTH CARE FACILITIES, AND THEIR ANCILLARY EQUIPMENT, 3,292
75
AND ANY PROPERTY NECESSARY IN THE TRANSACTION OF THE BUSINESS OF 3,293
THE HEALTH INSURING CORPORATION. 3,294
NOTHING IN THIS SECTION SHALL BE CONSTRUED AS PROHIBITING A 3,296
HEALTH INSURING CORPORATION WITHOUT OTHER COMMERCIAL ENROLLMENT 3,297
FROM CONTRACTING SOLELY WITH FEDERAL HEALTH CARE PROGRAMS 3,298
REGULATED BY FEDERAL REGULATORY BODIES.
NOTHING IN THIS SECTION SHALL BE CONSTRUED TO LIMIT THE 3,300
AUTHORITY OF A HEALTH INSURING CORPORATION TO PERFORM THOSE 3,301
FUNCTIONS NOT OTHERWISE PROHIBITED BY LAW. 3,302
Sec. 1751.07. ANY TRUSTEE, DIRECTOR, OFFICER, OR EMPLOYEE 3,304
OF A HEALTH INSURING CORPORATION WHO RECEIVES, COLLECTS, 3,305
DISBURSES, OR INVESTS FUNDS IN CONNECTION WITH THE ACTIVITIES OF 3,306
THE HEALTH INSURING CORPORATION SHALL BE RESPONSIBLE FOR SUCH 3,307
FUNDS IN A FIDUCIARY RELATIONSHIP TO THE CORPORATION. 3,308
Sec. 1751.08. (A) EXCEPT AS OTHERWISE SPECIFICALLY 3,311
PROVIDED IN THIS CHAPTER OR TITLE XXXIX OF THE REVISED CODE, 3,313
PROVISIONS OF TITLE XXXIX OF THE REVISED CODE SHALL NOT BE 3,314
APPLICABLE TO ANY HEALTH INSURING CORPORATION HOLDING A 3,315
CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER. THIS DIVISION SHALL 3,316
NOT APPLY TO AN INSURER LICENSED AND REGULATED PURSUANT TO TITLE 3,318
XXXIX OF THE REVISED CODE EXCEPT WITH RESPECT TO ITS HEALTH 3,320
INSURING CORPORATION ACTIVITIES AUTHORIZED AND REGULATED PURSUANT 3,321
TO THIS CHAPTER.
(B) FOR THE PURPOSE OF CLARIFYING JURISDICTION UNDER THE 3,325
"BANKRUPTCY REFORM ACT OF 1978," 92 STAT. 2549, 11 U.S.C.A. 101, 3,327
AND IN RECOGNITION OF THE RIGHT OF THIS STATE TO REGULATE
DOMESTIC INSURANCE COMPANIES UNDER THE "McCARRAN-FERGUSON ACT," 3,329
59 STAT. 33 (1945), 15 U.S.C.A. 1011, A HEALTH INSURING 3,332
CORPORATION IS DEEMED TO BE A DOMESTIC INSURANCE COMPANY. 3,333
(C) SOLICITATION OF ENROLLEES BY A HEALTH INSURING 3,336
CORPORATION HOLDING A CERTIFICATE OF AUTHORITY UNDER THIS 3,337
CHAPTER, OR ITS REPRESENTATIVES, SHALL NOT BE CONSTRUED TO 3,338
VIOLATE ANY PROVISION OF LAW RELATING TO SOLICITATION OR 3,339
ADVERTISING BY HEALTH PROFESSIONALS.
76
(D) ANY HEALTH INSURING CORPORATION HOLDING A CERTIFICATE 3,342
OF AUTHORITY UNDER THIS CHAPTER SHALL NOT BE CONSIDERED TO BE 3,343
PRACTICING MEDICINE. 3,344
Sec. 1751.11. (A) EVERY SUBSCRIBER OF A HEALTH INSURING 3,347
CORPORATION IS ENTITLED TO AN EVIDENCE OF COVERAGE FOR THE HEALTH 3,348
CARE PLAN UNDER WHICH HEALTH CARE BENEFITS ARE PROVIDED. 3,350
(B) EVERY SUBSCRIBER OF A HEALTH INSURING CORPORATION THAT 3,352
OFFERS BASIC HEALTH CARE SERVICES IS ENTITLED TO AN 3,353
IDENTIFICATION CARD OR SIMILAR DOCUMENT THAT SPECIFIES THE HEALTH 3,354
INSURING CORPORATION'S NAME AS STATED IN ITS ARTICLES OF 3,355
INCORPORATION, AND ANY TRADE OR FICTITIOUS NAMES USED BY THE 3,356
HEALTH INSURING CORPORATION. THE IDENTIFICATION CARD OR DOCUMENT 3,357
SHALL LIST AT LEAST ONE TELEPHONE NUMBER THAT PROVIDES THE 3,358
SUBSCRIBER WITH ACCESS TO HEALTH CARE ON A 3,359
TWENTY-FOUR-HOUR-PER-DAY, SEVEN-DAY-PER-WEEK BASIS.
(C) NO EVIDENCE OF COVERAGE, OR AMENDMENT TO THE EVIDENCE 3,361
OF COVERAGE, SHALL BE DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR 3,362
USED, UNTIL THE FORM OF THE EVIDENCE OF COVERAGE OR AMENDMENT HAS 3,363
BEEN FILED BY THE HEALTH INSURING CORPORATION WITH THE 3,364
SUPERINTENDENT OF INSURANCE. IF THE SUPERINTENDENT DOES NOT 3,365
DISAPPROVE THE EVIDENCE OF COVERAGE OR AMENDMENT WITHIN SIXTY 3,366
DAYS AFTER IT IS FILED IT SHALL BE DEEMED APPROVED, UNLESS THE 3,367
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE EVIDENCE OF COVERAGE 3,368
OR AMENDMENT. WITH RESPECT TO AN AMENDMENT TO AN APPROVED 3,369
EVIDENCE OF COVERAGE, THE SUPERINTENDENT ONLY MAY DISAPPROVE 3,370
PROVISIONS AMENDED OR ADDED TO THE EVIDENCE OF COVERAGE. IF THE 3,371
SUPERINTENDENT DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT ANY 3,372
EVIDENCE OF COVERAGE OR AMENDMENT FAILS TO MEET THE REQUIREMENTS 3,373
OF THIS SECTION, THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH 3,374
INSURING CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH 3,375
INSURING CORPORATION TO USE SUCH EVIDENCE OF COVERAGE OR 3,376
AMENDMENT. AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,378
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,379
WITHDRAW AN APPROVAL, DEEMED OR ACTUAL, OF ANY EVIDENCE OF
77
COVERAGE OR AMENDMENT ON ANY OF THE GROUNDS STATED IN THIS 3,380
SECTION. SUCH DISAPPROVAL SHALL BE EFFECTED BY A WRITTEN ORDER, 3,381
WHICH SHALL STATE THE GROUNDS FOR DISAPPROVAL AND SHALL BE ISSUED 3,383
IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE. 3,385
(D) NO EVIDENCE OF COVERAGE OR AMENDMENT SHALL BE 3,387
DELIVERED, ISSUED FOR DELIVERY, RENEWED, OR USED: 3,388
(1) IF IT CONTAINS PROVISIONS OR STATEMENTS THAT ARE 3,390
INEQUITABLE, UNTRUE, MISLEADING, OR DECEPTIVE; 3,391
(2) UNLESS IT CONTAINS A CLEAR, CONCISE, AND COMPLETE 3,393
STATEMENT OF THE FOLLOWING: 3,394
(a) THE HEALTH CARE SERVICES AND INSURANCE OR OTHER 3,397
BENEFITS, IF ANY, TO WHICH THE ENROLLEE IS ENTITLED UNDER THE 3,398
HEALTH CARE PLAN;
(b) ANY EXCLUSIONS OR LIMITATIONS ON THE HEALTH CARE 3,401
SERVICES, TYPE OF HEALTH CARE SERVICES, BENEFITS, OR TYPE OF 3,402
BENEFITS TO BE PROVIDED, INCLUDING COPAYMENTS OR DEDUCTIBLES; 3,403
(c) THE ENROLLEE'S PERSONAL FINANCIAL OBLIGATION FOR 3,405
NONCOVERED SERVICES; 3,406
(d) WHERE AND IN WHAT MANNER GENERAL INFORMATION AND 3,409
INFORMATION AS TO HOW SERVICES MAY BE OBTAINED IS AVAILABLE, 3,410
INCLUDING THE TELEPHONE NUMBER; 3,411
(e) THE PREMIUM RATE WITH RESPECT TO INDIVIDUAL AND 3,413
CONVERSION CONTRACTS, AND RELEVANT COPAYMENT PROVISIONS WITH 3,414
RESPECT TO ALL CONTRACTS. THE STATEMENT OF THE PREMIUM RATE, 3,415
HOWEVER, MAY BE CONTAINED IN A SEPARATE INSERT. 3,416
(f) THE METHOD UTILIZED BY THE HEALTH INSURING CORPORATION 3,419
FOR RESOLVING ENROLLEE COMPLAINTS. 3,420
(3) UNLESS IT PROVIDES FOR THE CONTINUATION OF AN 3,422
ENROLLEE'S COVERAGE, IN THE EVENT THAT THE ENROLLEE'S COVERAGE 3,423
UNDER THE POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT TERMINATES 3,424
WHILE THE ENROLLEE IS RECEIVING INPATIENT CARE IN A HOSPITAL. 3,425
THIS CONTINUATION OF COVERAGE SHALL TERMINATE AT THE EARLIEST 3,426
OCCURRENCE OF ANY OF THE FOLLOWING: 3,427
(a) THE ENROLLEE'S DISCHARGE FROM THE HOSPITAL; 3,429
78
(b) THE DETERMINATION BY THE ENROLLEE'S ATTENDING 3,431
PHYSICIAN THAT INPATIENT CARE IS NO LONGER MEDICALLY INDICATED 3,432
FOR THE ENROLLEE;
(c) THE ENROLLEE'S REACHING THE LIMIT FOR CONTRACTUAL 3,434
BENEFITS. 3,435
(4) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,437
SUBSTANCE, THAT THE HEALTH INSURING CORPORATION IS NOT A MEMBER 3,438
OF ANY GUARANTY FUND, AND THAT IN THE EVENT OF THE HEALTH 3,439
INSURING CORPORATION'S INSOLVENCY, THE ENROLLEE IS PROTECTED ONLY 3,441
TO THE EXTENT THAT THE HOLD HARMLESS PROVISION REQUIRED BY
SECTION 1751.13 OF THE REVISED CODE APPLIES TO THE HEALTH CARE 3,443
SERVICES RENDERED; 3,444
(5) UNLESS IT CONTAINS A PROVISION THAT STATES, IN 3,446
SUBSTANCE, THAT IN THE EVENT OF THE INSOLVENCY OF THE HEALTH 3,447
INSURING CORPORATION, THE ENROLLEE MAY BE FINANCIALLY RESPONSIBLE 3,449
FOR HEALTH CARE SERVICES RENDERED BY A PROVIDER OR HEALTH CARE 3,450
FACILITY THAT IS NOT UNDER CONTRACT TO THE HEALTH INSURING 3,451
CORPORATION, WHETHER OR NOT THE HEALTH INSURING CORPORATION 3,452
AUTHORIZED THE USE OF THE PROVIDER OR HEALTH CARE FACILITY. 3,453
(E) NOTWITHSTANDING DIVISION (D) OF THIS SECTION, A HEALTH 3,457
INSURING CORPORATION MAY USE AN EVIDENCE OF COVERAGE THAT
PROVIDES FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,459
XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,461
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 3,462
MEDICARE COST CONTRACT, OR AN EVIDENCE OF COVERAGE THAT PROVIDES 3,463
FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL 3,464
EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR 3,467
AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE OF 3,468
BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY ACT," 3,470
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS THE 3,471
MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 3,473
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 3,474
CODE, OR AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE 3,475
OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE PROGRAM 3,476
79
REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE FOLLOWING
APPLY: 3,477
(1) THE EVIDENCE OF COVERAGE HAS BEEN APPROVED BY THE 3,480
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 3,481
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 3,482
HUMAN SERVICES.
(2) THE EVIDENCE OF COVERAGE IS FILED WITH THE 3,484
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 3,485
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,487
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,488
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,489
Sec. 1751.12. (A)(1) NO CONTRACTUAL PERIODIC PREPAYMENT 3,492
AND NO PREMIUM RATE FOR NONGROUP AND CONVERSION POLICIES FOR 3,493
HEALTH CARE SERVICES, OR ANY AMENDMENT TO THEM, MAY BE USED BY 3,494
ANY HEALTH INSURING CORPORATION AT ANY TIME UNTIL THE CONTRACTUAL 3,495
PERIODIC PREPAYMENT AND PREMIUM RATE, OR AMENDMENT, HAVE BEEN 3,496
FILED WITH THE SUPERINTENDENT OF INSURANCE, AND SHALL NOT BE 3,497
EFFECTIVE UNTIL THE EXPIRATION OF SIXTY DAYS AFTER THEIR FILING 3,498
UNLESS THE SUPERINTENDENT SOONER GIVES APPROVAL. THE 3,499
SUPERINTENDENT SHALL DISAPPROVE THE FILING, IF THE SUPERINTENDENT 3,500
DETERMINES WITHIN THE SIXTY-DAY PERIOD THAT THE CONTRACTUAL 3,501
PERIODIC PREPAYMENT OR PREMIUM RATE, OR AMENDMENT, IS NOT IN 3,502
ACCORDANCE WITH SOUND ACTUARIAL PRINCIPLES OR IS NOT REASONABLY 3,503
RELATED TO THE APPLICABLE COVERAGE AND CHARACTERISTICS OF THE 3,504
APPLICABLE CLASS OF ENROLLEES. THE SUPERINTENDENT SHALL NOTIFY 3,505
THE HEALTH INSURING CORPORATION OF THE DISAPPROVAL, AND IT SHALL 3,506
THEREAFTER BE UNLAWFUL FOR THE HEALTH INSURING CORPORATION TO USE 3,507
THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, OR 3,508
AMENDMENT.
(2) NO CONTRACTUAL PERIODIC PREPAYMENT FOR GROUP POLICIES 3,511
FOR HEALTH CARE SERVICES SHALL BE USED UNTIL THE CONTRACTUAL 3,512
PERIODIC PREPAYMENT HAS BEEN FILED WITH THE SUPERINTENDENT. THE 3,513
SUPERINTENDENT MAY REJECT A FILING MADE UNDER DIVISION (A)(2) OF 3,514
THIS SECTION AT ANY TIME, WITH AT LEAST THIRTY DAYS' WRITTEN 3,515
80
NOTICE TO A HEALTH INSURING CORPORATION, IF THE CONTRACTUAL 3,516
PERIODIC PREPAYMENT IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,518
PRINCIPLES OR IS NOT REASONABLY RELATED TO THE APPLICABLE 3,519
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,520
ENROLLEES.
(3) AT ANY TIME, THE SUPERINTENDENT, UPON AT LEAST THIRTY 3,522
DAYS' WRITTEN NOTICE TO A HEALTH INSURING CORPORATION, MAY 3,523
WITHDRAW THE APPROVAL GIVEN UNDER DIVISION (A)(1) OF THIS 3,524
SECTION, DEEMED OR ACTUAL, OF ANY CONTRACTUAL PERIODIC PREPAYMENT 3,526
OR PREMIUM RATE, OR AMENDMENT, BASED ON INFORMATION THAT EITHER 3,527
OF THE FOLLOWING APPLIES:
(a) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,530
OR AMENDMENT, IS NOT IN ACCORDANCE WITH SOUND ACTUARIAL 3,531
PRINCIPLES.
(b) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE, 3,534
OR AMENDMENT, IS NOT REASONABLY RELATED TO THE APPLICABLE 3,535
COVERAGE AND CHARACTERISTICS OF THE APPLICABLE CLASS OF 3,536
ENROLLEES.
(4) ANY DISAPPROVAL UNDER DIVISION (A)(1) OF THIS SECTION, 3,538
ANY REJECTION OF A FILING MADE UNDER DIVISION (A)(2) OF THIS 3,540
SECTION, OR ANY WITHDRAWAL OF APPROVAL UNDER DIVISION (A)(3) OF 3,541
THIS SECTION, SHALL BE EFFECTED BY A WRITTEN NOTICE, WHICH SHALL 3,542
STATE THE SPECIFIC BASIS FOR THE DISAPPROVAL, REJECTION, OR 3,543
WITHDRAWAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. OF 3,544
THE REVISED CODE. 3,545
(B) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 3,548
INSURING CORPORATION MAY USE A CONTRACTUAL PERIODIC PREPAYMENT OR 3,549
PREMIUM RATE FOR POLICIES USED FOR THE COVERAGE OF BENEFICIARIES 3,550
ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 3,552
620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE 3,554
RISK CONTRACT OR MEDICARE COST CONTRACT, OR FOR POLICIES USED FOR 3,555
THE COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEES 3,556
HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR FOR 3,559
POLICIES USED FOR THE COVERAGE OF BENEFICIARIES ENROLLED IN TITLE 3,560
81
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 3,563
U.S.C.A. 301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM 3,565
OR MEDICAID, PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES 3,566
UNDER CHAPTER 5111. OF THE REVISED CODE, OR FOR POLICIES USED FOR 3,567
THE COVERAGE OF BENEFICIARIES UNDER ANY OTHER FEDERAL HEALTH CARE 3,568
PROGRAM REGULATED BY A FEDERAL REGULATORY BODY, IF BOTH OF THE 3,569
FOLLOWING APPLY: 3,570
(1) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE 3,572
HAS BEEN APPROVED BY THE UNITED STATES DEPARTMENT OF HEALTH AND 3,573
HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL MANAGEMENT, 3,575
OR THE OHIO DEPARTMENT OF HUMAN SERVICES.
(2) THE CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE IS 3,577
FILED WITH THE SUPERINTENDENT PRIOR TO USE AND IS ACCOMPANIED BY 3,578
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 3,580
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 3,582
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 3,584
(C) THE ADMINISTRATIVE EXPENSE PORTION OF ALL CONTRACTUAL 3,587
PERIODIC PREPAYMENT OR PREMIUM RATE FILINGS SUBMITTED TO THE 3,588
SUPERINTENDENT FOR REVIEW MUST REFLECT THE ACTUAL COST OF 3,589
ADMINISTERING THE PRODUCT. THE SUPERINTENDENT MAY REQUIRE THAT 3,590
THE ADMINISTRATIVE EXPENSE PORTION OF THE FILINGS BE ITEMIZED AND 3,591
SUPPORTED.
(D)(1) COPAYMENTS AND DEDUCTIBLES MUST BE REASONABLE AND 3,594
MUST NOT BE A BARRIER TO THE NECESSARY UTILIZATION OF SERVICES BY 3,595
ENROLLEES.
(2) A HEALTH INSURING CORPORATION MAY NOT IMPOSE COPAYMENT 3,598
CHARGES ON BASIC HEALTH CARE SERVICES THAT EXCEED THIRTY PER CENT 3,599
OF THE TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE 3,600
SERVICE, EXCEPT FOR EMERGENCY HEALTH SERVICES AND URGENT CARE 3,601
SERVICES. THE TOTAL COST OF PROVIDING A HEALTH CARE SERVICE IS 3,602
THE COST TO THE HEALTH INSURING CORPORATION OF PROVIDING THE 3,603
HEALTH CARE SERVICE TO THE ENROLLEE AS REDUCED BY ANY APPLICABLE 3,604
PROVIDER DISCOUNT. AN OPEN PANEL PLAN MAY NOT IMPOSE COPAYMENTS 3,605
ON OUT-OF-NETWORK BENEFITS THAT EXCEED FIFTY PER CENT OF THE 3,606
82
TOTAL COST OF PROVIDING ANY SINGLE COVERED HEALTH CARE SERVICE. 3,607
(3) TO ENSURE THAT COPAYMENTS ARE NOT A BARRIER TO THE 3,609
UTILIZATION OF BASIC HEALTH CARE SERVICES, A HEALTH INSURING 3,610
CORPORATION MAY NOT IMPOSE, IN ANY CONTRACT YEAR, ON ANY 3,611
SUBSCRIBER OR ENROLLEE, COPAYMENTS THAT EXCEED TWO HUNDRED PER 3,612
CENT OF THE TOTAL ANNUAL PREMIUM RATE TO THE SUBSCRIBER OR 3,613
ENROLLEES. THIS LIMITATION OF TWO HUNDRED PER CENT DOES NOT 3,615
INCLUDE ANY REASONABLE COPAYMENTS THAT ARE NOT A BARRIER TO THE 3,616
NECESSARY UTILIZATION OF HEALTH CARE SERVICES BY ENROLLEES AND 3,617
THAT ARE IMPOSED ON PHYSICIAN OFFICE VISITS, EMERGENCY HEALTH 3,618
SERVICES, URGENT CARE SERVICES, SUPPLEMENTAL HEALTH CARE 3,619
SERVICES, OR SPECIALTY HEALTH CARE SERVICES.
(E) A HEALTH INSURING CORPORATION SHALL NOT IMPOSE 3,622
LIFETIME MAXIMUMS ON BASIC HEALTH CARE SERVICES. HOWEVER, A 3,623
HEALTH INSURING CORPORATION MAY ESTABLISH A BENEFIT LIMIT FOR 3,624
INPATIENT HOSPITAL SERVICES THAT ARE PROVIDED PURSUANT TO A 3,625
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT FOR SUPPLEMENTAL 3,626
HEALTH CARE SERVICES.
Sec. 1751.13. (A)(1) A HEALTH INSURING CORPORATION SHALL, 3,629
EITHER DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS FOR THE 3,630
PROVISION OF HEALTH CARE SERVICES WITH A SUFFICIENT NUMBER AND 3,631
TYPES OF PROVIDERS AND HEALTH CARE FACILITIES TO ENSURE THAT ALL 3,632
COVERED HEALTH CARE SERVICES WILL BE ACCESSIBLE TO ENROLLEES FROM 3,633
A CONTRACTED PROVIDER OR HEALTH CARE FACILITY. 3,634
(2) WHEN A HEALTH INSURING CORPORATION IS UNABLE TO 3,636
PROVIDE A COVERED HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,637
OR HEALTH CARE FACILITY, THE HEALTH INSURING CORPORATION MUST 3,638
PROVIDE THAT HEALTH CARE SERVICE FROM A NONCONTRACTED PROVIDER OR 3,640
HEALTH CARE FACILITY CONSISTENT WITH THE TERMS OF THE ENROLLEE'S 3,641
POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT. THE HEALTH INSURING 3,642
CORPORATION SHALL EITHER ENSURE THAT THE HEALTH CARE SERVICE BE 3,643
PROVIDED AT NO GREATER COST TO THE ENROLLEE THAN IF THE ENROLLEE 3,644
HAD OBTAINED THE HEALTH CARE SERVICE FROM A CONTRACTED PROVIDER 3,645
OR HEALTH CARE FACILITY, OR MAKE OTHER ARRANGEMENTS ACCEPTABLE TO 3,646
83
THE SUPERINTENDENT OF INSURANCE. 3,647
(3) NOTHING IN THIS SECTION SHALL PROHIBIT A HEALTH 3,649
INSURING CORPORATION FROM ENTERING INTO CONTRACTS WITH 3,650
OUT-OF-STATE PROVIDERS OR HEALTH CARE FACILITIES THAT ARE 3,651
LICENSED, CERTIFIED, ACCREDITED, OR OTHERWISE AUTHORIZED IN THAT 3,652
STATE. 3,653
(B)(1) A HEALTH INSURING CORPORATION SHALL, EITHER 3,656
DIRECTLY OR INDIRECTLY, ENTER INTO CONTRACTS WITH ALL PROVIDERS 3,657
AND HEALTH CARE FACILITIES THROUGH WHICH HEALTH CARE SERVICES ARE 3,658
PROVIDED TO ITS ENROLLEES.
(2) A HEALTH INSURING CORPORATION, UPON WRITTEN REQUEST, 3,660
SHALL ASSIST ITS CONTRACTED PROVIDERS IN FINDING STOP-LOSS OR 3,661
REINSURANCE CARRIERS.
(C) A HEALTH INSURING CORPORATION SHALL FILE AN ANNUAL 3,662
CERTIFICATE WITH THE SUPERINTENDENT CERTIFYING THAT ALL PROVIDER 3,663
CONTRACTS AND CONTRACTS WITH HEALTH CARE FACILITIES THROUGH WHICH 3,664
HEALTH CARE SERVICES ARE BEING PROVIDED CONTAIN THE FOLLOWING: 3,665
(1) A DESCRIPTION OF THE METHOD BY WHICH THE PROVIDER OR 3,667
HEALTH CARE FACILITY WILL BE NOTIFIED OF THE SPECIFIC HEALTH CARE 3,669
SERVICES FOR WHICH THE PROVIDER OR HEALTH CARE FACILITY WILL BE 3,670
RESPONSIBLE, INCLUDING ANY LIMITATIONS OR CONDITIONS ON SUCH 3,671
SERVICES;
(2) THE SPECIFIC HOLD HARMLESS PROVISION SPECIFYING 3,673
PROTECTION OF ENROLLEES SET FORTH AS FOLLOWS: 3,674
"[PROVIDER/HEALTH CARE FACILITY< AGREES THAT IN NO EVENT, 3,677
INCLUDING BUT NOT LIMITED TO NONPAYMENT BY THE HEALTH INSURING 3,678
CORPORATION, INSOLVENCY OF THE HEALTH INSURING CORPORATION, OR 3,679
BREACH OF THIS AGREEMENT, SHALL [PROVIDER/HEALTH CARE FACILITY< 3,681
BILL, CHARGE, COLLECT A DEPOSIT FROM, SEEK REMUNERATION OR 3,682
REIMBURSEMENT FROM, OR HAVE ANY RECOURSE AGAINST, A SUBSCRIBER, 3,683
ENROLLEE, PERSON TO WHOM HEALTH CARE SERVICES HAVE BEEN PROVIDED, 3,685
OR PERSON ACTING ON BEHALF OF THE COVERED ENROLLEE, FOR HEALTH 3,686
CARE SERVICES PROVIDED PURSUANT TO THIS AGREEMENT. THIS DOES NOT 3,687
PROHIBIT [PROVIDER/HEALTH CARE FACILITY< FROM COLLECTING 3,688
84
CO-INSURANCE, DEDUCTIBLES, OR COPAYMENTS AS SPECIFICALLY PROVIDED 3,690
IN THE EVIDENCE OF COVERAGE, OR FEES FOR UNCOVERED HEALTH CARE 3,691
SERVICES DELIVERED ON A FEE-FOR-SERVICE BASIS TO PERSONS 3,692
REFERENCED ABOVE, NOR FROM ANY RECOURSE AGAINST THE HEALTH 3,693
INSURING CORPORATION OR ITS SUCCESSOR."
(3) PROVISIONS REQUIRING THE PROVIDER OR HEALTH CARE 3,695
FACILITY TO CONTINUE TO PROVIDE COVERED HEALTH CARE SERVICES TO 3,696
ENROLLEES IN THE EVENT OF THE HEALTH INSURING CORPORATION'S 3,697
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. THE PROVISIONS SHALL 3,699
REQUIRE THE PROVIDER OR HEALTH CARE FACILITY TO CONTINUE TO 3,700
PROVIDE COVERED HEALTH CARE SERVICES TO ENROLLEES AS NEEDED TO 3,701
COMPLETE ANY MEDICALLY NECESSARY PROCEDURES COMMENCED BUT 3,702
UNFINISHED AT THE TIME OF THE HEALTH INSURING CORPORATION'S
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. IF AN ENROLLEE IS 3,703
RECEIVING NECESSARY INPATIENT CARE AT A HOSPITAL, THE PROVISIONS 3,704
MAY LIMIT THE REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES 3,705
RELATING TO THAT INPATIENT CARE IN ACCORDANCE WITH DIVISION 3,707
(D)(3) OF SECTION 1751.11 OF THE REVISED CODE, AND MAY ALSO LIMIT 3,708
SUCH REQUIRED PROVISION OF COVERED HEALTH CARE SERVICES TO THE 3,709
PERIOD ENDING THIRTY DAYS AFTER THE HEALTH INSURING CORPORATION'S 3,710
INSOLVENCY OR DISCONTINUANCE OF OPERATIONS. 3,711
THE PROVISIONS REQUIRED BY DIVISION (C)(3) OF THIS SECTION 3,714
SHALL NOT REQUIRE ANY PROVIDER OR HEALTH CARE FACILITY TO 3,715
CONTINUE TO PROVIDE ANY COVERED HEALTH CARE SERVICE AFTER THE
OCCURRENCE OF ANY OF THE FOLLOWING: 3,716
(a) THE END OF THE THIRTY-DAY PERIOD FOLLOWING THE ENTRY OF 3,719
A LIQUIDATION ORDER UNDER CHAPTER 3903. OF THE REVISED CODE; 3,720
(b) THE END OF THE ENROLLEE'S PERIOD OF COVERAGE FOR A 3,722
CONTRACTUAL PREPAYMENT OR PREMIUM; 3,723
(c) THE ENROLLEE OBTAINS EQUIVALENT COVERAGE WITH ANOTHER 3,725
HEALTH INSURING CORPORATION OR INSURER, OR THE ENROLLEE'S 3,726
EMPLOYER OBTAINS SUCH COVERAGE FOR THE ENROLLEE; 3,727
(d) THE ENROLLEE OR THE ENROLLEE'S EMPLOYER TERMINATES 3,729
COVERAGE UNDER THE CONTRACT; 3,730
85
(e) A LIQUIDATOR EFFECTS A TRANSFER OF THE HEALTH INSURING 3,733
CORPORATION'S OBLIGATIONS UNDER THE CONTRACT UNDER DIVISION 3,734
(A)(8) OF SECTION 3903.21 OF THE REVISED CODE. 3,735
(4) A PROVISION CLEARLY STATING THE RIGHTS AND 3,737
RESPONSIBILITIES OF THE HEALTH INSURING CORPORATION, AND OF THE 3,738
CONTRACTED PROVIDERS AND HEALTH CARE FACILITIES, WITH RESPECT TO 3,739
ADMINISTRATIVE POLICIES AND PROGRAMS, INCLUDING, BUT NOT LIMITED 3,740
TO, PAYMENTS SYSTEMS, UTILIZATION REVIEW, QUALITY ASSESSMENT AND 3,741
IMPROVEMENT PROGRAMS, CREDENTIALING, CONFIDENTIALITY 3,742
REQUIREMENTS, AND ANY APPLICABLE FEDERAL OR STATE PROGRAMS; 3,744
(5) A PROVISION REGARDING THE AVAILABILITY AND 3,746
CONFIDENTIALITY OF THOSE HEALTH RECORDS MAINTAINED BY PROVIDERS 3,747
AND HEALTH CARE FACILITIES TO MONITOR AND EVALUATE THE QUALITY OF 3,749
CARE, TO CONDUCT EVALUATIONS AND AUDITS, AND TO DETERMINE ON A 3,750
CONCURRENT OR RETROSPECTIVE BASIS THE NECESSITY OF AND
APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED TO ENROLLEES. 3,751
THE PROVISION SHALL INCLUDE TERMS REQUIRING THE PROVIDER OR 3,752
HEALTH CARE FACILITY TO MAKE THESE HEALTH RECORDS AVAILABLE TO 3,753
APPROPRIATE STATE AND FEDERAL AUTHORITIES INVOLVED IN ASSESSING 3,754
THE QUALITY OF CARE OR IN INVESTIGATING THE GRIEVANCES OR 3,755
COMPLAINTS OF ENROLLEES, AND REQUIRING THE PROVIDER OR HEALTH 3,756
CARE FACILITY TO COMPLY WITH APPLICABLE STATE AND FEDERAL LAWS 3,757
RELATED TO THE CONFIDENTIALITY OF MEDICAL OR HEALTH RECORDS. 3,759
(6) A PROVISION THAT STATES THAT CONTRACTUAL RIGHTS AND 3,761
RESPONSIBILITIES MAY NOT BE ASSIGNED OR DELEGATED BY THE PROVIDER 3,763
OR HEALTH CARE FACILITY WITHOUT THE PRIOR WRITTEN CONSENT OF THE 3,764
HEALTH INSURING CORPORATION;
(7) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,766
FACILITY TO MAINTAIN ADEQUATE PROFESSIONAL LIABILITY AND 3,767
MALPRACTICE INSURANCE. THE PROVISION SHALL ALSO REQUIRE THE 3,768
PROVIDER OR HEALTH CARE FACILITY TO NOTIFY THE HEALTH INSURING 3,769
CORPORATION NOT MORE THAN TEN DAYS AFTER THE PROVIDER'S OR HEALTH 3,771
CARE FACILITY'S RECEIPT OF NOTICE OF ANY REDUCTION OR
CANCELLATION OF SUCH COVERAGE. 3,772
86
(8) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,774
FACILITY TO OBSERVE, PROTECT, AND PROMOTE THE RIGHTS OF ENROLLEES 3,776
AS PATIENTS;
(9) A PROVISION REQUIRING THE PROVIDER OR HEALTH CARE 3,778
FACILITY TO PROVIDE HEALTH CARE SERVICES WITHOUT DISCRIMINATION 3,779
ON THE BASIS OF A PATIENT'S PARTICIPATION IN THE HEALTH CARE 3,780
PLAN, AGE, SEX, ETHNICITY, RELIGION, SEXUAL PREFERENCE, HEALTH 3,781
STATUS, OR DISABILITY, AND WITHOUT REGARD TO THE SOURCE OF 3,782
PAYMENTS MADE FOR HEALTH CARE SERVICES RENDERED TO A PATIENT. 3,783
THIS REQUIREMENT SHALL NOT APPLY TO CIRCUMSTANCES WHEN THE 3,784
PROVIDER OR HEALTH CARE FACILITY APPROPRIATELY DOES NOT RENDER 3,785
SERVICES DUE TO LIMITATIONS ARISING FROM THE PROVIDER'S OR HEALTH 3,787
CARE FACILITY'S LACK OF TRAINING, EXPERIENCE, OR SKILL, OR DUE TO 3,788
LICENSING RESTRICTIONS.
(10) A PROVISION CONTAINING THE SPECIFICS OF ANY 3,790
OBLIGATION ON THE PROVIDER OR HEALTH CARE FACILITY TO PROVIDE, OR 3,792
TO ARRANGE FOR THE PROVISION OF, COVERED HEALTH CARE SERVICES
TWENTY-FOUR HOURS PER DAY, SEVEN DAYS PER WEEK; 3,793
(11) A PROVISION SETTING FORTH PROCEDURES FOR THE 3,795
RESOLUTION OF DISPUTES ARISING OUT OF THE CONTRACT; 3,796
(12) A PROVISION STATING THAT THE HOLD HARMLESS PROVISION 3,798
REQUIRED BY DIVISION (C)(2) OF THIS SECTION SHALL SURVIVE THE 3,800
TERMINATION OF THE CONTRACT WITH RESPECT TO SERVICES COVERED AND 3,801
PROVIDED UNDER THE CONTRACT DURING THE TIME THE CONTRACT WAS IN 3,802
EFFECT, REGARDLESS OF THE REASON FOR THE TERMINATION, INCLUDING
THE INSOLVENCY OF THE HEALTH INSURING CORPORATION; 3,803
(13) A PROVISION REQUIRING THOSE TERMS THAT ARE USED IN 3,805
THE CONTRACT AND THAT ARE DEFINED BY THIS CHAPTER, BE USED IN THE 3,807
CONTRACT IN A MANNER CONSISTENT WITH THOSE DEFINITIONS. 3,808
(D) NO HEALTH INSURING CORPORATION CONTRACT WITH A 3,811
PROVIDER OR HEALTH CARE FACILITY SHALL DO EITHER OF THE 3,812
FOLLOWING:
(1) OFFER AN INDUCEMENT TO THE PROVIDER OR HEALTH CARE 3,814
FACILITY, DIRECTLY OR INDIRECTLY, TO REDUCE OR LIMIT MEDICALLY 3,815
87
NECESSARY HEALTH CARE SERVICES TO A COVERED ENROLLEE; 3,816
(2) PENALIZE A PROVIDER OR HEALTH CARE FACILITY THAT 3,818
ASSISTS AN ENROLLEE TO SEEK A RECONSIDERATION OF THE HEALTH 3,819
INSURING CORPORATION'S DECISION TO DENY OR LIMIT BENEFITS TO THE 3,820
ENROLLEE. 3,821
(E) ANY CONTRACT BETWEEN A HEALTH INSURING CORPORATION AND 3,824
AN INTERMEDIARY ORGANIZATION SHALL CLEARLY SPECIFY THAT THE 3,825
HEALTH INSURING CORPORATION MUST APPROVE OR DISAPPROVE THE 3,826
PARTICIPATION OF ANY PROVIDER OR HEALTH CARE FACILITY WITH WHICH 3,827
THE INTERMEDIARY ORGANIZATION CONTRACTS. 3,828
(F) IF AN INTERMEDIARY ORGANIZATION THAT IS NOT A HEALTH 3,830
DELIVERY NETWORK CONTRACTING SOLELY WITH SELF-INSURED EMPLOYERS 3,831
SUBCONTRACTS WITH A PROVIDER OR HEALTH CARE FACILITY, THE 3,832
SUBCONTRACT WITH THE PROVIDER OR HEALTH CARE FACILITY SHALL DO 3,833
ALL OF THE FOLLOWING:
(1) CONTAIN THE PROVISIONS REQUIRED BY DIVISIONS (C) AND 3,836
(G) OF THIS SECTION, AS MADE APPLICABLE TO AN INTERMEDIARY 3,837
ORGANIZATION, WITHOUT THE INCLUSION OF INDUCEMENTS OR PENALTIES 3,838
DESCRIBED IN DIVISION (D) OF THIS SECTION; 3,839
(2) ACKNOWLEDGE THAT THE HEALTH INSURING CORPORATION IS A 3,841
THIRD-PARTY BENEFICIARY TO THE AGREEMENT; 3,842
(3) ACKNOWLEDGE THE HEALTH INSURING CORPORATION'S ROLE IN 3,844
APPROVING THE PARTICIPATION OF THE PROVIDER OR HEALTH CARE 3,845
FACILITY, PURSUANT TO DIVISION (E) OF THIS SECTION. 3,847
(G) ANY PROVIDER CONTRACT OR CONTRACT WITH A HEALTH CARE 3,850
FACILITY SHALL CLEARLY SPECIFY THE HEALTH INSURING CORPORATION'S 3,851
STATUTORY RESPONSIBILITY TO MONITOR AND OVERSEE THE OFFERING OF 3,852
COVERED HEALTH CARE SERVICES TO ITS ENROLLEES. 3,853
(H)(1) A HEALTH INSURING CORPORATION SHALL MAINTAIN ITS 3,856
PROVIDER CONTRACTS AND ITS CONTRACTS WITH HEALTH CARE FACILITIES 3,857
AT ONE OR MORE OF ITS PLACES OF BUSINESS IN THIS STATE, AND SHALL 3,858
PROVIDE COPIES OF THESE CONTRACTS TO FACILITATE REGULATORY REVIEW 3,859
UPON WRITTEN NOTICE BY THE SUPERINTENDENT OF INSURANCE. 3,860
(2) ANY CONTRACT WITH AN INTERMEDIARY ORGANIZATION SHALL 3,862
88
INCLUDE PROVISIONS REQUIRING THE INTERMEDIARY ORGANIZATION TO 3,863
PROVIDE THE SUPERINTENDENT WITH REGULATORY ACCESS TO ALL BOOKS, 3,864
RECORDS, FINANCIAL INFORMATION, AND DOCUMENTS RELATED TO THE 3,865
PROVISION OF HEALTH CARE SERVICES TO SUBSCRIBERS AND ENROLLEES 3,866
UNDER THE CONTRACT. THE CONTRACT SHALL REQUIRE THE INTERMEDIARY 3,867
ORGANIZATION TO MAINTAIN SUCH BOOKS, RECORDS, FINANCIAL 3,868
INFORMATION, AND DOCUMENTS AT ITS PRINCIPAL PLACE OF BUSINESS IN 3,869
THIS STATE AND TO PRESERVE THEM FOR AT LEAST THREE YEARS IN A 3,870
MANNER THAT FACILITATES REGULATORY REVIEW. 3,871
(I) A HEALTH INSURING CORPORATION SHALL PROVIDE NOTICE OF 3,874
THE TERMINATION OF ANY CONTRACT WITH A PRIMARY CARE PHYSICIAN OR 3,875
HOSPITAL.
(J) DIVISIONS (A) AND (B) OF THIS SECTION DO NOT APPLY TO 3,878
ANY HEALTH INSURING CORPORATION THAT, ON THE EFFECTIVE DATE OF 3,879
THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY OR LICENSE TO 3,880
OPERATE UNDER CHAPTER 1740. OF THE REVISED CODE. 3,881
Sec. 1751.14. (A) ANY POLICY, CONTRACT, OR AGREEMENT FOR 3,884
HEALTH CARE SERVICES AUTHORIZED BY THIS CHAPTER THAT IS ISSUED, 3,885
DELIVERED, OR RENEWED IN THIS STATE AND THAT PROVIDES THAT 3,886
COVERAGE OF AN UNMARRIED DEPENDENT CHILD WILL TERMINATE UPON 3,887
ATTAINMENT OF THE LIMITING AGE FOR DEPENDENT CHILDREN SPECIFIED 3,888
IN THE POLICY, CONTRACT, OR AGREEMENT, SHALL ALSO PROVIDE IN 3,889
SUBSTANCE THAT ATTAINMENT OF THE LIMITING AGE SHALL NOT OPERATE 3,890
TO TERMINATE THE COVERAGE OF THE CHILD IF THE CHILD IS AND 3,891
CONTINUES TO BE BOTH:
(1) INCAPABLE OF SELF-SUSTAINING EMPLOYMENT BY REASON OF 3,893
MENTAL RETARDATION OR PHYSICAL HANDICAP; 3,894
(2) PRIMARILY DEPENDENT UPON THE SUBSCRIBER FOR SUPPORT 3,896
AND MAINTENANCE. 3,897
(B) PROOF OF INCAPACITY AND DEPENDENCE FOR PURPOSES OF 3,899
DIVISION (A) OF THIS SECTION SHALL BE FURNISHED TO THE HEALTH 3,900
INSURING CORPORATION WITHIN THIRTY-ONE DAYS OF THE CHILD'S 3,902
ATTAINMENT OF THE LIMITING AGE. UPON REQUEST, BUT NOT MORE 3,903
FREQUENTLY THAN ANNUALLY, THE HEALTH INSURING CORPORATION MAY 3,904
89
REQUIRE PROOF SATISFACTORY TO IT OF THE CONTINUANCE OF SUCH 3,905
INCAPACITY AND DEPENDENCY.
(C) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 3,908
A HEALTH INSURING CORPORATION TO COVER A DEPENDENT CHILD WHO IS 3,909
MENTALLY RETARDED OR PHYSICALLY HANDICAPPED IF THE POLICY, 3,910
CONTRACT, OR AGREEMENT IS UNDERWRITTEN ON EVIDENCE OF 3,911
INSURABILITY BASED ON HEALTH FACTORS SET FORTH IN THE 3,912
APPLICATION, OR IF THE DEPENDENT CHILD DOES NOT SATISFY THE 3,913
CONDITIONS OF THE POLICY, CONTRACT, OR AGREEMENT AS TO ANY 3,914
REQUIREMENT FOR EVIDENCE OF INSURABILITY OR ANY OTHER PROVISION 3,915
OF THE POLICY, CONTRACT, OR AGREEMENT, SATISFACTION OF WHICH IS 3,916
REQUIRED FOR COVERAGE THEREUNDER TO TAKE EFFECT. IN ANY SUCH 3,917
CASE, THE TERMS OF THE POLICY, CONTRACT, OR AGREEMENT SHALL APPLY 3,918
WITH REGARD TO THE COVERAGE OR EXCLUSION OF THE DEPENDENT FROM 3,919
SUCH COVERAGE.
(D) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 3,922
CORPORATION, POLICY, CONTRACT, OR AGREEMENT OFFERING ONLY 3,923
SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE
SERVICES. 3,924
Sec. 1751.15. (A) AFTER A HEALTH INSURING CORPORATION HAS 3,927
FURNISHED, DIRECTLY OR INDIRECTLY, BASIC HEALTH CARE SERVICES FOR 3,928
A PERIOD OF TWENTY-FOUR MONTHS, AND IF IT CURRENTLY MEETS THE 3,929
FINANCIAL REQUIREMENTS SET FORTH IN SECTION 1751.28 OF THE 3,931
REVISED CODE AND HAD NET INCOME AS REPORTED TO THE SUPERINTENDENT 3,932
OF INSURANCE FOR AT LEAST ONE OF THE PRECEDING FOUR CALENDAR 3,933
QUARTERS, IT SHALL HOLD AN ANNUAL OPEN ENROLLMENT PERIOD OF NOT 3,934
LESS THAN THIRTY DAYS DURING ITS MONTH OF LICENSURE. 3,935
(B) DURING THE OPEN ENROLLMENT PERIOD DESCRIBED IN 3,937
DIVISION (A) OF THIS SECTION, THE HEALTH INSURING CORPORATION 3,938
SHALL ACCEPT APPLICANTS AND THEIR DEPENDENTS IN THE ORDER IN 3,939
WHICH THEY APPLY FOR ENROLLMENT AND IN ACCORDANCE WITH ANY OF THE 3,940
FOLLOWING:
(1) UP TO ITS CAPACITY, AS DETERMINED BY THE HEALTH 3,942
INSURING CORPORATION SUBJECT TO REVIEW BY THE SUPERINTENDENT; 3,943
90
(2) IF LESS THAN ITS CAPACITY, ONE PER CENT OF THE HEALTH 3,945
INSURING CORPORATION'S TOTAL NUMBER OF SUBSCRIBERS RESIDING IN 3,946
THIS STATE AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF 3,948
DECEMBER.
(C) WHERE A HEALTH INSURING CORPORATION DEMONSTRATES TO 3,951
THE SATISFACTION OF THE SUPERINTENDENT THAT SUCH OPEN ENROLLMENT 3,952
WOULD JEOPARDIZE ITS ECONOMIC VIABILITY, THE SUPERINTENDENT MAY 3,953
DO ANY OF THE FOLLOWING: 3,954
(1) WAIVE THE REQUIREMENT FOR OPEN ENROLLMENT; 3,956
(2) IMPOSE A LIMIT ON THE NUMBER OF APPLICANTS AND THEIR 3,958
DEPENDENTS THAT MUST BE ENROLLED; 3,959
(3) AUTHORIZE SUCH UNDERWRITING RESTRICTIONS UPON OPEN 3,961
ENROLLMENT AS ARE NECESSARY TO DO ANY OF THE FOLLOWING: 3,962
(a) PRESERVE ITS FINANCIAL STABILITY; 3,964
(b) PREVENT EXCESSIVE ADVERSE SELECTION; 3,966
(c) AVOID UNREASONABLY HIGH OR UNMARKETABLE CHARGES FOR 3,968
COVERAGE OF HEALTH CARE SERVICES. 3,969
(D)(1) A REQUEST TO THE SUPERINTENDENT UNDER DIVISION (C) 3,972
OF THIS SECTION FOR ANY RESTRICTION, LIMIT, OR WAIVER DURING AN
OPEN ENROLLMENT PERIOD MUST BE ACCOMPANIED BY SUPPORTING 3,974
DOCUMENTATION, INCLUDING FINANCIAL DATA. IN REVIEWING THE 3,975
REQUEST, THE SUPERINTENDENT MAY CONSIDER VARIOUS FACTORS, 3,976
INCLUDING THE SIZE OF THE HEALTH INSURING CORPORATION, THE HEALTH 3,977
INSURING CORPORATION'S NET WORTH AND PROFITABILITY, THE HEALTH 3,978
INSURING CORPORATION'S DELIVERY SYSTEM STRUCTURE, AND THE EFFECT 3,979
ON PROFITABILITY OF PRIOR OPEN ENROLLMENTS. 3,980
(2) ANY ACTION TAKEN BY THE SUPERINTENDENT UNDER DIVISION 3,982
(C) OF THIS SECTION SHALL BE EFFECTIVE FOR A PERIOD OF NOT MORE 3,984
THAN ONE YEAR. AT THE EXPIRATION OF SUCH TIME, A NEW 3,985
DEMONSTRATION OF THE HEALTH INSURING CORPORATION'S NEED FOR THE 3,986
RESTRICTION, LIMIT, OR WAIVER SHALL BE MADE BEFORE A NEW 3,987
RESTRICTION, LIMIT, OR WAIVER IS GRANTED BY THE SUPERINTENDENT. 3,988
(3) IRRESPECTIVE OF THE GRANTING OF ANY RESTRICTION, 3,990
LIMIT, OR WAIVER BY THE SUPERINTENDENT, A HEALTH INSURING 3,991
91
CORPORATION MAY REJECT AN APPLICANT OR A DEPENDENT OF THE 3,992
APPLICANT DURING ITS OPEN ENROLLMENT PERIOD IF THE APPLICANT OR 3,993
DEPENDENT: 3,994
(a) WAS ELIGIBLE FOR AND WAS COVERED UNDER ANY 3,997
EMPLOYER-SPONSORED HEALTH CARE COVERAGE, OR IF EMPLOYER-SPONSORED 3,998
HEALTH CARE COVERAGE WAS AVAILABLE AT THE TIME OF OPEN 3,999
ENROLLMENT;
(b) IS ELIGIBLE FOR CONVERSION OR CONTINUATION COVERAGE 4,002
UNDER STATE OR FEDERAL LAW; 4,003
(c) IS ELIGIBLE FOR MEDICARE, AND THE HEALTH INSURING 4,006
CORPORATION DOES NOT HAVE AN AGREEMENT ON APPROPRIATE PAYMENT 4,007
MECHANISMS WITH THE GOVERNMENTAL AGENCY ADMINISTERING THE 4,008
MEDICARE PROGRAM.
(E) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED 4,011
EITHER TO ENROLL APPLICANTS OR THEIR DEPENDENTS WHO ARE CONFINED 4,012
TO A HEALTH CARE FACILITY BECAUSE OF CHRONIC ILLNESS, PERMANENT 4,013
INJURY, OR OTHER INFIRMITY THAT WOULD CAUSE ECONOMIC IMPAIRMENT 4,014
TO THE HEALTH INSURING CORPORATION IF SUCH APPLICANTS OR THEIR 4,015
DEPENDENTS WERE ENROLLED OR TO MAKE THE EFFECTIVE DATE OF 4,016
BENEFITS FOR APPLICANTS OR THEIR DEPENDENTS ENROLLED UNDER THIS 4,017
SECTION EARLIER THAN NINETY DAYS AFTER THE DATE OF ENROLLMENT. 4,018
(F) A HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO 4,021
COVER THE FEES OR COSTS, OR BOTH, FOR ANY BASIC HEALTH CARE 4,022
SERVICE RELATED TO A TRANSPLANT OF A BODY ORGAN IF THE TRANSPLANT 4,023
OCCURS WITHIN ONE YEAR AFTER THE EFFECTIVE DATE OF AN ENROLLEE'S 4,024
COVERAGE UNDER THIS SECTION. THIS LIMITATION ON COVERAGE DOES 4,025
NOT APPLY TO A NEWLY BORN CHILD WHO MEETS THE REQUIREMENTS FOR 4,026
COVERAGE UNDER SECTION 1751.61 OF THE REVISED CODE. 4,028
(G) EACH HEALTH INSURING CORPORATION REQUIRED TO HOLD AN 4,031
OPEN ENROLLMENT PURSUANT TO DIVISION (A) OF THIS SECTION SHALL 4,033
FILE WITH THE SUPERINTENDENT, NOT LATER THAN SIXTY DAYS PRIOR TO 4,034
THE COMMENCEMENT OF THE PROPOSED OPEN ENROLLMENT PERIOD, THE 4,035
FOLLOWING DOCUMENTS:
(1) THE PROPOSED PUBLIC NOTICE OF OPEN ENROLLMENT; 4,037
92
(2) THE EVIDENCE OF COVERAGE APPROVED PURSUANT TO SECTION 4,039
1751.11 OF THE REVISED CODE THAT WILL BE USED DURING OPEN 4,042
ENROLLMENT;
(3) THE CONTRACTUAL PERIODIC PREPAYMENT AND PREMIUM RATE 4,044
APPROVED PURSUANT TO SECTION 1751.12 OF THE REVISED CODE THAT 4,047
WILL BE APPLICABLE DURING OPEN ENROLLMENT; 4,048
(4) ANY SOLICITATION DOCUMENT APPROVED PURSUANT TO SECTION 4,051
1751.31 OF THE REVISED CODE TO BE SENT TO APPLICANTS, INCLUDING 4,053
THE APPLICATION FORM THAT WILL BE USED DURING OPEN ENROLLMENT; 4,054
(5) A LIST OF THE PROPOSED DATES OF PUBLICATION OF THE 4,056
PUBLIC NOTICE, AND THE NAMES OF THE NEWSPAPERS IN WHICH THE 4,057
NOTICE WILL APPEAR; 4,058
(6) ANY REQUEST FOR A RESTRICTION, LIMIT, OR WAIVER WITH 4,060
RESPECT TO THE OPEN ENROLLMENT PERIOD, ALONG WITH ANY SUPPORTING 4,061
DOCUMENTATION. 4,062
(H)(1) AN OPEN ENROLLMENT PERIOD SHALL NOT SATISFY THE 4,065
REQUIREMENTS OF THIS SECTION UNLESS THE HEALTH INSURING 4,066
CORPORATION PROVIDES ADEQUATE PUBLIC NOTICE IN ACCORDANCE WITH 4,067
DIVISIONS (H)(2) AND (3) OF THIS SECTION. NO PUBLIC NOTICE SHALL 4,069
BE USED UNTIL THE FORM OF THE PUBLIC NOTICE HAS BEEN FILED BY THE 4,070
HEALTH INSURING CORPORATION WITH THE SUPERINTENDENT. IF THE 4,071
SUPERINTENDENT DOES NOT DISAPPROVE THE PUBLIC NOTICE WITHIN SIXTY 4,072
DAYS AFTER IT IS FILED, IT SHALL BE DEEMED APPROVED, UNLESS THE 4,073
SUPERINTENDENT SOONER GIVES APPROVAL FOR THE PUBLIC NOTICE. IF 4,074
THE SUPERINTENDENT DETERMINES WITHIN THIS SIXTY-DAY PERIOD THAT 4,075
THE PUBLIC NOTICE FAILS TO MEET THE REQUIREMENTS OF THIS SECTION, 4,076
THE SUPERINTENDENT SHALL SO NOTIFY THE HEALTH INSURING 4,077
CORPORATION AND IT SHALL BE UNLAWFUL FOR THE HEALTH INSURING 4,078
CORPORATION TO USE THE PUBLIC NOTICE. SUCH DISAPPROVAL SHALL BE 4,079
EFFECTED BY A WRITTEN ORDER, WHICH SHALL STATE THE GROUNDS FOR 4,080
DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 119. 4,082
OF THE REVISED CODE. 4,084
(2) A PUBLIC NOTICE PURSUANT TO DIVISION (H)(1) OF THIS 4,087
SECTION SHALL BE PUBLISHED IN AT LEAST ONE NEWSPAPER OF GENERAL 4,088
93
CIRCULATION IN EACH COUNTY IN THE HEALTH INSURING CORPORATION'S 4,089
SERVICE AREA, AT LEAST ONCE IN EACH OF THE TWO WEEKS IMMEDIATELY 4,090
PRECEDING THE MONTH IN WHICH THE OPEN ENROLLMENT IS TO OCCUR AND 4,091
IN EACH WEEK OF THAT MONTH, OR UNTIL THE ENROLLMENT LIMITATION IS 4,092
REACHED, WHICHEVER OCCURS FIRST. THE NOTICE PUBLISHED DURING THE 4,093
LAST WEEK OF OPEN ENROLLMENT SHALL APPEAR NOT LESS THAN FIVE DAYS 4,094
BEFORE THE END OF THE OPEN ENROLLMENT PERIOD. IT SHALL BE AT 4,095
LEAST TWO NEWSPAPER COLUMNS WIDE OR TWO AND ONE-HALF INCHES WIDE, 4,097
WHICHEVER IS LARGER. THE FIRST TWO LINES OF THE TEXT SHALL BE 4,098
PUBLISHED IN NOT LESS THAN TWELVE-POINT, BOLDFACE TYPE. THE 4,099
REMAINDER OF THE TEXT OF THE NOTICE SHALL BE PUBLISHED IN NOT 4,100
LESS THAN EIGHT-POINT TYPE. THE ENTIRE PUBLIC NOTICE SHALL BE 4,101
SURROUNDED BY A CONTINUOUS BLACK LINE NOT LESS THAN ONE-EIGHTH OF 4,102
AN INCH WIDE.
(3) THE FOLLOWING INFORMATION SHALL BE INCLUDED IN THE 4,104
PUBLIC NOTICE PROVIDED UNDER DIVISION (H)(2) OF THIS SECTION: 4,106
(a) THE DATES THAT OPEN ENROLLMENT WILL BE HELD AND THE 4,109
DATE COVERAGE OBTAINED UNDER THE OPEN ENROLLMENT WILL BECOME 4,110
EFFECTIVE;
(b) NOTICE THAT AN APPLICANT OR THE APPLICANT'S DEPENDENTS 4,113
WILL NOT BE DENIED COVERAGE DURING OPEN ENROLLMENT BECAUSE OF A 4,114
PREEXISTING HEALTH CONDITION, BUT THAT SOME LIMITATIONS AND 4,115
RESTRICTIONS MAY APPLY; 4,116
(c) THE ADDRESS WHERE A PERSON MAY OBTAIN AN APPLICATION; 4,119
(d) THE TELEPHONE NUMBER THAT A PERSON MAY CALL TO REQUEST 4,122
AN APPLICATION OR TO ASK QUESTIONS; 4,123
(e) THE DATE THE FIRST PAYMENT WILL BE DUE; 4,126
(f) THE ACTUAL RATES OR RANGE OF RATES THAT WILL BE 4,129
APPLICABLE FOR APPLICANTS;
(g) ANY LIMITATION GRANTED BY THE SUPERINTENDENT ON THE 4,132
NUMBER OF APPLICATIONS THAT WILL BE ACCEPTED BY THE HEALTH 4,133
INSURING CORPORATION.
(4) WITHIN THIRTY DAYS AFTER THE END OF AN OPEN ENROLLMENT 4,136
PERIOD, THE HEALTH INSURING CORPORATION SHALL SUBMIT TO THE 4,137
94
SUPERINTENDENT PROOF OF PUBLICATION FOR THE PUBLIC NOTICES, AND 4,138
SHALL REPORT THE TOTAL NUMBER OF APPLICANTS AND THEIR DEPENDENTS 4,139
ENROLLED DURING THE OPEN ENROLLMENT PERIOD. 4,140
(I)(1) NO HEALTH INSURING CORPORATION MAY EMPLOY ANY 4,143
SCHEME, PLAN, OR DEVICE THAT RESTRICTS THE ABILITY OF ANY PERSON 4,144
TO ENROLL DURING OPEN ENROLLMENT. 4,145
(2) NO HEALTH INSURING CORPORATION MAY REQUIRE ENROLLMENT 4,147
TO BE MADE IN PERSON. EVERY HEALTH INSURING CORPORATION SHALL 4,148
PERMIT APPLICATION FOR COVERAGE BY MAIL. A REPRESENTATIVE OF THE 4,150
HEALTH INSURING CORPORATION MAY VISIT AN APPLICANT WHO HAS
SUBMITTED AN APPLICATION BY MAIL, IN ORDER TO EXPLAIN THE 4,151
OPERATIONS OF THE HEALTH INSURING CORPORATION AND TO ANSWER ANY 4,152
QUESTIONS THE APPLICANT MAY HAVE. EVERY HEALTH INSURING 4,153
CORPORATION SHALL MAKE OPEN ENROLLMENT APPLICATIONS AND 4,154
SOLICITATION DOCUMENTS READILY AVAILABLE TO ANY POTENTIAL 4,155
APPLICANT WHO REQUESTS SUCH MATERIAL. 4,156
(J) AN APPLICATION POSTMARKED ON THE LAST DAY OF AN OPEN 4,159
ENROLLMENT PERIOD SHALL QUALIFY AS A VALID APPLICATION, 4,160
REGARDLESS OF THE DATE ON WHICH IT IS RECEIVED BY THE HEALTH 4,161
INSURING CORPORATION.
(K) THIS SECTION DOES NOT APPLY TO ANY HEALTH INSURING 4,163
CORPORATION THAT OFFERS ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR 4,165
SPECIALTY HEALTH CARE SERVICES, OR TO ANY HEALTH INSURING
CORPORATION THAT OFFERS PLANS ONLY THROUGH TITLE XVIII OR TITLE 4,168
XIX OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,170
U.S.C.A. 301, AS AMENDED, AND THAT HAS NO OTHER COMMERCIAL 4,171
ENROLLMENT, OR TO ANY HEALTH INSURING CORPORATION THAT OFFERS 4,172
PLANS ONLY THROUGH OTHER FEDERAL HEALTH CARE PROGRAMS REGULATED 4,173
BY FEDERAL REGULATORY BODIES AND THAT HAS NO OTHER COMMERCIAL 4,174
ENROLLMENT.
Sec. 1751.16. (A) EXCEPT AS PROVIDED IN DIVISION (F) OF 4,177
THIS SECTION, EVERY GROUP CONTRACT ISSUED BY A HEALTH INSURING 4,178
CORPORATION SHALL PROVIDE AN OPTION FOR CONVERSION TO AN 4,179
INDIVIDUAL CONTRACT ISSUED ON A DIRECT-PAYMENT BASIS TO ANY 4,180
95
SUBSCRIBER COVERED BY THE GROUP CONTRACT WHO TERMINATES 4,181
EMPLOYMENT OR MEMBERSHIP IN THE GROUP, UNLESS: 4,182
(1) TERMINATION OF THE CONVERSION OPTION OR CONTRACT IS 4,184
BASED UPON NONPAYMENT OF PREMIUM AFTER REASONABLE NOTICE IN 4,185
WRITING HAS BEEN GIVEN BY THE HEALTH INSURING CORPORATION TO THE 4,186
SUBSCRIBER. 4,187
(2) THE SUBSCRIBER IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,189
BENEFITS AT LEAST COMPARABLE TO THE GROUP CONTRACT UNDER ANY OF 4,190
THE FOLLOWING: 4,191
(a) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,194
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,195
(b) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,198
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,200
TO THE BENEFITS UNDER DIVISION (A)(2)(a) OF THIS SECTION; 4,201
(c) ANY POLICY OF INSURANCE OR HEALTH CARE PLAN PROVIDING 4,204
COVERAGE AT LEAST COMPARABLE TO THE BENEFITS UNDER DIVISION 4,205
(A)(2)(a) OF THIS SECTION. 4,206
(B) THE DIRECT-PAYMENT CONTRACT OFFERED BY THE HEALTH 4,209
INSURING CORPORATION PURSUANT TO DIVISION (A) OF THIS SECTION 4,210
SHALL PROVIDE BENEFITS COMPARABLE TO THE BENEFITS BEING PROVIDED 4,211
BY ANY OF THE INDIVIDUAL CONTRACTS THEN BEING ISSUED TO 4,212
INDIVIDUAL SUBSCRIBERS BY THE HEALTH INSURING CORPORATION. THE 4,213
CONTRACT MAY CONTAIN A COORDINATION OF BENEFITS PROVISION AS 4,214
APPROVED BY THE SUPERINTENDENT OF INSURANCE. 4,215
(C) THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,218
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,220
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,221
COVERED BY THE GROUP CONTRACT; 4,222
(2) TO A CHILD SOLELY WITH RESPECT TO THE CHILD UPON THE 4,224
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE GROUP 4,225
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT; 4,226
(3) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,228
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,229
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER. 4,231
96
(D) NO HEALTH INSURING CORPORATION SHALL DO ANY OF THE 4,234
FOLLOWING:
(1) USE AGE AS THE BASIS FOR REFUSING TO RENEW A CONVERTED 4,237
CONTRACT;
(2) REQUIRE A SUBSCRIBER TO PRODUCE EVIDENCE OF 4,239
INSURABILITY IN ORDER TO EXERCISE THE OPTION FOR CONVERSION 4,240
PROVIDED BY THIS SECTION; 4,241
(3) INCLUDE PREEXISTING CONDITION LIMITATIONS IN A 4,243
CONVERTED CONTRACT. 4,244
(E) WRITTEN NOTICE OF THE CONVERSION OPTION PROVIDED BY 4,247
THIS SECTION SHALL BE GIVEN TO THE SUBSCRIBER BY THE HEALTH 4,248
INSURING CORPORATION BY MAIL. THE NOTICE SHALL BE SENT TO THE 4,249
SUBSCRIBER'S ADDRESS IN THE RECORDS OF THE EMPLOYER UPON RECEIPT 4,250
OF NOTICE FROM THE EMPLOYER OF THE EVENT GIVING RISE TO THE 4,251
CONVERSION OPTION. IF THE SUBSCRIBER HAS NOT RECEIVED NOTICE OF 4,252
THE CONVERSION PRIVILEGE AT LEAST FIFTEEN DAYS PRIOR TO THE 4,253
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD, THEN THE 4,254
SUBSCRIBER SHALL HAVE AN ADDITIONAL PERIOD WITHIN WHICH TO 4,255
EXERCISE THE PRIVILEGE. THIS ADDITIONAL PERIOD SHALL EXPIRE 4,256
FIFTEEN DAYS AFTER THE SUBSCRIBER RECEIVES NOTICE, BUT IN NO 4,257
EVENT SHALL THE PERIOD EXTEND BEYOND SIXTY DAYS AFTER THE 4,258
EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD. 4,259
(F) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 4,262
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,263
HEALTH CARE SERVICES.
Sec. 1751.17. (A) AS USED IN THIS SECTION, "NONGROUP 4,266
CONTRACT" MEANS A CONTRACT ISSUED BY A HEALTH INSURING 4,267
CORPORATION TO AN INDIVIDUAL WHO MAKES DIRECT APPLICATION FOR 4,268
COVERAGE UNDER THE CONTRACT AND WHO, IF REQUIRED BY THE HEALTH 4,269
INSURING CORPORATION, SUBMITS TO MEDICAL UNDERWRITING. "NONGROUP 4,270
CONTRACT" DOES NOT INCLUDE GROUP CONVERSION COVERAGE, COVERAGE 4,271
OBTAINED THROUGH OPEN ENROLLMENT, OR COVERAGE ISSUED ON THE BASIS 4,272
OF MEMBERSHIP IN A GROUP. 4,273
(B) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 4,277
97
EVERY NONGROUP CONTRACT THAT IS ISSUED BY A HEALTH INSURING 4,278
CORPORATION AND THAT MAKES AVAILABLE BASIC HEALTH CARE SERVICES 4,279
SHALL PROVIDE AN OPTION FOR CONVERSION TO A CONTRACT ISSUED ON A 4,280
DIRECT-PAYMENT BASIS TO AN ENROLLEE COVERED BY THE NONGROUP 4,281
CONTRACT. THE OPTION FOR CONVERSION SHALL BE AVAILABLE: 4,282
(1) UPON THE DEATH OF THE SUBSCRIBER, TO THE SURVIVING 4,284
SPOUSE WITH RESPECT TO THE SPOUSE OR DEPENDENTS WHO WERE THEN 4,285
COVERED BY THE NONGROUP CONTRACT; 4,286
(2) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE 4,288
MARRIAGE OF THE SUBSCRIBER, TO THE DIVORCED SPOUSE, OR, IN THE 4,289
EVENT OF ANNULMENT, TO THE FORMER SPOUSE OF THE SUBSCRIBER; 4,291
(3) TO A CHILD SOLELY WITH RESPECT TO THE CHILD, UPON THE 4,293
CHILD'S ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE NONGROUP 4,295
CONTRACT WHILE COVERED AS A DEPENDENT UNDER THE CONTRACT. 4,296
(C) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,299
DIVISION (B) OF THIS SECTION SHALL NOT BE MADE AVAILABLE TO AN 4,301
ENROLLEE IF ANY OF THE FOLLOWING APPLIES: 4,302
(1) THE ENROLLEE IS, OR IS ELIGIBLE TO BE, COVERED FOR 4,304
BENEFITS AT LEAST COMPARABLE TO THE NONGROUP CONTRACT UNDER ANY 4,305
OF THE FOLLOWING: 4,306
(a) THE MEDICAL ASSISTANCE PROGRAM UNDER CHAPTER 5111. OF 4,309
THE REVISED CODE;
(b) TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 4,312
(1935), 42 U.S.C.A. 301, AS AMENDED; 4,313
(c) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER 4,315
STATE OF THE UNITED STATES PROVIDING COVERAGE AT LEAST COMPARABLE 4,317
TO THE BENEFITS OFFERED UNDER DIVISION (C)(1)(a) OR (b) OF THIS 4,318
SECTION.
(2) THE NONGROUP CONTRACT UNDER WHICH THE ENROLLEE WAS 4,320
COVERED WAS TERMINATED DUE TO NONPAYMENT OF A PREMIUM RATE. 4,321
(3) THE ENROLLEE IS ELIGIBLE FOR GROUP COVERAGE PROVIDED 4,323
BY, OR AVAILABLE THROUGH, AN EMPLOYER OR ASSOCIATION AND THE 4,324
GROUP COVERAGE PROVIDES BENEFITS COMPARABLE TO THE BENEFITS 4,325
PROVIDED UNDER A DIRECT PAYMENT CONTRACT. 4,326
98
(D) THE DIRECT PAYMENT CONTRACT OFFERED PURSUANT TO 4,328
DIVISION (B) OF THIS SECTION SHALL PROVIDE BENEFITS THAT ARE AT 4,329
LEAST COMPARABLE TO THE BENEFITS PROVIDED BY THE NONGROUP 4,331
CONTRACT UNDER WHICH THE ENROLLEE WAS COVERED AT THE TIME OF THE 4,332
OCCURRENCE OF ANY OF THE EVENTS SET FORTH IN DIVISION (B) OF THIS 4,333
SECTION. THE COVERAGE PROVIDED UNDER THE DIRECT PAYMENT CONTRACT 4,335
SHALL BE CONTINUOUS, PROVIDED THAT THE ENROLLEE MAKES THE 4,336
REQUIRED PREMIUM RATE PAYMENT WITHIN THE THIRTY-DAY PERIOD 4,337
IMMEDIATELY FOLLOWING THE OCCURRENCE OF THE EVENT, AND MAY BE 4,338
TERMINATED FOR NONPAYMENT OF ANY REQUIRED PREMIUM RATE PAYMENT. 4,339
(E) THE EVIDENCE OF COVERAGE OF EVERY NONGROUP CONTRACT 4,342
SHALL CONTAIN NOTICE THAT AN OPTION FOR CONVERSION TO A CONTRACT 4,343
ISSUED ON A DIRECT-PAYMENT BASIS IS AVAILABLE, IN ACCORDANCE WITH 4,344
THIS SECTION, TO ANY ENROLLEE COVERED BY THE CONTRACT. 4,345
(F) BENEFITS OTHERWISE PAYABLE TO AN ENROLLEE UNDER A 4,348
DIRECT PAYMENT CONTRACT SHALL BE REDUCED BY THE AMOUNT OF ANY 4,349
BENEFITS AVAILABLE TO THE ENROLLEE UNDER ANY APPLICABLE GROUP 4,350
HEALTH INSURING CORPORATION CONTRACT OR GROUP SICKNESS AND 4,351
ACCIDENT INSURANCE POLICY.
(G) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 4,354
REQUIRING A HEALTH INSURING CORPORATION TO OFFER NONGROUP 4,355
CONTRACTS.
(H) THIS SECTION DOES NOT APPLY TO ANY NONGROUP CONTRACT 4,358
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 4,359
HEALTH CARE SERVICES. 4,360
Sec. 1751.18. (A)(1) NO HEALTH INSURING CORPORATION SHALL 4,363
CANCEL OR FAIL TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE 4,364
BECAUSE OF THE SUBSCRIBER'S OR ENROLLEE'S HEALTH STATUS OR 4,365
REQUIREMENT FOR HEALTH CARE SERVICES, OR FOR ANY OTHER REASON 4,366
DESIGNATED UNDER RULES ADOPTED BY THE SUPERINTENDENT OF
INSURANCE. 4,367
(2) UNLESS OTHERWISE REQUIRED BY STATE OR FEDERAL LAW, NO 4,369
HEALTH INSURING CORPORATION, OR HEALTH CARE FACILITY OR PROVIDER 4,370
THROUGH WHICH THE HEALTH INSURING CORPORATION HAS MADE 4,371
99
ARRANGEMENTS TO PROVIDE HEALTH CARE SERVICES, SHALL DISCRIMINATE 4,372
AGAINST ANY INDIVIDUAL WITH REGARD TO ENROLLMENT, DISENROLLMENT, 4,373
OR THE QUALITY OF HEALTH CARE SERVICES RENDERED, ON THE BASIS OF 4,374
THE INDIVIDUAL'S RACE, COLOR, SEX, AGE, RELIGION, STATE OF 4,375
HEALTH, OR STATUS AS A RECIPIENT OF MEDICARE OR MEDICAL 4,376
ASSISTANCE UNDER TITLE XVIII OR XIX OF THE "SOCIAL SECURITY ACT," 4,378
49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. HOWEVER, A 4,381
HEALTH INSURING CORPORATION SHALL NOT BE REQUIRED TO ACCEPT A 4,382
RECIPIENT OF MEDICARE OR MEDICAL ASSISTANCE, IF AN AGREEMENT HAS 4,383
NOT BEEN REACHED ON APPROPRIATE PAYMENT MECHANISMS BETWEEN THE 4,384
HEALTH INSURING CORPORATION AND THE GOVERNMENTAL AGENCY 4,385
ADMINISTERING THESE PROGRAMS. FURTHER, EXCEPT DURING A PERIOD OF 4,386
OPEN ENROLLMENT UNDER SECTION 1751.15 OF THE REVISED CODE, A 4,388
HEALTH INSURING CORPORATION MAY REJECT AN APPLICANT FOR NONGROUP 4,389
ENROLLMENT ON THE BASIS OF THE STATE OF HEALTH OF THE APPLICANT. 4,390
(B) A HEALTH INSURING CORPORATION MAY CANCEL OR DECIDE NOT 4,393
TO RENEW THE COVERAGE OF A SUBSCRIBER OR ENROLLEE FOR ANY OF THE 4,394
FOLLOWING REASONS:
(1) FAILURE OF THE SUBSCRIBER OR ENROLLEE TO PAY, OR TO 4,396
HAVE PAID ON THE SUBSCRIBER'S OR ENROLLEE'S BEHALF, THE REQUIRED 4,397
PREMIUM RATE OR OTHER CHARGE; 4,398
(2) FRAUD OR FORGERY; 4,400
(3) ANY MATERIAL MISREPRESENTATION ON THE APPLICATION FOR 4,402
COVERAGE; 4,403
(4) THE SUBSCRIBER'S OR ENROLLEE'S PERMITTING THE USE OF 4,405
AN IDENTIFICATION CARD OR SIMILAR DOCUMENTS BY ANOTHER PERSON, 4,406
ALLOWING THAT PERSON TO RECEIVE SERVICES FOR WHICH THAT PERSON IS 4,408
NOT ENTITLED;
(5) THE SUBSCRIBER'S OR ENROLLEE'S INABILITY TO ESTABLISH 4,410
OR MAINTAIN A PROVIDER-PATIENT RELATIONSHIP WITH ANY PROVIDER 4,411
ASSOCIATED WITH THE HEALTH INSURING CORPORATION, WHICH INABILITY 4,412
MAY INCLUDE THE SUBSCRIBER'S OR ENROLLEE'S DISRUPTIVE OR ABUSIVE 4,413
BEHAVIOR TOWARD PROVIDERS OR THE STAFF OF THE HEALTH CARE PLAN. 4,415
(C) A SUBSCRIBER OR ENROLLEE MAY APPEAL ANY ACTION OR 4,418
100
DECISION OF THE HEALTH INSURING CORPORATION UNDER DIVISION (B) OF 4,420
THIS SECTION. TO APPEAL, THE SUBSCRIBER OR ENROLLEE MAY SUBMIT A 4,421
WRITTEN COMPLAINT TO THE HEALTH INSURING CORPORATION PURSUANT TO 4,422
SECTION 1751.19 OF THE REVISED CODE. THE SUBSCRIBER OR ENROLLEE 4,423
MAY, WITHIN THIRTY DAYS AFTER RECEIVING A WRITTEN RESPONSE FROM 4,424
THE HEALTH INSURING CORPORATION, APPEAL THE HEALTH INSURING 4,425
CORPORATION'S ACTION OR DECISION TO THE SUPERINTENDENT. 4,426
Sec. 1751.19. (A) A HEALTH INSURING CORPORATION SHALL 4,429
ESTABLISH AND MAINTAIN A COMPLAINT SYSTEM THAT HAS BEEN APPROVED 4,430
BY THE SUPERINTENDENT OF INSURANCE TO PROVIDE ADEQUATE AND 4,431
REASONABLE PROCEDURES FOR THE EXPEDITIOUS RESOLUTION OF WRITTEN 4,432
COMPLAINTS INITIATED BY SUBSCRIBERS OR ENROLLEES CONCERNING ANY 4,433
MATTER RELATING TO SERVICES PROVIDED, DIRECTLY OR INDIRECTLY, BY 4,434
THE HEALTH INSURING CORPORATION, INCLUDING, BUT NOT LIMITED TO, 4,435
CLAIMS REGARDING THE SCOPE OF COVERAGE FOR HEALTH CARE SERVICES, 4,436
AND DENIALS, CANCELLATIONS, OR NONRENEWALS OF COVERAGE. 4,437
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE A TIMELY 4,440
WRITTEN RESPONSE TO EACH WRITTEN COMPLAINT IT RECEIVES. 4,441
RESPONSES TO WRITTEN COMPLAINTS RELATING TO QUALITY OR 4,442
APPROPRIATENESS OF CARE SHALL SET FORTH A STATEMENT INFORMING THE 4,443
COMPLAINANT IN DETAIL OF ANY RIGHTS THE COMPLAINANT MAY HAVE TO 4,444
SUBMIT SUCH COMPLAINT TO ANY PROFESSIONAL PEER REVIEW 4,445
ORGANIZATION OR HEALTH INSURING CORPORATION PEER REVIEW COMMITTEE 4,446
THAT HAS BEEN SET UP TO MONITOR THE QUALITY OR APPROPRIATENESS OF 4,447
PROVIDER SERVICES RENDERED. SUCH STATEMENT SHALL SET FORTH THE 4,448
NAME OF THE PEER REVIEW ORGANIZATION OR HEALTH INSURING 4,449
CORPORATION PEER REVIEW COMMITTEE, ITS ADDRESS, TELEPHONE NUMBER, 4,450
AND ANY OTHER PERTINENT DATA THAT WILL ENABLE THE COMPLAINANT TO 4,451
SEEK FURTHER INDEPENDENT REVIEW OF THE COMPLAINT. SUCH APPEAL 4,452
SHALL NOT BE MADE TO THE PEER REVIEW CORPORATION OR HEALTH 4,453
INSURING CORPORATION PEER REVIEW COMMITTEE UNTIL THE COMPLAINT 4,454
SYSTEM OF THE HEALTH INSURING CORPORATION HAS BEEN EXHAUSTED. 4,455
(C) COPIES OF COMPLAINTS AND RESPONSES, INCLUDING MEDICAL 4,458
RECORDS RELATED TO THOSE COMPLAINTS, SHALL BE AVAILABLE TO THE 4,459
101
SUPERINTENDENT AND THE DIRECTOR OF HEALTH FOR INSPECTION FOR 4,460
THREE YEARS. ANY DOCUMENT OR INFORMATION PROVIDED TO THE 4,461
SUPERINTENDENT PURSUANT TO THIS DIVISION THAT CONTAINS A MEDICAL 4,462
RECORD IS CONFIDENTIAL, AND IS NOT A PUBLIC RECORD SUBJECT TO 4,463
SECTION 149.43 OF THE REVISED CODE.
(D) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 4,466
MAINTAIN A PROCEDURE TO ACCEPT COMPLAINTS OVER THE TELEPHONE OR 4,467
IN PERSON. THESE COMPLAINTS ARE NOT SUBJECT TO THE REPORTING 4,468
REQUIREMENT UNDER DIVISION (C) OF SECTION 1751.32 OF THE REVISED 4,470
CODE.
Sec. 1751.20. (A) NO HEALTH INSURING CORPORATION, OR 4,473
AGENT, EMPLOYEE, OR REPRESENTATIVE OF A HEALTH INSURING 4,474
CORPORATION, SHALL USE ANY ADVERTISEMENT OR SOLICITATION 4,475
DOCUMENT, OR SHALL ENGAGE IN ANY ACTIVITY, THAT IS UNFAIR, 4,476
UNTRUE, MISLEADING, OR DECEPTIVE.
(B) NO HEALTH INSURING CORPORATION SHALL USE A NAME THAT 4,479
IS DECEPTIVELY SIMILAR TO THE NAME OR DESCRIPTION OF ANY 4,480
INSURANCE OR SURETY CORPORATION DOING BUSINESS IN THIS STATE. 4,481
(C) ALL SOLICITATION DOCUMENTS, ADVERTISEMENTS, EVIDENCES 4,484
OF COVERAGE, AND ENROLLEE IDENTIFICATION CARDS USED BY A HEALTH 4,485
INSURING CORPORATION SHALL CONTAIN THE HEALTH INSURING 4,486
CORPORATION'S NAME. THE USE OF A TRADE NAME, AN INSURANCE GROUP 4,487
DESIGNATION, THE NAME OF A PARENT COMPANY, THE NAME OF A DIVISION 4,488
OF AN AFFILIATED INSURANCE COMPANY, A SERVICE MARK, A SLOGAN, A 4,489
SYMBOL, OR OTHER DEVICE, WITHOUT THE NAME OF THE HEALTH INSURING 4,490
CORPORATION AS STATED IN ITS ARTICLES OF INCORPORATION, SHALL NOT 4,491
SATISFY THIS REQUIREMENT IF THE USAGE WOULD HAVE THE CAPACITY AND 4,492
TENDENCY TO MISLEAD OR DECEIVE PERSONS AS TO THE TRUE IDENTITY OF 4,493
THE HEALTH INSURING CORPORATION. 4,494
(D) NO SOLICITATION DOCUMENT OR ADVERTISEMENT USED BY A 4,497
HEALTH INSURING CORPORATION SHALL CONTAIN ANY WORDS, SYMBOLS, OR 4,498
PHYSICAL MATERIALS THAT ARE SO SIMILAR IN CONTENT, PHRASEOLOGY, 4,499
SHAPE, COLOR, OR OTHER CHARACTERISTIC TO THOSE USED BY AN AGENCY 4,500
OF THE FEDERAL GOVERNMENT OR THIS STATE, THAT PROSPECTIVE 4,501
102
ENROLLEES MAY BE LED TO BELIEVE THAT THE SOLICITATION DOCUMENT OR 4,502
ADVERTISEMENT IS CONNECTED WITH AN AGENCY OF THE FEDERAL 4,503
GOVERNMENT OR THIS STATE. 4,504
(E) THIS SECTION DOES NOT APPLY TO THE COVERAGE OF 4,506
BENEFICIARIES ENROLLED IN TITLE XVIII OF THE "SOCIAL SECURITY 4,508
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, PURSUANT 4,511
TO A MEDICARE RISK CONTRACT OR MEDICARE COST CONTRACT, OR TO THE 4,512
COVERAGE OF BENEFICIARIES ENROLLED IN THE FEDERAL EMPLOYEE HEALTH 4,513
BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 8905, OR TO THE COVERAGE 4,515
OF BENEFICIARIES ENROLLED IN TITLE XIX OF THE "SOCIAL SECURITY 4,516
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED, KNOWN AS 4,518
THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, PROVIDED BY THE OHIO 4,519
DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 5111. OF THE REVISED 4,521
CODE, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY FEDERAL 4,522
HEALTH CARE PROGRAM REGULATED BY A FEDERAL REGULATORY BODY. 4,523
Sec. 1751.21. (A) A PEER REVIEW COMMITTEE OF A HOSPITAL 4,526
OR OTHER HEALTH CARE FACILITY OR PROVIDER, OR OF AN INTERMEDIARY 4,527
ORGANIZATION OR HEALTH DELIVERY NETWORK, WITH WHICH A HEALTH 4,528
INSURING CORPORATION HAS A CONTRACT FOR HEALTH CARE SERVICES MAY 4,529
PROVIDE TO A PEER REVIEW COMMITTEE OF THE HEALTH INSURING 4,530
CORPORATION ANY INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,531
RECORDS RELATING TO ANY MATTER THAT IS THE SUBJECT OF EVALUATION 4,532
OR REVIEW BY THE PEER REVIEW COMMITTEES, IF CONSENT IS PROVIDED 4,533
BY THE HEALTH CARE FACILITY AND ANY PHYSICIAN OR OTHER PROVIDER 4,534
WHOSE PROFESSIONAL QUALIFICATIONS OR ACTIVITIES ARE THE SUBJECT 4,535
OF EVALUATION OR REVIEW. 4,536
(B) ANY IMMUNITY FROM LIABILITY FOR DAMAGES THAT IS 4,539
PROVIDED UNDER SECTION 2305.25 OF THE REVISED CODE AND THAT WOULD 4,541
OTHERWISE APPLY WITH RESPECT TO THE CONDUCT OF ANY PEER REVIEW 4,542
COMMITTEE DESCRIBED IN DIVISION (A) OF THIS SECTION SHALL 4,544
CONTINUE TO APPLY, NOTWITHSTANDING THE PROVISION OF INFORMATION 4,545
AS PERMITTED UNDER DIVISION (A) OF THIS SECTION. 4,546
(C) THE INFORMATION, DOCUMENTS, TESTIMONY, OR OTHER 4,549
RECORDS DESCRIBED IN DIVISION (A) OF THIS SECTION, IF OTHERWISE 4,551
103
PROTECTED UNDER SECTION 2305.251 OF THE REVISED CODE, SHALL NOT 4,553
BE CONSTRUED AS BEING AVAILABLE FOR DISCOVERY OR FOR USE IN ANY 4,554
CIVIL ACTION SOLELY ON THE BASIS THAT THEY WERE PROVIDED BY THE 4,555
PEER REVIEW COMMITTEE AS PERMITTED UNDER DIVISION (A) OF THIS 4,556
SECTION. 4,557
Sec. 1751.25. THE FUNDS OF A HEALTH INSURING CORPORATION 4,559
SHALL BE INVESTED ONLY IN SECURITIES OR OTHER INVESTMENTS OR 4,560
ASSETS THAT CONSTITUTE PERMISSIBLE INVESTMENTS UNDER SECTION 4,561
1751.26 OR 3925.08 OF THE REVISED CODE. 4,562
Sec. 1751.26. (A) FOR PURPOSES OF THIS SECTION, REAL 4,565
ESTATE USED FOR "THE ACCOMMODATION OF THE HEALTH INSURING 4,566
CORPORATION'S BUSINESS OPERATIONS" INCLUDES THE HEALTH INSURING 4,567
CORPORATION'S HOME OFFICE, BRANCH OFFICE, MEDICAL FACILITIES, AND 4,568
FIELD OFFICE OPERATIONS. 4,569
(B) NO HEALTH INSURING CORPORATION SHALL PURCHASE, HOLD, 4,572
OR CONVEY REAL ESTATE, OR ANY INTEREST IN REAL ESTATE, TO BE USED 4,573
AS AN INVESTMENT FOR THE PRODUCTION OF INCOME, TO BE DEVELOPED 4,574
FOR THE PRODUCTION OF INCOME, OR TO BE OTHERWISE USED FOR 4,575
PURPOSES OTHER THAN THE ACCOMMODATION OF THE HEALTH INSURING 4,576
CORPORATION'S BUSINESS OPERATIONS, WITHOUT THE PRIOR APPROVAL OF 4,577
THE SUPERINTENDENT OF INSURANCE. 4,578
(C)(1) NO HEALTH INSURING CORPORATION SHALL INVEST, 4,581
WITHOUT THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT 4,582
EXCEEDS FORTY PER CENT OF ITS ADMITTED ASSETS AS OF THE 4,583
IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE 4,584
USED FOR THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S 4,585
BUSINESS OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION 4,586
PROVIDES HEALTH CARE SERVICES. 4,587
(2) NO HEALTH INSURING CORPORATION SHALL INVEST, WITHOUT 4,589
THE PRIOR APPROVAL OF THE SUPERINTENDENT, AN AMOUNT THAT EXCEEDS 4,590
TWENTY-FIVE PER CENT OF ITS ADMITTED ASSETS AS OF THE IMMEDIATELY 4,592
PRECEDING THIRTY-FIRST DAY OF DECEMBER IN REAL ESTATE USED FOR 4,594
THE ACCOMMODATION OF THE HEALTH INSURING CORPORATION'S BUSINESS 4,595
OPERATIONS FROM WHICH THE HEALTH INSURING CORPORATION DOES NOT 4,596
104
PROVIDE HEALTH CARE SERVICES.
Sec. 1751.27. (A) EACH HEALTH INSURING CORPORATION 4,599
HOLDING A CERTIFICATE OF AUTHORITY TO OPERATE IN THIS STATE SHALL 4,600
HAVE DEPOSITED SECURITIES WITH THE SUPERINTENDENT OF INSURANCE OR 4,601
AN APPROVED CUSTODIAN IN THE AMOUNT REQUIRED BY THIS DIVISION. 4,602
(1) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,605
BASIC HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS 4,606
THAN TWO HUNDRED FIFTY THOUSAND DOLLARS.
(2) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,609
ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT 4,610
OF NOT LESS THAN ONE HUNDRED FIFTY THOUSAND DOLLARS.
(3) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,612
ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN A DEPOSIT OF 4,613
NOT LESS THAN SEVENTY-FIVE THOUSAND DOLLARS. 4,614
(4) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,617
BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH CARE 4,618
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN FOUR HUNDRED 4,619
THOUSAND DOLLARS.
(5) EACH HEALTH INSURING CORPORATION AUTHORIZED TO PROVIDE 4,621
BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,622
SERVICES SHALL MAINTAIN A DEPOSIT OF NOT LESS THAN THREE HUNDRED 4,623
TWENTY-FIVE THOUSAND DOLLARS. 4,624
(B) THE SECURITIES DEPOSITED UNDER DIVISION (A) OF THIS 4,628
SECTION SHALL BE HELD AS SECURITY FOR THE FULFILLMENT OF THE 4,629
OBLIGATIONS OF THE HEALTH INSURING CORPORATION TO ITS ENROLLEES 4,630
UNDER THIS CHAPTER.
(C) THE INTEREST FROM THE DEPOSIT MADE UNDER DIVISION (A) 4,634
OF THIS SECTION SHALL ACCRUE TO THE HEALTH INSURING CORPORATION 4,635
THAT MADE THE DEPOSIT. THE DEPOSIT SHALL BE CONSIDERED TO BE AN 4,636
ADMITTED ASSET OF THE HEALTH INSURING CORPORATION. 4,637
(D) THE SUPERINTENDENT SHALL ADOPT RULES SETTING FORTH THE 4,640
QUALIFICATIONS AND RESPONSIBILITIES OF AN APPROVED CUSTODIAN. 4,641
Sec. 1751.28. (A) AS USED IN THIS SECTION: 4,644
(1) "ADMITTED ASSETS" INCLUDES THE INVESTMENTS AUTHORIZED 4,646
105
BY SECTION 1751.25 OF THE REVISED CODE, AND, IN ADDITION TO THESE 4,648
INVESTMENTS, ONLY THE FOLLOWING:
(a) PETTY CASH AND OTHER CASH FUNDS THAT ARE IN THE HEALTH 4,651
INSURING CORPORATION'S PRINCIPAL OFFICE OR ANY OFFICIAL BRANCH 4,652
OFFICE AND THAT ARE UNDER THE CONTROL OF THE CORPORATION; 4,653
(b) IMMEDIATELY WITHDRAWABLE FUNDS ON DEPOSIT IN DEMAND 4,655
ACCOUNTS IN A BANK OR TRUST COMPANY, OR SIMILAR FUNDS THAT ARE 4,656
ACTUALLY IN THE HEALTH INSURING CORPORATION'S PRINCIPAL OFFICE OR 4,657
ANY OFFICIAL BRANCH OFFICE AT STATEMENT DATE AND THAT ARE IN 4,658
TRANSIT TO THE BANK OR TRUST COMPANY WITH AUTHENTIC DEPOSIT 4,659
CREDIT GIVEN PRIOR TO THE CLOSE OF BUSINESS ON THE FIFTH BANK 4,660
BUSINESS DAY FOLLOWING THE STATEMENT DATE; 4,661
(c) THE AMOUNT FAIRLY ESTIMATED AS RECOVERABLE ON CASH 4,664
DEPOSITED IN A BANK OR TRUST COMPANY THE OPERATIONS OF WHICH HAVE 4,665
BEEN SUSPENDED OR FOR WHICH A RECEIVER HAS BEEN APPOINTED, IF 4,666
QUALIFYING UNDER THIS SECTION PRIOR TO THE SUSPENSION OF 4,667
OPERATIONS OF OR THE APPOINTMENT OF A RECEIVER FOR THE BANK OR 4,668
TRUST COMPANY;
(d) BILLS AND ACCOUNTS RECEIVABLE COLLATERALIZED BY 4,671
SECURITIES OF THE KIND IN WHICH THE HEALTH INSURING CORPORATION 4,672
MAY INVEST;
(e) PREMIUMS RECEIVABLE FROM GROUPS OR INDIVIDUALS THAT 4,675
ARE NOT MORE THAN NINETY DAYS PAST DUE; 4,676
(f) ACCOUNTS RECEIVABLE THAT ARE NOT MORE THAN NINETY DAYS 4,679
PAST DUE;
(g) AMOUNTS DUE UNDER REINSURANCE ARRANGEMENTS FROM 4,682
INSURANCE COMPANIES AUTHORIZED TO DO BUSINESS IN THIS STATE; 4,683
(h) TAX REFUNDS DUE FROM THE UNITED STATES OR ANY STATE; 4,687
(i) THE INTEREST ACCRUED ON MORTGAGE LOANS THAT CONFORM TO 4,690
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON AN 4,691
INDIVIDUAL LOAN AN AGGREGATE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,692
ACCRUED INTEREST; 4,693
(j) THE RENTS ACCRUED AND OWING TO THE HEALTH INSURING 4,696
CORPORATION ON REAL AND PERSONAL PROPERTY, DIRECTLY OR 4,697
106
BENEFICIALLY OWNED, NOT EXCEEDING ON EACH INDIVIDUAL PROPERTY THE 4,698
AMOUNT OF ONE YEAR'S TOTAL DUE AND ACCRUED RENT; 4,699
(k) INTEREST OR RENTS ACCRUED ON CONDITIONAL SALES 4,702
AGREEMENTS, SECURITY INTERESTS, CHATTEL MORTGAGES, AND REAL OR 4,703
PERSONAL PROPERTY UNDER LEASE TO OTHER CORPORATIONS, THAT CONFORM 4,704
TO SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING ON ANY 4,706
INDIVIDUAL INVESTMENT THE AMOUNT OF ONE YEAR'S TOTAL DUE AND 4,707
ACCRUED INTEREST OR RENT; 4,708
(l) THE FIXED AND REQUIRED INTEREST DUE AND ACCRUED ON 4,711
BONDS AND OTHER SIMILAR EVIDENCES OF INDEBTEDNESS, THAT CONFORM 4,712
TO SECTION 3925.08 OF THE REVISED CODE, AND NOT IN DEFAULT; 4,713
(m) DIVIDENDS RECEIVABLE ON SHARES OF STOCK THAT CONFORM 4,716
TO SECTION 3925.08 OF THE REVISED CODE, PROVIDED THAT THE MARKET 4,717
PRICE TAKEN FOR VALUATION PURPOSES DOES NOT INCLUDE THE VALUE OF 4,718
THE DIVIDEND;
(n) THE INTEREST OR DIVIDENDS DUE AND PAYABLE, BUT NOT 4,721
CREDITED, ON DEPOSITS IN BANKS AND TRUST COMPANIES OR ON ACCOUNTS 4,722
WITH SAVINGS AND LOAN ASSOCIATIONS; 4,723
(o) INTEREST ACCRUED ON SECURED LOANS THAT CONFORM TO 4,726
SECTION 3925.08 OF THE REVISED CODE, NOT EXCEEDING THE AMOUNT OF 4,729
ONE YEAR'S INTEREST ON ANY LOAN;
(p) INTEREST ACCRUED ON TAX ANTICIPATION WARRANTS; 4,732
(q) THE AMORTIZED VALUE OF ELECTRONIC COMPUTER OR DATA 4,735
PROCESSING MACHINES OR SYSTEMS PURCHASED FOR USE IN CONNECTION 4,736
WITH THE BUSINESS OF THE HEALTH INSURING CORPORATION, INCLUDING 4,737
SOFTWARE PURCHASED AND DEVELOPED SPECIFICALLY FOR THE USE AND 4,738
PURPOSES OF THE CORPORATION;
(r) THE COST OF FURNITURE, EQUIPMENT, AND MEDICAL 4,741
EQUIPMENT, LESS ACCUMULATED DEPRECIATION ON THE FURNITURE AND 4,742
EQUIPMENT TO BE APPLIED PRO RATA OVER A PERIOD NOT TO EXCEED FIVE 4,743
YEARS, AND OF MEDICAL AND PHARMACEUTICAL SUPPLIES, THAT ARE UNDER 4,744
THE CONTROL OF THE HEALTH INSURING CORPORATION, PROVIDED THESE 4,745
ASSETS DO NOT EXCEED FIFTEEN PER CENT OF ADMITTED ASSETS; 4,746
(s) AMOUNTS DUE FROM AFFILIATES TO THE EXTENT THAT THE 4,749
107
AFFILIATE HAS LIQUID ASSETS WITH WHICH TO PAY THE BALANCE AND 4,750
MAINTAIN ITS ACCOUNTS ON A CURRENT BASIS. ANY AMOUNT OUTSTANDING 4,751
MORE THAN THREE MONTHS SHALL BE CONSIDERED NOT CURRENT. 4,752
(2) "LIABILITIES" MEANS THE LIABILITIES OF THE HEALTH 4,754
INSURING CORPORATION AS DETERMINED BY THE SUPERINTENDENT OF 4,755
INSURANCE. 4,756
(B) ALL ADMITTED ASSETS OF A HEALTH INSURING CORPORATION 4,759
MUST BE HELD IN THE HEALTH INSURING CORPORATION'S NAME AND MUST 4,760
BE FREE AND CLEAR OF ANY ENCUMBRANCES, PLEDGES, OR HYPOTHECATION. 4,761
(C)(1) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,764
PROVIDE BASIC HEALTH CARE SERVICES, WHICH HEALTH INSURING 4,765
CORPORATION IS NOT A PROVIDER SPONSORED ORGANIZATION, SHALL 4,766
MAINTAIN TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN 4,767
PER CENT OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO 4,768
TIME SHALL THE CORPORATION'S NET WORTH BE LESS THAN ONE MILLION 4,769
TWO HUNDRED THOUSAND DOLLARS.
(2) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,771
PROVIDE ONLY SUPPLEMENTAL HEALTH CARE SERVICES SHALL MAINTAIN 4,772
TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT 4,773
OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL 4,775
THE CORPORATION'S NET WORTH BE LESS THAN FIVE HUNDRED THOUSAND 4,776
DOLLARS.
(3) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,778
PROVIDE ONLY SPECIALTY HEALTH CARE SERVICES SHALL MAINTAIN TOTAL 4,779
ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE 4,780
LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL THE 4,781
CORPORATION'S NET WORTH BE LESS THAN TWO HUNDRED FIFTY THOUSAND 4,782
DOLLARS. 4,783
(4) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,785
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 4,786
CARE SERVICES, WHICH HEALTH INSURING CORPORATION IS NOT A 4,787
PROVIDER SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED 4,788
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
108
CORPORATION'S NET WORTH BE LESS THAN ONE MILLION SEVEN HUNDRED 4,791
THOUSAND DOLLARS. 4,792
(5) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,794
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,795
SERVICES, WHICH HEALTH INSURING CORPORATION IS NOT A PROVIDER 4,796
SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED ASSETS 4,797
EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF 4,798
THE CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,799
WORTH BE LESS THAN ONE MILLION FOUR HUNDRED FIFTY THOUSAND 4,800
DOLLARS.
(6) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,802
PROVIDE BASIC HEALTH CARE SERVICES, WHICH HEALTH INSURING 4,803
CORPORATION IS A PROVIDER SPONSORED ORGANIZATION, SHALL MAINTAIN 4,804
TOTAL ADMITTED ASSETS EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT 4,805
OF THE LIABILITIES OF THE CORPORATION. HOWEVER, AT NO TIME SHALL 4,806
THE CORPORATION'S NET WORTH BE LESS THAN ONE MILLION DOLLARS. 4,807
(7) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,809
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SUPPLEMENTAL HEALTH 4,810
CARE SERVICES, WHICH HEALTH INSURING CORPORATION IS A PROVIDER 4,811
SPONSORED ORGANIZATION, SHALL MAINTAIN TOTAL ADMITTED ASSETS 4,812
EQUAL TO AT LEAST ONE HUNDRED TEN PER CENT OF THE LIABILITIES OF 4,813
THE CORPORATION. HOWEVER, AT NO TIME SHALL THE CORPORATION'S NET 4,815
WORTH BE LESS THAN ONE MILLION FIVE HUNDRED THOUSAND DOLLARS. 4,816
(8) EVERY HEALTH INSURING CORPORATION AUTHORIZED TO 4,818
PROVIDE BOTH BASIC HEALTH CARE SERVICES AND SPECIALTY HEALTH CARE 4,819
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 TWO HUNDRED FIFTY THOUSAND
DOLLARS. 4,825
(D) THE ADMITTED VALUE OF ANY REAL ESTATE OWNED BY A 4,828
HEALTH INSURING CORPORATION, WHETHER USED FOR THE ACCOMMODATION 4,829
OF THE HEALTH INSURING CORPORATION'S BUSINESS OPERATIONS OR 4,830
109
OTHERWISE, SHALL BE THE ORIGINAL COST PLUS THE COST OF 4,831
IMPROVEMENTS, LESS ENCUMBRANCES AND ACCUMULATED DEPRECIATION. 4,832
(E) THE NET WORTH OTHERWISE REQUIRED BY THIS SECTION SHALL 4,834
BE REDUCED BY AN AMOUNT REPRESENTING CREDIT GIVEN TO RESERVE 4,835
LIABILITIES WHEN A HEALTH INSURING CORPORATION CARRIES 4,836
REINSURANCE WITH AN ADMITTED REINSURER. HOWEVER, SUCH AN AMOUNT 4,837
SHALL NOT AFFECT THE MINIMUM AMOUNTS SET FORTH IN THIS SECTION 4,838
AND SECTION 1751.27 OF THE REVISED CODE.
Sec. 1751.31. (A) ANY CHANGES IN A HEALTH INSURING 4,841
CORPORATION'S SOLICITATION DOCUMENT SHALL BE FILED WITH THE 4,842
SUPERINTENDENT OF INSURANCE. THE SUPERINTENDENT, WITHIN SIXTY 4,843
DAYS OF FILING, MAY DISAPPROVE ANY SOLICITATION DOCUMENT OR 4,844
AMENDMENT TO IT ON ANY OF THE GROUNDS STATED IN THIS SECTION. 4,845
SUCH DISAPPROVAL SHALL BE EFFECTED BY WRITTEN NOTICE TO THE 4,846
HEALTH INSURING CORPORATION. THE NOTICE SHALL STATE THE GROUNDS 4,847
FOR DISAPPROVAL AND SHALL BE ISSUED IN ACCORDANCE WITH CHAPTER 4,848
119. OF THE REVISED CODE. 4,849
(B) THE SOLICITATION DOCUMENT SHALL CONTAIN ALL 4,852
INFORMATION NECESSARY TO ENABLE A CONSUMER TO MAKE AN INFORMED 4,853
CHOICE AS TO WHETHER OR NOT TO ENROLL IN THE HEALTH INSURING 4,854
CORPORATION. THE INFORMATION SHALL INCLUDE A SPECIFIC 4,855
DESCRIPTION OF THE HEALTH CARE SERVICES TO BE AVAILABLE AND THE 4,856
APPROXIMATE NUMBER AND TYPE OF FULL-TIME EQUIVALENT MEDICAL 4,857
PRACTITIONERS. THE INFORMATION SHALL BE PRESENTED IN THE 4,858
SOLICITATION DOCUMENT IN A MANNER THAT IS CLEAR, CONCISE, AND 4,859
INTELLIGIBLE TO PROSPECTIVE APPLICANTS IN THE PROPOSED SERVICE 4,860
AREA.
(C) EVERY POTENTIAL APPLICANT WHOSE SUBSCRIPTION TO A 4,863
HEALTH CARE PLAN IS SOLICITED SHALL RECEIVE, AT OR BEFORE THE 4,864
TIME OF SOLICITATION, A SOLICITATION DOCUMENT APPROVED BY THE 4,865
SUPERINTENDENT.
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A HEALTH 4,868
INSURING CORPORATION MAY USE A SOLICITATION DOCUMENT THAT THE 4,869
CORPORATION USES IN CONNECTION WITH POLICIES FOR BENEFICIARIES OF 4,870
110
TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 4,872
U.S.C.A. 301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR 4,874
MEDICARE COST CONTRACT, OR FOR POLICIES FOR BENEFICIARIES OF THE 4,875
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM PURSUANT TO 5 U.S.C.A. 4,877
8905, OR FOR POLICIES FOR BENEFICIARIES OF TITLE XIX OF THE 4,879
"SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 4,882
AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR MEDICAID, 4,883
PROVIDED BY THE OHIO DEPARTMENT OF HUMAN SERVICES UNDER CHAPTER 4,884
5111. OF THE REVISED CODE, OR FOR POLICIES FOR BENEFICIARIES OF 4,885
ANY OTHER FEDERAL HEALTH CARE PROGRAM REGULATED BY A FEDERAL 4,886
REGULATORY BODY, IF BOTH OF THE FOLLOWING APPLY: 4,887
(1) THE SOLICITATION DOCUMENT HAS BEEN APPROVED BY THE 4,889
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE UNITED 4,890
STATES OFFICE OF PERSONNEL MANAGEMENT, OR THE OHIO DEPARTMENT OF 4,892
HUMAN SERVICES.
(2) THE SOLICITATION DOCUMENT IS FILED WITH THE 4,894
SUPERINTENDENT OF INSURANCE PRIOR TO USE AND IS ACCOMPANIED BY 4,895
DOCUMENTATION OF APPROVAL FROM THE UNITED STATES DEPARTMENT OF 4,898
HEALTH AND HUMAN SERVICES, THE UNITED STATES OFFICE OF PERSONNEL 4,900
MANAGEMENT, OR THE OHIO DEPARTMENT OF HUMAN SERVICES. 4,902
(E) NO HEALTH INSURING CORPORATION, OR ITS AGENTS OR 4,905
REPRESENTATIVES, SHALL USE MONETARY OR OTHER VALUABLE 4,906
CONSIDERATION, ENGAGE IN MISLEADING OR DECEPTIVE PRACTICES, OR 4,907
MAKE UNTRUE, MISLEADING, OR DECEPTIVE REPRESENTATIONS TO INDUCE 4,908
ENROLLMENT. NOTHING IN THIS DIVISION SHALL PROHIBIT INCENTIVE 4,909
FORMS OF REMUNERATION SUCH AS COMMISSION SALES PROGRAMS FOR THE 4,910
HEALTH INSURING CORPORATION'S EMPLOYEES AND AGENTS. 4,911
(F) ANY PERSON OBLIGATED FOR ANY PART OF A PREMIUM RATE IN 4,914
CONNECTION WITH AN ENROLLMENT AGREEMENT, IN ADDITION TO ANY RIGHT 4,915
OTHERWISE AVAILABLE TO REVOKE AN OFFER, MAY CANCEL SUCH AGREEMENT 4,916
WITHIN SEVENTY-TWO HOURS AFTER HAVING SIGNED THE AGREEMENT OR 4,917
OFFER TO ENROLL. CANCELLATION OCCURS WHEN WRITTEN NOTICE OF THE 4,918
CANCELLATION IS GIVEN TO THE HEALTH INSURING CORPORATION OR ITS 4,919
AGENTS OR OTHER REPRESENTATIVES. A NOTICE OF CANCELLATION MAILED 4,920
111
TO THE HEALTH INSURING CORPORATION SHALL BE CONSIDERED TO HAVE 4,921
BEEN FILED ON ITS POSTMARK DATE. 4,922
(G) NOTHING IN THIS SECTION SHALL PROHIBIT HEALTHY 4,924
LIFESTYLE PROGRAMS. 4,925
Sec. 1751.32. EACH HEALTH INSURING CORPORATION, ANNUALLY, 4,927
ON OR BEFORE THE FIRST DAY OF MARCH, SHALL FILE A REPORT WITH THE 4,929
SUPERINTENDENT OF INSURANCE AND THE DIRECTOR OF HEALTH, COVERING 4,930
THE PRECEDING CALENDAR YEAR.
THE REPORT SHALL BE VERIFIED BY AN OFFICER OF THE HEALTH 4,932
INSURING CORPORATION, SHALL BE IN THE FORM THE SUPERINTENDENT 4,933
PRESCRIBES, AND SHALL INCLUDE: 4,934
(A) A FINANCIAL STATEMENT OF THE HEALTH INSURING 4,937
CORPORATION, INCLUDING ITS BALANCE SHEET AND RECEIPTS AND 4,938
DISBURSEMENTS FOR THE PRECEDING YEAR, WHICH REFLECT, AT A 4,939
MINIMUM:
(1) ALL PREMIUM RATE AND OTHER PAYMENTS RECEIVED FOR 4,941
HEALTH CARE SERVICES RENDERED; 4,942
(2) EXPENDITURES WITH RESPECT TO ALL CATEGORIES OF 4,944
PROVIDERS, FACILITIES, INSURANCE COMPANIES, AND OTHER PERSONS 4,945
ENGAGED TO FULFILL OBLIGATIONS OF THE HEALTH INSURING CORPORATION 4,947
ARISING OUT OF ITS HEALTH CARE POLICIES, CONTRACTS, CERTIFICATES, 4,948
AND AGREEMENTS;
(3) EXPENDITURES FOR CAPITAL IMPROVEMENTS OR ADDITIONS 4,950
THERETO, INCLUDING, BUT NOT LIMITED TO, CONSTRUCTION, RENOVATION, 4,952
OR PURCHASE OF FACILITIES AND EQUIPMENT.
(B) A DESCRIPTION OF THE ENROLLEE POPULATION AND 4,955
COMPOSITION, GROUP AND NONGROUP;
(C) A SUMMARY OF ENROLLEE WRITTEN COMPLAINTS AND THEIR 4,958
DISPOSITION;
(D) A STATEMENT OF THE NUMBER OF SUBSCRIBER POLICIES, 4,961
CONTRACTS, CERTIFICATES, AND AGREEMENTS THAT HAVE BEEN TERMINATED 4,962
BY ACTION OF THE HEALTH INSURING CORPORATION, INCLUDING THE 4,963
NUMBER OF ENROLLEES AFFECTED; 4,964
(E) A SUMMARY OF THE INFORMATION COMPILED PURSUANT TO 4,967
112
DIVISION (B)(5) OF SECTION 1751.04 OF THE REVISED CODE; 4,968
(F) A CURRENT REPORT OF THE NAMES AND ADDRESSES OF THE 4,971
PERSONS RESPONSIBLE FOR THE CONDUCT OF THE AFFAIRS OF THE HEALTH 4,972
INSURING CORPORATION AS REQUIRED BY SECTION 1751.03 OF THE 4,973
REVISED CODE. ADDITIONALLY, THE REPORT SHALL INCLUDE THE AMOUNT 4,975
OF WAGES, EXPENSE REIMBURSEMENTS, AND OTHER PAYMENTS TO THESE 4,976
PERSONS FOR SERVICES TO THE HEALTH INSURING CORPORATION, AND 4,977
SHALL INCLUDE A FULL DISCLOSURE OF THE FINANCIAL INTERESTS 4,978
RELATED TO THE OPERATIONS OF THE HEALTH INSURING CORPORATION 4,979
ACQUIRED BY THESE PERSONS DURING THE PRECEDING YEAR. 4,980
(G) AN AUDIT REPORT CERTIFIED BY AN INDEPENDENT CERTIFIED 4,983
PUBLIC ACCOUNTANT IN THE FORM PRESCRIBED BY THE SUPERINTENDENT BY 4,984
RULE;
(H) AN ACTUARIAL OPINION IN THE FORM PRESCRIBED BY THE 4,987
SUPERINTENDENT BY RULE;
(I) ANY OTHER INFORMATION RELATING TO THE PERFORMANCE OF 4,990
THE HEALTH INSURING CORPORATION THAT IS NECESSARY TO ENABLE THE 4,991
SUPERINTENDENT TO CARRY OUT THE SUPERINTENDENT'S DUTIES UNDER 4,992
THIS CHAPTER.
Sec. 1751.33. (A) EACH HEALTH INSURING CORPORATION SHALL 4,994
PROVIDE TO ITS SUBSCRIBERS, BY MAIL, A DESCRIPTION OF THE HEALTH 4,995
INSURING CORPORATION, ITS METHOD OF OPERATION, ITS SERVICE AREA, 4,996
ITS MOST RECENT PROVIDER LIST, AND ITS COMPLAINT PROCEDURE 4,997
ESTABLISHED PURSUANT TO SECTION 1751.19 OF THE REVISED CODE. A 4,999
HEALTH INSURING CORPORATION PROVIDING BASIC HEALTH CARE SERVICES 5,000
OR SUPPLEMENTAL HEALTH CARE SERVICES SHALL PROVIDE THIS 5,001
INFORMATION ANNUALLY. A HEALTH INSURING CORPORATION PROVIDING
ONLY SPECIALTY HEALTH CARE SERVICES SHALL PROVIDE THIS 5,002
INFORMATION BIENNIALLY.
(B) EACH HEALTH INSURING CORPORATION, UPON THE REQUEST OF 5,005
A SUBSCRIBER, SHALL MAKE AVAILABLE ITS MOST RECENT STATUTORY 5,006
FINANCIAL STATEMENT.
Sec. 1751.34. (A) EACH HEALTH INSURING CORPORATION AND 5,009
EACH APPLICANT FOR A CERTIFICATE OF AUTHORITY UNDER THIS CHAPTER 5,010
113
SHALL BE SUBJECT TO EXAMINATION BY THE SUPERINTENDENT OF 5,011
INSURANCE IN ACCORDANCE WITH SECTION 3901.07 OF THE REVISED CODE. 5,013
SECTION 3901.07 OF THE REVISED CODE SHALL GOVERN EVERY ASPECT OF 5,015
THE EXAMINATION, INCLUDING THE CIRCUMSTANCES UNDER AND FREQUENCY 5,016
WITH WHICH IT IS CONDUCTED, THE AUTHORITY OF THE SUPERINTENDENT 5,017
AND ANY EXAMINER OR OTHER PERSON APPOINTED BY THE SUPERINTENDENT, 5,018
THE LIABILITY FOR THE ASSESSMENT OF EXPENSES INCURRED IN 5,019
CONDUCTING THE EXAMINATION, AND THE REMITTANCE OF THE ASSESSMENT 5,020
TO THE SUPERINTENDENT'S EXAMINATION FUND.
(B) THE DIRECTOR OF HEALTH SHALL MAKE AN EXAMINATION 5,023
CONCERNING THE MATTERS SUBJECT TO THE DIRECTOR'S CONSIDERATION IN 5,024
SECTION 1751.04 OF THE REVISED CODE AS OFTEN AS THE DIRECTOR 5,025
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF THE 5,027
PEOPLE OF THIS STATE, BUT NOT LESS FREQUENTLY THAN ONCE EVERY 5,028
THREE YEARS. THE EXPENSES OF SUCH EXAMINATIONS SHALL BE ASSESSED 5,029
AGAINST THE HEALTH INSURING CORPORATION BEING EXAMINED IN THE 5,030
MANNER IN WHICH EXPENSES OF EXAMINATIONS ARE ASSESSED AGAINST AN 5,031
INSURANCE COMPANY UNDER SECTION 3901.07 OF THE REVISED CODE. 5,032
(C) AN EXAMINATION, PURSUANT TO SECTION 3901.07 OF THE 5,035
REVISED CODE, OF AN INSURANCE COMPANY HOLDING A CERTIFICATE OF 5,036
AUTHORITY UNDER THIS CHAPTER TO ORGANIZE AND OPERATE A HEALTH 5,037
INSURING CORPORATION SHALL INCLUDE AN EXAMINATION OF THE HEALTH 5,038
INSURING CORPORATION PURSUANT TO THIS SECTION AND THE EXAMINATION 5,039
SHALL SATISFY THE REQUIREMENTS OF DIVISIONS (A) AND (B) OF THIS 5,041
SECTION.
(D) THE SUPERINTENDENT MAY CONDUCT MARKET CONDUCT 5,044
EXAMINATIONS PURSUANT TO SECTION 3901.011 OF THE REVISED CODE OF 5,046
ANY HEALTH INSURING CORPORATION AS OFTEN AS THE SUPERINTENDENT 5,047
CONSIDERS IT NECESSARY FOR THE PROTECTION OF THE INTERESTS OF 5,048
SUBSCRIBERS AND ENROLLEES. THE EXPENSES OF SUCH MARKET CONDUCT 5,049
EXAMINATIONS SHALL BE ASSESSED AGAINST THE HEALTH INSURING 5,050
CORPORATION BEING EXAMINED. ALL COSTS, ASSESSMENTS, OR FINES 5,051
COLLECTED UNDER THIS DIVISION SHALL BE PAID INTO THE STATE 5,052
TREASURY TO THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING 5,053
114
FUND.
Sec. 1751.35. (A) THE SUPERINTENDENT OF INSURANCE MAY 5,056
SUSPEND OR REVOKE ANY CERTIFICATE OF AUTHORITY ISSUED TO A HEALTH 5,057
INSURING CORPORATION UNDER THIS CHAPTER IF THE SUPERINTENDENT 5,058
FINDS THAT:
(1) THE HEALTH INSURING CORPORATION IS OPERATING IN 5,060
CONTRAVENTION OF ITS ARTICLES OF INCORPORATION, ITS HEALTH CARE 5,061
PLAN OR PLANS, OR IN A MANNER CONTRARY TO THAT DESCRIBED IN AND 5,062
REASONABLY INFERRED FROM ANY OTHER INFORMATION SUBMITTED UNDER 5,063
SECTION 1751.03 OF THE REVISED CODE, UNLESS AMENDMENTS TO SUCH 5,065
SUBMISSIONS HAVE BEEN FILED AND HAVE TAKEN EFFECT IN COMPLIANCE 5,066
WITH THIS CHAPTER. 5,067
(2) THE HEALTH INSURING CORPORATION FAILS TO ISSUE 5,069
EVIDENCES OF COVERAGE IN COMPLIANCE WITH THE REQUIREMENTS OF 5,070
SECTION 1751.11 OF THE REVISED CODE. 5,072
(3) THE CONTRACTUAL PERIODIC PREPAYMENTS OR PREMIUM RATES 5,074
USED DO NOT COMPLY WITH THE REQUIREMENTS OF SECTION 1751.12 OF 5,075
THE REVISED CODE. 5,076
(4) THE HEALTH INSURING CORPORATION ENTERS INTO A 5,078
CONTRACT, AGREEMENT, OR OTHER ARRANGEMENT WITH ANY HEALTH CARE 5,079
FACILITY OR PROVIDER, THAT DOES NOT COMPLY WITH THE REQUIREMENTS 5,080
OF SECTION 1751.13 OF THE REVISED CODE, OR THE CORPORATION FAILS 5,082
TO PROVIDE AN ANNUAL CERTIFICATE AS REQUIRED BY SECTION 1751.13 5,083
OF THE REVISED CODE. 5,085
(5) THE DIRECTOR OF HEALTH HAS CERTIFIED, AFTER A HEARING 5,087
CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, 5,089
THAT THE HEALTH INSURING CORPORATION NO LONGER MEETS THE 5,090
REQUIREMENTS OF SECTION 1751.04 OF THE REVISED CODE. 5,092
(6) THE HEALTH INSURING CORPORATION IS NO LONGER 5,094
FINANCIALLY RESPONSIBLE AND MAY REASONABLY BE EXPECTED TO BE 5,095
UNABLE TO MEET ITS OBLIGATIONS TO ENROLLEES OR PROSPECTIVE 5,096
ENROLLEES. 5,097
(7) THE HEALTH INSURING CORPORATION HAS FAILED TO 5,099
IMPLEMENT THE COMPLAINT SYSTEM THAT COMPLIES WITH THE 5,100
115
REQUIREMENTS OF SECTION 1751.19 OF THE REVISED CODE. 5,103
(8) THE HEALTH INSURING CORPORATION, OR ANY AGENT OR 5,105
REPRESENTATIVE OF THE CORPORATION, HAS ADVERTISED, MERCHANDISED, 5,106
OR SOLICITED ON ITS BEHALF IN CONTRAVENTION OF THE REQUIREMENTS 5,107
OF SECTION 1751.31 OF THE REVISED CODE. 5,108
(9) THE HEALTH INSURING CORPORATION HAS UNLAWFULLY 5,110
DISCRIMINATED AGAINST ANY ENROLLEE OR PROSPECTIVE ENROLLEE WITH 5,111
RESPECT TO ENROLLMENT, DISENROLLMENT, OR PRICE OR QUALITY OF 5,112
HEALTH CARE SERVICES. 5,113
(10) THE CONTINUED OPERATION OF THE HEALTH INSURING 5,115
CORPORATION WOULD BE HAZARDOUS OR OTHERWISE DETRIMENTAL TO ITS 5,116
ENROLLEES. 5,117
(11) THE HEALTH INSURING CORPORATION HAS SUBMITTED FALSE 5,119
INFORMATION IN ANY FILING OR SUBMISSION REQUIRED UNDER THIS 5,120
CHAPTER OR ANY RULE ADOPTED UNDER THIS CHAPTER. 5,121
(12) THE HEALTH INSURING CORPORATION HAS OTHERWISE FAILED 5,123
TO SUBSTANTIALLY COMPLY WITH THIS CHAPTER OR ANY RULE ADOPTED 5,124
UNDER THIS CHAPTER. 5,125
(13) THE HEALTH INSURING CORPORATION IS NOT OPERATING A 5,127
HEALTH CARE PLAN. 5,128
(B) A CERTIFICATE OF AUTHORITY SHALL BE SUSPENDED OR 5,131
REVOKED ONLY AFTER COMPLIANCE WITH THE REQUIREMENTS OF CHAPTER 5,132
119. OF THE REVISED CODE. 5,133
(C) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,136
CORPORATION IS SUSPENDED, THE HEALTH INSURING CORPORATION, DURING 5,137
THE PERIOD OF SUSPENSION, SHALL NOT ENROLL ANY ADDITIONAL 5,138
SUBSCRIBERS OR ENROLLEES EXCEPT NEWBORN CHILDREN OR OTHER NEWLY 5,139
ACQUIRED DEPENDENTS OF EXISTING SUBSCRIBERS OR ENROLLEES, AND 5,140
SHALL NOT ENGAGE IN ANY ADVERTISING OR SOLICITATION WHATSOEVER. 5,141
(D) WHEN THE CERTIFICATE OF AUTHORITY OF A HEALTH INSURING 5,144
CORPORATION IS REVOKED, THE HEALTH INSURING CORPORATION, 5,145
FOLLOWING THE EFFECTIVE DATE OF THE ORDER OF REVOCATION, SHALL 5,146
CONDUCT NO FURTHER BUSINESS EXCEPT AS MAY BE ESSENTIAL TO THE 5,147
ORDERLY CONCLUSION OF THE AFFAIRS OF THE HEALTH INSURING 5,148
116
CORPORATION. THE HEALTH INSURING CORPORATION SHALL ENGAGE IN NO 5,149
FURTHER ADVERTISING OR SOLICITATION WHATSOEVER. THE 5,150
SUPERINTENDENT, BY WRITTEN ORDER, MAY PERMIT SUCH FURTHER 5,151
OPERATION OF THE HEALTH INSURING CORPORATION AS THE 5,152
SUPERINTENDENT MAY FIND TO BE IN THE BEST INTEREST OF ENROLLEES, 5,153
TO THE END THAT ENROLLEES WILL BE AFFORDED THE GREATEST PRACTICAL 5,154
OPPORTUNITY TO OBTAIN CONTINUING HEALTH CARE COVERAGE. 5,155
Sec. 1751.36. (A) WHEN THE SUPERINTENDENT OF INSURANCE 5,158
HAS CAUSE TO BELIEVE THAT GROUNDS FOR THE DENIAL OF AN 5,159
APPLICATION FOR A CERTIFICATE OF AUTHORITY EXIST, OR THAT GROUNDS 5,160
FOR THE SUSPENSION OR REVOCATION OF A CERTIFICATE OF AUTHORITY 5,161
EXIST, THE SUPERINTENDENT SHALL NOTIFY THE APPLICANT OR HEALTH 5,162
INSURING CORPORATION AND THE DIRECTOR OF HEALTH IN WRITING, 5,163
SPECIFICALLY STATING THE GROUNDS FOR THE DENIAL, SUSPENSION, OR 5,164
REVOCATION AND SETTING A DATE OF AT LEAST THIRTY DAYS AFTER THE 5,165
NOTIFICATION FOR A HEARING ON THE MATTER.
(B) THE RECOMMENDATIONS AND FINDINGS OF THE DIRECTOR OF 5,168
HEALTH WITH RESPECT TO MATTERS SUBJECT TO THE DIRECTOR'S 5,169
CONSIDERATION UNDER SECTION 1751.04 OF THE REVISED CODE, PROVIDED 5,171
IN CONNECTION WITH ANY DECISION REGARDING THE DENIAL, SUSPENSION, 5,172
OR REVOCATION OF A CERTIFICATE OF AUTHORITY, SHALL BE REVIEWED 5,173
AND CONSIDERED BY THE SUPERINTENDENT. AFTER THE HEARING 5,174
AUTHORIZED BY DIVISION (A) OF THIS SECTION, OR UPON THE FAILURE 5,176
OF THE APPLICANT OR HEALTH INSURING CORPORATION TO APPEAR AT THE 5,177
HEARING, THE SUPERINTENDENT SHALL TAKE SUCH ACTION AS IN 5,178
ACCORDANCE WITH LAW AND THE EVIDENCE. THE ACTION SHALL BE SET 5,179
OUT IN WRITTEN FINDINGS WHICH SHALL BE MAILED TO THE APPLICANT OR 5,180
HEALTH INSURING CORPORATION WITH A COPY TO THE DIRECTOR OF
HEALTH. THE ACTION OF THE SUPERINTENDENT IS SUBJECT TO REVIEW IN 5,182
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, EXCEPT THAT A 5,184
CERTIFICATION BY THE DIRECTOR UNDER DIVISION (D) OF SECTION 5,186
1751.04 OR DIVISION (A)(5) OF SECTION 1751.35 OF THE REVISED CODE 5,188
THAT WAS MADE IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE 5,189
SHALL BE FINAL AS TO THE MATTERS CERTIFIED.
117
(C) CHAPTER 119. OF THE REVISED CODE APPLIES TO 5,191
PROCEEDINGS UNDER THIS SECTION TO THE EXTENT THAT IT IS NOT IN 5,192
CONFLICT WITH DIVISIONS (A) AND (B) OF THIS SECTION. 5,193
Sec. 1751.38. (A) AS USED IN THIS SECTION, "AGENT" MEANS 5,196
A PERSON APPOINTED BY A HEALTH INSURING CORPORATION TO ENGAGE IN 5,197
THE SOLICITATION OR ENROLLMENT OF SUBSCRIBERS OR ENROLLEES. 5,198
(B) AGENTS OF HEALTH INSURING CORPORATIONS SHALL BE 5,201
LICENSED PURSUANT TO SECTION 3905.01 OR 3905.18 OF THE REVISED 5,204
CODE.
(C) SECTIONS 3905.01, 3905.03, 3905.05, 3905.16 TO 5,207
3905.18, 3905.181, 3905.19, 3905.23, 3905.40, 3905.41, 3905.42, 5,208
3905.46 TO 3905.48, 3905.481, 3905.482, 3905.486, 3905.49, 5,209
3905.50, 3905.71 TO 3905.79, AND 3905.99 OF THE REVISED CODE 5,210
SHALL APPLY TO HEALTH INSURING CORPORATIONS AND THE AGENTS OF 5,211
HEALTH INSURING CORPORATIONS IN THE SAME MANNER IN WHICH THESE 5,212
SECTIONS APPLY TO INSURERS AND AGENTS OF INSURERS. 5,213
Sec. 1751.40. (A) NOTWITHSTANDING ANY PROVISION OF TITLE 5,215
XXXIX OF THE REVISED CODE, ANY INSURANCE COMPANY HOLDING A 5,219
CERTIFICATE OF AUTHORITY ISSUED PURSUANT TO TITLE XXXIX OF THE 5,221
REVISED CODE, OR ANY CORPORATION THAT IS A SUBSIDIARY OR 5,222
AFFILIATE OF THE INSURANCE COMPANY, MAY APPLY FOR AND OBTAIN A 5,223
CERTIFICATE OF AUTHORITY TO ORGANIZE AND OPERATE A HEALTH 5,224
INSURING CORPORATION IN COMPLIANCE WITH THIS CHAPTER. 5,225
NOTWITHSTANDING ANY OTHER LAW THAT MAY BE INCONSISTENT WITH THIS 5,226
DIVISION, ANY TWO OR MORE SUCH INSURANCE COMPANIES, OR
SUBSIDIARIES OR AFFILIATES THEREOF, MAY JOINTLY ORGANIZE AND 5,227
OPERATE A HEALTH INSURING CORPORATION UNDER THIS CHAPTER. THE 5,228
BUSINESS OF INSURANCE IS DEEMED TO INCLUDE THE PROVIDING OF 5,229
HEALTH CARE BY A HEALTH INSURING CORPORATION OWNED OR OPERATED BY 5,231
AN INSURANCE COMPANY OR A SUBSIDIARY OR AFFILIATE OF AN INSURANCE 5,232
COMPANY.
(B) NOTWITHSTANDING ANY PROVISION OF ANY INSURANCE LAWS OF 5,235
THIS STATE, AN INSURANCE COMPANY MAY CONTRACT WITH A HEALTH 5,236
INSURING CORPORATION TO PROVIDE INSURANCE OR SIMILAR PROTECTION 5,237
118
AGAINST THE COST OF CARE PROVIDED THROUGH HEALTH INSURING 5,238
CORPORATIONS AND TO PROVIDE COVERAGE IN THE EVENT OF THE FAILURE 5,239
OF THE HEALTH INSURING CORPORATION TO MEET ITS OBLIGATIONS. THE 5,240
ENROLLEES OF A HEALTH INSURING CORPORATION CONSTITUTE A 5,241
PERMISSIBLE GROUP UNDER SUCH LAWS. AMONG OTHER THINGS, UNDER 5,242
SUCH CONTRACTS, THE INSURER MAY MAKE BENEFIT PAYMENTS TO HEALTH 5,243
INSURING CORPORATIONS FOR HEALTH CARE SERVICES RENDERED BY 5,244
FACILITIES AND PROVIDERS PURSUANT TO A HEALTH CARE PLAN. 5,245
Sec. 1751.42. ANY REHABILITATION, LIQUIDATION, 5,247
SUPERVISION, OR CONSERVATION OF A HEALTH INSURING CORPORATION 5,248
SHALL BE DEEMED TO BE THE REHABILITATION, LIQUIDATION, 5,249
SUPERVISION, OR CONSERVATION OF AN INSURANCE COMPANY AND SHALL BE 5,250
CONDUCTED UNDER THE SUPERVISION OF THE SUPERINTENDENT OF 5,251
INSURANCE PURSUANT TO CHAPTER 3903. OF THE REVISED CODE. 5,254
Sec. 1751.44. (A) EACH HEALTH INSURING CORPORATION SHALL 5,257
PAY TO THE SUPERINTENDENT OF INSURANCE THE FOLLOWING FEES: 5,258
(1) FOR FILING AN APPLICATION FOR A CERTIFICATE OF 5,260
AUTHORITY, FIFTEEN HUNDRED DOLLARS; 5,261
(2) FOR FILING A REQUEST FOR A SERVICE AREA EXPANSION 5,263
UNDER SECTION 1751.03 OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,265
(3) FOR FILING A MAJOR MODIFICATION UNDER SECTION 1751.03 5,267
OF THE REVISED CODE, THREE HUNDRED DOLLARS; 5,270
(4) FOR FILING EACH ANNUAL REPORT, TWENTY-FIVE DOLLARS; 5,273
(5) FOR ALL OTHER REQUIRED FILINGS FOR WHICH NO FILING FEE 5,276
IS OTHERWISE PROVIDED FOR BY THIS CHAPTER, FIFTY DOLLARS. 5,277
(B) ALL FEES COLLECTED UNDER THIS SECTION SHALL BE PAID 5,280
INTO THE STATE TREASURY TO THE CREDIT OF THE DEPARTMENT OF 5,281
INSURANCE OPERATING FUND.
Sec. 1751.45. (A) IN LIEU OF THE SUSPENSION OR REVOCATION 5,284
OF A CERTIFICATE OF AUTHORITY UNDER SECTION 1751.35 OF THE 5,285
REVISED CODE, THE SUPERINTENDENT OF INSURANCE, PURSUANT TO AN 5,287
ADJUDICATION HEARING INITIATED AND CONDUCTED IN ACCORDANCE WITH 5,288
CHAPTER 119. OF THE REVISED CODE, OR BY CONSENT OF THE HEALTH 5,290
INSURING CORPORATION WITHOUT AN ADJUDICATION HEARING, MAY LEVY AN 5,291
119
ADMINISTRATIVE PENALTY. THE ADMINISTRATIVE PENALTY SHALL BE IN
AN AMOUNT DETERMINED BY THE SUPERINTENDENT, BUT THE 5,293
ADMINISTRATIVE PENALTY SHALL NOT EXCEED ONE HUNDRED THOUSAND 5,294
DOLLARS PER VIOLATION. ADDITIONALLY, THE SUPERINTENDENT MAY 5,295
REQUIRE THE HEALTH INSURING CORPORATION TO CORRECT ANY DEFICIENCY 5,297
THAT MAY BE THE BASIS FOR THE SUSPENSION OR REVOCATION OF THE 5,298
HEALTH INSURING CORPORATION'S CERTIFICATE OF AUTHORITY. ALL 5,299
PENALTIES COLLECTED SHALL BE PAID INTO THE STATE TREASURY TO THE 5,300
CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING FUND. 5,301
(B) IF THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH FOR 5,304
ANY REASON HAS CAUSE TO BELIEVE THAT ANY VIOLATION OF THIS 5,305
CHAPTER HAS OCCURRED OR IS THREATENED, THE SUPERINTENDENT OR THE 5,306
DIRECTOR MAY GIVE NOTICE TO THE HEALTH INSURING CORPORATION AND 5,307
TO THE REPRESENTATIVES OR OTHER PERSONS WHO APPEAR TO BE INVOLVED 5,308
IN THE SUSPECTED VIOLATION TO ARRANGE A CONFERENCE WITH THE 5,309
SUSPECTED VIOLATORS OR THEIR AUTHORIZED REPRESENTATIVES FOR THE 5,310
PURPOSE OF ATTEMPTING TO ASCERTAIN THE FACTS RELATING TO THE 5,311
SUSPECTED VIOLATION, AND, IF IT APPEARS THAT ANY VIOLATION HAS 5,312
OCCURRED OR IS THREATENED, TO ARRIVE AT AN ADEQUATE AND EFFECTIVE 5,314
MEANS OF CORRECTING OR PREVENTING THE VIOLATION.
PROCEEDINGS UNDER THIS DIVISION SHALL NOT BE COVERED BY ANY 5,317
FORMAL PROCEDURAL REQUIREMENTS, AND MAY BE CONDUCTED IN THE
MANNER THE SUPERINTENDENT OR THE DIRECTOR OF HEALTH MAY CONSIDER 5,318
APPROPRIATE UNDER THE CIRCUMSTANCES. 5,319
(C)(1) THE SUPERINTENDENT MAY ISSUE AN ORDER DIRECTING A 5,322
HEALTH INSURING CORPORATION OR A REPRESENTATIVE OF THE HEALTH 5,323
INSURING CORPORATION TO CEASE AND DESIST FROM ENGAGING IN ANY ACT 5,324
OR PRACTICE IN VIOLATION OF THIS CHAPTER. WITHIN THIRTY DAYS 5,325
AFTER SERVICE OF THE ORDER TO CEASE AND DESIST, THE RESPONDENT 5,326
MAY REQUEST A HEARING ON THE QUESTION OF WHETHER ACTS OR 5,327
PRACTICES IN VIOLATION OF THIS CHAPTER HAVE OCCURRED. SUCH 5,328
HEARINGS SHALL BE CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF 5,329
THE REVISED CODE AND JUDICIAL REVIEW SHALL BE AVAILABLE AS 5,331
PROVIDED BY THAT CHAPTER.
120
(2) IF THE SUPERINTENDENT HAS REASONABLE CAUSE TO BELIEVE 5,333
THAT AN ORDER ISSUED PURSUANT TO THIS DIVISION HAS BEEN VIOLATED 5,334
IN WHOLE OR IN PART, THE SUPERINTENDENT MAY REQUEST THE ATTORNEY 5,335
GENERAL TO COMMENCE AND PROSECUTE ANY APPROPRIATE ACTION OR 5,336
PROCEEDING IN THE NAME OF THE STATE AGAINST THE VIOLATORS IN THE 5,337
COURT OF COMMON PLEAS OF FRANKLIN COUNTY. THE COURT IN ANY SUCH 5,340
ACTION OR PROCEEDING MAY LEVY CIVIL PENALTIES, NOT TO EXCEED ONE 5,341
HUNDRED THOUSAND DOLLARS PER VIOLATION, IN ADDITION TO ANY OTHER 5,342
APPROPRIATE RELIEF, INCLUDING REQUIRING A VIOLATOR TO PAY THE 5,343
EXPENSES REASONABLY INCURRED BY THE SUPERINTENDENT IN ENFORCING 5,344
THE ORDER. THE PENALTIES AND FEES COLLECTED UNDER THIS DIVISION 5,345
SHALL BE PAID INTO THE STATE TREASURY TO THE CREDIT OF THE 5,346
DEPARTMENT OF INSURANCE OPERATING FUND.
Sec. 1751.46. (A) THE SUPERINTENDENT OF INSURANCE AND THE 5,349
DIRECTOR OF HEALTH MAY CONTRACT WITH QUALIFIED PERSONS TO MAKE 5,350
RECOMMENDATIONS CONCERNING THE DETERMINATIONS REQUIRED TO BE MADE 5,351
BY THE SUPERINTENDENT OR THE DIRECTOR RELATIVE TO AN EXPANSION OF 5,352
A SERVICE AREA PURSUANT TO DIVISION (C) OF SECTION 1751.03 OF THE 5,354
REVISED CODE, AN APPLICATION FOR A CERTIFICATE OF AUTHORITY 5,356
PURSUANT TO SECTIONS 1751.04 AND 1751.05 OF THE REVISED CODE, A 5,358
CONTRACTUAL PERIODIC PREPAYMENT OR PREMIUM RATE PURSUANT TO 5,359
SECTION 1751.12 OF THE REVISED CODE, AND AN EXAMINATION PURSUANT 5,361
TO DIVISION (B) OF SECTION 1751.34 OF THE REVISED CODE. THE 5,363
RECOMMENDATIONS MAY BE ACCEPTED IN FULL OR IN PART, OR MAY BE 5,364
REJECTED, BY THE SUPERINTENDENT OR DIRECTOR. 5,365
(B) NO QUALIFIED PERSON PLACED ON CONTRACT BY THE 5,368
SUPERINTENDENT OR THE DIRECTOR PURSUANT TO DIVISION (A) OF THIS 5,370
SECTION SHALL HAVE A CONFLICT OF INTEREST WITH THE DEPARTMENT OF 5,371
INSURANCE, THE DEPARTMENT OF HEALTH, OR THE HEALTH INSURING 5,372
CORPORATION.
Sec. 1751.47. (A) THE SUPERINTENDENT OF INSURANCE SHALL 5,374
ADOPT THE FORMS, INSTRUCTIONS, AND MANUALS PRESCRIBED BY THE 5,376
NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS FOR THE 5,377
PREPARATION AND FILING OF STATUTORY FINANCIAL STATEMENTS AND 5,378
121
OTHER FINANCIAL INFORMATION. HOWEVER, THE SUPERINTENDENT MAY BY 5,379
RULE ADOPT MODIFICATIONS TO SUCH PRESCRIBED FORMS, INSTRUCTIONS, 5,380
AND MANUALS AS THE SUPERINTENDENT CONSIDERS TO BE NECESSARY. 5,381
(B) FOR PURPOSES OF PREPARING STATUTORY FINANCIAL 5,384
STATEMENTS AND OTHER FINANCIAL INFORMATION INVOLVING 5,385
CIRCUMSTANCES NOT ADDRESSED BY THE FORMS, INSTRUCTIONS, AND 5,386
MANUALS PRESCRIBED BY THE NATIONAL ASSOCIATION OF INSURANCE 5,387
COMMISSIONERS, THE SUPERINTENDENT MAY DETERMINE ACCOUNTING 5,388
PRACTICES AND METHODS TO BE USED BY HEALTH INSURING CORPORATIONS. 5,389
(C) THE SUPERINTENDENT SHALL FURNISH EACH DOMESTIC HEALTH 5,392
INSURING CORPORATION A COPY OF THE FORMS FOR THE FILING OF THOSE 5,393
STATUTORY FINANCIAL STATEMENTS AND OTHER FINANCIAL INFORMATION AS 5,394
THE CORPORATION IS REQUIRED TO FILE WITH THE SUPERINTENDENT. 5,395
Sec. 1751.48. (A) THE SUPERINTENDENT OF INSURANCE MAY 5,398
ADOPT RULES AS ARE NECESSARY TO CARRY OUT THE PROVISIONS OF THIS 5,399
CHAPTER. THESE RULES SHALL BE ADOPTED IN ACCORDANCE WITH CHAPTER 5,400
119. OF THE REVISED CODE. 5,401
(B) THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS TO THE 5,404
SUPERINTENDENT FOR RULES THAT ARE NECESSARY TO ENABLE THE 5,405
DIRECTOR TO CARRY OUT THE DIRECTOR'S RESPONSIBILITIES UNDER THIS 5,406
CHAPTER, INCLUDING RULES THAT PRESCRIBE STANDARDS RELATING TO THE 5,407
REQUIREMENTS SET FORTH IN DIVISION (B) OF SECTION 1751.04 OF THE 5,409
REVISED CODE. IN ADOPTING ANY RULES PERTAINING TO THE DIRECTOR'S 5,411
RESPONSIBILITIES, THE SUPERINTENDENT SHALL CONSIDER THE 5,412
RECOMMENDATIONS OF THE DIRECTOR. 5,413
Sec. 1751.51. IF A HEALTH CARE PLAN OF A HEALTH INSURING 5,415
CORPORATION COVERS HEALTH CARE SERVICES THAT MAY BE LEGALLY 5,416
PERFORMED BY A CLASS OF PROVIDERS REFERRED TO IN SECTION 3923.23 5,417
OR 3923.231 OF THE REVISED CODE BUT WOULD RESTRICT AN ENROLLEE'S 5,420
ABILITY TO RECEIVE THESE HEALTH CARE SERVICES FROM MEMBERS OF 5,421
THAT CLASS IN ANY MANNER THAT DIFFERS FROM AN ENROLLEE'S ABILITY 5,422
UNDER THE HEALTH CARE PLAN TO RECEIVE THESE HEALTH CARE SERVICES 5,423
FROM ANY OTHER CLASS OF PROVIDERS THAT MAY LEGALLY PERFORM THESE 5,424
HEALTH CARE SERVICES, THEN THE HEALTH INSURING CORPORATION SHALL 5,425
122
DO BOTH OF THE FOLLOWING:
(A) SET FORTH, WITHIN ANY EVIDENCE OF COVERAGE PERTAINING 5,428
TO THE HEALTH CARE PLAN, UNDER A HEADING THAT READS "RESTRICTIONS 5,429
ON CHOICE OF PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT 5,431
OF THE RESTRICTION THAT CONFORMS TO THE REQUIREMENTS OF SECTION 5,432
1751.11 OF THE REVISED CODE; 5,433
(B) SET FORTH, WITHIN ANY SOLICITATION DOCUMENT PERTAINING 5,436
TO THE HEALTH CARE PLAN AND WITHIN ANY SOLICITATION MATERIALS 5,437
PERTAINING TO THE HEALTH CARE PLAN THAT THE HEALTH INSURING 5,438
CORPORATION PROVIDES TO ANY EMPLOYER OR ANY EMPLOYEE BENEFIT 5,439
FUND, UNDER A HEADING THAT READS "RESTRICTIONS ON CHOICE OF 5,440
PROVIDERS," A CLEAR, CONCISE, AND COMPLETE STATEMENT OF THE 5,442
RESTRICTION, SUCH STATEMENT BEING SUBJECT TO PRIOR APPROVAL BY 5,443
THE SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH THE SAME FORM 5,444
AND CONTENT REQUIREMENTS THAT ARE SPECIFIED IN SECTION 1751.11 OF 5,445
THE REVISED CODE WITH REGARD TO EVIDENCE OF COVERAGE. 5,446
Sec. 1751.52. (A) ALL APPLICATIONS, FILINGS, AND REPORTS 5,449
REQUIRED UNDER THIS CHAPTER SHALL BE TREATED AS PUBLIC DOCUMENTS 5,450
AFTER THE DATE THE APPLICATION, FILING, OR REPORT BECOMES 5,451
EFFECTIVE, REGARDLESS OF THE APPLICATION OF THE UNIFORM TRADE 5,452
SECRETS ACT SET FORTH IN SECTIONS 1333.61 TO 1333.69 OF THE 5,454
REVISED CODE.
(B) ANY DATA OR INFORMATION PERTAINING TO THE DIAGNOSIS, 5,457
TREATMENT, OR HEALTH OF ANY ENROLLEE OR APPLICANT FOR ENROLLMENT 5,458
THAT IS OBTAINED BY THE HEALTH INSURING CORPORATION FROM THE 5,459
ENROLLEE OR APPLICANT, OR FROM ANY HEALTH CARE FACILITY OR 5,460
PROVIDER, SHALL BE HELD IN CONFIDENCE AND SHALL NOT BE DISCLOSED 5,461
TO ANY PERSON EXCEPT UNDER ONE OF THE FOLLOWING CIRCUMSTANCES: 5,462
(1) TO THE EXTENT THAT IT MAY BE NECESSARY TO CARRY OUT 5,464
THE PURPOSES OF THIS CHAPTER; 5,465
(2) UPON THE EXPRESS CONSENT OF THE ENROLLEE OR APPLICANT; 5,468
(3) PURSUANT TO STATUTE OR COURT ORDER FOR THE PRODUCTION 5,470
OF EVIDENCE; 5,471
(4) IN THE EVENT OF CLAIM LITIGATION BETWEEN SUCH PERSON 5,473
123
AND THE HEALTH INSURING CORPORATION WHEREIN SUCH DATA OR 5,474
INFORMATION IS PERTINENT. 5,475
(C) A HEALTH INSURING CORPORATION SHALL BE ENTITLED TO 5,478
CLAIM ANY STATUTORY PRIVILEGES AGAINST DISCLOSURE UNDER DIVISION 5,479
(B) OF THIS SECTION THAT THE FACILITY OR PROVIDER WHO FURNISHED 5,481
THE DATA OR INFORMATION TO THE HEALTH INSURING CORPORATION IS 5,482
ENTITLED TO CLAIM.
Sec. 1751.53. (A) AS USED IN THIS SECTION: 5,484
(1) "GROUP CONTRACT" MEANS A GROUP HEALTH INSURING 5,486
CORPORATION CONTRACT COVERING EMPLOYEES THAT MEETS EITHER OF THE 5,487
FOLLOWING CONDITIONS: 5,488
(a) THE CONTRACT WAS ISSUED BY AN ENTITY THAT, ON THE 5,491
EFFECTIVE DATE OF THIS SECTION, HOLDS A CERTIFICATE OF AUTHORITY 5,492
OR LICENSE TO OPERATE UNDER CHAPTER 1738. OR 1742. OF THE REVISED 5,494
CODE, AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S 5,495
EMPLOYMENT IS TERMINATED.
(b) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,498
RENEWED IN THIS STATE AFTER THE EFFECTIVE DATE OF THIS SECTION 5,499
AND COVERS AN EMPLOYEE AT THE TIME THE EMPLOYEE'S EMPLOYMENT IS 5,500
TERMINATED.
(2) "ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE TO WHOM ALL OF 5,502
THE FOLLOWING APPLY: 5,503
(a) THE EMPLOYEE HAS BEEN CONTINUOUSLY COVERED UNDER A 5,506
GROUP CONTRACT OR UNDER THE CONTRACT AND ANY PRIOR SIMILAR GROUP 5,507
COVERAGE REPLACED BY THE CONTRACT, DURING THE ENTIRE THREE-MONTH 5,508
PERIOD PRECEDING THE TERMINATION OF THE EMPLOYEE'S EMPLOYMENT. 5,509
(b) THE EMPLOYEE IS ENTITLED, AT THE TIME OF THE 5,512
TERMINATION OF THIS EMPLOYMENT, TO UNEMPLOYMENT COMPENSATION 5,513
BENEFITS UNDER CHAPTER 4141. OF THE REVISED CODE. 5,514
(c) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,517
OR ELIGIBLE FOR COVERAGE BY MEDICARE UNDER TITLE XVIII OF THE 5,519
"SOCIAL SECURITY ACT, "49 STAT. 620 (1935), 42 U.S.C.A. 301, AS 5,521
AMENDED.
(d) THE EMPLOYEE IS NOT, AND DOES NOT BECOME, COVERED BY 5,524
124
OR ELIGIBLE FOR COVERAGE BY ANY OTHER INSURED OR UNINSURED 5,525
ARRANGEMENT THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL COVERAGE 5,526
FOR INDIVIDUALS IN A GROUP AND UNDER WHICH THE EMPLOYEE WAS NOT 5,527
COVERED IMMEDIATELY PRIOR TO THE TERMINATION OF EMPLOYMENT. A 5,528
PERSON ELIGIBLE FOR CONTINUATION OF COVERAGE UNDER THIS SECTION, 5,529
WHO IS ALSO ELIGIBLE FOR COVERAGE UNDER SECTION 3923.123 OF THE 5,531
REVISED CODE, MAY ELECT EITHER COVERAGE, BUT NOT BOTH. A PERSON 5,532
WHO ELECTS CONTINUATION OF COVERAGE MAY ELECT ANY COVERAGE 5,533
AVAILABLE UNDER SECTION 3923.123 OF THE REVISED CODE UPON THE 5,535
TERMINATION OF THE CONTINUATION OF COVERAGE. 5,536
(B) A GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,539
EMPLOYEE MAY CONTINUE THE COVERAGE UNDER THE CONTRACT, FOR THE 5,540
EMPLOYEE AND THE EMPLOYEE'S ELIGIBLE DEPENDENTS, FOR A PERIOD OF 5,541
SIX MONTHS AFTER THE DATE THAT THE GROUP COVERAGE WOULD OTHERWISE 5,542
TERMINATE BY REASON OF THE TERMINATION OF THE EMPLOYEE'S 5,543
EMPLOYMENT. EACH CERTIFICATE OF COVERAGE ISSUED TO EMPLOYEES 5,544
UNDER THE CONTRACT SHALL INCLUDE A NOTICE OF THE EMPLOYEE'S 5,545
PRIVILEGE OF CONTINUATION.
(C) ALL OF THE FOLLOWING APPLY TO THE CONTINUATION OF 5,548
GROUP COVERAGE REQUIRED UNDER DIVISION (B) OF THIS SECTION: 5,550
(1) CONTINUATION NEED NOT INCLUDE ANY SUPPLEMENTAL HEALTH 5,552
CARE SERVICES BENEFITS OR SPECIALTY HEALTH CARE SERVICES BENEFITS 5,553
PROVIDED BY THE GROUP CONTRACT. 5,554
(2) THE EMPLOYER SHALL NOTIFY THE EMPLOYEE OF THE RIGHT OF 5,557
CONTINUATION AT THE TIME THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,558
THE TERMINATION OF EMPLOYMENT. THE NOTICE SHALL INFORM THE
EMPLOYEE OF THE AMOUNT OF CONTRIBUTION REQUIRED BY THE EMPLOYER 5,559
UNDER DIVISION (C)(4) OF THIS SECTION. 5,561
(3) THE EMPLOYEE SHALL FILE A WRITTEN ELECTION OF 5,563
CONTINUATION WITH THE EMPLOYER AND PAY THE EMPLOYER THE FIRST 5,564
CONTRIBUTION REQUIRED UNDER DIVISION (C)(4) OF THIS SECTION. THE 5,566
REQUEST AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER 5,567
THAN THE EARLIER OF ANY OF THE FOLLOWING DATES: 5,568
(a) THIRTY-ONE DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,571
125
COVERAGE WOULD OTHERWISE TERMINATE; 5,572
(b) TEN DAYS AFTER THE DATE ON WHICH THE EMPLOYEE'S 5,575
COVERAGE WOULD OTHERWISE TERMINATE, IF THE EMPLOYER HAS NOTIFIED 5,576
THE EMPLOYEE OF THE RIGHT OF CONTINUATION PRIOR TO THIS DATE; 5,577
(c) TEN DAYS AFTER THE EMPLOYER NOTIFIES THE EMPLOYEE OF 5,580
THE RIGHT OF CONTINUATION, IF THE NOTICE IS GIVEN AFTER THE DATE 5,581
ON WHICH THE EMPLOYEE'S COVERAGE WOULD OTHERWISE TERMINATE. 5,582
(4) THE EMPLOYEE MUST PAY TO THE EMPLOYER, ON A MONTHLY 5,584
BASIS, IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED BY THE 5,585
EMPLOYER. THE AMOUNT REQUIRED SHALL NOT EXCEED THE GROUP RATE 5,586
FOR THE INSURANCE BEING CONTINUED UNDER THE POLICY ON THE DUE 5,587
DATE OF EACH PAYMENT. 5,588
(5) THE EMPLOYEE'S PRIVILEGE TO CONTINUE COVERAGE AND THE 5,590
COVERAGE UNDER ANY CONTINUATION CEASES IF ANY OF THE FOLLOWING 5,591
OCCURS: 5,592
(a) THE EMPLOYEE CEASES TO BE AN ELIGIBLE EMPLOYEE UNDER 5,594
DIVISION (A)(2)(c) OR (d) OF THIS SECTION; 5,596
(b) A PERIOD OF SIX MONTHS EXPIRES AFTER THE DATE THAT THE 5,599
EMPLOYEE'S COVERAGE UNDER THE GROUP CONTRACT WOULD OTHERWISE HAVE 5,600
TERMINATED BECAUSE OF THE TERMINATION OF EMPLOYMENT; 5,601
(c) THE EMPLOYEE FAILS TO MAKE A TIMELY PAYMENT OF A 5,604
REQUIRED CONTRIBUTION, IN WHICH EVENT THE COVERAGE SHALL CEASE AT 5,605
THE END OF THE COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE; 5,606
(d) THE GROUP CONTRACT IS TERMINATED, OR THE EMPLOYER 5,609
TERMINATES PARTICIPATION UNDER THE CONTRACT, UNLESS THE EMPLOYER 5,610
REPLACES THE COVERAGE BY SIMILAR COVERAGE UNDER ANOTHER CONTRACT 5,611
OR OTHER GROUP HEALTH ARRANGEMENT. IF THE EMPLOYER REPLACES THE 5,612
CONTRACT WITH SIMILAR GROUP HEALTH COVERAGE, ALL OF THE FOLLOWING 5,613
APPLY:
(i) THE MEMBER SHALL BE COVERED UNDER THE REPLACEMENT 5,616
COVERAGE, FOR THE BALANCE OF THE PERIOD THAT THE MEMBER WOULD 5,617
HAVE REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT 5,618
BEEN TERMINATED.
(ii) THE MINIMUM LEVEL OF BENEFITS UNDER THE REPLACEMENT 5,621
126
COVERAGE SHALL BE THE APPLICABLE LEVEL OF BENEFITS OF THE 5,622
CONTRACT REPLACED REDUCED BY ANY BENEFITS PAYABLE UNDER THE 5,623
CONTRACT REPLACED.
(iii) THE CONTRACT REPLACED SHALL CONTINUE TO PROVIDE 5,626
BENEFITS TO THE EXTENT OF ITS ACCRUED LIABILITIES AND EXTENSIONS 5,627
OF BENEFITS AS IF THE REPLACEMENT HAD NOT OCCURRED. 5,628
(D) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,631
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,632
HEALTH CARE SERVICES.
Sec. 1751.54. (A) AS USED IN THIS SECTION: 5,634
(1) "ELIGIBLE PERSON" MEANS ANY PERSON WHO, AT THE TIME A 5,636
RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, IS COVERED UNDER A 5,638
GROUP CONTRACT AND IS EITHER OF THE FOLLOWING:
(a) AN EMPLOYEE WHO IS A RESERVIST CALLED OR ORDERED TO 5,641
ACTIVE DUTY;
(b) THE SPOUSE OR A DEPENDENT CHILD OF AN EMPLOYEE 5,644
DESCRIBED IN DIVISION (A)(1)(a) OF THIS SECTION. 5,645
(2) "GROUP CONTRACT" INCLUDES ANY GROUP HEALTH INSURING 5,647
CORPORATION CONTRACT THAT SATISFIES ALL OF THE FOLLOWING: 5,648
(a) THE CONTRACT IS DELIVERED, ISSUED FOR DELIVERY, OR 5,651
RENEWED IN THIS STATE ON OR AFTER THE EFFECTIVE DATE OF THIS 5,652
SECTION.
(b) THE CONTRACT COVERS EMPLOYEES FOR HEALTH CARE 5,655
SERVICES, INCLUDING BASIC HEALTH CARE SERVICES. 5,656
(c) THE CONTRACT IS IN EFFECT AND COVERS AN ELIGIBLE 5,659
PERSON AT THE TIME A RESERVIST IS CALLED OR ORDERED TO ACTIVE 5,660
DUTY.
(3) "RESERVIST" MEANS A MEMBER OF A RESERVE COMPONENT OF 5,662
THE ARMED FORCES OF THE UNITED STATES. "RESERVIST" INCLUDES A 5,664
MEMBER OF THE OHIO NATIONAL GUARD AND THE OHIO AIR NATIONAL 5,666
GUARD. 5,667
(B) EVERY GROUP CONTRACT SHALL PROVIDE THAT ANY ELIGIBLE 5,670
PERSON MAY CONTINUE THE COVERAGE UNDER THE CONTRACT FOR A PERIOD 5,671
OF EIGHTEEN MONTHS AFTER THE DATE ON WHICH THE COVERAGE WOULD 5,672
127
OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR ORDERED TO 5,673
ACTIVE DUTY.
(C)(1) AN ELIGIBLE PERSON MAY EXTEND THE EIGHTEEN-MONTH 5,676
PERIOD OF CONTINUATION OF COVERAGE TO A THIRTY-SIX-MONTH PERIOD 5,677
OF CONTINUATION OF COVERAGE, IF ANY OF THE FOLLOWING OCCURS 5,678
DURING THE EIGHTEEN-MONTH PERIOD: 5,679
(a) THE DEATH OF THE RESERVIST; 5,682
(b) THE DIVORCE OR SEPARATION OF A RESERVIST FROM THE 5,685
RESERVIST'S SPOUSE;
(c) THE CESSATION OF DEPENDENCY OF A CHILD PURSUANT TO THE 5,688
TERMS OF THE CONTRACT. 5,689
(2) THE THIRTY-SIX-MONTH PERIOD OF CONTINUATION OF 5,691
COVERAGE IS DEEMED TO BEGIN ON THE DATE ON WHICH THE COVERAGE 5,692
WOULD OTHERWISE TERMINATE BECAUSE THE RESERVIST IS CALLED OR 5,693
ORDERED TO ACTIVE DUTY. 5,694
(3) THE EMPLOYER MAY BEGIN THE THIRTY-SIX-MONTH PERIOD ON 5,696
THE DATE OF ANY OCCURRENCE DESCRIBED IN DIVISION (C)(1) OF THIS 5,698
SECTION.
(D) ALL OF THE FOLLOWING APPLY TO ANY CONTINUATION OF 5,701
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,702
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION: 5,704
(1) THE CONTINUATION OF COVERAGE SHALL PROVIDE THE SAME 5,706
BENEFITS AS THOSE PROVIDED TO ANY SIMILARLY SITUATED ELIGIBLE 5,707
PERSON WHO IS COVERED UNDER THE SAME GROUP CONTRACT AND AN 5,708
EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE DUTY. 5,710
(2) AN EMPLOYER SHALL NOTIFY EACH EMPLOYEE OF THE RIGHT OF 5,713
CONTINUATION OF COVERAGE AT THE TIME OF EMPLOYMENT. AT THE TIME 5,714
THE RESERVIST IS CALLED OR ORDERED TO ACTIVE DUTY, THE EMPLOYER 5,715
SHALL NOTIFY EACH ELIGIBLE PERSON OF THE REQUIREMENTS FOR THE 5,716
CONTINUATION OF COVERAGE.
(3) EACH CERTIFICATE OF COVERAGE ISSUED BY A HEALTH 5,718
INSURING CORPORATION TO AN EMPLOYEE UNDER THE GROUP CONTRACT 5,719
SHALL INCLUDE A NOTICE OF THE ELIGIBLE PERSON'S RIGHT OF 5,720
CONTINUATION OF COVERAGE. 5,721
128
(4) AN ELIGIBLE PERSON SHALL FILE A WRITTEN ELECTION OF 5,723
CONTINUATION OF COVERAGE WITH THE EMPLOYER AND PAY THE EMPLOYER 5,724
THE FIRST CONTRIBUTION REQUIRED UNDER DIVISION (D)(5) OF THIS 5,726
SECTION. THE WRITTEN ELECTION AND PAYMENT MUST BE RECEIVED BY 5,727
THE EMPLOYER NO LATER THAN THIRTY-ONE DAYS AFTER THE DATE ON 5,728
WHICH THE ELIGIBLE PERSON'S COVERAGE WOULD OTHERWISE TERMINATE. 5,729
IF THE EMPLOYER NOTIFIES THE ELIGIBLE PERSON OF THE RIGHT OF 5,730
CONTINUATION OF COVERAGE AFTER THE DATE ON WHICH THE ELIGIBLE 5,731
PERSON'S COVERAGE WOULD OTHERWISE TERMINATE, THE WRITTEN ELECTION 5,732
AND PAYMENT MUST BE RECEIVED BY THE EMPLOYER NO LATER THAN 5,733
THIRTY-ONE DAYS AFTER THE DATE OF THE NOTIFICATION. 5,734
(5)(a) EXCEPT AS PROVIDED IN DIVISION (D)(5)(b) OF THIS 5,737
SECTION, THE ELIGIBLE PERSON SHALL PAY TO THE EMPLOYER, ON A 5,738
MONTHLY BASIS AND IN ADVANCE, THE AMOUNT OF CONTRIBUTION REQUIRED 5,739
BY THE EMPLOYER. THE AMOUNT SHALL NOT EXCEED ONE HUNDRED TWO PER 5,740
CENT OF THE GROUP RATE FOR THE COVERAGE BEING CONTINUED UNDER THE 5,741
GROUP CONTRACT ON THE DUE DATE OF EACH PAYMENT. 5,742
(b) THE EMPLOYER MAY PAY A PORTION OR ALL OF THE ELIGIBLE 5,745
PERSON'S CONTRIBUTION.
(E) THE ELIGIBLE PERSON'S RIGHT TO ANY CONTINUATION OF 5,748
COVERAGE, OR THE EXTENSION OF ANY CONTINUATION OF COVERAGE, 5,749
PROVIDED UNDER DIVISION (B) OR (C) OF THIS SECTION CEASES ON THE 5,752
DATE ON WHICH ANY OF THE FOLLOWING OCCURS:
(1) THE ELIGIBLE PERSON, WHETHER AS AN EMPLOYEE OR 5,754
OTHERWISE, BECOMES COVERED BY ANOTHER GROUP CONTRACT OR OTHER 5,755
GROUP HEALTH PLAN OR ARRANGEMENT THAT DOES NOT CONTAIN ANY 5,756
EXCLUSION OR LIMITATION WITH RESPECT TO ANY PREEXISTING CONDITION 5,758
OF THAT ELIGIBLE PERSON. FOR PURPOSES OF DIVISION (E)(1) OF THIS 5,759
SECTION, A GROUP CONTRACT OR OTHER GROUP HEALTH PLAN OR 5,760
ARRANGEMENT DOES NOT INCLUDE THE CIVILIAN HEALTH AND MEDICAL 5,761
PROGRAM OF THE UNIFORMED SERVICES AS DEFINED IN PUBLIC LAW 5,763
99-661, 100 STAT. 3898 (1986), 10 U.S.C.A. 1072. 5,765
(2) THE PERIOD OF EITHER EIGHTEEN MONTHS PROVIDED UNDER 5,767
DIVISION (B) OF THIS SECTION OR THIRTY-SIX MONTHS PROVIDED UNDER 5,769
129
DIVISION (C) OF THIS SECTION EXPIRES. 5,771
(3) THE ELIGIBLE PERSON FAILS TO MAKE A TIMELY PAYMENT OF 5,773
A REQUIRED CONTRIBUTION, IN WHICH CASE THE COVERAGE CEASES AT THE 5,775
END OF THE PERIOD OF COVERAGE FOR WHICH CONTRIBUTIONS WERE MADE. 5,776
(4) THE GROUP CONTRACT, OR PARTICIPATION UNDER THE GROUP 5,778
CONTRACT, IS TERMINATED, UNLESS THE EMPLOYER, IN ACCORDANCE WITH 5,779
DIVISION (F) OF THIS SECTION, REPLACES THE COVERAGE WITH SIMILAR 5,781
COVERAGE UNDER ANOTHER GROUP CONTRACT OR OTHER GROUP HEALTH PLAN 5,782
OR ARRANGEMENT.
(F) IF THE EMPLOYER REPLACES THE GROUP CONTRACT WITH 5,785
SIMILAR COVERAGE AS DESCRIBED IN DIVISION (E)(4) OF THIS SECTION, 5,787
BOTH OF THE FOLLOWING APPLY:
(1) THE ELIGIBLE PERSON IS COVERED UNDER THE REPLACEMENT 5,789
COVERAGE FOR THE BALANCE OF THE PERIOD THAT THE PERSON WOULD HAVE 5,791
REMAINED COVERED UNDER THE TERMINATED COVERAGE IF IT HAD NOT BEEN 5,792
TERMINATED.
(2) THE LEVEL OF BENEFITS UNDER THE REPLACEMENT COVERAGE 5,794
IS THE SAME AS THE LEVEL OF BENEFITS PROVIDED TO ANY SIMILARLY 5,795
SITUATED ELIGIBLE PERSON WHO IS COVERED UNDER THE GROUP CONTRACT 5,796
AND AN EMPLOYEE WHO HAS NOT BEEN CALLED OR ORDERED TO ACTIVE 5,797
DUTY. 5,798
(G) UPON THE RESERVIST'S RELEASE FROM ACTIVE DUTY AND THE 5,801
RESERVIST'S RETURN TO EMPLOYMENT FOR THE EMPLOYER BY WHOM THE 5,802
RESERVIST WAS EMPLOYED AT THE TIME THE RESERVIST WAS CALLED OR 5,803
ORDERED TO ACTIVE DUTY, BOTH OF THE FOLLOWING APPLY: 5,804
(1) EVERY ELIGIBLE PERSON IS ENTITLED, WITHOUT ANY WAITING 5,807
PERIOD, TO COVERAGE UNDER THE EMPLOYER'S GROUP CONTRACT THAT IS 5,808
IN EFFECT AT THE TIME OF THE RESERVIST'S RETURN TO EMPLOYMENT. 5,809
(2) EVERY ELIGIBLE PERSON IS ENTITLED TO ALL BENEFITS 5,811
UNDER THE GROUP CONTRACT DESCRIBED IN DIVISION (G)(1) OF THIS 5,813
SECTION FROM THE DATE OF THE ORIGINAL COVERAGE UNDER THE 5,814
CONTRACT.
(H)(1) NO HEALTH INSURING CORPORATION SHALL FAIL TO 5,817
PROVIDE FOR A CONTINUATION OF COVERAGE, OR AN EXTENSION OF A 5,818
130
CONTINUATION OF COVERAGE, IN A GROUP CONTRACT AS REQUIRED BY AND 5,819
IN ACCORDANCE WITH THE TERMS AND CONDITIONS SET FORTH UNDER THIS 5,820
SECTION.
(2) NO HEALTH INSURING CORPORATION SHALL FAIL TO ISSUE A 5,822
CERTIFICATE OF COVERAGE IN COMPLIANCE WITH DIVISION (D)(3) OF 5,824
THIS SECTION.
(3) NO EMPLOYER SHALL FAIL TO PROVIDE AN EMPLOYEE OR 5,826
ELIGIBLE PERSON WITH NOTICE OF THE RIGHT TO A CONTINUATION OF 5,827
COVERAGE UNDER A GROUP CONTRACT IN ACCORDANCE WITH DIVISION 5,829
(D)(2) OF THIS SECTION.
(I) WHOEVER VIOLATES DIVISION (H)(1), (2), OR (3) OF THIS 5,833
SECTION IS DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT 5,834
OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 5,835
TO 3901.26 OF THE REVISED CODE. 5,836
(J) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT THAT 5,839
IS SUBJECT TO SECTION 5923.051 OF THE REVISED CODE. 5,841
(K) THIS SECTION DOES NOT APPLY TO ANY GROUP CONTRACT 5,844
OFFERING ONLY SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY 5,845
HEALTH CARE SERVICES.
Sec. 1751.55. A HEALTH INSURING CORPORATION POLICY, 5,847
CONTRACT, OR AGREEMENT SHALL NOT BE CONSTRUED TO EXCLUDE ILLNESS 5,848
OR INJURY UPON THE GROUND THAT THE SUBSCRIBER MIGHT HAVE ELECTED 5,849
TO HAVE SUCH ILLNESS OR INJURY COVERED BY WORKERS' COMPENSATION 5,850
UNDER DIVISION (A)(3) OF SECTION 4123.01 OF THE REVISED CODE 5,853
UNLESS THE POLICY, CONTRACT, OR AGREEMENT CLEARLY EXCLUDES WORK 5,854
OR OCCUPATIONAL RELATED ILLNESS OR INJURY, OR THE POLICY, 5,855
CONTRACT, OR AGREEMENT, OR A SEPARATE WRITING SIGNED BY THE 5,856
SUBSCRIBER, INFORMS THE SUBSCRIBER THAT SUCH COVERAGE IS EXCLUDED 5,857
AND MAY BE AVAILABLE TO THE SUBSCRIBER UNDER WORKERS' 5,858
COMPENSATION AS THE SOLE PROPRIETOR OF A BUSINESS, A MEMBER OF A 5,859
PARTNERSHIP, OR AN OFFICER OF A FAMILY FARM CORPORATION. 5,860
Sec. 1751.56. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,863
CORPORATION POLICY, CONTRACT, OR AGREEMENT SHALL BE DELIVERED, 5,864
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE, IF THE POLICY, 5,865
131
CONTRACT, OR AGREEMENT EXCLUDES OR REDUCES THE BENEFITS PAYABLE 5,866
TO OR ON BEHALF OF AN INSURED BECAUSE BENEFITS ARE ALSO PAYABLE 5,867
OR HAVE BEEN PAID UNDER A SUPPLEMENTAL SICKNESS AND ACCIDENT 5,868
INSURANCE POLICY TO WHICH ALL OF THE FOLLOWING APPLY: 5,869
(1) THE POLICY COVERS A SPECIFIED DISEASE OR A LIMITED 5,871
PLAN OF COVERAGE. 5,872
(2) THE POLICY IS SPECIFICALLY DESIGNED, ADVERTISED, 5,874
REPRESENTED, AND SOLD AS A SUPPLEMENT TO OTHER BASIC SICKNESS AND 5,876
ACCIDENT INSURANCE COVERAGE.
(3) THE ENTIRE PREMIUM FOR THE POLICY IS PAID BY THE 5,878
INSURED, THE INSURED'S FAMILY, OR THE INSURED'S GUARDIAN. 5,879
(B) THIS SECTION APPLIES TO SUPPLEMENTAL SICKNESS AND 5,882
ACCIDENT INSURANCE POLICIES IRRESPECTIVE OF THE MODE OR CHANNEL 5,883
OF PREMIUM PAYMENT TO THE INSURER OR OF ANY REDUCTION IN THE 5,884
PREMIUM BY VIRTUE OF THE INSURED'S MEMBERSHIP IN ANY HEALTH 5,885
INSURING CORPORATION OR THE INSURED'S STATUS AS AN EMPLOYEE. 5,886
Sec. 1751.59. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 5,889
CORPORATION POLICY, CONTRACT, OR AGREEMENT PROVIDING FAMILY 5,890
COVERAGE MAY BE DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 5,891
THIS STATE, UNLESS THE POLICY, CONTRACT, OR AGREEMENT COVERS 5,892
ADOPTED CHILDREN OF THE SUBSCRIBER ON THE SAME BASIS AS OTHER 5,893
DEPENDENTS.
(B) THE COVERAGE REQUIRED BY THIS SECTION IS SUBJECT TO 5,896
THE REQUIREMENTS AND RESTRICTIONS SET FORTH IN SECTION 3924.51 OF 5,897
THE REVISED CODE. COVERAGE FOR DEPENDENT CHILDREN LIVING OUTSIDE 5,900
THE HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA MUST BE 5,901
PROVIDED IF A COURT ORDER REQUIRES THE SUBSCRIBER TO PROVIDE 5,902
HEALTH CARE COVERAGE.
Sec. 1751.60. (A) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) 5,905
AND (F) OF THIS SECTION, EVERY PROVIDER OR HEALTH CARE FACILITY 5,907
THAT CONTRACTS WITH A HEALTH INSURING CORPORATION TO PROVIDE 5,908
HEALTH CARE SERVICES TO THE HEALTH INSURING CORPORATION'S 5,909
ENROLLEES OR SUBSCRIBERS SHALL SEEK COMPENSATION FOR COVERED 5,910
SERVICES SOLELY FROM THE HEALTH INSURING CORPORATION AND NOT, 5,911
132
UNDER ANY CIRCUMSTANCES, FROM THE ENROLLEES OR SUBSCRIBERS, 5,912
EXCEPT FOR APPROVED DEDUCTIBLES AND COPAYMENTS. 5,913
(B) NO SUBSCRIBER OR ENROLLEE OF A HEALTH INSURING 5,916
CORPORATION IS LIABLE TO ANY CONTRACTING PROVIDER OR HEALTH CARE 5,917
FACILITY FOR THE COST OF ANY COVERED HEALTH CARE SERVICES, IF THE 5,918
SUBSCRIBER OR ENROLLEE HAS ACTED IN ACCORDANCE WITH THE EVIDENCE 5,919
OF COVERAGE.
(C) EXCEPT AS PROVIDED FOR IN DIVISIONS (E) AND (F) OF 5,923
THIS SECTION, EVERY CONTRACT BETWEEN A HEALTH INSURING 5,924
CORPORATION AND PROVIDER OR HEALTH CARE FACILITY SHALL CONTAIN A 5,925
PROVISION APPROVED BY THE SUPERINTENDENT OF INSURANCE REQUIRING 5,926
THE PROVIDER OR HEALTH CARE FACILITY TO SEEK COMPENSATION SOLELY 5,927
FROM THE HEALTH INSURING CORPORATION AND NOT, UNDER ANY 5,928
CIRCUMSTANCES, FROM THE SUBSCRIBER OR ENROLLEE, EXCEPT FOR 5,929
APPROVED DEDUCTIBLES AND COPAYMENTS. 5,930
(D) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 5,933
PREVENTING A PROVIDER OR HEALTH CARE FACILITY FROM BILLING THE 5,934
ENROLLEE OR SUBSCRIBER OF A HEALTH INSURING CORPORATION FOR 5,935
NONCOVERED SERVICES.
(E) UPON APPLICATION BY A HEALTH INSURING CORPORATION AND 5,938
A PROVIDER OR HEALTH CARE FACILITY, THE SUPERINTENDENT MAY WAIVE 5,939
THE REQUIREMENTS OF DIVISIONS (A) AND (C) OF THIS SECTION WHEN, 5,941
IN ADDITION TO THE RESERVE REQUIREMENTS CONTAINED IN SECTION 5,942
1751.28 OF THE REVISED CODE, THE HEALTH INSURING CORPORATION 5,945
PROVIDES SUFFICIENT ASSURANCES TO THE SUPERINTENDENT THAT THE 5,946
PROVIDER OR HEALTH CARE FACILITY HAS BEEN PROVIDED WITH FINANCIAL 5,947
GUARANTEES. NO WAIVER OF THE REQUIREMENTS OF DIVISIONS (A) AND 5,949
(C) OF THIS SECTION IS EFFECTIVE AS TO ENROLLEES OR SUBSCRIBERS 5,950
FOR WHOM THE HEALTH INSURING CORPORATION IS COMPENSATED UNDER A 5,951
PROVIDER AGREEMENT OR RISK CONTRACT ENTERED INTO PURSUANT TO 5,953
CHAPTER 5111. OR 5115. OF THE REVISED CODE. 5,955
(F) THE REQUIREMENTS OF DIVISIONS (A) TO (C) OF THIS 5,959
SECTION APPLY ONLY TO HEALTH CARE SERVICES PROVIDED TO AN 5,960
ENROLLEE OR SUBSCRIBER PRIOR TO THE EFFECTIVE DATE OF A 5,961
133
TERMINATION OF A CONTRACT BETWEEN THE HEALTH INSURING CORPORATION 5,962
AND THE PROVIDER OR HEALTH CARE FACILITY. 5,963
Sec. 1751.61. (A) EACH INDIVIDUAL OR GROUP EVIDENCE OF 5,966
COVERAGE THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED BY A 5,967
HEALTH INSURING CORPORATION IN THIS STATE, AND THAT PROVIDES 5,968
COVERAGE FOR FAMILY MEMBERS OF A SUBSCRIBER, ALSO SHALL PROVIDE 5,969
THAT COVERAGE APPLICABLE TO CHILDREN IS PAYABLE FROM THE MOMENT 5,970
OF BIRTH WITH RESPECT TO A NEWLY BORN CHILD OF THE SUBSCRIBER OR 5,971
SUBSCRIBER'S SPOUSE. 5,972
(B) COVERAGE FOR A NEWLY BORN CHILD IS EFFECTIVE FOR A 5,975
PERIOD OF THIRTY-ONE DAYS FROM THE DATE OF BIRTH. 5,976
(C) TO CONTINUE COVERAGE FOR A NEWLY BORN CHILD BEYOND THE 5,979
THIRTY-ONE DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION, 5,981
THE SUBSCRIBER SHALL NOTIFY THE HEALTH INSURING CORPORATION 5,982
WITHIN THAT PERIOD.
(D) IF PAYMENT OF A SPECIFIC PREMIUM RATE IS REQUIRED TO 5,985
PROVIDE COVERAGE UNDER THIS SECTION FOR AN ADDITIONAL CHILD, THE 5,986
EVIDENCE OF COVERAGE MAY REQUIRE THE SUBSCRIBER TO MAKE THIS 5,987
PAYMENT TO THE HEALTH INSURING CORPORATION WITHIN THE THIRTY-ONE 5,988
DAY PERIOD DESCRIBED IN DIVISION (B) OF THIS SECTION IN ORDER TO 5,990
CONTINUE THE COVERAGE BEYOND THAT PERIOD. 5,991
Sec. 1751.62. (A) AS USED IN THIS SECTION, "SCREENING 5,994
MAMMOGRAPHY" MEANS A RADIOLOGIC EXAMINATION UTILIZED TO DETECT 5,995
UNSUSPECTED BREAST CANCER AT AN EARLY STAGE IN AN ASYMPTOMATIC 5,996
WOMAN AND INCLUDES THE X-RAY EXAMINATION OF THE BREAST USING 5,997
EQUIPMENT THAT IS DEDICATED SPECIFICALLY FOR MAMMOGRAPHY, 5,998
INCLUDING THE X-RAY TUBE, FILTER, COMPRESSION DEVICE, SCREENS, 5,999
FILM, AND CASSETTES, AND THAT HAS AN AVERAGE RADIATION EXPOSURE 6,000
DELIVERY OF LESS THAN ONE RAD MID-BREAST. "SCREENING 6,001
MAMMOGRAPHY" INCLUDES TWO VIEWS FOR EACH BREAST. THE TERM ALSO 6,002
INCLUDES THE PROFESSIONAL INTERPRETATION OF THE FILM. 6,003
"SCREENING MAMMOGRAPHY" DOES NOT INCLUDE DIAGNOSTIC 6,005
MAMMOGRAPHY. 6,006
(B) EVERY INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION 6,009
134
POLICY, CONTRACT, OR AGREEMENT PROVIDING BASIC HEALTH CARE 6,010
SERVICES THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED IN 6,011
THIS STATE SHALL PROVIDE BENEFITS FOR THE EXPENSES OF BOTH OF THE 6,012
FOLLOWING: 6,013
(1) SCREENING MAMMOGRAPHY TO DETECT THE PRESENCE OF BREAST 6,016
CANCER IN ADULT WOMEN;
(2) CYTOLOGIC SCREENING FOR THE PRESENCE OF CERVICAL 6,018
CANCER. 6,019
(C) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,023
SECTION SHALL COVER EXPENSES IN ACCORDANCE WITH ALL OF THE 6,024
FOLLOWING:
(1) IF A WOMAN IS AT LEAST THIRTY-FIVE YEARS OF AGE BUT 6,026
UNDER FORTY YEARS OF AGE, ONE SCREENING MAMMOGRAPHY; 6,027
(2) IF A WOMAN IS AT LEAST FORTY YEARS OF AGE BUT UNDER 6,029
FIFTY YEARS OF AGE, EITHER OF THE FOLLOWING: 6,030
(a) ONE SCREENING MAMMOGRAPHY EVERY TWO YEARS; 6,033
(b) IF A LICENSED PHYSICIAN HAS DETERMINED THAT THE WOMAN 6,036
HAS RISK FACTORS TO BREAST CANCER, ONE SCREENING MAMMOGRAPHY 6,037
EVERY YEAR.
(3) IF A WOMAN IS AT LEAST FIFTY YEARS OF AGE BUT UNDER 6,039
SIXTY-FIVE YEARS OF AGE, ONE SCREENING MAMMOGRAPHY EVERY YEAR. 6,041
(D)(1) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,045
SECTION SHALL NOT EXCEED EIGHTY-FIVE DOLLARS PER YEAR UNLESS A 6,046
LOWER AMOUNT IS ESTABLISHED PURSUANT TO A PROVIDER CONTRACT. 6,047
(2) THE BENEFIT PAID IN ACCORDANCE WITH DIVISION (D)(1) OF 6,050
THIS SECTION SHALL CONSTITUTE FULL PAYMENT. NO INSTITUTIONAL OR 6,051
PROFESSIONAL HEALTH CARE PROVIDER SHALL SEEK OR RECEIVE 6,052
REMUNERATION IN EXCESS OF THE PAYMENT MADE IN ACCORDANCE WITH 6,053
DIVISION (D)(1) OF THIS SECTION, EXCEPT FOR APPROVED DEDUCTIBLES 6,055
AND COPAYMENTS.
(E) THE BENEFITS PROVIDED UNDER DIVISION (B)(1) OF THIS 6,059
SECTION SHALL BE PROVIDED ONLY FOR SCREENING MAMMOGRAPHIES THAT 6,060
ARE PERFORMED IN A HEALTH CARE FACILITY OR MOBILE MAMMOGRAPHY 6,061
SCREENING UNIT THAT IS ACCREDITED UNDER THE AMERICAN COLLEGE OF 6,062
135
RADIOLOGY MAMMOGRAPHY ACCREDITATION PROGRAM OR IN A HOSPITAL AS 6,063
DEFINED IN SECTION 3727.01 OF THE REVISED CODE. 6,065
(F) THE BENEFITS PROVIDED UNDER DIVISIONS (B)(1) AND (2) 6,069
OF THIS SECTION SHALL BE PROVIDED ACCORDING TO THE TERMS OF THE 6,070
SUBSCRIBER CONTRACT.
(G) THE BENEFITS PROVIDED UNDER DIVISION (B)(2) OF THIS 6,074
SECTION SHALL BE PROVIDED ONLY FOR CYTOLOGIC SCREENINGS THAT ARE 6,075
PROCESSED AND INTERPRETED IN A LABORATORY CERTIFIED BY THE 6,076
COLLEGE OF AMERICAN PATHOLOGISTS OR IN A HOSPITAL AS DEFINED IN 6,077
SECTION 3727.01 OF THE REVISED CODE. 6,079
Sec. 1751.63. SECTIONS 3923.41 TO 3923.48 OF THE REVISED 6,082
CODE APPLY TO EVERY HEALTH INSURING CORPORATION THAT OFFERS 6,083
LONG-TERM CARE AND THAT HOLDS A CERTIFICATE OF AUTHORITY UNDER 6,084
THIS CHAPTER.
Sec. 1751.64. (A) AS USED IN THIS SECTION, "GENETIC 6,087
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 6,088
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 6,089
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 6,090
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 6,091
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 6,092
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 6,093
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 6,094
DISORDERS.
(B) NO HEALTH INSURING CORPORATION, IN PROCESSING AN 6,097
APPLICATION FOR COVERAGE FOR HEALTH CARE SERVICES UNDER AN 6,098
INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, CONTRACT, 6,099
OR AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,100
CONTRACT, OR AGREEMENT, SHALL DO ANY OF THE FOLLOWING: 6,101
(1) REQUIRE AN INDIVIDUAL SEEKING COVERAGE TO SUBMIT TO 6,103
GENETIC SCREENING OR TESTING; 6,104
(2) TAKE INTO CONSIDERATION, OTHER THAN IN ACCORDANCE WITH 6,107
DIVISION (F) OF THIS SECTION, THE RESULTS OF GENETIC SCREENING OR 6,108
TESTING;
(3) MAKE ANY INQUIRY TO DETERMINE THE RESULTS OF GENETIC 6,110
136
SCREENING OR TESTING; 6,111
(4) MAKE A DECISION ADVERSE TO THE APPLICANT BASED ON 6,113
ENTRIES IN MEDICAL RECORDS OR OTHER REPORTS OF GENETIC SCREENING 6,114
OR TESTING. 6,115
(C) IN DEVELOPING AND ASKING QUESTIONS REGARDING MEDICAL 6,118
HISTORIES OF APPLICANTS FOR COVERAGE UNDER AN INDIVIDUAL OR GROUP 6,119
HEALTH INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT, NO 6,120
HEALTH INSURING CORPORATION SHALL ASK FOR THE RESULTS OF GENETIC 6,121
SCREENING OR TESTING OR ASK QUESTIONS DESIGNED TO ASCERTAIN THE 6,122
RESULTS OF GENETIC SCREENING OR TESTING. 6,123
(D) NO HEALTH INSURING CORPORATION SHALL CANCEL OR REFUSE 6,126
TO ISSUE OR RENEW COVERAGE FOR HEALTH CARE SERVICES BASED ON THE 6,127
RESULTS OF GENETIC SCREENING OR TESTING. 6,128
(E) NO HEALTH INSURING CORPORATION SHALL DELIVER, ISSUE 6,131
FOR DELIVERY, OR RENEW AN INDIVIDUAL OR GROUP POLICY, CONTRACT, 6,132
OR AGREEMENT IN THIS STATE THAT LIMITS BENEFITS BASED ON THE 6,133
RESULTS OF GENETIC SCREENING OR TESTING. 6,134
(F) A HEALTH INSURING CORPORATION MAY CONSIDER THE RESULTS 6,137
OF GENETIC SCREENING OR TESTING IF THE RESULTS ARE VOLUNTARILY 6,138
SUBMITTED BY AN APPLICANT FOR COVERAGE OR RENEWAL OF COVERAGE AND 6,139
THE RESULTS ARE FAVORABLE TO THE APPLICANT. 6,140
(G) A VIOLATION OF THIS SECTION IS AN UNFAIR AND DECEPTIVE 6,143
ACT OR PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 6,144
3901.19 TO 3901.26 OF THE REVISED CODE. 6,146
Sec. 1751.65. (A) AS USED IN THIS SECTION, "GENETIC 6,149
SCREENING OR TESTING" MEANS A LABORATORY TEST OF A PERSON'S GENES 6,150
OR CHROMOSOMES FOR ABNORMALITIES, DEFECTS, OR DEFICIENCIES, 6,151
INCLUDING CARRIER STATUS, THAT ARE LINKED TO PHYSICAL OR MENTAL 6,152
DISORDERS OR IMPAIRMENTS, OR THAT INDICATE A SUSCEPTIBILITY TO 6,153
ILLNESS, DISEASE, OR OTHER DISORDERS, WHETHER PHYSICAL OR MENTAL, 6,154
WHICH TEST IS A DIRECT TEST FOR ABNORMALITIES, DEFECTS, OR 6,155
DEFICIENCIES, AND NOT AN INDIRECT MANIFESTATION OF GENETIC 6,156
DISORDERS. 6,157
(B) UPON THE REPEAL OF SECTION 1751.64 OF THE REVISED 6,161
137
CODE, NO HEALTH INSURING CORPORATION SHALL DO EITHER OF THE 6,162
FOLLOWING:
(1) CONSIDER, IN A MANNER ADVERSE TO AN APPLICANT OR 6,164
INSURED, ANY INFORMATION OBTAINED FROM GENETIC SCREENING OR 6,165
TESTING CONDUCTED PRIOR TO THE REPEAL OF SECTION 1751.64 OF THE 6,167
REVISED CODE IN PROCESSING AN APPLICATION FOR COVERAGE FOR HEALTH 6,169
CARE SERVICES UNDER AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,170
AGREEMENT OR IN DETERMINING INSURABILITY UNDER SUCH A POLICY, 6,171
CONTRACT, OR AGREEMENT; 6,172
(2) INQUIRE, DIRECTLY OR INDIRECTLY, INTO THE RESULTS OF 6,174
GENETIC SCREENING OR TESTING CONDUCTED PRIOR TO THE REPEAL OF 6,175
SECTION 1751.64 OF THE REVISED CODE, OR USE SUCH INFORMATION, IN 6,178
WHOLE OR IN PART, TO CANCEL, REFUSE TO ISSUE OR RENEW, OR LIMIT 6,179
BENEFITS UNDER, AN INDIVIDUAL OR GROUP POLICY, CONTRACT, OR 6,180
AGREEMENT.
(C) ANY HEALTH INSURING CORPORATION THAT HAS ENGAGED IN, 6,183
IS ENGAGED IN, OR IS ABOUT TO ENGAGE IN A VIOLATION OF DIVISION 6,185
(B) OF THIS SECTION IS SUBJECT TO THE JURISDICTION OF THE 6,186
SUPERINTENDENT OF INSURANCE UNDER SECTION 3901.04 OF THE REVISED 6,187
CODE.
Sec. 1751.66. (A) NO INDIVIDUAL OR GROUP HEALTH INSURING 6,190
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES COVERAGE 6,191
FOR PRESCRIPTION DRUGS SHALL LIMIT OR EXCLUDE COVERAGE FOR ANY 6,192
DRUG APPROVED BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION 6,193
ON THE BASIS THAT THE DRUG HAS NOT BEEN APPROVED BY THE UNITED 6,194
STATES FOOD AND DRUG ADMINISTRATION FOR THE TREATMENT OF THE 6,195
PARTICULAR INDICATION FOR WHICH THE DRUG HAS BEEN PRESCRIBED, 6,196
PROVIDED THE DRUG HAS BEEN RECOGNIZED AS SAFE AND EFFECTIVE FOR 6,197
TREATMENT OF THAT INDICATION IN ONE OR MORE OF THE STANDARD 6,198
MEDICAL REFERENCE COMPENDIA SPECIFIED IN DIVISION (B)(1) OF THIS 6,200
SECTION OR IN MEDICAL LITERATURE THAT MEETS THE CRITERIA 6,201
SPECIFIED IN DIVISION (B)(2) OF THIS SECTION. 6,202
(B)(1) THE COMPENDIA ACCEPTED FOR PURPOSES OF DIVISION (A) 6,205
OF THIS SECTION ARE THE FOLLOWING:
138
(a) THE "AMA DRUG EVALUATIONS," A PUBLICATION OF THE 6,208
AMERICAN MEDICAL ASSOCIATION;
(b) THE "AHFS (AMERICAN HOSPITAL FORMULARY SERVICE) DRUG 6,211
INFORMATION," A PUBLICATION OF THE AMERICAN SOCIETY OF HEALTH 6,212
SYSTEM PHARMACISTS;
(c) "DRUG INFORMATION FOR THE HEALTH CARE PROVIDER," A 6,215
PUBLICATION OF THE UNITED STATES PHARMACOPOEIA CONVENTION. 6,216
(2) MEDICAL LITERATURE MAY BE ACCEPTED FOR PURPOSES OF 6,218
DIVISION (A) OF THIS SECTION ONLY IF ALL OF THE FOLLOWING APPLY: 6,220
(a) TWO ARTICLES FROM MAJOR PEER-REVIEWED PROFESSIONAL 6,223
MEDICAL JOURNALS HAVE RECOGNIZED, BASED ON SCIENTIFIC OR MEDICAL 6,224
CRITERIA, THE DRUG'S SAFETY AND EFFECTIVENESS FOR TREATMENT OF 6,225
THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,226
(b) NO ARTICLE FROM A MAJOR PEER-REVIEWED PROFESSIONAL 6,229
MEDICAL JOURNAL HAS CONCLUDED, BASED ON SCIENTIFIC OR MEDICAL 6,230
CRITERIA, THAT THE DRUG IS UNSAFE OR INEFFECTIVE OR THAT THE 6,231
DRUG'S SAFETY AND EFFECTIVENESS CANNOT BE DETERMINED FOR THE 6,232
TREATMENT OF THE INDICATION FOR WHICH IT HAS BEEN PRESCRIBED; 6,233
(c) EACH ARTICLE MEETS THE UNIFORM REQUIREMENTS FOR 6,236
MANUSCRIPTS SUBMITTED TO BIOMEDICAL JOURNALS ESTABLISHED BY THE 6,237
INTERNATIONAL COMMITTEE OF MEDICAL JOURNAL EDITORS OR IS 6,238
PUBLISHED IN A JOURNAL SPECIFIED BY THE UNITED STATES DEPARTMENT 6,239
OF HEALTH AND HUMAN SERVICES PURSUANT TO SECTION 1861(t)(2)(B) OF 6,240
THE "SOCIAL SECURITY ACT," 107 STAT. 591 (1993), 42 U.S.C. 1395 6,243
(x)(t)(2)(B), AS AMENDED, AS ACCEPTED PEER-REVIEWED MEDICAL 6,244
LITERATURE.
(C) COVERAGE OF A DRUG REQUIRED BY DIVISION (A) OF THIS 6,248
SECTION INCLUDES MEDICALLY NECESSARY SERVICES ASSOCIATED WITH THE 6,249
ADMINISTRATION OF THE DRUG.
(D) DIVISION (A) OF THIS SECTION SHALL NOT BE CONSTRUED TO 6,253
DO ANY OF THE FOLLOWING:
(1) REQUIRE COVERAGE FOR ANY DRUG IF THE UNITED STATES 6,257
FOOD AND DRUG ADMINISTRATION HAS DETERMINED ITS USE TO BE 6,258
CONTRAINDICATED FOR THE TREATMENT OF THE PARTICULAR INDICATION 6,259
139
FOR WHICH THE DRUG HAS BEEN PRESCRIBED; 6,260
(2) REQUIRE COVERAGE FOR EXPERIMENTAL DRUGS NOT APPROVED 6,262
FOR ANY INDICATION BY THE UNITED STATES FOOD AND DRUG 6,265
ADMINISTRATION; 6,266
(3) ALTER ANY LAW WITH REGARD TO PROVISIONS LIMITING THE 6,268
COVERAGE OF DRUGS THAT HAVE NOT BEEN APPROVED BY THE UNITED 6,271
STATES FOOD AND DRUG ADMINISTRATION; 6,272
(4) REQUIRE REIMBURSEMENT OR COVERAGE FOR ANY DRUG NOT 6,274
INCLUDED IN THE DRUG FORMULARY OR LIST OF COVERED DRUGS SPECIFIED 6,276
IN A HEALTH INSURING CORPORATION CONTRACT;
(5) PROHIBIT A HEALTH INSURING CORPORATION FROM LIMITING 6,278
OR EXCLUDING COVERAGE OF A DRUG, PROVIDED THAT THE DECISION TO 6,279
LIMIT OR EXCLUDE COVERAGE OF THE DRUG IS NOT BASED PRIMARILY ON 6,280
THE COVERAGE OF DRUGS REQUIRED BY THIS SECTION. 6,281
(E) THIS SECTION APPLIES ONLY TO HEALTH INSURING 6,284
CORPORATION POLICIES, CONTRACTS, AND AGREEMENTS THAT ARE 6,285
DESCRIBED IN DIVISION (A) OF THIS SECTION AND THAT ARE DELIVERED, 6,287
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE ON OR AFTER JULY 1, 6,288
1997.
Sec. 1751.67. (A) EACH INDIVIDUAL OR GROUP HEALTH 6,290
INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT DELIVERED, 6,291
ISSUED FOR DELIVERY, OR RENEWED IN THIS STATE THAT PROVIDES 6,292
MATERNITY BENEFITS SHALL PROVIDE COVERAGE OF INPATIENT CARE AND 6,293
FOLLOW-UP CARE FOR A MOTHER AND HER NEWBORN AS FOLLOWS: 6,294
(1) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,296
MINIMUM OF FORTY-EIGHT HOURS OF INPATIENT CARE FOLLOWING A NORMAL 6,297
VAGINAL DELIVERY AND A MINIMUM OF NINETY-SIX HOURS OF INPATIENT 6,298
CARE FOLLOWING A CESAREAN DELIVERY. SERVICES COVERED AS 6,299
INPATIENT CARE SHALL INCLUDE MEDICAL, EDUCATIONAL, AND ANY OTHER 6,300
SERVICES THAT ARE CONSISTENT WITH THE INPATIENT CARE RECOMMENDED 6,301
IN THE PROTOCOLS AND GUIDELINES DEVELOPED BY NATIONAL 6,302
ORGANIZATIONS THAT REPRESENT PEDIATRIC, OBSTETRIC, AND NURSING 6,303
PROFESSIONALS.
(2) THE POLICY, CONTRACT, OR AGREEMENT SHALL COVER A 6,305
140
PHYSICIAN-DIRECTED SOURCE OF FOLLOW-UP CARE. SERVICES COVERED AS 6,307
FOLLOW-UP CARE SHALL INCLUDE PHYSICAL ASSESSMENT OF THE MOTHER 6,308
AND NEWBORN, PARENT EDUCATION, ASSISTANCE AND TRAINING IN BREAST 6,309
OR BOTTLE FEEDING, ASSESSMENT OF THE HOME SUPPORT SYSTEM,
PERFORMANCE OF ANY MEDICALLY NECESSARY AND APPROPRIATE CLINICAL 6,310
TESTS, AND ANY OTHER SERVICES THAT ARE CONSISTENT WITH THE 6,311
FOLLOW-UP CARE RECOMMENDED IN THE PROTOCOLS AND GUIDELINES 6,312
DEVELOPED BY NATIONAL ORGANIZATIONS THAT REPRESENT PEDIATRIC, 6,313
OBSTETRIC, AND NURSING PROFESSIONALS. THE COVERAGE SHALL APPLY 6,314
TO SERVICES PROVIDED IN A MEDICAL SETTING OR THROUGH HOME HEALTH 6,315
CARE VISITS. THE COVERAGE SHALL APPLY TO A HOME HEALTH CARE 6,316
VISIT ONLY IF THE PROVIDER WHO CONDUCTS THE VISIT IS 6,317
KNOWLEDGEABLE AND EXPERIENCED IN MATERNITY AND NEWBORN CARE. 6,318
WHEN A DECISION IS MADE IN ACCORDANCE WITH DIVISION (B) OF 6,321
THIS SECTION TO DISCHARGE A MOTHER OR NEWBORN PRIOR TO THE
EXPIRATION OF THE APPLICABLE NUMBER OF HOURS OF INPATIENT CARE 6,322
REQUIRED TO BE COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL 6,323
APPLY TO ALL FOLLOW-UP CARE THAT IS PROVIDED WITHIN FORTY-EIGHT 6,324
HOURS AFTER DISCHARGE. WHEN A MOTHER OR NEWBORN RECEIVES AT 6,325
LEAST THE NUMBER OF HOURS OF INPATIENT CARE REQUIRED TO BE 6,326
COVERED, THE COVERAGE OF FOLLOW-UP CARE SHALL APPLY TO FOLLOW-UP 6,327
CARE THAT IS DETERMINED TO BE MEDICALLY NECESSARY BY THE PROVIDER 6,329
RESPONSIBLE FOR DISCHARGING THE MOTHER OR NEWBORN.
(B) ANY DECISION TO SHORTEN THE LENGTH OF INPATIENT STAY 6,331
TO LESS THAN THAT SPECIFIED UNDER DIVISION (A)(1) OF THIS SECTION 6,333
SHALL BE MADE BY THE PHYSICIAN ATTENDING THE MOTHER OR NEWBORN, 6,334
EXCEPT THAT IF A NURSE-MIDWIFE IS ATTENDING THE MOTHER IN 6,335
COLLABORATION WITH A PHYSICIAN, THE DECISION MAY BE MADE BY THE 6,336
NURSE-MIDWIFE. DECISIONS REGARDING EARLY DISCHARGE SHALL BE MADE 6,337
ONLY AFTER CONFERRING WITH THE MOTHER OR A PERSON RESPONSIBLE FOR 6,338
THE MOTHER OR NEWBORN. FOR PURPOSES OF THIS DIVISION, A PERSON 6,339
RESPONSIBLE FOR THE MOTHER OR NEWBORN MAY INCLUDE A PARENT, 6,340
GUARDIAN, OR ANY OTHER PERSON WITH AUTHORITY TO MAKE MEDICAL 6,341
DECISIONS FOR THE MOTHER OR NEWBORN.
141
(C)(1) NO HEALTH INSURING CORPORATION MAY DO EITHER OF THE 6,344
FOLLOWING:
(a) TERMINATE THE PARTICIPATION OF A PROVIDER OR HEALTH 6,346
CARE FACILITY IN AN INDIVIDUAL OR GROUP HEALTH CARE PLAN SOLELY 6,347
FOR MAKING RECOMMENDATIONS FOR INPATIENT OR FOLLOW-UP CARE FOR A 6,348
PARTICULAR MOTHER OR NEWBORN THAT ARE CONSISTENT WITH THE CARE 6,349
REQUIRED TO BE COVERED BY THIS SECTION; 6,350
(b) ESTABLISH OR OFFER MONETARY OR OTHER FINANCIAL 6,352
INCENTIVES FOR THE PURPOSE OF ENCOURAGING A PERSON TO DECLINE THE 6,354
INPATIENT OR FOLLOW-UP CARE REQUIRED TO BE COVERED BY THIS
SECTION. 6,355
(2) WHOEVER VIOLATES DIVISION (C)(1)(a) OR (b) OF THIS 6,358
SECTION HAS ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE IN 6,359
THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 6,360
THE REVISED CODE.
(D) THIS SECTION DOES NOT DO ANY OF THE FOLLOWING: 6,362
(1) REQUIRE A POLICY, CONTRACT, OR AGREEMENT TO COVER 6,364
INPATIENT OR FOLLOW-UP CARE THAT IS NOT RECEIVED IN ACCORDANCE 6,365
WITH THE POLICY'S, CONTRACT'S, OR AGREEMENT'S TERMS PERTAINING TO 6,366
THE PROVIDERS AND FACILITIES FROM WHICH AN INDIVIDUAL IS 6,367
AUTHORIZED TO RECEIVE HEALTH CARE SERVICES; 6,368
(2) REQUIRE A MOTHER OR NEWBORN TO STAY IN A HOSPITAL OR 6,370
OTHER INPATIENT SETTING FOR A FIXED PERIOD OF TIME FOLLOWING 6,371
DELIVERY;
(3) REQUIRE A CHILD TO BE DELIVERED IN A HOSPITAL OR OTHER 6,373
INPATIENT SETTING; 6,374
(4) AUTHORIZE A NURSE-MIDWIFE TO PRACTICE BEYOND THE 6,376
AUTHORITY TO PRACTICE NURSE-MIDWIFERY IN ACCORDANCE WITH CHAPTER 6,377
4723. OF THE REVISED CODE; 6,378
(5) ESTABLISH MINIMUM STANDARDS OF MEDICAL DIAGNOSIS, 6,380
CARE, OR TREATMENT FOR INPATIENT OR FOLLOW-UP CARE FOR A MOTHER 6,381
OR NEWBORN. A DEVIATION FROM THE CARE REQUIRED TO BE COVERED 6,382
UNDER THIS SECTION SHALL NOT, SOLELY ON THE BASIS OF THIS 6,383
SECTION, GIVE RISE TO A MEDICAL CLAIM OR TO DERIVATIVE CLAIMS FOR 6,384
142
RELIEF, AS THOSE TERMS ARE DEFINED IN SECTION 2305.11 OF THE 6,386
REVISED CODE.
Sec. 1751.70. (A) AN EMPLOYEE OF THE STATE, OF ANY 6,389
POLITICAL SUBDIVISION OF THE STATE, OR OF ANY INSTITUTION 6,390
SUPPORTED IN WHOLE OR IN PART BY THE STATE, MAY AUTHORIZE THE 6,391
DEDUCTION FROM THE EMPLOYEE'S SALARY OR WAGES OF THE AMOUNT OF 6,392
THE EMPLOYEE'S PREMIUM RATE TO ANY HEALTH INSURING CORPORATION 6,393
HOLDING A CERTIFICATE OF AUTHORITY PURSUANT TO THIS CHAPTER. THE 6,395
EMPLOYEE'S AUTHORIZATION SHALL BE EVIDENCED BY APPROVAL OF THE 6,396
HEAD OF THE DEPARTMENT, DIVISION, OFFICE, OR INSTITUTION IN WHICH 6,397
THE EMPLOYEE IS EMPLOYED.
(B) IN THE CASE OF EMPLOYEES OF THE STATE, THE EMPLOYEE'S 6,400
AUTHORIZATION SHALL BE DIRECTED TO AND FILED WITH THE DIRECTOR OF 6,401
ADMINISTRATIVE SERVICES. IN THE CASE OF EMPLOYEES OF A POLITICAL 6,402
SUBDIVISION, THE EMPLOYEE'S AUTHORIZATION SHALL BE DIRECTED TO 6,403
AND FILED WITH THE FISCAL OFFICER OF SUCH POLITICAL SUBDIVISION. 6,404
IN THE CASE OF EMPLOYEES OF ANY INSTITUTION SUPPORTED IN WHOLE OR 6,405
IN PART BY THE STATE, THE EMPLOYEE'S AUTHORIZATION SHALL BE 6,406
DIRECTED TO AND FILED WITH THE FISCAL OFFICER OF SUCH 6,407
INSTITUTION.
(C) UPON THE FILING OF THE EMPLOYEE'S AUTHORIZATION IN 6,410
ACCORDANCE WITH DIVISION (B) OF THIS SECTION, THE DIRECTOR OR 6,412
FISCAL OFFICER SHALL PROVIDE FOR PAYMENT TO THE HEALTH INSURING 6,413
CORPORATION REFERRED TO IN THE EMPLOYEE'S AUTHORIZATION, FOR THE 6,414
AMOUNT COVERING THE SUM OF THE DEDUCTIONS THEREBY AUTHORIZED. 6,415
Sec. 1751.71. EACH HEALTH INSURING CORPORATION SUBJECT TO 6,417
THIS CHAPTER MAY ACCEPT FROM GOVERNMENTAL AGENCIES, OR FROM 6,418
PRIVATE PERSONS, PAYMENTS COVERING ALL OR PART OF THE COST OF 6,419
POLICIES, CONTRACTS, AND AGREEMENTS ENTERED INTO BETWEEN THE 6,420
HEALTH INSURING CORPORATION AND ITS SUBSCRIBERS OR GROUPS OF 6,421
SUBSCRIBERS.
Sec. 1901.111. (A) As used in this section, "health care 6,430
coverage" means sickness and accident insurance or other coverage 6,431
of hospitalization, surgical care, major medical care, 6,432
143
disability, dental care, eye care, medical care, hearing aids, 6,433
and prescription drugs, or any combination of those benefits or 6,434
services. 6,435
(B) The legislative authority, after consultation with the 6,437
judges of the municipal court, shall negotiate and contract for, 6,438
purchase, or otherwise procure group health care coverage for the 6,439
judges and their spouses and dependents from insurance companies 6,440
authorized to engage in the business of insurance in this state 6,441
under Title XXXIX of the Revised Code, medical care corporations 6,442
organized under Chapter 1737. of the Revised Code, OR health care 6,444
INSURING corporations organized HOLDING CERTIFICATES OF AUTHORITY 6,445
under Chapter 1738. 1751. of the Revised Code, or health 6,446
maintenance organizations organized under Chapter 1742. of the 6,447
Revised Code, except that if the county or municipal corporation 6,448
served by the legislative authority provides group health care 6,449
coverage for its employees, the group health care coverage 6,450
required by this section shall be provided, if possible, through 6,451
the policy or plan under which the group health care coverage is 6,452
provided for the county or municipal corporation employees. 6,453
(C) The portion of the costs, premiums, or charges for the 6,455
group health care coverage procured pursuant to division (B) of 6,456
this section that is not paid by the judges of the municipal 6,457
court, or all of the costs, premiums, or charges for the group 6,458
health care coverage if the judges will not be paying any such 6,459
portion, shall be paid as follows: 6,460
(1) If the municipal court is a county-operated municipal 6,462
court, the portion of the costs, premiums, or charges or all of 6,463
the costs, premiums, or charges shall be paid out of the treasury 6,464
of the county. 6,465
(2) If the municipal court is not a county-operated 6,467
municipal court, the portion of the costs, premiums, or charges 6,468
or all of the costs, premiums, or charges shall be paid in 6,469
three-fifths and two-fifths shares from the city treasury and 6,470
appropriate county treasuries as described in division (C) of 6,471
144
section 1901.11 of the Revised Code. The three-fifths share of a 6,472
city treasury is subject to apportionment under section 1901.026 6,473
of the Revised Code. 6,474
Sec. 1901.312. (A) As used in this section, "health care 6,483
coverage" has the same meaning as in section 1901.111 of the 6,484
Revised Code. 6,485
(B) The legislative authority, after consultation with 6,487
the clerk and deputy clerks of the municipal court, shall 6,488
negotiate and contract for, purchase, or otherwise procure group 6,489
health care coverage for the clerk and deputy clerks and their 6,490
spouses and dependents from insurance companies authorized to 6,491
engage in the business of insurance in this state under Title 6,492
XXXIX of the Revised Code, medical care corporations organized 6,493
under Chapter 1737. of the Revised Code, OR health care INSURING 6,495
corporations organized HOLDING CERTIFICATES OF AUTHORITY under 6,496
Chapter 1738. 1751. of the Revised Code, or health maintenance 6,498
organizations organized under Chapter 1742. of the Revised Code, 6,499
except that if the county or municipal corporation served by the 6,500
legislative authority provides group health care coverage for its 6,501
employees, the group health care coverage required by this 6,502
section shall be provided, if possible, through the policy or 6,503
plan under which the group health care coverage is provided for 6,504
the county or municipal corporation employees.
(C) The portion of the costs, premiums, or charges for the 6,506
group health care coverage procured pursuant to division (B) of 6,507
this section that is not paid by the clerk and deputy clerks of 6,508
the municipal court, or all of the costs, premiums, or charges 6,509
for the group health care coverage if the clerk and deputy clerks 6,510
will not be paying any such portion, shall be paid as follows: 6,511
(1) If the municipal court is a county-operated municipal 6,513
court, the portion of the costs, premiums, or charges or all of 6,514
the costs, premiums, or charges shall be paid out of the treasury 6,515
of the county. 6,516
(2)(a) If the municipal court is not a county-operated 6,518
145
municipal court, the portion of the costs, premiums, or charges 6,519
in connection with the clerk or all of the costs, premiums, or 6,520
charges in connection with the clerk shall be paid in 6,521
three-fifths and two-fifths shares from the city treasury and 6,522
appropriate county treasuries as described in division (C) of 6,523
section 1901.31 of the Revised Code. The three-fifths share of a 6,524
city treasury is subject to apportionment under section 1901.026 6,525
of the Revised Code. 6,526
(b) If the municipal court is not a county-operated 6,528
municipal court, the portion of the costs, premiums, or charges 6,529
in connection with the deputy clerks or all of the costs, 6,530
premiums, or charges in connection with the deputy clerks shall 6,531
be paid from the city treasury and shall be subject to 6,532
apportionment under section 1901.026 of the Revised Code. 6,533
(D) This section does not apply to the clerk of the 6,535
Auglaize county, Hamilton county, Portage county, or Wayne county 6,536
municipal court, if health care coverage is provided to the clerk 6,537
by virtue of his THE CLERK'S employment as the clerk of the court 6,539
of common pleas of Auglaize county, Hamilton county, Portage
county, or Wayne county. 6,540
Sec. 2133.12. (A) The death of a qualified patient or 6,549
other patient resulting from the withholding or withdrawal of 6,550
life-sustaining treatment in accordance with this chapter does 6,551
not constitute a suicide, aggravated murder, murder, or any other 6,552
homicide offense for any purpose. 6,553
(B)(1) The execution of a declaration shall not do either 6,555
of the following: 6,556
(a) Affect the sale, procurement, issuance, or renewal of 6,558
any policy of life insurance or annuity, notwithstanding any term 6,559
of a policy or annuity to the contrary; 6,560
(b) Be deemed to modify or invalidate the terms of any 6,562
policy of life insurance or annuity that is in effect on October 6,563
10, 1991. 6,564
(2) Notwithstanding any term of a policy of life insurance 6,566
146
or annuity to the contrary, the withholding or withdrawal of 6,567
life-sustaining treatment from an insured, qualified patient or 6,568
other patient in accordance with this chapter shall not impair or 6,569
invalidate any policy of life insurance or annuity. 6,570
(3) Notwithstanding any term of a policy or plan to the 6,572
contrary, the use or continuation, or the withholding or 6,573
withdrawal, of life-sustaining treatment from an insured, 6,574
qualified patient or other patient in accordance with this 6,575
chapter shall not impair or invalidate any policy of health 6,576
insurance or any health care benefit plan. 6,577
(4) No physician, health care facility, other health care 6,579
provider, person authorized to engage in the business of 6,580
insurance in this state under Title XXXIX of the Revised Code, 6,581
medical care corporation, health care INSURING corporation, 6,583
health maintenance organization, other health care plan, legal 6,584
entity that is self-insured and provides benefits to its 6,585
employees or members, or other person shall require any 6,586
individual to execute or refrain from executing a declaration, or 6,587
shall require an individual to revoke or refrain from revoking a 6,588
declaration, as a condition of being insured or of receiving 6,589
health care benefits or services. 6,590
(C)(1) This chapter does not create any presumption 6,592
concerning the intention of an individual who has revoked or has 6,593
not executed a declaration with respect to the use or 6,594
continuation, or the withholding or withdrawal, of 6,595
life-sustaining treatment if he THE INDIVIDUAL should be in a 6,596
terminal condition or in a permanently unconscious state at any 6,597
time.
(2) This chapter does not affect the right of a qualified 6,599
patient or other patient to make informed decisions regarding the 6,600
use or continuation, or the withholding or withdrawal, of 6,601
life-sustaining treatment as long as he THE QUALIFIED PATIENT OR 6,602
OTHER PATIENT is able to make those decisions. 6,605
(3) This chapter does not require a physician, other 6,607
147
health care personnel, or a health care facility to take action 6,608
that is contrary to reasonable medical standards. 6,609
(4) This chapter and, if applicable, a declaration do not 6,611
affect or limit the authority of a physician or a health care 6,612
facility to provide or not to provide life-sustaining treatment 6,613
to a person in accordance with reasonable medical standards 6,614
applicable in an emergency situation. 6,615
(D) Nothing in this chapter condones, authorizes, or 6,617
approves of mercy killing, assisted suicide, or euthanasia. 6,618
(E)(1) This chapter does not affect the responsibility of 6,620
the attending physician of a qualified patient or other patient, 6,621
or other health care personnel acting under the direction of the 6,622
patient's attending physician, to provide comfort care to the 6,623
patient. Nothing in this chapter precludes the attending 6,624
physician of a qualified patient or other patient who carries out 6,625
the responsibility to provide comfort care to the patient in good 6,626
faith and while acting within the scope of his THE ATTENDING 6,627
PHYSICIAN'S authority from prescribing, dispensing, 6,630
administering, or causing to be administered any particular 6,631
medical procedure, treatment, intervention, or other measure to 6,632
the patient, including, but not limited to, prescribing, 6,633
dispensing, administering, or causing to be administered by 6,634
judicious titration or in another manner any form of medication, 6,635
for the purpose of diminishing his THE QUALIFIED PATIENT'S OR 6,636
OTHER PATIENT'S pain or discomfort and not for the purpose of 6,637
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,638
PATIENT'S death, even though the medical procedure, treatment, 6,640
intervention, or other measure may appear to hasten or increase 6,641
the risk of the patient's death. Nothing in this chapter 6,642
precludes health care personnel acting under the direction of the 6,643
patient's attending physician who carry out the responsibility to 6,644
provide comfort care to the patient in good faith and while 6,645
acting within the scope of their authority from dispensing, 6,646
administering, or causing to be administered any particular 6,647
148
medical procedure, treatment, intervention, or other measure to 6,648
the patient, including, but not limited to, dispensing, 6,649
administering, or causing to be administered by judicious 6,650
titration or in another manner any form of medication, for the 6,651
purpose of diminishing his THE QUALIFIED PATIENT'S OR OTHER 6,652
PATIENT'S pain or discomfort and not for the purpose of 6,654
postponing or causing his THE QUALIFIED PATIENT'S OR OTHER 6,655
PATIENT'S death, even though the medical procedure, treatment, 6,656
intervention, or other measure may appear to hasten or increase 6,657
the risk of the patient's death.
(2)(a) If, at any time, a person described in division 6,659
(A)(2)(a)(i) of section 2133.05 of the Revised Code or the 6,660
individual or a majority of the individuals in either of the 6,661
first two classes of individuals that pertain to a declarant in 6,662
the descending order of priority set forth in division 6,663
(A)(2)(a)(ii) of section 2133.05 of the Revised Code believes in 6,664
good faith that both of the following circumstances apply, the 6,665
person or the individual or majority of individuals in either of 6,666
the first two classes of individuals may commence an action in 6,667
the probate court of the county in which a declarant who is in a 6,668
terminal condition or permanently unconscious state is located 6,669
for the issuance of an order mandating the use or continuation of 6,670
comfort care in connection with the declarant in a manner that is 6,671
consistent with division (E)(1) of this section: 6,672
(i) Comfort care is not being used or continued in 6,674
connection with the declarant. 6,675
(ii) The withholding or withdrawal of the comfort care is 6,677
contrary to division (E)(1) of this section. 6,678
(b) If a declarant did not designate in his THE 6,680
DECLARANT'S declaration a person as described in division 6,681
(A)(2)(a)(i) of section 2133.05 of the Revised Code and if, at 6,682
any time, a priority individual or any member of a priority class 6,683
of individuals under division (A)(2)(a)(ii) of section 2133.05 of 6,684
the Revised Code or, at any time, the individual or a majority of 6,685
149
the individuals in the next class of individuals that pertains to 6,686
the declarant in the descending order of priority set forth in 6,687
that division believes in good faith that both of the following 6,688
circumstances apply, the priority individual, the member of the 6,689
priority class of individuals, or the individual or majority of 6,690
individuals in the next class of individuals that pertains to the 6,691
declarant may commence an action in the probate court of the 6,692
county in which a declarant who is in a terminal condition or 6,693
permanently unconscious state is located for the issuance of an 6,694
order mandating the use or continuation of comfort care in 6,695
connection with the declarant in a manner that is consistent with 6,696
division (E)(1) of this section: 6,697
(i) Comfort care is not being used or continued in 6,699
connection with the declarant. 6,700
(ii) The withholding or withdrawal of the comfort care is 6,702
contrary to division (E)(1) of this section. 6,703
(c) If, at any time, a priority individual or any member 6,705
of a priority class of individuals under division (B) of section 6,706
2133.08 of the Revised Code or, at any time, the individual or a 6,707
majority of the individuals in the next class of individuals that 6,708
pertains to the patient in the descending order of priority set 6,709
forth in that division believes in good faith that both of the 6,710
following circumstances apply, the priority individual, the 6,711
member of the priority class of individuals, or the individual or 6,712
majority of individuals in the next class of individuals that 6,713
pertains to the patient may commence an action in the probate 6,714
court of the county in which a patient as described in division 6,715
(A) of section 2133.08 of the Revised Code is located for the 6,716
issuance of an order mandating the use or continuation of comfort 6,717
care in connection with the patient in a manner that is 6,718
consistent with division (E)(1) of this section: 6,719
(i) Comfort care is not being used or continued in 6,721
connection with the patient. 6,722
(ii) The withholding or withdrawal of the comfort care is 6,724
150
contrary to division (E)(1) of this section. 6,725
Sec. 2305.25. (A) No health care entity and no individual 6,735
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 6,736
following corporations shall be liable in damages to any person 6,737
for any acts, omissions, decisions, or other conduct within the 6,738
scope of the functions of the board, committee, or corporation: 6,739
(1) A peer review committee of a hospital, a nonprofit 6,741
health care corporation which is a member of the hospital or of 6,742
which the hospital is a member, or a community mental health 6,743
center; 6,744
(2) A board or committee of a hospital or of a nonprofit 6,747
health care corporation which is a member of the hospital or of 6,748
which the hospital is a member reviewing professional
qualifications or activities of the hospital medical staff or 6,749
applicants for admission to the medical staff; 6,750
(3) A utilization committee of a state or local society 6,752
composed of doctors of medicine or doctors of osteopathic 6,753
medicine and surgery or doctors of podiatric medicine; 6,754
(4) A peer review committee of nursing home providers or 6,756
administrators, including a corporation engaged in performing the 6,758
functions of a peer review committee of nursing home providers or 6,759
administrators, or a corporation engaged in the functions of
another type of peer review or professional standards review 6,760
committee; 6,761
(5) A peer review committee, professional standards review 6,763
committee, or arbitration committee of a state or local society 6,764
composed of doctors of medicine, doctors of osteopathic medicine 6,765
and surgery, doctors of dentistry, doctors of optometry, doctors 6,766
of podiatric medicine, psychologists, or registered pharmacists; 6,767
(6) A peer review committee of a health maintenance 6,769
organization INSURING CORPORATION that has at least a two-thirds 6,770
majority of member physicians in active practice and that 6,772
conducts professional credentialing and quality review activities 6,773
151
involving the competence or professional conduct of health care 6,774
providers, which conduct adversely affects, or could adversely 6,775
affect, the health or welfare of any patient. For purposes of 6,776
this division, "health maintenance organization INSURING 6,777
CORPORATION" includes wholly owned subsidiaries of a health 6,779
maintenance organization INSURING CORPORATION. 6,780
(7) A peer review committee of any insurer authorized 6,782
under Title XXXIX of the Revised Code to do the business of 6,783
sickness and accident insurance in this state that has at least a 6,784
two-thirds majority of physicians in active practice and that 6,785
conducts professional credentialing and quality review activities 6,786
involving the competence or professional conduct of health care 6,787
providers, which conduct adversely affects, or could adversely 6,788
affect, the health or welfare of any patient; 6,789
(8) 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 a health care 6,796
facility that has contracted with the insurer to provide health 6,797
care services to insureds, which conduct adversely affects, or 6,798
could adversely affect, the health or welfare of any patient; 6,799
(9) A quality assurance committee of a state correctional 6,801
institution operated by the department of rehabilitation and 6,803
correction;
(10) A quality assurance committee of the central office 6,805
of the department of rehabilitation and correction or department 6,807
of mental health.;
(11) A peer review committee of an insurer authorized 6,809
under Title XXXIX of the Revised Code to do the business of 6,810
medical professional liability insurance in this state and that 6,811
conducts professional quality review activities involving the 6,813
competence or professional conduct of health care providers, 6,814
152
which conduct adversely affects, or could affect, the health or
welfare of any patient; 6,815
(12) A peer review committee of a health care entity. 6,817
(B)(1) A hospital shall be presumed to not be negligent in 6,819
the credentialing of a qualified person if the hospital proves by 6,820
a preponderance of the evidence that at the time of the alleged 6,821
negligent credentialing of the qualified person it was accredited 6,822
by the joint commission on accreditation of health care 6,823
organizations, the American osteopathic association, or the
national committee for quality assurance. 6,824
(2) The presumption that a hospital is not negligent as 6,826
provided in division (B)(1) of this section may be rebutted only 6,827
by proof, by a preponderance of the evidence, of any of the 6,828
following:
(a) The credentialing and review requirements of the 6,830
accrediting organization did not apply to the hospital, the 6,831
qualified person, or the type of professional care that is the 6,832
basis of the claim against the hospital.
(b) The hospital failed to comply with all material 6,834
credentialing and review requirements of the accrediting 6,835
organization that applied to the qualified person. 6,836
(c) The hospital, through its medical staff executive 6,838
committee or its governing body and sufficiently in advance to 6,839
take appropriate action, knew that a previously competent 6,840
qualified person with staff privileges at the hospital had 6,841
developed a pattern of incompetence that indicated that the 6,842
qualified person's privileges should have been limited prior to 6,843
treating the plaintiff at the hospital. 6,844
(d) 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 would 6,849
provide fraudulent medical treatment but failed to limit the 6,850
qualified person's privileges prior to treating the plaintiff at 6,851
153
the hospital. 6,852
(3) If the plaintiff fails to rebut the presumption 6,854
provided in division (B)(1) of this section, upon the motion of 6,855
the hospital, the court shall enter judgment in favor of the 6,856
hospital on the claim of negligent credentialing.
(C) Nothing in this section otherwise shall relieve any 6,858
individual or health care entity from liability arising from 6,859
treatment of a patient. Nothing in this section shall be 6,860
construed as creating an exception to section 2305.251 of the 6,861
Revised Code.
(D) No person who provides information under this section 6,863
without malice and in the reasonable belief that the information 6,865
is warranted by the facts known to the person shall be subject to 6,866
suit for civil damages as a result of providing the information. 6,867
(E) For purposes of this section: 6,869
(1) "Peer review committee" means a utilization review 6,871
committee, quality assurance committee, quality improvement 6,872
committee, tissue committee, credentialing committee, or other 6,873
committee that conducts professional credentialing and quality 6,874
review activities involving the competence or professional 6,875
conduct of health care practitioners.
(2) "Health care entity" means a government entity, a 6,877
for-profit or nonprofit corporation, a limited liability company, 6,878
a partnership, a professional corporation, a state or local 6,879
society as described in division (A)(3) of this section, or other 6,880
health care organization, including, but not limited to, health 6,881
care entities described in division (A) of this section, whether 6,882
acting on its own behalf or on behalf of or in affiliation with 6,883
other health care entities, that conducts, as part of its
purpose, professional credentialing or quality review activities 6,884
involving the competence or professional conduct of health care 6,885
practitioners or providers. 6,886
(3) "Hospital" means either of the following: 6,888
(a) An institution that has been registered or licensed by 6,890
154
the Ohio department of health as a hospital; 6,891
(b) An entity, other than an insurance company authorized 6,893
to do business in this state, that owns, controls, or is 6,894
affiliated with an institution that has been registered or 6,896
licensed by the Ohio department of health as a hospital.
(4) "Qualified person" means a member of the medical staff 6,898
of a hospital or a person who has professional privileges at a 6,899
hospital pursuant to section 3701.351 of the Revised Code. 6,900
(F) This section shall be considered to be purely remedial 6,903
in its operation and shall be applied in a remedial manner in any 6,904
civil action in which this section is relevant, whether the civil 6,905
action is pending in court or commenced on or after the effective 6,906
date of this section, regardless of when the cause of action 6,907
accrued and notwithstanding any other section of the Revised Code 6,909
or prior rule of law of this state.
Sec. 2913.47. (A) As used in this section: 6,919
(1) "Data" has the same meaning as in section 2913.01 of 6,921
the Revised Code and additionally includes any other 6,922
representation of information, knowledge, facts, concepts, or 6,923
instructions that are being or have been prepared in a formalized 6,924
manner. 6,925
(2) "Deceptive" means that a statement, in whole or in 6,927
part, would cause another to be deceived because it contains a 6,928
misleading representation, withholds information, prevents the 6,929
acquisition of information, or by any other conduct, act, or 6,930
omission creates, confirms, or perpetuates a false impression, 6,931
including, but not limited to, a false impression as to law, 6,932
value, state of mind, or other objective or subjective fact. 6,933
(3) "Insurer" means any person that is authorized to 6,935
engage in the business of insurance in this state under Title 6,936
XXXIX of the Revised Code;, the Ohio fair plan underwriting 6,937
association created under section 3929.43 of the Revised Code;, 6,938
any prepaid dental plan, medical care corporation, health care 6,941
INSURING corporation, dental care corporation, or health 6,943
155
maintenance organization; and any legal entity that is
self-insured and provides benefits to its employees or members. 6,944
(4) "Policy" means a policy, certificate, contract, or 6,946
plan that is issued by an insurer. 6,947
(5) "Statement" includes, but is not limited to, any 6,949
notice, letter, or memorandum; proof of loss; bill of lading; 6,950
receipt for payment; invoice, account, or other financial 6,951
statement; estimate of property damage; bill for services; 6,952
diagnosis or prognosis; prescription; hospital, medical, or 6,953
dental chart or other record; x-ray, photograph, videotape, or 6,954
movie film; test result; other evidence of loss, injury, or 6,955
expense; computer-generated document; and data in any form. 6,956
(B) No person, with purpose to defraud or knowing that the 6,958
person is facilitating a fraud, shall do either of the following: 6,959
(1) Present to, or cause to be presented to, an insurer 6,961
any written or oral statement that is part of, or in support of, 6,962
an application for insurance, a claim for payment pursuant to a 6,963
policy, or a claim for any other benefit pursuant to a policy, 6,964
knowing that the statement, or any part of the statement, is 6,965
false or deceptive; 6,966
(2) Assist, aid, abet, solicit, procure, or conspire with 6,968
another to prepare or make any written or oral statement that is 6,969
intended to be presented to an insurer as part of, or in support 6,970
of, an application for insurance, a claim for payment pursuant to 6,971
a 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
(C) Whoever violates this section is guilty of insurance 6,976
fraud. Except as otherwise provided in this division, insurance 6,977
fraud is a misdemeanor of the first degree. If the amount of the 6,978
claim that is false or deceptive is five hundred dollars or more 6,979
and is less than five thousand dollars, insurance fraud is a 6,980
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 6,982
156
than one hundred thousand dollars, insurance fraud is a felony of 6,983
the fourth degree. If the amount of the claim that is false or 6,985
deceptive is one hundred thousand dollars or more, insurance 6,986
fraud is a felony of the third degree.
(D) This section shall not be construed to abrogate, 6,988
waive, or modify division (A) of section 2317.02 of the Revised 6,989
Code. 6,990
Sec. 3105.71. (A) If a party to an action for divorce, 6,999
annulment, dissolution of marriage, or legal separation was the 7,000
named insured or subscriber under, or the policyholder, 7,001
certificate holder, or contract holder of, a policy, contract, or 7,002
plan of health insurance that provided health insurance coverage 7,003
for his THAT PARTY'S spouse and dependents immediately prior to 7,004
the filing of the action, that party shall not cancel or 7,005
otherwise terminate or cause the termination of such coverage for 7,006
which the spouse and dependents would otherwise be eligible until 7,007
the court determines that the party is no longer responsible for 7,008
providing such health insurance coverage for his THAT PARTY'S 7,009
spouse and dependents.
(B) If the party responsible for providing health 7,011
insurance coverage for his THAT PARTY'S spouse and dependents 7,012
under division (A) of this section fails to provide that coverage 7,013
in accordance with that division, the court shall issue an order 7,014
that includes all of the following: 7,015
(1) A requirement that the party make payment to his THAT 7,017
PARTY'S spouse in the amount of any premium he THAT PARTY failed 7,019
to pay or contribution he THAT PARTY failed to make that resulted 7,020
in his THAT PARTY'S failure to provide health insurance coverage 7,021
in compliance with division (A) of this section;
(2) A requirement that the party make payment to his THAT 7,023
PARTY'S spouse for reimbursement of any hospital, surgical, and 7,024
medical expenses incurred as a result of his THAT PARTY'S failure 7,025
to comply with division (A) of this section; 7,026
(3) A requirement that, if the party fails to comply with 7,028
157
divisions (B)(1) and (2) of this section, the employer of the 7,029
party deduct from the party's earnings an amount necessary to 7,030
make any payments required under divisions (B)(1) and (2) of this 7,031
section. 7,032
(C) If the party responsible for providing health 7,034
insurance coverage for his THAT PARTY'S spouse and dependents 7,035
under division (A) of this section cancels or otherwise 7,036
terminates or causes the termination of such coverage for which 7,037
the spouse and dependents would otherwise be eligible, the spouse 7,038
may apply to the insurer, health maintenance organization 7,039
INSURING CORPORATION, or other third-party payer that provided 7,040
the coverage for a policy or contract of health insurance. The 7,041
spouse and dependents shall have the same rights and be subject 7,042
to the same limitations as a person applying for or covered under 7,043
a converted or separate policy under section 3923.32 of the 7,044
Revised Code upon the divorce, annulment, dissolution of 7,045
marriage, or the legal separation of the spouse from the named 7,046
insured.
Sec. 3111.241. (A) As used in this section, "insurer" 7,055
means any person that is authorized to engage in the business of 7,056
insurance in this state under Title XXXIX of the Revised Code;, 7,057
any prepaid dental plan, medical care corporation, health care 7,058
INSURING corporation, dental care corporation, or health 7,059
maintenance organization; and any legal entity that is 7,060
self-insured and provides benefits to its employees or members. 7,061
(B) If an administrative officer of a child support 7,063
enforcement agency issues an administrative support order under 7,064
section 3111.20, 3111.21, or 3111.22 of the Revised Code, in 7,065
addition to any requirements in those sections, the agency also 7,067
shall issue a separate order that includes all of the following: 7,068
(1) A requirement that the obligor under the child support 7,070
order obtain health insurance coverage for the children who are 7,071
the subject of the administrative child support order from an 7,072
insurer that provides a group health insurance or health care 7,073
158
policy, contract, or plan that is specified in the order and a 7,074
requirement that the obligor, no later than thirty days after the 7,075
issuance of the order under division (B)(1) of this section, 7,076
furnish written proof to the child support enforcement agency 7,077
that the required health insurance coverage has been obtained, if 7,078
that coverage is available at a reasonable cost through a group 7,079
health insurance or health care policy, contract, or plan offered 7,080
by the obligor's employer or through any other group health 7,081
insurance or health care policy, contract, or plan available to 7,082
the obligor and if health insurance coverage for the children is 7,083
not available for a more reasonable cost through a group health 7,084
insurance or health care policy, contract, or plan available to 7,085
the obligee under the administrative child support order; 7,086
(2) If the obligor is required under division (B)(1) of 7,088
this section to obtain health insurance coverage for the children 7,089
who are the subject of the administrative child support order, a 7,090
requirement that the obligor supply the obligee with information 7,091
regarding the benefits, limitations, and exclusions of the health 7,092
insurance coverage, copies of any insurance forms necessary to 7,093
receive reimbursement, payment, or other benefits under the 7,094
health insurance coverage, and a copy of any necessary insurance 7,095
cards, a requirement that the obligor submit a copy of the 7,096
administrative order issued pursuant to division (B) of this 7,097
section to the insurer at the time that the obligor makes 7,098
application to enroll the children in the health insurance or 7,099
health care policy, contract, or plan, and a requirement that the 7,100
obligor, no later than thirty days after the issuance of the 7,101
administrative order under division (B)(2) of this section, 7,102
furnish written proof to the child support enforcement agency 7,103
that division (B)(2) of this section has been complied with; 7,104
(3) A requirement that the obligee under the 7,106
administrative child support order obtain health insurance 7,107
coverage for the children who are the subject of the 7,108
administrative child support order from an insurer that provides 7,109
159
a group health insurance or health care policy, contract, or plan 7,110
that is specified in the administrative order and a requirement 7,111
that the obligee, no later than thirty days after the issuance of 7,112
the administrative order under division (B)(1) of this section, 7,113
furnish written proof to the child support enforcement agency 7,114
that the required health insurance coverage has been obtained, if 7,115
that coverage is available through a group health insurance or 7,116
health care policy, contract, or plan offered by the obligee's 7,117
employer or through any other group health insurance or health 7,118
care policy, contract, or plan available to the obligee and if 7,119
that coverage is available at a more reasonable cost than health 7,120
insurance coverage for the children through a group health 7,121
insurance or health care policy, contract, or plan available to 7,122
the obligor; 7,123
(4) If the obligee is required under division (B)(3) of 7,125
this section to obtain health insurance coverage for the children 7,126
who are the subject of the administrative child support order, a 7,127
requirement that the obligee submit a copy of the administrative 7,128
order issued pursuant to division (B) of this section to the 7,129
insurer at the time that the obligee makes application to enroll 7,130
the children in the health insurance or health care policy, 7,131
contract, or plan; 7,132
(5) A list of the group health insurance and health care 7,134
policies, contracts, and plans that the child support enforcement 7,135
agency determines are available at a reasonable cost to the 7,136
obligor or to the obligee and the name of the insurer that issues 7,137
each policy, contract, or plan; 7,138
(6) A statement setting forth the name, address, and 7,140
telephone number of the individual who is to be reimbursed for 7,141
out-of-pocket medical, optical, hospital, dental, or prescription 7,142
expenses paid for each child who is the subject of the 7,143
administrative child support order and a statement that the 7,144
insurer that provides the health insurance coverage for the 7,145
children may continue making payment for medical, optical, 7,146
160
hospital, dental, or prescription services directly to any health 7,147
care provider in accordance with the applicable health insurance 7,148
or health care policy, contract, or plan; 7,149
(7) A requirement that the obligor and the obligee 7,151
designate the children who are the subject of the administrative 7,152
child support order as covered dependents under any health 7,153
insurance or health care policy, contract, or plan for which they 7,154
contract; 7,155
(8) A requirement that the obligor, the obligee, or both 7,157
of them under a formula established by the child support 7,158
enforcement agency pay copayment or deductible costs required 7,159
under the health insurance or health care policy, contract, or 7,160
plan that covers the children; 7,161
(9) If health insurance coverage for the children who are 7,163
the subject of the administrative order is not available at a 7,164
reasonable cost through a group health insurance or health care 7,165
policy, contract, or plan offered by the obligor's employer or 7,166
through any other group health insurance or health care policy, 7,167
contract, or plan available to the obligor and is not available 7,168
at a reasonable cost through a group health insurance or health 7,169
care policy, contract, or plan offered by the obligee's employer 7,170
or through any other group health insurance or health care 7,171
policy, contract, or plan available to the obligee, a requirement 7,172
that the obligor and the obligee share liability for the cost of 7,173
the medical and health care needs of the children who are the 7,174
subject of the administrative order, under an equitable formula 7,175
established by the agency, and a requirement that if, after the 7,176
issuance of the order, health insurance coverage for the children 7,177
who are the subject of the administrative order becomes available 7,178
at a reasonable cost through a group health insurance or health 7,179
care policy, contract, or plan offered by the obligor's or 7,180
obligee's employer or through any other group health insurance or 7,181
health care policy, contract, or plan available to the obligor or 7,182
obligee, the obligor or obligee to whom the coverage becomes 7,183
161
available immediately inform the agency of that fact.; 7,184
(10) A notice that, if the obligor is required under 7,186
divisions (B)(1) and (2) of this section to obtain health 7,187
insurance coverage for the children who are the subject of the 7,188
administrative child support order and if the obligor fails to 7,189
comply with the requirements of those divisions, the child 7,190
support enforcement agency immediately shall issue an 7,191
administrative order to the employer of the obligor, upon written 7,192
notice from the child support enforcement agency, requiring the 7,193
employer to take whatever action is necessary to make application 7,194
to enroll the obligor in any available group health insurance or 7,195
health care policy, contract, or plan with coverage for the 7,196
children who are the subject of the administrative child support 7,197
order, to submit a copy of the administrative order issued 7,198
pursuant to division (B) of this section to the insurer at the 7,199
time that the employer makes application to enroll the children 7,200
in the health insurance or health care policy, contract, or plan, 7,201
and, if the obligor's application is accepted, to deduct any 7,202
additional amount from the obligor's earnings necessary to pay 7,203
any additional cost for that health insurance coverage; 7,204
(11) A notice that during the time that an order under 7,206
this section is in effect, the employer of the obligor is 7,207
required to release to the obligee or the child support 7,208
enforcement agency upon written request any necessary information 7,209
on the health insurance coverage of the obligor, including, but 7,210
not limited to, the name and address of the insurer and any 7,211
policy, contract, or plan number, and to otherwise comply with 7,212
this section and any court order issued under this section; 7,213
(12) A statement setting forth the full name and date of 7,215
birth of each child who is the subject of the administrative 7,216
child support order; 7,217
(13) A requirement that the obligor and the obligee comply 7,219
with any requirement described in division (B)(1), (2), (3), (4), 7,220
or (7) of this section that is contained in the order issued 7,221
162
under this section no later than thirty days after the issuance 7,222
of the order. 7,223
(C) If an administrative officer of a child support 7,225
enforcement agency issues an administrative support order under 7,226
section 3111.20, 3111.21, or 3111.22 of the Revised Code, the 7,227
child support enforcement agency, in addition to any requirements 7,229
in those sections and in lieu of an order issued under division 7,230
(B) of this section, may issue a separate order requiring both 7,231
the obligor and the obligee to obtain health insurance coverage 7,232
for the children who are the subject of the administrative child 7,233
support order, if health insurance coverage is available for the 7,234
children and if the agency determines that the coverage is 7,235
available at a reasonable cost to both the obligor and the 7,236
obligee and that the dual coverage by both parents would provide 7,237
for coordination of medical benefits without unnecessary 7,238
duplication of coverage. If the agency issues an order under 7,239
this division, it shall include in the order any of the 7,240
requirements, notices, and information set forth in divisions 7,241
(B)(1) to (13) of this section that are applicable. 7,242
(D) Any administrative order issued under this section 7,244
shall be binding upon the obligor and the obligee, their 7,245
employers, and any insurer that provides health insurance 7,246
coverage for either of them or their children. The agency shall 7,247
send a copy of any administrative order issued under this section 7,248
that contains any requirement or notice described in division 7,249
(B)(1), (2), (3), (4), (7), (8), or (10) of this section by 7,250
ordinary mail to the obligor, the obligee, and any employer that 7,251
is subject to the administrative order. The agency shall send a 7,252
copy of any administrative order issued under this section that 7,253
contains any requirement contained in division (B)(9) of this 7,254
section by ordinary mail to the obligor and obligee. 7,255
(E) If an obligor does not comply with any administrative 7,257
order issued under this section that contains any requirement or 7,258
notice described in division (B)(1), (2), (4), (7), (8), or (10) 7,259
163
of this section within thirty days after the administrative order 7,260
is issued, the child support enforcement agency shall notify the 7,261
court of common pleas of the county in which the agency is 7,262
located in writing of the failure of the obligor to comply with 7,263
the administrative order. Upon receipt of the notice from the 7,264
agency, the court shall issue an order to the employer of the 7,265
obligor requiring the employer to take whatever action is 7,266
necessary to make application to enroll the obligor in any 7,267
available group health insurance or health care policy, contract, 7,268
or plan with coverage for the children who are the subject of the 7,269
administrative child support order, to submit a copy of the 7,270
administrative order issued pursuant to division (B) of this 7,271
section to the insurer at the time that the employer makes 7,272
application to enroll the children in the health insurance or 7,273
health care policy, contract, or plan, and, if the obligor's 7,274
application is accepted, to deduct from the wages or other income 7,275
of the obligor the cost of the coverage for the children. Upon 7,276
receipt of any court order under this division, the employer 7,277
shall take whatever action is necessary to comply with the court 7,278
order. 7,279
During the time that any administrative or court order 7,281
issued under this section is in effect and after the employer has 7,282
received a copy of the administrative or court order, the 7,283
employer of the obligor who is the subject of the administrative 7,284
or court order shall comply with the administrative or court 7,285
order and, upon request from the obligee or agency, shall release 7,286
to the obligee and the child support enforcement agency all 7,287
information about the obligor's health insurance coverage that is 7,288
necessary to ensure compliance with this section or any 7,289
administrative or court order issued under this section, 7,290
including, but not limited to, the name and address of the 7,291
insurer and any policy, contract, or plan number. Any 7,292
information provided by an employer pursuant to this division 7,293
shall be used only for the purpose of the enforcement of an 7,294
164
administrative or court order issued under this section. 7,295
Any employer who receives a copy of an administrative or 7,297
court order issued under this section shall notify the child 7,298
support enforcement agency of any change in or the termination of 7,299
the obligor's health insurance coverage that is maintained 7,300
pursuant to an order issued under this section. 7,301
(F) Any insurer that receives a copy of an administrative 7,303
order issued under this section shall comply with this section 7,304
and any administrative order issued under this section, 7,305
regardless of the residence of the children. If an insurer 7,306
provides health insurance coverage for the children who are the 7,307
subject of an administrative child support order in accordance 7,308
with an order issued under this section, the insurer shall 7,309
reimburse the parent, who is designated to receive reimbursement 7,310
in the administrative order issued under this section, for 7,311
covered out-of-pocket medical, optical, hospital, dental, or 7,312
prescription expenses incurred on behalf of the children subject 7,313
to the administrative order. 7,314
(G) If an obligee under an administrative child support 7,316
order is eligible for medical assistance under Chapter 5111. or 7,317
5115. of the Revised Code and the obligor has obtained health 7,318
insurance coverage pursuant to an administrative order issued 7,319
under division (B) of this section, the obligee shall notify any 7,320
physician, hospital, or other provider of medical services for 7,321
which medical assistance is available of the name and address of 7,322
the obligor's insurer and of the number of the obligor's health 7,323
insurance or health care policy, contract, or plan. Any 7,324
physician, hospital, or other provider of medical services for 7,325
which medical assistance is available under Chapter 5111. or 7,326
5115. of the Revised Code who is notified under this division of 7,327
the existence of a health insurance or health care policy, 7,328
contract, or plan with coverage for children who are eligible for 7,329
medical assistance first shall bill the insurer for any services 7,330
provided for those children. If the insurer fails to pay all or 7,331
165
any part of a claim filed under this division by the physician, 7,332
hospital, or other medical services provider and the services for 7,333
which the claim is filed are covered by Chapter 5111. or 5115. of 7,334
the Revised Code, the physician, hospital, or other medical 7,336
services provider shall bill the remaining unpaid costs of the 7,337
services in accordance with Chapter 5111. or 5115. of the Revised 7,338
Code.
(H) Any obligor who fails to comply with an administrative 7,340
order issued under this section is liable to the obligee for any 7,341
medical expenses incurred as a result of the failure to comply 7,342
with the administrative order. 7,343
(I) Nothing in this section shall be construed to require 7,345
an insurer to accept for enrollment any child who does not meet 7,346
the underwriting standards of the health insurance or health care 7,347
policy, contract, or plan for which application is made. 7,348
(J) If any person fails to comply with an administrative 7,350
order issued under this section, the agency may bring an action 7,351
under section 3111.242 of the Revised Code in the juvenile court 7,352
of the county in which the agency is located requesting the court 7,353
to find the obligor or any other person in contempt pursuant to 7,355
section 2705.02 of the Revised Code.
Sec. 3113.217. (A) As used in this section: 7,364
(1) "Obligor," "obligee," and "child support enforcement 7,366
agency" have the same meanings as in section 3113.21 of the 7,367
Revised Code. 7,368
(2) "Insurer" means any person that is authorized to 7,370
engage in the business of insurance in this state under Title 7,371
XXXIX of the Revised Code;, any prepaid dental plan, medical care 7,373
corporation, health care INSURING corporation, dental care 7,375
corporation, or health maintenance organization; and any legal 7,376
entity that is self-insured and provides benefits to its 7,377
employees or members.
(B) In any action or proceeding in which a child support 7,379
order is issued or modified on or after July 1, 1990, under 7,380
166
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,381
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,383
3113.07, 3113.216, or 3113.31 of the Revised Code, the child 7,385
support enforcement agency shall determine whether the obligor or 7,386
obligee has satisfactory health insurance coverage, other than 7,387
medical assistance under Title XIX of the "Social Security Act," 7,388
49 Stat. 620 (1935), 42 U.S.C. 301, as amended, for the children 7,389
who are the subject of the child support order. If the agency 7,390
determines that neither the obligor nor the obligee has 7,391
satisfactory health insurance coverage for the children, it shall 7,392
file a motion with the court requesting the court to issue an 7,393
order in accordance with divisions (C) to (K) of this section. 7,394
(C) In any action or proceeding in which a child support 7,396
order is issued or modified on or after July 1, 1990, under 7,397
Chapter 3115. or section 2151.23, 2151.231, 2151.33, 2151.36, 7,398
2151.49, 3105.18, 3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 7,400
3113.07, 3113.216, or 3113.31 of the Revised Code, in addition to 7,402
any requirements in those sections, the court also shall issue a 7,403
separate order that includes all of the following: 7,404
(1) A requirement that the obligor under the child support 7,406
order obtain health insurance coverage for the children who are 7,407
the subject of the child support order from an insurer that 7,408
provides a group health insurance or health care policy, 7,409
contract, or plan that is specified in the order and a 7,410
requirement that the obligor, no later than thirty days after the 7,411
issuance of the order under division (C)(1) of this section, 7,412
furnish written proof to the child support enforcement agency 7,413
that the required health insurance coverage has been obtained, if 7,414
that coverage is available at a reasonable cost through a group 7,415
health insurance or health care policy, contract, or plan offered 7,416
by the obligor's employer or through any other group health 7,417
insurance or health care policy, contract, or plan available to 7,418
the obligor and if health insurance coverage for the children is 7,419
not available for a more reasonable cost through a group health 7,420
167
insurance or health care policy, contract, or plan available to 7,421
the obligee under the child support order; 7,422
(2) If the obligor is required under division (C)(1) of 7,424
this section to obtain health insurance coverage for the children 7,425
who are the subject of the child support order, a requirement 7,426
that the obligor supply the obligee with information regarding 7,427
the benefits, limitations, and exclusions of the health insurance 7,428
coverage, copies of any insurance forms necessary to receive 7,429
reimbursement, payment, or other benefits under the health 7,430
insurance coverage, and a copy of any necessary insurance cards, 7,431
a requirement that the obligor submit a copy of the court order 7,432
issued pursuant to division (C) of this section to the insurer at 7,433
the time that the obligor makes application to enroll the 7,434
children in the health insurance or health care policy, contract, 7,435
or plan, and a requirement that the obligor, no later than thirty 7,436
days after the issuance of the order under division (C)(2) of 7,437
this section, furnish written proof to the child support 7,438
enforcement agency that division (C)(2) of this section has been 7,439
complied with; 7,440
(3) A requirement that the obligee under the child support 7,442
order obtain health insurance coverage for the children who are 7,443
the subject of the child support order from an insurer that 7,444
provides a group health insurance or health care policy, 7,445
contract, or plan that is specified in the order and a 7,446
requirement that the obligee, no later than thirty days after the 7,447
issuance of the order under division (C)(1) of this section, 7,448
furnish written proof to the child support enforcement agency 7,449
that the required health insurance coverage has been obtained, if 7,450
that coverage is available through a group health insurance or 7,451
health care policy, contract, or plan offered by the obligee's 7,452
employer or through any other group health insurance or health 7,453
care policy, contract, or plan available to the obligee and if 7,454
that coverage is available at a more reasonable cost than health 7,455
insurance coverage for the children through a group health 7,456
168
insurance or health care policy, contract, or plan available to 7,457
the obligor; 7,458
(4) If the obligee is required under division (C)(3) of 7,460
this section to obtain health insurance coverage for the children 7,461
who are the subject of the child support order, a requirement 7,462
that the obligee submit a copy of the court order issued pursuant 7,463
to division (C) of this section to the insurer at the time that 7,464
the obligee makes application to enroll the children in the 7,465
health insurance or health care policy, contract, or plan; 7,466
(5) A list of the group health insurance and health care 7,468
policies, contracts, and plans that the court determines are 7,469
available at a reasonable cost to the obligor or to the obligee 7,470
and the name of the insurer that issues each policy, contract, or 7,471
plan; 7,472
(6) A statement setting forth the name, address, and 7,474
telephone number of the individual who is to be reimbursed for 7,475
out-of-pocket medical, optical, hospital, dental, or prescription 7,476
expenses paid for each child who is the subject of the support 7,477
order and a statement that the insurer that provides the health 7,478
insurance coverage for the children may continue making payment 7,479
for medical, optical, hospital, dental, or prescription services 7,480
directly to any health care provider in accordance with the 7,481
applicable health insurance or health care policy, contract, or 7,482
plan; 7,483
(7) A requirement that the obligor and the obligee 7,485
designate the children who are the subject of the child support 7,486
order as covered dependents under any health insurance or health 7,487
care policy, contract, or plan for which they contract; 7,488
(8) A requirement that the obligor, the obligee, or both 7,490
of them under a formula established by the court pay co-payment 7,491
or deductible costs required under the health insurance or health 7,492
care policy, contract, or plan that covers the children; 7,493
(9) If health insurance coverage for the children who are 7,495
the subject of the order is not available at a reasonable cost 7,496
169
through a group health insurance or health care policy, contract, 7,497
or plan offered by the obligor's employer or through any other 7,498
group health insurance or health care policy, contract, or plan 7,499
available to the obligor and is not available at a reasonable 7,500
cost through a group health insurance or health care policy, 7,501
contract, or plan offered by the obligee's employer or through 7,502
any other group health insurance or health care policy, contract, 7,503
or plan available to the obligee, a requirement that the obligor 7,504
and the obligee share liability for the cost of the medical and 7,505
health care needs of the children who are the subject of the 7,506
order, under an equitable formula established by the court, and a 7,507
requirement that if, after the issuance of the order, health 7,508
insurance coverage for the children who are the subject of the 7,509
order becomes available at a reasonable cost through a group 7,510
health insurance or health care policy, contract, or plan offered 7,511
by the obligor's or obligee's employer or through any other group 7,512
health insurance or health care policy, contract, or plan 7,513
available to the obligor or obligee, the obligor or obligee to 7,514
whom the coverage becomes available immediately inform the court 7,515
of that fact.; 7,516
(10) A notice that, if the obligor is required under 7,518
divisions (C)(1) and (2) of this section to obtain health 7,519
insurance coverage for the children who are the subject of the 7,520
child support order and if the obligor fails to comply with the 7,521
requirements of those divisions, the court immediately shall 7,522
issue an order to the employer of the obligor, upon written 7,523
notice from the child support enforcement agency, requiring the 7,524
employer to take whatever action is necessary to make application 7,525
to enroll the obligor in any available group health insurance or 7,526
health care policy, contract, or plan with coverage for the 7,527
children who are the subject of the child support order, to 7,528
submit a copy of the court order issued pursuant to division (C) 7,529
of this section to the insurer at the time that the employer 7,530
makes application to enroll the children in the health insurance 7,531
170
or health care policy, contract, or plan, and, if the obligor's 7,532
application is accepted, to deduct any additional amount from the 7,533
obligor's earnings necessary to pay any additional cost for that 7,534
health insurance coverage; 7,535
(11) A notice that during the time that an order under 7,537
this section is in effect, the employer of the obligor is 7,538
required to release to the obligee or the child support 7,539
enforcement agency upon written request any necessary information 7,540
on the health insurance coverage of the obligor, including, but 7,541
not limited to, the name and address of the insurer and any 7,542
policy, contract, or plan number, and to otherwise comply with 7,543
this section and any court order issued under this section; 7,544
(12) A statement setting forth the full name and date of 7,546
birth of each child who is the subject of the child support 7,547
order; 7,548
(13) A requirement that the obligor and the obligee comply 7,550
with any requirement described in division (C)(1), (2), (3), (4), 7,551
or (7) of this section that is contained in the order issued 7,552
under this section no later than thirty days after the issuance 7,553
of the order. 7,554
(D) In any action in which a child support order is issued 7,556
or modified on or after July 1, 1990, under Chapter 3115. or 7,557
section 2151.23, 2151.231, 2151.33, 2151.36, 2151.49, 3105.18, 7,558
3105.21, 3109.05, 3109.19, 3111.13, 3113.04, 3113.07, 3113.216, 7,560
or 3113.31 of the Revised Code, the court, in addition to any 7,561
requirements in those sections and in lieu of an order issued 7,562
under division (C) of this section, may issue a separate order 7,563
requiring both the obligor and the obligee to obtain health 7,564
insurance coverage for the children who are the subject of the 7,565
child support order, if health insurance coverage is available 7,566
for the children and if the court determines that the coverage is 7,567
available at a reasonable cost to both the obligor and the 7,568
obligee and that the dual coverage by both parents would provide 7,569
for coordination of medical benefits without unnecessary 7,570
171
duplication of coverage. If the court issues an order under this 7,571
division, it shall include in the order any of the requirements, 7,572
notices, and information set forth in divisions (C)(1) to (13) of 7,573
this section that are applicable. 7,574
(E) Any order issued under this section shall be binding 7,576
upon the obligor and the obligee, their employers, and any 7,577
insurer that provides health insurance coverage for either of 7,578
them or their children. The court shall send a copy of any order 7,579
issued under this section that contains any requirement or notice 7,580
described in division (C)(1), (2), (3), (4), (7), (8), or (10) of 7,581
this section by ordinary mail to the obligor, the obligee, and 7,582
any employer that is subject to the order. The court shall send 7,583
a copy of any order issued under this section that contains any 7,584
requirement contained in division (C)(9) of this section by 7,585
ordinary mail to the obligor and obligee. 7,586
(F) If an obligor does not comply with any order issued 7,588
under this section that contains any requirement or notice 7,589
described in division (C)(1), (2), (4), (7), (8), or (10) of this 7,590
section within thirty days after the order is issued, the child 7,591
support enforcement agency shall notify the court in writing of 7,592
the failure of the obligor to comply with the order. Upon 7,593
receipt of the notice from the agency, the court shall issue an 7,594
order to the employer of the obligor requiring the employer to 7,595
take whatever action is necessary to make application to enroll 7,596
the obligor in any available group health insurance or health 7,597
care policy, contract, or plan with coverage for the children who 7,598
are the subject of the child support order, to submit a copy of 7,599
the court order issued pursuant to division (C) of this section 7,600
to the insurer at the time that the employer makes application to 7,601
enroll the children in the health insurance or health care 7,602
policy, contract, or plan, and, if the obligor's application is 7,603
accepted, to deduct from the wages or other income of the obligor 7,604
the cost of the coverage for the children. Upon receipt of any 7,605
order under this division, the employer shall take whatever 7,606
172
action is necessary to comply with the order. 7,607
During the time that any order issued under this section is 7,609
in effect and after the employer has received a copy of the 7,610
order, the employer of the obligor who is the subject of the 7,611
order shall comply with the order and, upon request from the 7,612
obligee or agency, shall release to the obligee and the child 7,613
support enforcement agency all information about the obligor's 7,614
health insurance coverage that is necessary to ensure compliance 7,615
with this section or any order issued under this section, 7,616
including, but not limited to, the name and address of the 7,617
insurer and any policy, contract, or plan number. Any 7,618
information provided by an employer pursuant to this division 7,619
shall be used only for the purpose of the enforcement of an order 7,620
issued under this section. 7,621
Any employer who receives a copy of an order issued under 7,623
this section shall notify the child support enforcement agency of 7,624
any change in or the termination of the obligor's health 7,625
insurance coverage that is maintained pursuant to an order issued 7,626
under this section. 7,627
(G) Any insurer that receives a copy of an order issued 7,629
under this section shall comply with this section and any order 7,630
issued under this section, regardless of the residence of the 7,631
children. If an insurer provides health insurance coverage for 7,632
the children who are the subject of a child support order in 7,633
accordance with an order issued under this section, the insurer 7,634
shall reimburse the parent, who is designated to receive 7,635
reimbursement in the order issued under this section, for covered 7,636
out-of-pocket medical, optical, hospital, dental, or prescription 7,637
expenses incurred on behalf of the children subject to the order. 7,638
(H) If an obligee under a child support order is eligible 7,640
for medical assistance under Chapter 5111. or 5115. of the 7,641
Revised Code and the obligor has obtained health insurance 7,642
coverage pursuant to an order issued under division (C) of this 7,643
section, the obligee shall notify any physician, hospital, or 7,644
173
other provider of medical services for which medical assistance 7,645
is available of the name and address of the obligor's insurer and 7,646
of the number of the obligor's health insurance or health care 7,647
policy, contract, or plan. Any physician, hospital, or other 7,648
provider of medical services for which medical assistance is 7,649
available under Chapter 5111. or 5115. of the Revised Code who is 7,650
notified under this division of the existence of a health 7,651
insurance or health care policy, contract, or plan with coverage 7,652
for children who are eligible for medical assistance first shall 7,653
bill the insurer for any services provided for those children. 7,654
If the insurer fails to pay all or any part of a claim filed 7,655
under this division by the physician, hospital, or other medical 7,656
services provider and the services for which the claim is filed 7,657
are covered by Chapter 5111. or 5115. of the Revised Code, the 7,658
physician, hospital, or other medical services provider shall 7,659
bill the remaining unpaid costs of the services in accordance 7,660
with Chapter 5111. or 5115. of the Revised Code. 7,661
(I) Any obligor who fails to comply with an order issued 7,663
under this section is liable to the obligee for any medical 7,664
expenses incurred as a result of the failure to comply with the 7,665
order. 7,666
(J) Whoever violates an order issued under this section 7,668
may be punished as for contempt under Chapter 2705. of the 7,669
Revised Code. If an obligor is found in contempt under that 7,670
chapter for failing to comply with an order issued under this 7,671
section and if the obligor previously has been found in contempt 7,672
under that chapter, the court shall consider the obligor's 7,673
failure to comply with the court's order as a change in 7,674
circumstances for the purpose of modification of the amount of 7,675
support due under the child support order that is the basis of 7,676
the order issued under this section. 7,677
(K) Nothing in this section shall be construed to require 7,679
an insurer to accept for enrollment any child who does not meet 7,680
the underwriting standards of the health insurance or health care 7,681
174
policy, contract, or plan for which application is made. 7,682
(L) Notwithstanding section 3109.01 of the Revised Code, 7,684
if a court issues an order under this section requiring a parent 7,685
to obtain health insurance coverage for the children who are the 7,686
subject of a child support order, the order shall remain in 7,687
effect beyond the child's eighteenth birthday as long as the 7,688
child continuously attends on a full-time basis any recognized 7,689
and accredited high school. Any parent ordered to obtain health 7,690
insurance coverage for the children who are the subject of a 7,691
child support order shall continue to obtain the coverage for the 7,692
children under the order, including during seasonal vacation 7,693
periods, until the order terminates. 7,694
Sec. 3307.74. (A) The state teachers retirement board may 7,703
enter into an agreement with insurance companies, medical or 7,704
health care INSURING corporations, health maintenance 7,705
organizations, or government agencies authorized to do business 7,707
in the state for issuance of a policy or contract of health, 7,708
medical, hospital, or surgical benefits, or any combination 7,709
thereof, for those individuals receiving service retirement or a 7,710
disability or survivor benefit subscribing to the plan. 7,712
Notwithstanding any other provision of this chapter, the policy 7,714
or contract may also include coverage for any eligible
individual's spouse and dependent children and for any of the 7,716
individual's sponsored dependents as the board considers 7,717
appropriate. If all or any portion of the policy or contract 7,718
premium is to be paid by any individual receiving service 7,719
retirement or a disability or survivor benefit, the individual 7,720
shall, by written authorization, instruct the board to deduct the 7,722
premium agreed to be paid by the individual to the companies, 7,723
associations, corporations, or agencies. 7,724
The board may contract for coverage on the basis of part or 7,727
all of the cost of the coverage to be paid from appropriate funds 7,728
of the state teachers retirement system. The cost paid from the 7,729
funds of the system shall be included in the employer's 7,731
175
contribution rate provided by section 3307.53 of the Revised 7,732
Code.
The board may provide for self-insurance of risk or level 7,734
of risk as set forth in the contract with the companies, 7,735
corporations, or agencies, and may provide through the 7,736
self-insurance method specific benefits as authorized by the 7,737
rules of the board. 7,738
(B) If the board provides health, medical, hospital, or 7,740
surgical benefits through any means other than a health 7,741
maintenance organization INSURING CORPORATION, it shall offer to 7,742
each individual eligible for the benefits the alternative of 7,745
receiving benefits through enrollment in a health maintenance
organization INSURING CORPORATION, if all of the following apply: 7,747
(1) The health maintenance organization INSURING 7,749
CORPORATION provides HEALTH CARE services in the geographical 7,751
area in which the individual lives; 7,752
(2) The eligible individual was receiving health care 7,754
benefits through a health maintenance organization OR A HEALTH 7,756
INSURING CORPORATION before retirement; 7,757
(3) The rate and coverage provided by the health 7,759
maintenance organization INSURING CORPORATION to eligible 7,760
individuals is comparable to that currently provided by the board 7,763
under division (A) of this section. If the rate or coverage 7,764
provided by the health maintenance organization INSURING 7,765
CORPORATION is not comparable to that currently provided by the 7,767
board under division (A) of this section, the board may deduct 7,768
the additional cost from the eligible individual's monthly 7,769
benefit.
The health maintenance organization INSURING CORPORATION 7,771
shall accept as an enrollee any eligible individual who requests 7,773
enrollment.
The board shall permit each eligible individual to change 7,775
from one plan to another at least once a year at a time 7,776
determined by the board. 7,777
176
(C) The board shall, beginning the month following receipt 7,779
of satisfactory evidence of the payment for coverage, make a 7,780
monthly payment to each recipient of service retirement, or a 7,781
disability or survivor benefit under the state teachers 7,782
retirement system who is eligible for insurance coverage under 7,783
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,784
42 U.S.C.A. 1395j, as amended. The payment shall be the lesser 7,785
of an amount equal to the basic premium for such coverage, or an 7,787
amount equal to the basic premium in effect on April 10, 1991. 7,788
(D) The board shall establish by rule requirements for the 7,790
coordination of any coverage, payment, or benefit provided under 7,792
this section or section 3307.405 of the Revised Code with any 7,794
similar coverage, payment, or benefit made available to the same 7,795
individual by the public employees retirement system, police and 7,796
firemen's disability and pension fund, school employees 7,797
retirement system, or state highway patrol retirement system. 7,798
(E) The board shall make all other necessary rules 7,800
pursuant to the purpose and intent of this section. 7,801
Sec. 3307.741. The state teachers retirement board shall 7,810
establish a program under which members of the retirement system, 7,811
employers on behalf of members, and persons receiving service, 7,812
disability, or survivor benefits are permitted to participate in 7,813
contracts for long-term health care insurance. Participation may 7,814
include dependents and family members. If a participant in a 7,815
contract for long-term care insurance leaves his employment, he 7,816
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 7,818
members may, at their election, continue to participate in a 7,820
program established under this section in the same manner as if 7,821
he THE PARTICIPANT had not left his employment, except that no 7,823
part of the cost of the insurance shall be paid by his THE 7,824
PARTICIPANT'S former employer.
Such program may be established independently or jointly 7,826
with one or more of the other retirement systems. For purposes 7,827
of this section, "retirement systems" has the same meaning as in 7,828
177
division (A) of section 145.581 of the Revised Code. 7,829
The board may enter into an agreement with insurance 7,831
companies, medical or health care INSURING corporations, health 7,833
maintenance organizations, or government agencies authorized to
do business in the state for issuance of a long-term care 7,834
insurance policy or contract. However, prior to entering into 7,835
such an agreement with an insurance company, medical or health 7,836
care INSURING corporation, or health maintenance organization, 7,838
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 7,840
or organization. The board shall not enter into the agreement 7,841
if, according to that certification, the company, OR corporation, 7,842
or organization is insolvent, is determined by the superintendent 7,843
to be potentially unable to fulfill its contractual obligations, 7,845
or is placed under an order of rehabilitation or conservation by 7,846
a court of competent jurisdiction or under an order of 7,847
supervision by the superintendent. 7,848
The board shall adopt rules in accordance with section 7,850
111.15 of the Revised Code governing the program. The rules 7,851
shall establish methods of payment for participation under this 7,852
section, which may include establishment of a payroll deduction 7,853
plan under section 3307.281 of the Revised Code, deduction of the 7,854
full premium charged from a person's service, disability, or 7,855
survivor benefit, or any other method of payment considered 7,856
appropriate by the board. If the program is established jointly 7,857
with one or more of the other retirement systems, the rules also 7,858
shall establish the terms and conditions of such joint 7,859
participation. 7,860
Sec. 3309.69. (A) As used in this section, "ineligible 7,869
individual" means all of the following: 7,870
(1) A former member receiving benefits pursuant to section 7,872
3309.34, 3309.35, 3309.36, 3309.38, or 3309.381 of the Revised 7,873
Code for whom eligibility is established more than five years 7,874
after June 13, 1981, and who, at the time of establishing 7,875
178
eligibility, has accrued less than ten years of service credit, 7,876
exclusive of credit obtained after January 29, 1981, pursuant to 7,877
sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised 7,878
Code; 7,879
(2) The spouse of the former member; 7,881
(3) The beneficiary of the former member receiving 7,883
benefits pursuant to section 3309.46 of the Revised Code. 7,884
(B) The school employees retirement board may enter into 7,886
an agreement with insurance companies, medical or health care 7,887
INSURING corporations, health maintenance organizations, or 7,889
government agencies authorized to do business in the state for 7,890
issuance of a policy or contract of health, medical, hospital, or 7,891
surgical benefits, or any combination thereof, for those 7,892
individuals receiving service retirement or a disability or 7,893
survivor benefit subscribing to the plan and their eligible 7,895
dependents.
If all or any portion of the policy or contract premium is 7,897
to be paid by any individual receiving service retirement or a 7,899
disability or survivor benefit, the person shall, by written 7,900
authorization, instruct the board to deduct the premiums agreed 7,901
to be paid by the individual to the companies, corporations, or 7,903
agencies.
The board may contract for coverage on the basis of part or 7,906
all of the cost of the coverage to be paid from appropriate funds 7,907
of the school employees retirement system. The cost paid from 7,908
the funds of the system shall be included in the employer's 7,910
contribution rate provided by sections 3309.49 and 3309.491 of 7,911
the Revised Code. The board shall not pay or reimburse the cost 7,912
for health care under this section or section 3309.375 of the 7,913
Revised Code for any ineligible individual. 7,914
The board may provide for self-insurance of risk or level 7,916
of risk as set forth in the contract with the companies, 7,917
corporations, or agencies, and may provide through the 7,918
self-insurance method specific benefits as authorized by the 7,919
179
rules of the board. 7,920
(C) If the board provides health, medical, hospital, or 7,922
surgical benefits through any means other than a health 7,923
maintenance organization INSURING CORPORATION, it shall offer to 7,924
each individual eligible for the benefits the alternative of 7,927
receiving benefits through enrollment in a health maintenance 7,929
organization INSURING CORPORATION, if all of the following apply: 7,931
(1) The health maintenance organization INSURING 7,933
CORPORATION provides HEALTH CARE services in the geographical 7,935
area in which the individual lives; 7,936
(2) The eligible individual was receiving health care 7,938
benefits through a health maintenance organization OR A HEALTH 7,939
INSURING CORPORATION before retirement; 7,941
(3) The rate and coverage provided by the health 7,943
maintenance organization INSURING CORPORATION to eligible 7,944
individuals is comparable to that currently provided by the board 7,946
under division (B) of this section. If the rate or coverage 7,947
provided by the health maintenance organization INSURING 7,948
CORPORATION is not comparable to that currently provided by the 7,950
board under division (B) of this section, the board may deduct 7,951
the additional cost from the eligible individual's monthly 7,952
benefit.
The health maintenance organization INSURING CORPORATION 7,954
shall accept as an enrollee any eligible individual who requests 7,956
enrollment.
The board shall permit each eligible individual to change 7,958
from one plan to another at least once a year at a time 7,959
determined by the board. 7,960
(D) The board shall, beginning the month following receipt 7,962
of satisfactory evidence of the payment for coverage, make a 7,963
monthly payment to each recipient of service retirement, or a 7,964
disability or survivor benefit under the school employees 7,965
retirement system who is eligible for insurance coverage under 7,966
part B of "The Social Security Amendments of 1965," 79 Stat. 301, 7,967
180
42 U.S.C.A. 1395j, as amended, except that the board shall make 7,968
no such payment to any ineligible individual. The amount of the 7,969
payment shall be the lesser of an amount equal to the basic 7,970
premium for such coverage, or an amount equal to the basic 7,972
premium in effect on January 1, 1988.
(E) The board shall establish by rule requirements for the 7,974
coordination of any coverage, payment, or benefit provided under 7,976
this section or section 3309.375 of the Revised Code with any 7,978
similar coverage, payment, or benefit made available to the same 7,979
individual by the public employees retirement system, police and 7,980
firemen's disability and pension fund, state teachers retirement 7,981
system, or state highway patrol retirement system. 7,982
(F) The board shall make all other necessary rules 7,984
pursuant to the purpose and intent of this section. 7,985
Sec. 3309.691. The school employees retirement board shall 7,994
establish a program under which members of the retirement system, 7,995
employers on behalf of members, and persons receiving service, 7,996
disability, or survivor benefits are permitted to participate in 7,997
contracts for long-term health care insurance. Participation may 7,998
include dependents and family members. If a participant in a 7,999
contract for long-term care insurance leaves his employment, he 8,000
THE PARTICIPANT and his THE PARTICIPANT'S dependents and family 8,002
members may, at their election, continue to participate in a
program established under this section in the same manner as if 8,003
he THE PARTICIPANT had not left his employment, except that no 8,004
part of the cost of the insurance shall be paid by his THE 8,005
PARTICIPANT'S former employer. 8,006
Such program may be established independently or jointly 8,008
with one or more of the other retirement systems. For purposes 8,009
of this section, "retirement systems" has the same meaning as in 8,010
division (A) of section 145.581 of the Revised Code. 8,011
The board may enter into an agreement with insurance 8,013
companies, medical or health care INSURING corporations, health 8,015
maintenance organizations, or government agencies authorized to
181
do business in the state for issuance of a long-term care 8,016
insurance policy or contract. However, prior to entering into 8,017
such an agreement with an insurance company, medical or health 8,018
care INSURING corporation, or health maintenance organization, 8,020
the board shall request the superintendent of insurance to
certify the financial condition of the company, OR corporation, 8,022
or organization. The board shall not enter into the agreement 8,023
if, according to that certification, the company, OR corporation, 8,024
or organization is insolvent, is determined by the superintendent 8,025
to be potentially unable to fulfill its contractual obligations, 8,027
or is placed under an order of rehabilitation or conservation by 8,028
a court of competent jurisdiction or under an order of 8,029
supervision by the superintendent. 8,030
The board shall adopt rules in accordance with section 8,032
111.15 of the Revised Code governing the program. The rules 8,033
shall establish methods of payment for participation under this 8,034
section, which may include establishment of a payroll deduction 8,035
plan under section 3309.27 of the Revised Code, deduction of the 8,036
full premium charged from a person's service, disability, or 8,037
survivor benefit, or any other method of payment considered 8,038
appropriate by the board. If the program is established jointly 8,039
with one or more of the other retirement systems, the rules also 8,040
shall establish the terms and conditions of such joint 8,041
participation. 8,042
Sec. 3313.202. (A) The board of education of a school 8,051
district may procure and pay all or part of the cost of group 8,052
term life, hospitalization, surgical care, or major medical 8,053
insurance, disability, dental care, vision care, medical care, 8,054
hearing aids, prescription drugs, sickness and accident 8,055
insurance, group legal services, or a combination of any of the 8,056
foregoing types of insurance or coverage, whether issued by an 8,057
insurance company or a medical care corporation, health care 8,058
INSURING corporation, dental care corporation, or health 8,060
maintenance organization duly licensed by this state, covering 8,061
182
the teaching or nonteaching employees of the school district, or 8,062
a combination of both, or the dependent children and spouses of 8,063
such employees, provided if such coverage affects only the 8,064
teaching employees of the district such coverage shall be with 8,065
the consent of a majority of such employees of the school 8,066
district, or if such coverage affects only the nonteaching 8,067
employees of the district such coverage shall be with the consent 8,068
of a majority of such employees. If such coverage is proposed to 8,069
cover all the employees of a school district, both teaching and 8,070
nonteaching employees, such coverage shall be with the consent of 8,071
a majority of all the employees of a school district. A board of 8,072
education shall continue to carry, on payroll records, all school 8,073
employees whose sick leave accumulation has expired, or who are 8,074
on a disability leave of absence or an approved leave of absence, 8,075
for the purpose of group term life, hospitalization, surgical, 8,076
major medical, or any other insurance. A board of education may 8,077
pay all or part of such coverage except when such employees are 8,078
on an approved leave of absence, or on a disability leave of 8,079
absence for that period exceeding two years. As used in this 8,080
section, "teaching employees" means any person employed in the 8,081
public schools of this state in a position for which the person 8,082
is required to have a certificate or license pursuant to sections 8,083
3319.22 to 3319.31 of the Revised Code. "Nonteaching employees" 8,084
as used in this section means any person employed in the public 8,085
schools of the state in a position for which the person is not 8,086
required to have a certificate or license issued pursuant to 8,087
sections 3319.22 to 3319.31 of the Revised Code. 8,088
(B) The board of education of a school district may enter 8,090
into an agreement with a jointly administered trust fund which 8,091
receives contributions pursuant to a collective bargaining 8,092
agreement entered into between the board and any collective 8,093
bargaining representative of the employees of the board for the 8,094
purpose of providing for self-insurance of all risk in the 8,095
provision of fringe benefits similar to those that may be paid 8,096
183
pursuant to division (A) of this section, and may provide through 8,097
the self-insurance method specific fringe benefits as authorized 8,098
by the rules of the board of trustees of the jointly administered 8,099
trust fund. Benefits provided under this section include, but 8,100
are not limited to, hospitalization, surgical care, major medical 8,101
care, disability, dental care, vision care, medical care, hearing 8,102
aids, prescription drugs, group life insurance, sickness and 8,103
accident insurance, group legal services, or a combination of the 8,104
above benefits, for the employees and their dependents. 8,105
(C) Notwithstanding any other provision of the Revised 8,107
Code, the board of education and any collective bargaining 8,108
representative of employees of the board may agree in a 8,109
collective bargaining agreement that any mutually agreed fringe 8,110
benefit, including, but not limited to, hospitalization, surgical 8,111
care, major medical care, disability, dental care, vision care, 8,112
medical care, hearing aids, prescription drugs, group life 8,113
insurance, sickness and accident insurance, group legal services, 8,114
or a combination thereof, for employees and their dependents be 8,115
provided through a mutually agreed upon contribution to a jointly 8,116
administered trust fund. The amount, type, and structure of 8,117
fringe benefits provided under this division are subject to the 8,118
determination of the board of trustees of the jointly 8,119
administered trust fund. Notwithstanding any other provision of 8,120
the Revised Code, competitive bidding does not apply to the 8,121
purchase of fringe benefits for employees under this division 8,122
through a jointly administered trust fund. 8,123
(D) Any elected or appointed member of the board of 8,125
education and the dependent children and spouse of the member may 8,126
be covered, at the option of the member, as an employee of the 8,127
school district under any benefit plan adopted under this 8,128
section. The member shall pay to the school district the amount 8,129
certified for that coverage under division (D)(1) or (2) of this 8,130
section. Payments for such coverage shall be made, in advance, 8,131
in a manner prescribed by the board. The member's exercise of an 8,132
184
option to be covered under this section shall be in writing, 8,133
announced at a regular public meeting of the board, and recorded 8,134
as a public record in the minutes of the board. 8,135
For the purposes of determining the cost to board members 8,137
under this division: 8,138
(1) In the case of a benefit plan purchased under division 8,140
(A) of this section, the provider of the benefits shall certify 8,141
to the board the provider's charge for coverage under each option 8,142
available to employees under that benefit plan; 8,143
(2) In the case of benefits provided under division (B) or 8,145
(C) of this section, the board of trustees of the jointly 8,146
administered trust fund shall certify to the board of education 8,147
the trustees' charge for coverage under each option available to 8,148
employees under each benefit plan. 8,149
(E) The board may provide the benefits described in this 8,151
section through an individual self-insurance program or a joint 8,152
self-insurance program as provided in section 9.833 of the 8,153
Revised Code. 8,154
Sec. 3375.40. Each board of library trustees appointed 8,163
pursuant to sections 3375.06, 3375.10, 3375.12, 3375.15, 3375.22, 8,164
and 3375.30 of the Revised Code may: 8,165
(A) Hold title to and have the custody of all real and 8,167
personal property of the free public library under its 8,168
jurisdiction; 8,169
(B) Expend for library purposes, and in the exercise of 8,171
the power enumerated in this section, all moneys, whether derived 8,172
from the county library and local government support fund or 8,173
otherwise, credited to the free public library under its 8,174
jurisdiction and generally do all things it considers necessary 8,175
for the establishment, maintenance, and improvement of the public 8,176
library under its jurisdiction; 8,177
(C) Purchase, lease, construct, remodel, renovate, or 8,179
otherwise improve, equip, and furnish buildings or parts of 8,180
buildings and other real property, and purchase, lease, or 8,181
185
otherwise acquire motor vehicles and other personal property, 8,183
necessary for the proper maintenance and operation of the free 8,184
public libraries under its jurisdiction, and pay the costs 8,185
thereof in installments or otherwise. Financing of these costs 8,186
may be provided through the issuance of notes, through an 8,187
installment sale, or through a lease-purchase agreement. Any
such notes shall be issued pursuant to section 3375.404 of the 8,188
Revised Code.
(D) Purchase, lease, lease with an option to purchase, or 8,190
erect buildings or parts of buildings to be used as main 8,191
libraries, branch libraries, or library stations pursuant to 8,192
section 3375.41 of the Revised Code; 8,193
(E) Establish and maintain a main library, branches, 8,195
library stations, and traveling library service within the 8,196
territorial boundaries of the subdivision or district over which 8,197
it has jurisdiction of free public library service; 8,198
(F) Establish and maintain branches, library stations, and 8,200
traveling library service in any school district, outside the 8,201
territorial boundaries of the subdivision or district over which 8,202
it has jurisdiction of free public library service, upon 8,203
application to and approval of the state library board, pursuant 8,204
to section 3375.05 of the Revised Code; provided the board of 8,205
trustees of any free public library maintaining branches, 8,206
stations, or traveling-book service, outside the territorial 8,207
boundaries of the subdivision or district over which it has 8,208
jurisdiction of free public library service, on September 4, 8,209
1947, may continue to maintain and operate such branches, 8,210
stations, and traveling library service without the approval of 8,211
the state library board; 8,212
(G) Appoint and fix the compensation of all of the 8,214
employees of the free public library under its jurisdiction; pay 8,215
the reasonable cost of tuition for any of its employees who 8,216
enroll in a course of study the board considers essential to the 8,217
duties of the employee or to the improvement of the employee's 8,218
186
performance; and reimburse applicants for employment for any 8,219
reasonable expenses they incur by appearing for a personal 8,220
interview; 8,221
(H) Make and publish rules for the proper operation and 8,223
management of the free public library and facilities under its 8,224
jurisdiction, including rules pertaining to the provision of 8,225
library services to individuals, corporations, or institutions 8,226
that are not inhabitants of the county; 8,227
(I) Establish and maintain a museum in connection with and 8,229
as an adjunct to the free public library under its jurisdiction; 8,230
(J) By the adoption of a resolution accept any bequest, 8,232
gift, or endowment upon the conditions connected with such 8,233
bequest, gift, or endowment; provided no such bequest, gift, or 8,234
endowment shall be accepted by such board if the conditions 8,235
thereof remove any portion of the free public library under its 8,236
jurisdiction from the control of such board or if such 8,237
conditions, in any manner, limit the free use of such library or 8,238
any part thereof by the residents of the counties in which such 8,239
library is located; 8,240
(K) At the end of any fiscal year by a two-thirds vote of 8,242
its full membership set aside any unencumbered surplus remaining 8,243
in the general fund of the library under its jurisdiction for any 8,244
purpose including creating or increasing a special building and 8,245
repair fund, or for operating the library or acquiring equipment 8,246
and supplies; 8,247
(L) Procure and pay all or part of the cost of group life, 8,249
hospitalization, surgical, major medical, disability benefit, 8,250
dental care, eye care, hearing aids, or prescription drug 8,251
insurance, or a combination of any of the foregoing types of 8,252
insurance or coverage, whether issued by an insurance company, or 8,253
nonprofit medical or dental care A HEALTH INSURING corporation 8,254
duly licensed by the state, covering its employees and in the 8,255
case of hospitalization, surgical, major medical, dental care, 8,256
eye care, hearing aids, or prescription drug insurance, also 8,257
187
covering the dependents and spouses of such employees, and in the 8,258
case of disability benefits, also covering spouses of such 8,259
employees. With respect to life insurance, coverage for any 8,260
employee shall not exceed the greater of the sum of ten thousand 8,261
dollars or the annual salary of the employee, exclusive of any 8,262
double indemnity clause that is a part of the policy. 8,263
(M) Pay reasonable dues and expenses for the free public 8,265
library and library trustees in library associations. 8,266
Sec. 3381.14. A regional arts and cultural district may 8,275
procure and pay all or any part of the cost of group 8,276
hospitalization, surgical, major medical, or sickness and 8,277
accident insurance or a combination of any of the foregoing for 8,278
the employees of the district and their immediate dependents, 8,279
whether issued by an insurance company, nonprofit medical care OR 8,280
A HEALTH INSURING corporation, or hospital service association 8,281
duly authorized to do business in this state. 8,282
Sec. 3501.141. (A) The board of elections of any county 8,291
may contract, purchase, or otherwise procure and pay all or any 8,292
part of the cost of group insurance policies that may provide 8,293
benefits for hospitalization, surgical care, major medical care, 8,294
disability, dental care, eye care, medical care, hearing aids, or 8,295
prescription drugs, and that may provide sickness and accident 8,296
insurance, or group life insurance, or a combination of any of 8,297
the foregoing types of insurance or coverage for the full-time 8,298
employees of such board and their immediate dependents, whether 8,299
issued by an insurance company, a health or medical care 8,300
corporation, a dental care corporation, or a health maintenance 8,301
organization INSURING CORPORATION, duly authorized to do business 8,302
in this state. 8,303
(B) The board of elections of any county may procure and 8,305
pay all or any part of the cost of group hospitalization, 8,306
surgical, major medical, or sickness and accident insurance or a 8,307
combination of any of the foregoing types of insurance or 8,308
coverage for the members appointed to the board of elections 8,309
188
under section 3501.06 of the Revised Code and their immediate 8,310
dependents when each member's term begins, whether issued by an 8,311
insurance company or a health or medical care INSURING 8,312
corporation, duly authorized to do business in this state. 8,313
Sec. 3701.24. (A) As used in this section and sections 8,322
3701.241 to 3701.249 of the Revised Code: 8,323
(1) "AIDS" means the illness designated as acquired 8,325
immunodeficiency syndrome. 8,326
(2) "HIV" means the human immunodeficiency virus 8,328
identified as the causative agent of AIDS. 8,329
(3) "AIDS-related condition" means symptoms of illness 8,331
related to HIV infection, including AIDS-related complex, that 8,333
are confirmed by a positive HIV test. 8,334
(4) "HIV test" means any test for the antibody or antigen 8,336
to HIV that has been approved by the director of health under 8,337
division (B) of section 3701.241 of the Revised Code. 8,338
(5) "Health care facility" has the same meaning as in 8,340
section 1742.01 1751.01 of the Revised Code. 8,341
(6) "Director" means the director of health or any 8,343
employee of the department of health acting on his THE DIRECTOR'S 8,345
behalf.
(7) "Physician" means a person who holds a current, valid 8,347
certificate issued under Chapter 4731. of the Revised Code 8,348
authorizing the practice of medicine or surgery and osteopathic 8,349
medicine and surgery. 8,350
(8) "Nurse" means a registered nurse or licensed practical 8,352
nurse who holds a license or certificate issued under Chapter 8,353
4723. of the Revised Code. 8,354
(9) "Anonymous test" means an HIV test administered so 8,356
that the individual to be tested can give informed consent to the 8,357
test and receive the results by means of a code system that does 8,358
not link his THE identity OF THE INDIVIDUAL TESTED to the request 8,360
for the test or the test results.
(10) "Confidential test" means an HIV test administered so 8,362
189
that the identity of the individual tested is linked to the test 8,363
but is held in confidence to the extent provided by section 8,364
3701.24 to 3701.248 of the Revised Code. 8,365
(11) "Health care provider" means an individual who 8,367
provides diagnostic, evaluative, or treatment services. Pursuant 8,368
to Chapter 119. of the Revised Code, the public health council 8,369
may adopt rules further defining the scope of the term "health 8,370
care provider." 8,371
(12) "Significant exposure to body fluids" means a 8,373
percutaneous or mucous membrane exposure of an individual to the 8,374
blood, semen, vaginal secretions, or spinal, synovial, pleural, 8,375
peritoneal, pericardial, or amniotic fluid of another individual. 8,376
(13) "Emergency medical services worker" means all of the 8,378
following: 8,379
(a) A peace officer; 8,381
(b) An employee of an emergency medical service 8,383
organization as defined in section 4765.01 of the Revised Code; 8,384
(c) A firefighter employed by a political subdivision; 8,386
(d) A volunteer firefighter, emergency operator, or rescue 8,388
operator; 8,389
(e) An employee of a private organization that renders 8,391
rescue services, emergency medical services, or emergency medical 8,392
transportation to accident victims and persons suffering serious 8,393
illness or injury. 8,394
(14) "Peace officer" has the same meaning as in division 8,396
(A) of section 109.71 of the Revised Code, except that it also 8,397
includes a sheriff and the superintendent and troopers of the 8,398
state highway patrol. 8,399
(B) Boards of health, health authorities or officials, and 8,401
physicians in localities in which there are no health authorities 8,402
or officials, shall report promptly to the department of health 8,403
the existence of any one of the following diseases: 8,404
(1) Asiatic cholera; 8,406
(2) Yellow fever; 8,408
190
(3) Diphtheria; 8,410
(4) Typhus or typhoid fever; 8,412
(5) Any other contagious or infectious diseases that the 8,414
public health council specifies. 8,415
(C) Persons designated by rule adopted by the public 8,417
health council under section 3701.241 of the Revised Code shall 8,418
report promptly every case of AIDS, every AIDS-related condition, 8,420
and every confirmed positive HIV test to the department of health 8,421
on forms and in a manner prescribed by the director. In each 8,422
county the director shall designate the health commissioner of a 8,423
health district in the county to receive the reports. 8,424
Information reported under this division that identifies an 8,426
individual is confidential and may be released only with the 8,427
written consent of the individual except as the director 8,428
determines necessary to ensure the accuracy of the information, 8,429
as necessary to provide treatment to the individual, as ordered 8,430
by a court pursuant to section 3701.243 or 3701.247 of the 8,431
Revised Code, or pursuant to a search warrant or a subpoena 8,432
issued by or at the request of a grand jury, prosecuting 8,433
attorney, city director of law or similar chief legal officer of 8,434
a municipal corporation, or village solicitor, in connection with 8,435
a criminal investigation or prosecution. Information that does 8,436
not identify an individual may be released in summary, 8,437
statistical, or other form. 8,438
Sec. 3701.76. (A) The director of health shall establish 8,447
and maintain a statewide public information campaign on the 8,448
effects of diethylstilbestrol or other nonsteroidal synthetic 8,449
estrogens for the purpose of educating the public concerning the 8,450
potential hazards related to exposure to diethylstilbestrol or 8,451
other nonsteroidal synthetic estrogens and encouraging persons 8,452
exposed to diethylstilbestrol or other nonsteroidal synthetic 8,453
estrogens, including those exposed before birth, to seek medical 8,454
attention for the identification and treatment of any conditions 8,455
resulting from this exposure. 8,456
191
(B) The director shall maintain a registry of hospitals, 8,458
clinics, physicians, or other health care providers to whom he 8,459
THE DIRECTOR shall refer persons who make inquiries to the 8,460
department of health regarding possible exposure to 8,461
diethylstilbestrol or other nonsteroidal synthetic estrogens. In 8,462
order to be eligible for listing in the registry, a health care 8,463
provider shall make an application to the director, and shall 8,464
have the necessary experience, facilities, and equipment to make 8,465
examinations for possible effects of diethylstilbestrol or other 8,466
nonsteroidal synthetic estrogens. 8,467
(C) The director shall maintain a registry of persons who 8,469
have been exposed to diethylstilbestrol or other nonsteroidal 8,470
synthetic estrogens, including persons exposed before birth, for 8,471
the purpose of studying and monitoring conditions caused by 8,472
exposure to diethylstilbestrol or other nonsteroidal synthetic 8,473
estrogen. No person shall be listed in the registry without his 8,474
THE DIRECTOR'S consent. 8,475
(D) The director shall make an annual report to the 8,477
general assembly on the effectiveness of the programs established 8,478
under this section, and shall make recommendations concerning the 8,479
programs and possible legislation relating to them. 8,480
(E) No insurance company doing business under Title XXXIX 8,482
and no HEALTH INSURING corporation holding a certificate of 8,483
authority or license under Chapter 1737., 1738., or 1742. 1751. 8,484
of the Revised Code shall cancel or refuse to renew a policy or 8,486
subscription, contract, CERTIFICATE, OR AGREEMENT or limit 8,487
benefits provided under a policy or subscription, contract, 8,488
CERTIFICATE, OR AGREEMENT solely because a policyholder, 8,489
subscriber, or applicant for a policy or subscription, contract, 8,490
CERTIFICATE, OR AGREEMENT has been exposed to diethylstilbestrol 8,491
or other nonsteroidal synthetic estrogens. 8,492
Sec. 3702.51. As used in sections 3702.51 to 3702.62 of 8,501
the Revised Code: 8,502
(A) "Applicant" means any person that submits an 8,504
192
application for a certificate of need and who is designated in 8,505
the application as the applicant. 8,506
(B) "Person" means any individual, corporation, business 8,508
trust, estate, firm, partnership, association, joint stock 8,509
company, insurance company, government unit, or other entity. 8,510
(C) "Certificate of need" means a written approval granted 8,512
by the director of health to an applicant to authorize conducting 8,513
a reviewable activity. 8,514
(D) "Health service area" means a geographic region 8,516
designated by the director of health under section 3702.58 of the 8,517
Revised Code. 8,518
(E) "Health service" means a clinically related service, 8,520
such as a diagnostic, treatment, rehabilitative, or preventive 8,521
service. 8,522
(F) "Health service agency" means an agency designated to 8,524
serve a health service area in accordance with section 3702.58 of 8,525
the Revised Code. 8,526
(G) "Health care facility" means: 8,528
(1) A hospital registered under section 3701.07 of the 8,530
Revised Code; 8,531
(2) A nursing home licensed under section 3721.02 of the 8,533
Revised Code, or by a political subdivision certified under 8,534
section 3721.09 of the Revised Code; 8,535
(3) A county home or a county nursing home as defined in 8,537
section 5155.31 of the Revised Code that is certified under Title 8,538
XVIII or XIX of the "Social Security Act," 49 Stat. 620 (1935), 8,539
42 U.S.C.A. 301, as amended; 8,540
(4) A freestanding dialysis center; 8,542
(5) A freestanding inpatient rehabilitation facility; 8,544
(6) An ambulatory surgical facility; 8,546
(7) A freestanding cardiac catheterization facility; 8,548
(8) A freestanding birthing center; 8,550
(9) A freestanding or mobile diagnostic imaging center; 8,552
(10) A freestanding radiation therapy center. 8,554
193
A health care facility does not include the offices of 8,556
private physicians and dentists whether for individual or group 8,557
practice, Christian Science sanitoriums operated or listed and 8,558
certified by the First Church of Christ, Scientist, Boston, 8,559
Massachusetts, residential facilities licensed under section 8,560
5123.19 of the Revised Code, or habilitation centers certified by 8,561
the director of mental retardation and developmental disabilities 8,562
under section 5123.041 of the Revised Code. 8,563
(H) "Medical equipment" means a single unit of medical 8,565
equipment or a single system of components with related functions 8,566
that is used to provide health services. 8,567
(I) "Third-party payer" means a medical care corporation 8,569
or health care INSURING corporation licensed under Chapter 1737. 8,571
or 1738. 1751. of the Revised Code, a health maintenance 8,572
organization AS DEFINED IN DIVISION (K) OF THIS SECTION, an 8,573
insurance company that issues sickness and accident insurance in 8,574
conformity with Chapter 3923. of the Revised Code, a 8,575
state-financed health insurance program under Chapter 3701., 8,576
4123., or 5111. of the Revised Code, or any self-insurance plan. 8,577
(J) "Government unit" means the state and any county, 8,579
municipal corporation, township, or other political subdivision 8,580
of the state, or any department, division, board, or other agency 8,581
of the state or a political subdivision. 8,582
(K) "Health maintenance organization" means a public or 8,584
private organization organized under the law of any state that is 8,585
qualified under section 1310(d) of Title XIII of the "Public 8,586
Health Service Act," 87 Stat. 931 (1973), 42 U.S.C. 300e--9 or 8,587
that does all of the following: 8,588
(1) Provides or otherwise makes available to enrolled 8,590
participants health care services including at least the 8,591
following basic health care services: usual physician services, 8,592
hospitalization, laboratory, x-ray, emergency and preventive 8,593
services, and out-of-area coverage; 8,594
(2) Is compensated, except for copayments, for the 8,596
194
provision of basic health care services listed in division (K)(1) 8,597
of this section to enrolled participants by a payment that is 8,598
paid on a periodic basis without regard to the date the health 8,599
care services are provided and that is fixed without regard to 8,600
the frequency, extent, or kind of health service actually 8,601
provided; 8,602
(3) Provides physician services primarily either: 8,604
(a) Directly through physicians who are either employees 8,606
or partners of the organization; 8,607
(b) Through arrangements with individual physicians or one 8,609
or more groups of physicians organized on a group practice or 8,610
individual practice basis. 8,611
(L) "Existing health care facility" means a health care 8,613
facility that is licensed or otherwise approved to practice in 8,614
this state, in accordance with applicable law, is staffed and 8,615
equipped to provide health care services, and actively provides 8,616
health services or has not been actively providing health 8,617
services for less than twelve consecutive months. 8,618
(M) "State" means the state of Ohio, including, but not 8,620
limited to, the general assembly, the supreme court, the offices 8,621
of all elected state officers, and all departments, boards, 8,622
offices, commissions, agencies, institutions, and other 8,623
instrumentalities of the state of Ohio. "State" does not include 8,624
political subdivisions. 8,625
(N) "Political subdivision" means a municipal corporation, 8,627
township, county, school district, and all other bodies corporate 8,628
and politic responsible for governmental activities only in 8,629
geographic areas smaller than that of the state to which the 8,630
sovereign immunity of the state attaches. 8,631
(O) "Affected person" means: 8,633
(1) An applicant for a certificate of need, including an 8,635
applicant whose application was reviewed comparatively with the 8,636
application in question; 8,637
(2) The person that requested the reviewability ruling in 8,639
195
question;
(3) Any person that resides or regularly uses health care 8,641
facilities within the geographic area served or to be served by 8,642
the health care services that would be provided under the 8,643
certificate of need or reviewability ruling in question; 8,644
(4) Any health care facility that is located in the health 8,646
service area where the health care services would be provided 8,647
under the certificate of need or reviewability ruling in 8,648
question;
(5) Third-party payers that reimburse health care 8,650
facilities for services in the health service area where the 8,651
health care services would be provided under the certificate of 8,652
need or reviewability ruling in question; 8,653
(6) Any other person who testified at a public hearing 8,655
held under division (B) of section 3702.52 of the Revised Code or 8,656
submitted written comments in the course of review of the 8,657
certificate of need application in question. 8,658
(P) "Osteopathic hospital" means a hospital registered 8,660
under section 3701.07 of the Revised Code that advocates 8,661
osteopathic principles and the practice and perpetuation of 8,662
osteopathic medicine by doing any of the following: 8,663
(1) Maintaining a department or service of osteopathic 8,665
medicine or a committee on the utilization of osteopathic 8,666
principles and methods, under the supervision of an osteopathic 8,667
physician; 8,668
(2) Maintaining an active medical staff, the majority of 8,670
which is comprised of osteopathic physicians; 8,671
(3) Maintaining a medical staff executive committee that 8,673
has osteopathic physicians as a majority of its members. 8,674
(Q) "Ambulatory surgical facility" has the same meaning as 8,676
in section 3702.30 of the Revised Code. 8,677
(R) Except as otherwise provided in division (T) of this 8,679
section, and until the termination date specified in section 8,680
3702.511 of the Revised Code, "reviewable activity" means any of 8,681
196
the following:
(1) The addition by any person of any of the following 8,684
health services, regardless of the amount of operating costs or 8,685
capital expenditures: 8,686
(a) A heart, heart-lung, lung, liver, kidney, bowel, 8,688
pancreas, or bone marrow transplantation service, a stem cell 8,689
harvesting and reinfusion service, or a service for 8,690
transplantation of any other organ unless transplantation of the 8,691
organ is designated by public health council rule not to be a 8,692
reviewable activity; 8,693
(b) A cardiac catheterization service; 8,695
(c) An open-heart surgery service; 8,697
(d) Any new, experimental medical technology that is 8,700
designated by rule of the public health council.
(2) The acceptance of high-risk patients, as defined in 8,702
rules adopted under section 3702.57 of the Revised Code, by any 8,703
cardiac catheterization service that was initiated without a 8,704
certificate of need pursuant to division (R)(3)(b) of the version 8,706
of this section in effect immediately prior to April 20, 1995; 8,708
(3)(a) The establishment, development, or construction of 8,710
a new health care facility other than a new long-term care 8,711
facility or a new hospital; 8,712
(b) The establishment, development, or construction of a 8,714
new hospital or the relocation of an existing hospital; 8,715
(c) The relocation of hospital beds, other than long-term 8,717
care, perinatal, or pediatric intensive care beds, into or out of 8,718
a rural area. 8,719
(4)(a) The replacement of an existing hospital; 8,721
(b) The replacement of an existing hospital obstetric or 8,723
newborn care unit or freestanding birthing center. 8,725
(5)(a) The renovation of a hospital that involves a 8,729
capital expenditure, obligated on or after the effective date of
this amendment, of five million dollars or more, not including 8,731
expenditures for equipment, staffing, or operational costs. For
197
purposes of division (R)(5)(a) of this section, a capital 8,733
expenditure is obligated:
(i) When a contract enforceable under Ohio law is entered 8,735
into for the construction, acquisition, lease, or financing of a 8,736
capital asset; 8,737
(ii) When the governing body of a hospital takes formal 8,739
action to commit its own funds for a construction project 8,740
undertaken by the hospital as its own contractor; 8,741
(iii) In the case of donated property, on the date the 8,743
gift is completed under applicable Ohio law. 8,744
(b) The renovation of a hospital obstetric or newborn care 8,746
unit or freestanding birthing center that involves a capital 8,748
expenditure of five million dollars or more, not including 8,749
expenditures for equipment, staffing, or operational costs. 8,750
(6) Any change in the health care services, bed capacity, 8,752
or site, or any other failure to conduct the reviewable activity 8,753
in substantial accordance with the approved application for which 8,754
a certificate of need was granted, if the change is made prior to 8,755
the date the activity for which the certificate was issued ceases 8,756
to be a reviewable activity; 8,757
(7) Any of the following changes in perinatal bed capacity 8,759
or pediatric intensive care bed capacity: 8,760
(a) An increase in bed capacity; 8,762
(b) A change in service or service-level designation of 8,765
newborn care beds or obstetric beds in a hospital or freestanding 8,766
birthing center, other than a change of service that is provided
within the service-level designation of newborn care or obstetric 8,767
beds as registered by the department of health; 8,768
(c) A relocation of perinatal or pediatric intensive care 8,771
beds from one physical facility or site to another, excluding the 8,772
relocation of beds within a hospital or freestanding birthing 8,773
center or the relocation of beds among buildings of a hospital or 8,775
freestanding birthing center at the same site. 8,776
(8) The expenditure of more than one hundred ten per cent 8,778
198
of the maximum expenditure specified in a certificate of need; 8,779
(9) Any transfer of a certificate of need issued prior to 8,781
April 20, 1995, from the person to whom it was issued to another 8,783
person before the project that constitutes a reviewable activity 8,784
is completed, any agreement that contemplates the transfer of a 8,785
certificate of need issued prior to that date upon completion of 8,787
the project, and any transfer of the controlling interest in an 8,788
entity that holds a certificate of need issued prior to that
date. However, the transfer of a certificate of need issued 8,789
prior to that date or agreement to transfer such a certificate of 8,791
need from the person to whom the certificate of need was issued 8,792
to an affiliated or related person does not constitute a 8,793
reviewable transfer of a certificate of need for the purposes of 8,794
this division, unless the transfer results in a change in the 8,795
person that holds the ultimate controlling interest in the 8,796
certificate of need.
(10)(a) The acquisition by any person of any of the 8,798
following medical equipment, regardless of the amount of 8,800
operating costs or capital expenditure:
(i) A cobalt radiation therapy unit; 8,802
(ii) A linear accelerator; 8,804
(iii) A gamma knife unit. 8,806
(b) The acquisition by any person of medical equipment 8,808
with a cost of two million dollars or more. The cost of 8,809
acquiring medical equipment includes the sum of the following: 8,810
(i) The greater of its fair market value or the cost of 8,812
its lease or purchase; 8,813
(ii) The cost of installation and any other activities 8,815
essential to the acquisition of the equipment and its placement 8,816
into service.
(11) The addition of another cardiac catheterization 8,819
laboratory to an existing cardiac catheterization service. 8,820
(S) Except as provided in division (T) of this section, 8,823
"reviewable activity" also means any of the following activities, 8,825
199
none of which are subject to a termination date:
(1) The establishment, development, or construction of a 8,827
new long-term care facility; 8,828
(2) The replacement of an existing long-term care 8,830
facility; 8,831
(3) The renovation of a long-term care facility that 8,833
involves a capital expenditure of two million dollars or more, 8,834
not including expenditures for equipment, staffing, or 8,835
operational costs; 8,836
(4) Any of the following changes in long-term care bed 8,838
capacity: 8,839
(a) An increase in bed capacity; 8,841
(b) A relocation of beds from one physical facility or 8,844
site to another, excluding the relocation of beds within a 8,845
long-term care facility or among buildings of a long-term care 8,846
facility at the same site;
(c) A recategorization of hospital beds registered under 8,849
section 3701.07 of the Revised Code from another registration 8,851
category to skilled nursing beds or long-term care beds. 8,852
(5) Any change in the health services, bed capacity, or 8,854
site, or any other failure to conduct the reviewable activity in 8,855
substantial accordance with the approved application for which a 8,856
certificate of need concerning long-term care beds was granted, 8,857
if the change is made within five years after the implementation 8,858
of the reviewable activity for which the certificate was granted; 8,860
(6) The expenditure of more than one hundred ten per cent 8,862
of the maximum expenditure specified in a certificate of need 8,863
concerning long-term care beds; 8,864
(7) Any transfer of a certificate of need that concerns 8,866
long-term care beds and was issued prior to April 20, 1995, from 8,868
the person to whom it was issued to another person before the 8,869
project that constitutes a reviewable activity is completed, any 8,870
agreement that contemplates the transfer of such a certificate of 8,871
need upon completion of the project, and any transfer of the 8,872
200
controlling interest in an entity that holds such a certificate 8,873
of need. However, the transfer of a certificate of need that 8,874
concerns long-term care beds and was issued prior to April 20, 8,876
1995, or agreement to transfer such a certificate of need from 8,877
the person to whom the certificate was issued to an affiliated or 8,878
related person does not constitute a reviewable transfer of a 8,879
certificate of need for purposes of this division, unless the 8,880
transfer results in a change in the person that holds the 8,881
ultimate controlling interest in the certificate of need. 8,882
(T) "Reviewable activity" does not include any of the 8,884
following activities: 8,885
(1) Acquisition of computer hardware or software; 8,887
(2) Acquisition of a telephone system; 8,889
(3) Construction or acquisition of parking facilities; 8,891
(4) Correction of cited deficiencies that are in violation 8,893
of federal, state, or local fire, building, or safety laws and 8,894
rules and that constitute an imminent threat to public health or 8,895
safety; 8,896
(5) Acquisition of an existing health care facility that 8,898
does not involve a change in the number of the beds, by service, 8,899
or in the number or type of health services; 8,900
(6) Correction of cited deficiencies identified by 8,902
accreditation surveys of the joint commission on accreditation of 8,903
healthcare organizations or of the American osteopathic 8,904
association; 8,905
(7) Acquisition of medical equipment to replace the same 8,907
or similar equipment for which a certificate of need has been 8,908
issued if the replaced equipment is removed from service; 8,909
(8) Mergers, consolidations, or other corporate 8,911
reorganizations of health care facilities that do not involve a 8,912
change in the number of beds, by service, or in the number or 8,913
type of health services; 8,914
(9) Construction, repair, or renovation of bathroom 8,916
facilities; 8,917
201
(10) Construction of laundry facilities, waste disposal 8,919
facilities, dietary department projects, heating and air 8,920
conditioning projects, administrative offices, and portions of 8,921
medical office buildings used exclusively for physician services; 8,922
(11) Acquisition of medical equipment to conduct research 8,924
required by the United States food and drug administration or 8,925
clinical trials sponsored by the national institute of health. 8,926
Use of medical equipment that was acquired without a certificate 8,927
of need under division (T)(11) of this section and for which 8,929
premarket approval has been granted by the United States food and 8,930
drug administration to provide services for which patients or 8,931
reimbursement entities will be charged shall be a reviewable 8,932
activity. 8,933
(12) Removal of asbestos from a health care facility. 8,935
Only that portion of a project that meets the requirements 8,937
of division (T) of this section is not a reviewable activity. 8,939
(U) "Small rural hospital" means a hospital that is 8,941
located within a rural area, has fewer than one hundred beds, and 8,943
to which fewer than four thousand persons were admitted during 8,944
the most recent calendar year.
(V) "Children's hospital" means any of the following: 8,946
(1) A hospital registered under section 3701.07 of the 8,948
Revised Code that provides general pediatric medical and surgical 8,949
care, and in which at least seventy-five per cent of annual 8,950
inpatient discharges for the preceding two calendar years were 8,951
individuals less than eighteen years of age; 8,952
(2) A distinct portion of a hospital registered under 8,954
section 3701.07 of the Revised Code that provides general 8,955
pediatric medical and surgical care, has a total of at least one 8,956
hundred fifty registered pediatric special care and pediatric 8,957
acute care beds, and in which at least seventy-five per cent of 8,958
annual inpatient discharges for the preceding two calendar years 8,959
were individuals less than eighteen years of age; 8,960
(3) A distinct portion of a hospital, if the hospital is 8,962
202
registered under section 3701.07 of the Revised Code as a 8,963
children's hospital and the children's hospital meets all the 8,964
requirements of division (V)(1) of this section. 8,965
(W) "Long-term care facility" means any of the following: 8,967
(1) A nursing home licensed under section 3721.02 of the 8,969
Revised Code or by a political subdivision certified under 8,970
section 3721.09 of the Revised Code; 8,971
(2) The portion of any facility, including a county home 8,973
or county nursing home, that is certified as a skilled nursing 8,974
facility or a nursing facility under Title XVIII or XIX of the 8,975
"Social Security Act";
(3) The portion of any hospital that contains beds 8,977
registered under section 3701.07 of the Revised Code as skilled 8,978
nursing beds or long-term care beds. 8,979
(X) "Long-term care bed" means a bed in a long-term care 8,981
facility.
(Y) "Perinatal bed" means a bed in a hospital that is 8,983
registered under section 3701.07 of the Revised Code as a newborn 8,984
care bed or obstetric bed, or a bed in a freestanding birthing 8,985
center.
(Z) "Freestanding birthing center" means any facility in 8,987
which deliveries routinely occur, regardless of whether the 8,989
facility is located on the campus of another health care
facility, and which is not licensed under Chapter 3711. of the 8,991
Revised Code as a level one, two, or three maternity unit or a 8,993
limited maternity unit.
(AA)(1) "Reviewability ruling" means a ruling issued by 8,995
the director of health under division (A) of section 3702.52 of 8,996
the Revised Code as to whether a particular proposed project is 8,997
or is not a reviewable activity. 8,998
(2) "Nonreviewability ruling" means a ruling issued under 9,000
that division that a particular proposed project is not a 9,001
reviewable activity. 9,002
(BB)(1) "Metropolitan statistical area" means an area of 9,005
203
this state designated a metropolitan statistical area or primary 9,006
metropolitan statistical area in United States office of 9,008
management and budget bulletin No. 93-17, June 30, 1993, and its 9,010
attachments. 9,011
(2) "Rural area" means any area of this state not located 9,013
within a metropolitan statistical area. 9,014
Sec. 3702.62. (A) Any action pursuant to section 140.03, 9,023
140.04, 140.05, 307.091, 313.21, 339.01, 339.021, 339.03, 339.06, 9,024
339.08, 339.09, 339.12, 339.14, 339.21, 339.231, 339.24, 339.31, 9,025
339.36, 339.39, 513.05, 513.07, 513.08, 513.081, 513.12, 513.15, 9,026
513.17, 513.171, 749.02, 749.14, 749.16, 749.20, 749.25, 749.28, 9,027
749.35, 1742.06 1751.06, or 3707.29 of the Revised Code shall be 9,028
taken in accordance with sections 3702.51 to 3702.61 of the 9,029
Revised Code.
(B) A nursing home certified as an intermediate care 9,031
facility for the mentally retarded under Title XIX of the "Social 9,032
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, 9,033
that is required to apply for licensure as a residential facility 9,034
under section 5123.19 of the Revised Code is not, with respect to 9,035
the portion of the home certified as an intermediate care
facility for the mentally retarded, subject to sections 3702.51 9,036
to 3702.61 of the Revised Code. 9,037
Sec. 3709.16. The board of health of a city or general 9,046
health district shall determine the duties and fix the salaries 9,047
of its employees. 9,048
No member of the board shall be appointed as health officer 9,050
or ward physician. 9,051
The board of health of any health district may procure and 9,053
pay all or any part of the cost of group life, hospitalization, 9,054
surgical, major medical, sickness and accident insurance, or a 9,055
combination of any of the foregoing types of insurance or 9,056
coverage, for the health commissioner, the employees of the 9,057
health district, and their immediate dependents, from the funds 9,058
or budgets from which said health commissioner or employees are 9,059
204
compensated for services, issued by an insurance company or 9,060
nonprofit medical care A HEALTH INSURING corporation duly 9,061
authorized to do business in this state. 9,062
Notwithstanding section 3917.01 of the Revised Code, the 9,064
board of health of any health district may purchase group life 9,065
insurance authorized by this section by reason of payment of 9,066
premiums therefor by the board from its funds, and such group 9,067
life insurance may be issued and purchased if otherwise 9,068
consistent with sections 3917.01 to 3917.06 of the Revised Code. 9,069
Sec. 3729.12. Not later than a date specified by the 9,079
director of health, the Ohio health care data center shall make 9,080
its first submission of a report containing the health care 9,081
information specified in this section to the governor, the 9,082
speaker of the house of representatives, the president of the 9,083
senate, and the chairpersons of the standing committees of the 9,084
house of representatives and the senate that have primary 9,085
responsibility for the consideration of health legislation. Each 9,086
year thereafter, the data center shall submit a report not later 9,087
than the thirty-first day of December. The report shall contain, 9,088
to the extent possible with the data collected under sections 9,089
3729.15 to 3729.45 of the Revised Code, an analysis of all of the 9,090
following:
(A) The one hundred high priority diagnoses and one 9,092
hundred high priority medical procedures that account for eighty 9,093
per cent of public and private health care costs in this state, 9,094
and diagnoses and medical procedures for which a disproportionate 9,095
share of public and private expenditures are consumed relative to 9,096
the total number of diseases diagnosed and medical procedures 9,097
performed; 9,098
(B) The relationship between: 9,100
(1) Health care costs, access, outcomes, continuity of 9,102
care, and professional practice patterns for selected diseases 9,103
and procedures; 9,104
(2) An individual's source of payment, age, geographic 9,106
205
location, sex, race, and income. 9,107
(C) The differences in administrative expenses for 9,109
delivery of health care in the public sector versus the private 9,110
sector; 9,111
(D)(1) Compared to previous years when appropriate data 9,113
were collected, the increase in expenditures that has occurred in 9,114
the public health care programs in each of the following 9,115
categories: 9,116
(a) Long-term care facilities; 9,118
(b) Hospital inpatient services; 9,120
(c) Hospital outpatient services; 9,122
(d) Home-based health care; 9,124
(e) Physicians' services; 9,126
(f) Allied health services; 9,128
(g) Pharmaceuticals; 9,130
(h) Durable medical equipment and medical and surgical 9,132
products; 9,133
(i) Mental health services; 9,135
(j) Other health services selected by the director of 9,137
health. 9,138
(2) The factors that have contributed to the expenditure 9,140
increases in each of the categories specified by division (D)(1) 9,141
of this section. 9,142
(E) The extent to which physicians and other health care 9,144
providers selected by the director participate in public versus 9,145
private health care programs, and changes in this participation 9,146
from previous years when appropriate data were collected; 9,147
(F) The distribution of emergency medical services among 9,149
the population of this state, and the relationship between: 9,150
(1) Access to emergency medical services; 9,152
(2) An individual's source of payment, age, geographic 9,154
location, sex, race, and income. 9,155
(G) The number of residents of this state who are 9,157
uninsured or underinsured with respect to health care, the 9,158
206
distribution of this population by county, the demographic 9,159
characteristics, including employment status, of this population, 9,160
and the changes in those demographic characteristics from 9,161
previous years when appropriate data were collected; 9,162
(H) The percentage of individuals who seek or register for 9,164
health care services that: 9,165
(1) Are diagnosed or treated; 9,167
(2) Are denied services; 9,169
(3) Receive primary care services from emergency 9,171
facilities. 9,172
(I) The differences between primary care case managed 9,174
systems and other managed health care reimbursement systems in 9,175
health care costs and outcomes for one hundred high priority 9,176
diseases or procedures selected by the director, access to health 9,177
care, and professional practice patterns and variations, and the 9,178
factors that contribute to those differences; 9,179
(J) The relationship between: 9,181
(1) Long-term care facility admission, transfer, and 9,183
length-of-stay; 9,184
(2) An individual's source of payment, age, geographic 9,186
location, sex, race, and income. 9,187
(K) The percentage of hospitals' uncompensated care, 9,189
including uncompensated care provided by group practices as 9,190
defined in section 4731.65 of the Revised Code that have one 9,191
hundred members or more, that is attributable to each of the 9,193
following:
(1) Charity care; 9,195
(2) Courtesy care; 9,197
(3) Contractual allowances; 9,199
(4) The medical assistance program; 9,201
(5) The medicare program; 9,203
(6) Bad debts. 9,205
(L) The relationship between the number and type of 9,207
pharmaceutical prescriptions and each of the following: 9,208
207
(1) An individual's source of payment, age, geographic 9,210
location, and sex; 9,211
(2) Use of a therapeutic formulary by disease category. 9,213
(M) The extent to which physicians and other health care 9,215
providers selected by the director provide primary care services 9,216
to indigent individuals and the type of primary care services 9,217
provided; 9,218
(N) Public or private provider reimbursement strategies 9,220
that have been effective in containing health care costs; 9,221
(O) The effectiveness of quality improvement programs 9,223
introduced by health care organizations, including health 9,224
maintenance organizations INSURING CORPORATIONS and independent 9,225
practice associations, or health care plans in improving the 9,226
general quality of health care in this state; 9,227
(P) The comparison of health care costs, access, outcomes, 9,229
continuity of care, and professional practice patterns in this 9,230
state with other states and countries; 9,231
(Q) State and local statutes, ordinances, or rules that 9,233
may contribute to health care cost increases and suggested 9,234
changes in the regulatory framework to reduce costs without 9,235
adversely affecting quality or access; 9,236
(R) The increase in health care costs that can be 9,238
attributed to increases in malpractice insurance premiums and 9,239
increases in the practice of defensive medicine; 9,240
(S) The total number of visits by medical assistance 9,242
program recipients and medicare beneficiaries to clinics versus 9,243
primary care health care practitioner offices in this state, 9,244
categorized by type of clinic or primary care practitioner and 9,245
diagnosis; 9,246
(T) Variations in treatment, costs, and medical outcome of 9,248
a range of diagnoses selected by the director according to 9,249
practitioner specialty versus primary care case management with 9,250
global fees and comparison of individuals' source of payment, 9,251
age, geographic location, sex, race, and income; 9,252
208
(U) The major components of the cost of long-term care 9,254
facilities and the variations in the costs of the components 9,255
according to diagnosis, the resident's level of functioning, 9,256
facility size and geographic location, and source of payment; 9,257
(V) Factors that account for increases in the utilization 9,259
of long-term care facilities in comparison with home and 9,260
community outpatient care; 9,261
(W) The effect of health care utilization and costs on the 9,263
general health of residents of this state and the effect of 9,264
behaviorial BEHAVIORAL risk factors, including tobacco use, 9,265
alcohol and substance abuse, lack of exercise, being overweight, 9,267
and other factors selected by the director; 9,268
(X) The effect of utilization of preventive health care 9,270
services on health care costs and outcomes, categorized by age, 9,271
occupation, and type of health care coverage; 9,272
(Y) The number of individuals in each county who received 9,274
services the previous calendar year from a public health care 9,275
program administered in whole or in part by the department of 9,276
mental retardation and developmental disabilities or a county 9,277
board of mental retardation and developmental disabilities, 9,278
compared to the number of individuals in each county who applied 9,279
and were found eligible for those services that year but did not 9,280
receive them; 9,281
(Z) The number of individuals in each county that received 9,283
services the previous calendar year from a public health care 9,284
program administered in whole or in part by the department of 9,285
mental health, a community mental health board, or a board of 9,286
alcohol, drug abuse, and mental health services, compared to the 9,287
number of individuals in each county who applied and were found 9,288
eligible for those services that year but did not receive them. 9,289
The report must comply with section 3729.46 of the Revised 9,291
Code. 9,292
Sec. 3901.04. (A) As used in this section: 9,301
(1) "Laws of this state relating to insurance" include but 9,303
209
are not limited to Chapters 1736., 1737., 1738., 1739. 9,304
notwithstanding section 1739.02, 1740., and 1742. CHAPTER 1751. 9,306
notwithstanding section 1742.30 1751.08, Title XXXIX, sections 9,307
5725.18 to 5725.25, and Chapter 5729. of the Revised Code. 9,308
(2) "Person" has the meaning defined in division (A) of 9,310
section 3901.19 of the Revised Code. 9,311
(B) Whenever it appears to the superintendent of 9,313
insurance, from his THE SUPERINTENDENT'S files, upon complaint or 9,315
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 9,316
prohibited by the laws of this state relating to insurance, or 9,317
defined as unfair or deceptive by such laws, or when the 9,318
superintendent believes it to be in the best interest of the 9,319
public and necessary for the protection of the people in this 9,320
state, the superintendent or anyone designated by the 9,321
superintendent under his THE SUPERINTENDENT'S official seal may 9,322
do any one or more of the following:
(1) Require any person to file with the superintendent, on 9,324
a form that is appropriate for review by the superintendent, an 9,325
original or additional statement or report in writing, under oath 9,326
or otherwise, as to any facts or circumstances concerning the 9,327
person's conduct of the business of insurance within this state 9,328
and as to any other information that the superintendent considers 9,329
to be material or relevant to such business; 9,330
(2) Administer oaths, summon and compel by order or 9,332
subpoena the attendance of witnesses to testify in relation to 9,333
any matter which, by the laws of this state relating to 9,334
insurance, is the subject of inquiry and investigation, and 9,335
require the production of any book, paper, or document pertaining 9,336
to such matter. A subpoena, notice, or order under this section 9,337
may be served by certified mail, return receipt requested. If 9,338
the subpoena, notice, or order is returned because of inability 9,339
to deliver, or if no return is received within thirty days of the 9,340
date of mailing, the subpoena, notice, or order may be served by 9,341
210
ordinary mail. If no return of ordinary mail is received within 9,342
thirty days after the date of mailing, service shall be deemed to 9,343
have been made. If the subpoena, notice, or order is returned 9,344
because of inability to deliver, the superintendent may designate 9,345
a person or persons to effect either personal or residence 9,346
service upon the witness. Service of any subpoena, notice, or 9,347
order and return may also be made in any manner authorized under 9,348
the Rules of Civil Procedure. Such service shall be made by an 9,349
employee of the department designated by the superintendent, a 9,350
sheriff, a deputy sheriff, an attorney, or any person authorized 9,351
by the Rules of Civil Procedure to serve process. 9,352
In the case of disobedience of any notice, order, or 9,354
subpoena served on a person or the refusal of a witness to 9,355
testify to a matter regarding which he THE PERSON may lawfully be 9,357
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 9,358
obedience by attachment proceedings for contempt, as in the case 9,359
of disobedience of the requirements of a subpoena issued from 9,360
such court, or a refusal to testify therein. Witnesses shall 9,361
receive the fees and mileage allowed by section 2335.06 of the 9,362
Revised Code. All such fees, upon the presentation of proper 9,363
vouchers approved by the superintendent, shall be paid out of the 9,364
appropriation for the contingent fund of the department of 9,365
insurance. The fees and mileage of witnesses not summoned by the 9,366
superintendent or his THE SUPERINTENDENT'S designee shall not be 9,367
paid by the state. 9,368
(3) In a case in which there is no administrative 9,370
procedure available to the superintendent to resolve a matter at 9,371
issue, request the attorney general to commence an action for a 9,372
declaratory judgment under Chapter 2721. of the Revised Code with 9,373
respect to the matter. 9,374
(4) Initiate criminal proceedings by presenting evidence 9,376
of the commission of any criminal offense established under the 9,377
laws of this state relating to insurance to the prosecuting 9,378
211
attorney of any county in which the offense may be prosecuted. At 9,380
the request of the prosecuting attorney, the attorney general may 9,381
assist in the prosecution of the violation with all the rights, 9,382
privileges, and powers conferred by law on prosecuting attorneys 9,383
including, but not limited to, the power to appear before grand 9,384
juries and to interrogate witnesses before grand juries. 9,385
Sec. 3901.041. The superintendent of insurance shall 9,394
adopt, amend, and rescind rules and make adjudications, necessary 9,395
to discharge his THE SUPERINTENDENT'S duties and exercise his THE 9,396
SUPERINTENDENT'S powers, including, but not limited to, his THE 9,397
SUPERINTENDENT'S duties and powers under Chapters 1737., 1738., 9,398
and 1740. CHAPTER 1751. and Title XXXIX of the Revised Code, 9,400
subject to sections 119.01 to 119.13 CHAPTER 119. of the Revised 9,401
Code.
Sec. 3901.043. The superintendent of insurance may adopt 9,410
rules in accordance with Chapter 119. of the Revised Code to 9,411
establish reasonable fees for any service or transaction 9,412
performed by the department of insurance pursuant to section 9,413
1738.04, 1742.03 1751.03, 3901.321, 3901.341, 3907.09, 3907.10, 9,414
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 9,415
Revised Code or any provision in sections 3913.01 to 3913.23 or 9,416
in Chapter 3905. of the Revised Code, if no fee is otherwise 9,417
provided under Title XVII or XXXIX of the Revised Code for such 9,418
service or transaction. Any fee collected pursuant to those 9,419
rules shall be paid into the state treasury to the credit of the 9,420
department of insurance operating fund.
Sec. 3901.071. All moneys collected by the superintendent 9,429
of insurance for expenses incurred by him THE SUPERINTENDENT in 9,430
conducting examinations pursuant to the Revised Code of the 9,431
financial affairs of any insurance company doing business in this 9,432
state, for which the insurance company examined is required to 9,433
pay the costs, shall be paid to the superintendent. The 9,434
superintendent shall deposit the money in the state treasury to 9,435
212
the credit of the superintendent's examination fund, which is 9,436
hereby established. Any funds expended or obligated therefrom by 9,437
the superintendent shall be expended or obligated solely for 9,438
defrayment of the costs of examinations of the financial affairs 9,439
of insurance companies made by the superintendent pursuant to the 9,440
Revised Code. For purposes of this section, "insurance company" 9,441
means any domestic or foreign stock company, risk retention 9,442
group, mutual company, mutual protective association, fraternal 9,443
benefit society, reciprocal or inter-insurance exchange, 9,444
nonprofit medical care corporation, AND health care INSURING 9,446
corporation, and nonprofit dental care corporation, regardless of 9,447
the type of coverage written, benefits provided, or guarantees 9,448
made by each.
Sec. 3901.16. Any association, company, or corporation, 9,457
INCLUDING A HEALTH INSURING CORPORATION, which violates any law 9,458
relating to the superintendent of insurance, ANY PROVISION OF 9,460
CHAPTER 1751. OF THE REVISED CODE, or any insurance law of this
state, for the violation of which no forfeiture or penalty is 9,461
elsewhere provided in the Revised Code, shall forfeit and pay not 9,462
less than one thousand nor more than ten thousand dollars, to be 9,463
recovered by an action in the name of the state and on collection 9,464
to be paid to the superintendent, who shall pay such sum into the 9,465
state treasury.
Sec. 3901.19. As used in sections 3901.19 to 3901.26 of 9,474
the Revised Code: 9,475
(A) "Person" means any individual, corporation, 9,477
association, partnership, reciprocal exchange, inter-insurer, 9,478
fraternal benefit society, title guarantee and trust company, 9,479
prepaid dental plan organization, medical care corporation, 9,480
health care INSURING corporation, dental care corporation, health 9,482
maintenance organization incorporated under Chapter 1735., 1736.,
1737., 1738., 1740., or 1742. of the Revised Code, and any other 9,483
legal entity. 9,484
(B) "Residents" includes any individual, partnership, or 9,486
213
corporation. 9,487
(C) "Maternity benefits" means those benefits calculated 9,489
to indemnify the insured for hospital and medical expenses fairly 9,490
and reasonably associated with a pregnancy and childbirth. 9,491
(D) "Insurance" includes, but is not limited to, any 9,493
policy or contract offered, issued, sold, or marketed by an 9,494
insurer, corporation, association, organization, or entity 9,495
regulated by the superintendent of insurance or doing business in 9,496
this state. Nothing in any other section of the Revised Code 9,497
shall be construed to exclude single premium deferred annuities 9,498
from the regulation of the superintendent under sections 3901.19 9,499
to 3901.26 of the Revised Code. 9,500
Sec. 3901.31. (A) Every person who is directly or 9,509
indirectly the beneficial owner of more than ten per cent of any 9,510
class of any equity security of a domestic stock insurance 9,511
company which is not a wholly owned subsidiary of an insurance 9,512
holding company system or who is a director or officer of such 9,513
company, shall file with the superintendent of insurance within 9,514
ten days after he THE PERSON becomes such beneficial owner, 9,515
director, or officer, a statement in such form as the 9,517
superintendent of insurance may prescribe, of the amount of all 9,518
equity securities of such company of which he THE PERSON is the 9,519
beneficial owner, and within ten days after the close of each 9,521
calendar month thereafter, if there has been a change in such 9,522
ownership during such month, shall file with the superintendent 9,523
of insurance a statement, in such form as the superintendent of 9,524
insurance may prescribe, indicating his THE PERSON'S ownership at 9,525
the close of the calendar month and such changes in his THE 9,526
PERSON'S ownership as have occurred during such calendar month. 9,527
(B) For the purpose of preventing the unfair use of 9,529
information which may have been obtained by such beneficial 9,530
owner, director, or officer by reason of his THE BENEFICIAL 9,531
OWNER'S, DIRECTOR'S, OR OFFICER'S relationship to such company, 9,532
any profit realized by him THE BENEFICIAL OWNER, DIRECTOR, OR 9,533
214
OFFICER from any purchase and sale, or any sale and purchase, of 9,534
any equity security of such company within any period of less 9,536
than six months, unless such security was acquired in good faith 9,537
in connection with a debt previously contracted, shall inure to 9,538
and be recoverable by the company, irrespective of any intention 9,539
on the part of such beneficial owner, director, or officer in 9,540
entering into such transaction of holding the security purchased 9,541
or of not repurchasing the security sold for a period exceeding 9,542
six months. Suit to recover such profit may be instituted at law 9,543
or in equity in any court of competent jurisdiction by the 9,544
company, or by the owner of any security of the company in the 9,545
name and in behalf of the company if the company fails or refuses 9,546
to bring such suit within sixty days after request or fails 9,547
diligently to prosecute the same thereafter; but no such suit 9,548
shall be brought more than two years after the date such profit 9,549
was realized. Division (B) of this section shall not be 9,550
construed to cover any transaction where such beneficial owner 9,551
was not such both at the time of purchase and sale, or the sale 9,552
and purchase, of the security involved, or any transaction or 9,553
transactions which the superintendent of insurance by rules may 9,554
exempt as not comprehended within the purpose of division (B) of 9,555
this section.
(C) No such beneficial owner, director, or officer, 9,557
directly or indirectly, shall sell any equity security of such 9,558
company if the person selling the security or his THE PERSON'S 9,559
principal does not own the security sold, or if owning the 9,560
security, does not deliver it against such sale within twenty 9,561
days thereafter, or does not within five days after such sale 9,562
deposit it in the mails or other usual channels of 9,563
transportation; but no person shall be deemed to have violated 9,564
division (C) of this section if he THE PERSON proves that 9,565
notwithstanding the exercise of good faith he THE PERSON was 9,566
unable to make such delivery or deposit within such time, or that 9,567
to do so would cause undue inconvenience or expense.
215
(D) A domestic insurance company having at least fifty 9,569
shareholders or any other person soliciting proxies with respect 9,570
to such domestic insurance company shall not solicit voting 9,571
proxies from any shareholder or other person except upon a proxy 9,572
statement and pursuant to a notice of meeting, which statement 9,573
and notice have been submitted to the superintendent of insurance 9,574
at least ten days prior to being mailed to the intended 9,575
recipients. Such proxy statement and notice of meeting shall 9,576
make such disclosures pertinent to the business to be carried on 9,577
at the meeting or meetings with respect to which such proxies are 9,578
solicited and such notices are given as the superintendent by 9,579
rule requires. The superintendent shall retain such proxy 9,580
material for examination by any interested party for at least one 9,581
year. 9,582
(E) Division (B) of this section does not apply to any 9,584
purchase and sale, or sale and purchase, and division (C) of this 9,585
section does not apply to any sale, of an equity security of a 9,586
domestic stock insurance company not then or theretofore held by 9,587
him in an investment account, by a dealer in the ordinary course 9,588
of his THE DEALER'S business and incident to the establishment or 9,590
maintenance by him THE DEALER of a primary or secondary market 9,591
for such security. The superintendent of insurance may, by such 9,592
rules as he THE SUPERINTENDENT considers necessary or appropriate 9,593
in the public interest, describe and define the terms and 9,595
conditions with respect to securities held in an investment 9,596
account and transactions made in the ordinary course of business 9,597
and incident to the establishment or maintenance of a primary or 9,598
secondary market.
(F) Divisions (A), (B), and (C) of this section do not 9,600
apply to foreign or domestic arbitrage transactions unless made 9,601
in contravention of such rules as the superintendent of insurance 9,602
may adopt in order to carry out the purposes of this section. 9,603
(G) "Equity security" when used in this section means any 9,605
stock or similar security; or any security convertible, with or 9,606
216
without consideration, into such a security, or carrying any 9,607
warrant or right to subscribe to or purchase such a security; or 9,608
any such warrant or right; or any other security which the 9,609
superintendent of insurance determines to be of similar nature 9,610
and considers necessary or appropriate, by such rules as he THE 9,611
SUPERINTENDENT may prescribe in the public interest or for the 9,612
protection of investors, to treat as an equity security. 9,613
(H) The superintendent of insurance may adopt, amend, and 9,615
rescind rules, pursuant to Chapter 119. of the Revised Code, 9,616
which will enable him THE SUPERINTENDENT to carry out the duties 9,618
imposed upon him by this section.
(I) THIS SECTION APPLIES TO HEALTH INSURING CORPORATIONS 9,620
IN THE SAME MANNER IN WHICH THIS SECTION APPLIES TO DOMESTIC 9,621
STOCK INSURANCE COMPANIES. 9,622
Sec. 3901.32. As used in sections 3901.32 to 3901.37 of 9,631
the Revised Code: 9,632
(A) "Affiliate of" or "affiliated with" a specific person 9,634
means a person that, directly or indirectly, through one or more 9,635
intermediaries, controls, is controlled by, or is under common 9,636
control with, the person specified. 9,637
(B) "Control," including "controlling," "controlled by," 9,639
and "under common control with," means the possession, direct or 9,640
indirect, of the power to direct or cause the direction of the 9,641
management and policies of a person, whether through the 9,642
ownership of voting securities, by contract other than a 9,643
commercial contract for goods or nonmanagement services, or 9,644
otherwise, unless the power is the result of an official position 9,645
with or corporate office held by the person. Control shall be 9,646
presumed to exist if any person, directly or indirectly, owns, 9,647
controls, holds with the power to vote, or holds proxies 9,648
representing, ten per cent or more of the voting securities of 9,649
any other person. This presumption may be rebutted by a showing 9,650
made in the manner provided in division (J) of section 3901.33 of 9,652
the Revised Code that control does not exist in fact. The 9,653
217
superintendent of insurance may determine, after furnishing all 9,654
persons in interest notice and opportunity to be heard and making 9,655
specific findings of fact to support such determination, that 9,656
control exists in fact, notwithstanding the absence of a 9,657
presumption to that effect. 9,658
(C) "Insurance holding company system" means two or more 9,660
affiliated persons, one or more of which is an insurer. 9,661
(D) "Insurer" means any person engaged in the business of 9,663
insurance, guaranty, or membership, an inter-insurance exchange, 9,664
a mutual or fraternal benefit society, a prepaid dental plan 9,665
organization, a health maintenance organization, a medical care, 9,666
OR A health care, or dental care INSURING corporation, excepting 9,668
any agency, authority, or instrumentality of the United States,
its possessions and territories, the Commonwealth of Puerto Rico, 9,669
the District of Columbia, or a state or political subdivision of 9,670
a state. 9,671
(E) "Person" means an individual, a corporation, a 9,673
partnership, an association, a joint stock company, a trust, an 9,674
unincorporated organization, any similar entity, or any 9,675
combination of the foregoing acting in concert. 9,676
(F) "Subsidiary" of a specified person is an affiliate 9,678
controlled by such person, directly or indirectly, through one or 9,679
more intermediaries. 9,680
(G) "Voting security" includes any security convertible 9,682
into or evidencing a right to acquire a voting security. 9,683
Sec. 3901.38. (A) As used in this section: 9,692
(1) "Beneficiary" means any policyholder, subscriber, 9,694
member, employee, or other person who is eligible for benefits 9,695
under a benefits contract. 9,696
(2) "Benefits contract" means a sickness and accident 9,698
insurance policy providing hospital, surgical, or medical expense 9,699
coverage, OR A health maintenance organization INSURING 9,700
CORPORATION contract, preferred provider organization contract, 9,702
or other policy or agreement under which a third-party payer 9,703
218
agrees to reimburse for covered health care or dental services 9,704
rendered to beneficiaries, up to the limits and exclusions 9,705
contained in the benefits contract.
(3) "Completed claim" means a proof of loss or a claim for 9,707
payment for health care services which has been submitted to the 9,708
appropriate claims processing office of the third-party payer 9,709
accompanied by sufficient documentation for the third-party payer 9,710
to determine proof of loss and reasonably required by the 9,711
third-party payer to accept or reject the claim. 9,712
(4) "Hospital" has the same meaning set forth in section 9,714
3727.01 of the Revised Code. 9,715
(5) "Proof of loss" means a claim for payment for health 9,717
care services which has been submitted to the appropriate claims 9,718
processing office of the third-party payer accompanied by 9,719
sufficient documentation for the third-party payer to determine 9,720
benefits payable under the benefits contract and reasonably 9,721
required by the third-party payer to accept or reject the claim. 9,722
(6) "Provider" means a hospital, nursing home, physician, 9,724
podiatrist, dentist, pharmacist, chiropractor, or other licensed 9,725
health care provider entitled to reimbursement by a third-party 9,726
payer for services rendered to a beneficiary under a benefits 9,727
contract. 9,728
(7) "Reimburse" means indemnify, make payment, or 9,730
otherwise accept responsibility for payment for health care 9,731
services rendered to a beneficiary, or arrange for the provision 9,732
of health care services to a beneficiary. 9,733
(8) "Third-party payer" means any of the following: 9,735
(a) An insurance company; 9,737
(b) A health maintenance organization INSURING 9,739
CORPORATION;
(c) A preferred provider organization; 9,741
(d) A labor organization; 9,743
(e) An employer; 9,745
(f) A prepaid dental plan organization AN INTERMEDIARY 9,747
219
ORGANIZATION, AS DEFINED IN SECTION 1751.01 OF THE REVISED CODE, 9,748
THAT IS NOT A HEALTH DELIVERY NETWORK CONTRACTING SOLELY WITH 9,749
SELF-INSURED EMPLOYERS;
(g) An administrator subject to sections 3959.01 to 9,751
3959.16 of the Revised Code; 9,752
(h) A HEALTH DELIVERY NETWORK, AS DEFINED IN SECTION 9,754
1751.01 OF THE REVISED CODE; 9,755
(i) Any other person that is obligated pursuant to a 9,757
benefits contract to reimburse for covered health care services 9,758
rendered to beneficiaries under such contract. 9,759
(B)(1) Except as provided in division (B)(2) of this 9,761
section, within twenty-four days of the receipt of a completed 9,762
claim from a provider or a beneficiary for reimbursement for 9,763
health care services rendered by the provider to a beneficiary, a 9,764
third-party payer shall, in accordance with division (D) of this 9,765
section, make payment of any amount due on such claim. 9,766
(2) A third-party payer and a provider may, in negotiating 9,768
a reimbursement contract, agree to any time period by which a 9,769
third-party payer shall, subject to division (D) of this section, 9,770
make payment of any amount due on a completed claim. Nothing in 9,771
this division shall be construed as limiting in any manner the 9,772
application of the requirements of this section to any benefits 9,773
or reimbursement contract. 9,774
(3) Any provider or beneficiary aggrieved with respect to 9,776
any act of a third-party payer that such provider or beneficiary 9,777
believes to be a violation of division (B)(1) or (2) of this 9,778
section may file a written complaint with the superintendent of 9,779
insurance. If a series of such complaints is received by the 9,780
superintendent with respect to a particular third-party payer and 9,781
if, after investigation, the superintendent finds that such 9,782
third-party payer has engaged in a series of such violations 9,783
which, taken together, constitute a consistent pattern or a 9,784
practice of such third-party payer to violate division (B)(1) or 9,785
(2) of this section, the superintendent shall issue an order 9,786
220
requiring such third-party payer to cease and desist from 9,787
engaging in such violations and to pay a late payment penalty as 9,788
specified in divisions (B)(4) and (5) of this section with 9,789
respect to the claims the superintendent finds were not timely 9,790
paid. In the order, the superintendent shall specify the reasons 9,791
for his THE SUPERINTENDENT'S finding and order and state that a 9,792
hearing conducted pursuant to Chapter 119. of the Revised Code 9,794
shall be held within fifteen days after requested in writing by 9,795
the third-party payer. The provisions of this division (B)(3) of 9,796
this section are in addition to, and not in lieu of, such other 9,797
remedies as providers and beneficiaries may otherwise have by 9,798
law.
(4)(a) The late payment penalty shall be computed based 9,800
upon the number of days that have elapsed between the date 9,801
payment is due in accordance with division (B)(1) or (2) of this 9,802
section and the date payment is actually sent. 9,803
(b) The interest rate for determining the amount of the 9,805
late payment penalty shall be the rate agreed to by the provider 9,806
and the third-party payer or the rate specified by and determined 9,807
in accordance with division (A) of section 1343.01 of the Revised 9,808
Code. 9,809
(5) A provider and a third-party payer may enter into a 9,811
contractual agreement in which the timing of payments by the 9,812
third-party payer is not directly related to the receipt of a 9,813
completed claim. Such contractual arrangement may include 9,814
periodic interim payment arrangements, capitation payment 9,815
arrangements, or other payment arrangements acceptable to the 9,816
provider and the third-party payer. Except as agreed to under 9,817
such contract, this section does not apply to such payment 9,818
arrangements. 9,819
(6) Any late payment penalty due and payable by a 9,821
third-party payer in accordance with this section shall not be 9,822
used to reduce benefits or payments otherwise payable under a 9,823
benefits contract. 9,824
221
(C) No third-party payer shall refuse to process or pay 9,826
within the time period required under division (B)(1) or (2) of 9,827
this section a completed claim submitted by a provider on the 9,828
ground the beneficiary has not been discharged from the hospital 9,829
or the treatment has not been completed, if the submitted claim 9,830
covers services actually rendered and charges actually incurred 9,831
over at least a thirty-day period. 9,832
(D)(1) Nothwithstanding NOTWITHSTANDING section 1742.10 or 9,834
division (I)(2) of section 3923.04 of the Revised Code, a 9,835
reimbursement contract entered into or renewed on or after the 9,836
effective date of this section JUNE 29, 1988, between a 9,837
third-party payer and a hospital shall provide that reimbursement 9,838
for any service provided by a hospital pursuant to a 9,839
reimbursement contract and covered under a benefits contract 9,840
shall be made directly to the hospital. 9,841
(2) If the third-party payer and the hospital have not 9,843
entered into a contract regarding the provision and reimbursement 9,844
for covered services, the third-party payer shall accept and 9,845
honor a completed and validly executed assignment of benefits 9,846
with a hospital by a beneficiary, except when the third-party 9,847
payer has notified the hospital in writing of the conditions 9,848
under which the third-party payer will not accept and honor an 9,849
assignment of benefits. Such notice shall be made annually. 9,850
(3) A third-party payer may not refuse to accept and honor 9,852
a validly executed assignment of benefits with a hospital 9,853
pursuant to division (D)(2) of this section for medically 9,854
necessary hospital services provided on an emergency basis. 9,855
(E) A series of violations which taken together, 9,857
constitute a consistent pattern or a practice of violation of any 9,858
of the provisions of this section is an unfair and deceptive act 9,859
pursuant to sections 3901.19 to 3901.23 of the Revised Code and 9,860
is subject to proceedings pursuant to those sections. 9,861
Sec. 3901.40. No insurance company, medical care 9,870
corporation, health care INSURING corporation, OR self-insurance 9,872
222
plan, or dental care corporation authorized to do business in 9,874
this state shall include or provide in its policies or subscriber
agreements for benefit payments or reimbursement for services in 9,875
any hospital which is not certified or accredited as provided in 9,876
division (A) of section 3727.02 of the Revised Code. No hospital 9,877
located in this state shall charge any insurance company, medical 9,878
care corporation, health care INSURING corporation, dental care 9,880
corporation, federal, state, or local government agency, or
person for any services rendered unless the hospital is certified 9,882
or accredited as provided in division (A) of section 3727.02 of 9,883
the Revised Code. "Hospital" as used in this section means only 9,884
those institutions included within the definition of that term 9,885
contained in section 3727.01 of the Revised Code, and the 9,886
prohibitions in this section do not apply to facilities excluded
from that definition. 9,887
Sec. 3901.41. (A) An insurance company licensed to 9,896
transact business in this state, OR A HEALTH INSURING CORPORATION 9,898
HOLDING A CERTIFICATE OF AUTHORITY UNDER CHAPTER 1751. OF THE 9,899
REVISED CODE, shall notify the superintendent of insurance and 9,900
deliver a copy of any order or judgment to the superintendent 9,901
within thirty days of the happening in another state of any one 9,902
or more of the following:
(1) Suspension or revocation of its right to transact 9,904
business; 9,905
(2) Receipt of an order to show cause why its license 9,907
should not be suspended or revoked; 9,908
(3) Imposition of a penalty on it for any violation of the 9,910
insurance laws of such other state. 9,911
(B) Whenever the superintendent finds that an insurance 9,913
company OR A HEALTH INSURING CORPORATION has failed to notify the 9,914
superintendent and to deliver a copy of any order or judgment to 9,916
him THE SUPERINTENDENT pursuant to division (A) of this section, 9,917
he THE SUPERINTENDENT may order a hearing to be held not less 9,918
than thirty days after the service of notice, to require it to 9,919
223
show cause why an order should not be made by the superintendent, 9,920
as a result of the violation of division (A) of this section, 9,921
directing the company OR CORPORATION to suspend any transaction 9,922
of business in this state or levying a penalty against the 9,924
company in an amount not to exceed five hundred dollars. All 9,925
such hearings shall be conducted, and may be appealed, in 9,926
accordance with sections 119.01 to 119.13 CHAPTER 119. of the 9,927
Revised Code. 9,928
Sec. 3901.48. (A) The original work papers of a certified 9,937
public accountant performing an audit of an insurance company OR 9,939
HEALTH INSURING CORPORATION doing business in this state that is
required by rule or by any section of the Revised Code to file an 9,941
audited financial report with the superintendent of insurance 9,942
shall remain the property of the certified public accountant. 9,943
Any copies of these work papers voluntarily given to the 9,944
superintendent shall be the property of the superintendent. The 9,945
original work papers or any copies of them, whether in possession 9,946
of the certified public accountant or the department of 9,947
insurance, are confidential and are not a public record as 9,948
defined in section 149.43 of the Revised Code. The original work 9,949
papers and any copies of them are not subject to subpoena and 9,950
shall not be made public by the superintendent or any other 9,951
person. However, the original work papers and any copies of them 9,952
may be released by the superintendent to the insurance regulatory 9,953
authority of any other state if that authority agrees to maintain 9,954
the confidentiality of the work papers or copies and if the work 9,955
papers and copies are not public records under the laws of that 9,956
state. 9,957
(B) The work papers of the superintendent or of the person 9,959
appointed by him THE SUPERINTENDENT, resulting from the conduct 9,960
of an examination made pursuant to section 3901.07 of the Revised 9,962
Code, are confidential and are not a public record as defined in 9,963
section 149.43 of the Revised Code. The original work papers and 9,964
any copies of them are not subject to subpoena and shall not be 9,965
224
made public by the superintendent or any other person. However, 9,966
the original work papers and any copies of them may be released 9,967
by the superintendent to the insurance regulatory authority of 9,968
any other state if that authority agrees to maintain the 9,969
confidentiality of the work papers or copies and if the work 9,970
papers and copies are not public records under the laws of that 9,971
state. 9,972
(C) The work papers of the superintendent or of any person 9,974
appointed by the superintendent, resulting from the conduct of a 9,975
performance regulation examination made pursuant to authority 9,976
granted under section 3901.011 of the Revised Code, are 9,977
confidential and are not a public record as defined in section 9,978
149.43 of the Revised Code. The original work papers and any 9,979
copies of them are not subject to subpoena and shall not be made 9,980
public by the superintendent or any other person. However, the 9,981
original work papers and any copies of them may be released by 9,982
the superintendent to the insurance regulatory authority of any 9,983
other state if that authority agrees to maintain the 9,984
confidentiality of the work papers or copies and if the work 9,985
papers and copies are not public records under the laws of that 9,986
state.
Sec. 3901.72. Any person may advance to a domestic 9,996
insurance company or a health maintenance organization INSURING 9,997
CORPORATION any sum of money necessary for the purpose of the 9,999
insurance company's or health maintenance organization's INSURING 10,000
CORPORATION'S business, or to enable the insurance company or 10,002
health maintenance organization INSURING CORPORATION to comply 10,003
with any law, or as a cash guarantee fund. Such money, and 10,004
interest agreed upon, not exceeding ten per cent per annum or the 10,005
total of four hundred basis points plus the rate on United States 10,006
treasury notes or bonds closest in maturity to the final 10,007
repayment date of the money so advanced, whichever is greater, 10,008
shall not be a liability or claim against the insurance company 10,009
or health maintenance organization INSURING CORPORATION, or any 10,010
225
of its assets, except as provided in this section, and shall be 10,012
repaid only out of the surplus earnings of such insurance company 10,013
or health maintenance organization INSURING CORPORATION. Except 10,014
as ordered by the superintendent of insurance, no part of the 10,016
principal or interest thereof shall be repaid until the surplus 10,017
of the insurance company or health maintenance organization 10,018
INSURING CORPORATION remaining after such repayment is equal in 10,019
amount to the principal of the money so advanced. Such 10,020
advancement and repayment shall be subject to the approval of the 10,021
superintendent, provided that this section shall not affect the 10,022
power to borrow money which any such insurance company or health 10,023
maintenance organization INSURING CORPORATION possesses under 10,024
other laws. No commission or promotion expenses shall be paid by 10,026
the insurance company or health maintenance organization INSURING 10,027
CORPORATION, in connection with the advance of any such money to 10,029
the insurance company or health maintenance organization INSURING 10,030
CORPORATION, and the amount of any such unpaid advance shall be 10,032
reported in each annual statement.
Sec. 3902.01. (A) The purpose of sections 3902.01 to 10,041
3902.08 of the Revised Code is to establish minimum standards for 10,042
language used in policies and certificates of life insurance and 10,043
annuities, credit life insurance and credit disability insurance, 10,044
and sickness and accident insurance, and subscriber POLICIES OR 10,045
certificates of medical care corporations, health care INSURING 10,046
corporations, dental care corporations, and health maintenance 10,047
organizations, delivered or issued for deliver DELIVERY in this 10,049
state, to facilitate ease of reading by insureds and subscribers. 10,051
(B) Sections 3902.01 to 3902.08 of the Revised Code are 10,053
not intended to increase the risk assumed by insurance companies 10,054
or other entities subject to sections 3902.01 to 3902.08 of the 10,055
Revised Code or to supersede their obligation to comply with the 10,056
substance of other applicable insurance laws. Sections 3902.01 10,057
to 3902.08 of the Revised Code are not intended to impede
flexibility and innovation in the development of policy forms or 10,058
226
content, or to lead to the standardization of policy forms or 10,059
content.
Sec. 3902.02. As used in sections 3902.01 to 3902.08 of 10,068
the Revised Code: 10,069
(A) "Policy" or "policy form" means any policy, contract, 10,071
plan or agreement of life insurance and annuities, credit life 10,072
insurance and credit disability insurance, and sickness and 10,073
accident insurance, and subscriber POLICIES, CONTRACTS, 10,074
certificates, AND AGREEMENTS of medical care corporations, health 10,076
care INSURING corporations, dental care corporations, and health 10,078
maintenance organizations, delivered or issued for delivery in 10,079
this state by any company subject to sections 3902.01 to 3902.08 10,080
of the Revised Code; any certificate, contract or policy issued 10,081
by a fraternal benefit society; any certificate issued pursuant 10,082
to a group insurance policy delivered or issued for delivery in 10,083
this state; and any evidence of coverage issued by a health 10,084
maintenance organization INSURING CORPORATION.
(B) "Company" or "insurer" means any entity authorized to 10,086
do the business of life insurance and annuities, sickness and 10,087
accident insurance, credit life insurance, or credit disability 10,088
insurance; a fraternal benefit society; AND a medical care 10,089
corporation; a health care INSURING corporation; a dental care 10,091
corporation; and a health maintenance organization. 10,092
Sec. 3902.11. As used in sections 3902.11 to 3902.14 of 10,101
the Revised Code: 10,102
(A) "Beneficiary" has the same meaning as in division 10,104
(A)(1) of section 3901.38 of the Revised Code. 10,105
(B) "Plan of health coverage" means any of the following 10,107
if the policy, contract, or agreement contains a coordination of 10,108
benefits provision: 10,109
(1) An individual or group sickness and accident insurance 10,111
policy or an individual or group contract of a health maintenance 10,112
organization, which policy or contract provides for hospital, 10,113
dental, surgical, or medical services; 10,114
227
(2) Any individual or group contract that provides dental 10,116
benefits OF A HEALTH INSURING CORPORATION, WHICH CONTRACT 10,117
PROVIDES FOR HOSPITAL, DENTAL, SURGICAL, OR MEDICAL SERVICES; 10,118
(3) Any other individual or group policy or agreement 10,120
under which a third-party payer provides for hospital, dental, 10,121
surgical, or medical services; 10,122
(4) An individual or group contract of a health care 10,124
corporation. 10,125
(C) "Provider" has the same meaning as in division (A)(6) 10,127
of section 3901.38 of the Revised Code. 10,128
(D) "Third-party payer" has the same meaning as in 10,130
division (A)(8) of section 3901.38 of the Revised Code, and 10,131
includes any health care corporation. 10,132
Sec. 3902.13. (A) A plan of health coverage determines 10,141
its order of benefits using the first of the following that 10,142
applies: 10,143
(1) A plan that does not coordinate with other plans is 10,145
always the primary plan. 10,146
(2) The benefits of the plan that covers a person as an 10,148
employee, member, insured, or subscriber, other than a dependent, 10,149
is the primary plan. The plan that covers the person as a 10,150
dependent is the secondary plan. 10,151
(3) When more than one plan covers the same child as a 10,153
dependent of different parents who are not divorced or separated, 10,154
the primary plan is the plan of the parent whose birthday falls 10,155
earlier in the year. The secondary plan is the plan of the 10,156
parent whose birthday falls later in the year. If both parents 10,157
have the same birthday, the benefits of the plan that covered the 10,158
parent the longer is the primary plan. The plan that covered the 10,159
parent the shorter time is the secondary plan. If the other 10,160
plan's provision for coordination of benefits does not include 10,161
the rule contained in this division because it is not subject to 10,162
regulation under this division, but instead has a rule based on 10,163
the gender of the parent, and if, as a result, the plans do not 10,164
228
agree on the order of benefits, the rule of the other plan will 10,165
determine the order of benefits. 10,166
(4)(a) Except as provided in division (A)(4)(b) of this 10,168
section, if more than one plan covers a person as a dependent 10,169
child of divorced or separated parents, benefits for the child 10,170
are determined in the following order: 10,171
(i) The plan of the parent who is the residential parent 10,173
and legal custodian of the child; 10,174
(ii) The plan of the spouse of the parent who is the 10,176
residential parent and legal custodian of the child; 10,177
(iii) The plan of the parent who is not the residential 10,179
parent and legal custodian of the child. 10,180
(b) If the specific terms of a court decree state that one 10,182
parent is responsible for the health care expenses of the child, 10,183
the plan of that parent is the primary plan. A parent 10,184
responsible for the health care pursuant to a court decree must 10,185
notify the insurer or health maintenance organization INSURING 10,186
CORPORATION of the terms of the decree. 10,188
(5) The primary plan is the plan that covers a person as 10,190
an employee who is neither laid off or retired, or that 10,191
employee's dependent. The secondary plan is the plan that covers 10,192
that person as a laid-off or retired employee, or that employee's 10,193
dependent. 10,194
(6) If none of the rules in divisions (A)(1), (2), (3), 10,196
(4), and (5) of this section determines the order of benefits, 10,197
the primary plan is the plan that covered an employee, member, 10,198
insured, or subscriber longer. The secondary plan is the plan 10,199
that covered that person the shorter time. 10,200
(B) When a plan of health coverage is determined to be a 10,202
secondary plan it acts to provide benefits in excess of those 10,203
provided by the primary plan. 10,204
(C) The secondary plan shall not be required to make 10,206
payment in an amount which exceeds the amount it would have paid 10,207
if it were the primary plan, but in no event, when combined with 10,208
229
the amount paid by the primary plan, shall payments by the 10,209
secondary plan exceed one hundred per cent of expenses allowable 10,210
under the provisions of the applicable policies and contracts. 10,211
(D) A third-party payer may require a beneficiary to file 10,213
a claim with the primary plan before it determines the amount of 10,214
its payment obligation, if any, with regard to that claim. 10,215
(E) Nothing in this section shall be construed to require 10,217
a plan to make a payment until it determines whether it is the 10,218
primary plan or the secondary plan and what benefits are payable 10,219
under the primary plan. 10,220
(F) A plan may obtain any facts and information necessary 10,222
to apply the provisions of this section, or supply this 10,223
information to any other third-party payer or provider, or any 10,224
agent of such third-party payer or provider, without the consent 10,225
of the beneficiary. Each person claiming benefits under the plan 10,226
shall provide any information necessary to apply the provisions 10,227
of this section. 10,228
(G) If the amount of payments made by any plan is more 10,230
than should have been paid, the plan may recover the excess from 10,231
whichever party received the excess payment. 10,232
(H) No third-party payer shall administer a plan of health 10,234
coverage delivered, issued for delivery, or renewed on or after 10,235
June 29, 1988, unless such plan complies with this section. 10,236
(I)(1) A third-party payer that is subject to this section 10,238
and has reason to believe payment has been made by another 10,239
third-party payer for the same service may request from that 10,240
third-party payer, and shall be provided by the third-party 10,241
payer, such data as necessary to determine whether duplicate 10,242
payment has been made. 10,243
(2) A third-party payer that meets the criteria of a 10,245
secondary payer in accordance with this section may seek 10,246
repayment of any duplicate payment that may have been made from 10,247
the person to whom it made payment. If the person who received 10,248
the duplicate payment is a provider, absent a finding of a court 10,249
230
of competent jurisdiction that the provider has engaged in civil 10,250
or criminal fraudulent activities, the request for the return of 10,251
any duplicate payment shall be made within three years after the 10,252
close of the provider's fiscal year in which the duplicate 10,253
payment has been made. 10,254
(J) Nothing in this section shall be construed to affect 10,256
the prohibition of section 3923.37 of the Revised Code. 10,257
(K)(1) No third-party payer shall knowingly fail to comply 10,259
with the order of benefits as set forth in division (A) of this 10,260
section. 10,261
(2) No primary plan shall direct or encourage an insured 10,263
to use the benefits of a secondary plan that results in a 10,264
reduction of payment by such primary plan. 10,265
(L) Whoever violates division (K) of this section is 10,267
deemed to have engaged in an unfair and deceptive insurance act 10,268
or practice under sections 3901.19 to 3901.26 of the Revised 10,269
Code, and is subject to proceedings pursuant to those sections. 10,270
Sec. 3904.01. As used in sections 3904.01 to 3904.22 of 10,279
the Revised Code: 10,280
(A)(1) "Adverse underwriting decision" means any of the 10,282
following actions with respect to insurance transactions 10,283
involving life, health, or disability insurance coverage that is 10,284
individually underwritten: 10,285
(a) A declination of insurance coverage; 10,287
(b) A termination of insurance coverage; 10,289
(c) Failure of an agent to apply for insurance coverage 10,291
with a specific insurance institution that the agent represents 10,292
and that is requested by an applicant; 10,293
(d) An offer to insure at higher than standard rates. 10,295
(2) Notwithstanding division (A)(1) of this section, none 10,297
of the following actions is an adverse underwriting decision, but 10,298
the insurance institution or agent responsible for their 10,299
occurrence shall nevertheless provide the applicant or 10,300
policyholder with the specific reason or reasons for their 10,301
231
occurrence: 10,302
(a) The termination of an individual policy form on a 10,304
class or statewide basis; 10,305
(b) A declination of insurance coverage solely because the 10,307
coverage is not available on a class or statewide basis; 10,308
(c) The rescission of a policy. 10,310
(B) "Affiliate" or "affiliated" means a person that 10,312
directly, or indirectly through one or more intermediaries, 10,313
controls, is controlled by, or is under common control with 10,314
another person. 10,315
(C) "Agent" means a person licensed under Chapter 3905. of 10,317
the Revised Code to negotiate or solicit applications for a 10,318
policy or contract of life, health, or disability insurance. 10,319
(D) "Applicant" means any person that seeks to contract 10,321
for life, health, or disability insurance coverage other than a 10,322
person seeking group insurance that is not individually 10,323
underwritten. 10,324
(E) "Consumer report" means any written, oral, or other 10,326
communication of information bearing on a natural person's credit 10,327
worthiness, credit standing, credit capacity, character, general 10,328
reputation, personal characteristics, or mode of living that is 10,329
used or expected to be used in connection with a life, health, or 10,330
disability insurance transaction. 10,331
(F) "Consumer reporting agency" means any person that does 10,333
all of the following: 10,334
(1) Regularly engages, in whole or in part, in the 10,336
practice of assembling or preparing consumer reports for a 10,337
monetary fee; 10,338
(2) Obtains information primarily from sources other than 10,340
insurance institutions; 10,341
(3) Furnishes consumer reports to other persons. 10,343
(G) "Control," including the terms "controlled by" or 10,345
"under common control with," means the possession, direct or 10,346
indirect, of the power to direct or cause the direction of the 10,347
232
management and policies of a person, whether through the 10,348
ownership of voting securities, by contract other than a 10,349
commercial contract for goods or nonmanagement services, or 10,350
otherwise, unless the power is the result of an official position 10,351
with or corporate office held by the person. 10,352
(H) "Declination of insurance coverage" means a denial, in 10,354
whole or in part, by an insurance institution or agent of 10,355
requested insurance coverage. 10,356
(I) "Individual" means any natural person who in 10,358
connection with life, health, or disability insurance: 10,359
(1) Is a past, present, or proposed principal insured or 10,361
certificate holder; 10,362
(2) Is a past, present, or proposed policy owner; 10,364
(3) Is a past or present applicant; 10,366
(4) Is a past or present claimant; 10,368
(5) Derived, derives, or is proposed to derive insurance 10,370
coverage under an insurance policy or certificate subject to 10,371
sections 3904.01 to 3904.22 of the Revised Code. 10,372
(J) "Institutional source" means any person or 10,374
governmental entity that provides information about an individual 10,375
to an agent, insurance institution, or insurance support 10,376
organization, other than any of the following: 10,377
(1) An agent; 10,379
(2) The individual who is the subject of the information; 10,381
(3) A natural person acting in a personal capacity rather 10,383
than in a business or professional capacity. 10,384
(K) "Insurance institution" means any corporation, 10,386
association, partnership, fraternal benefit society, or other 10,387
person engaged in the business of life, health, or disability 10,388
insurance, including health maintenance organizations, prepaid 10,389
dental plan organizations, medical care corporations, health care 10,390
INSURING corporations, and dental care corporations. "Insurance 10,392
institution" does not include agents or insurance support 10,393
organizations. 10,394
233
(L)(1) "Insurance support organization" means any person 10,396
that regularly engages, in whole or in part, in the practice of 10,397
assembling or collecting information about natural persons for 10,398
the primary purpose of providing the information to an insurance 10,399
institution or agent for insurance transactions, including both 10,400
of the following: 10,401
(a) The furnishing of consumer reports or investigative 10,403
consumer reports to an insurance institution or agent for use in 10,404
connection with an insurance transaction; 10,405
(b) The collection of personal information from insurance 10,407
institutions, agents, or other insurance support organizations 10,408
for the purpose of detecting or preventing fraud, material 10,409
misrepresentation, or material nondisclosure in connection with 10,410
insurance underwriting or insurance claim activity. 10,411
(2) Notwithstanding division (L)(1) of this section, 10,413
agents, government institutions, insurance institutions, medical 10,414
care institutions, and medical professionals are not "insurance 10,415
support organizations" for purposes of sections 3904.01 to 10,416
3904.22 of the Revised Code. 10,417
(M) "Insurance transaction" means any transaction 10,419
involving life, health, or disability insurance primarily for 10,420
personal, family, or household needs rather than business or 10,421
professional needs and entailing either the determination of an 10,422
individual's eligibility for a life, health, or disability 10,423
insurance coverage, benefit, or payment, or the servicing of a 10,424
life, health, or disability insurance application, policy, 10,425
contract, or certificate. 10,426
(N) "Investigative consumer report" means a consumer 10,428
report or portion thereof in which information about a natural 10,429
person's character, general reputation, personal characteristics, 10,430
or mode of living is obtained through personal interviews with 10,431
the person's neighbors, friends, associates, acquaintances, or 10,432
others who may have knowledge concerning such items of 10,433
information. 10,434
234
(O) "Medical care institution" means any facility or 10,436
institution that is licensed to provide health care services to 10,437
natural persons, including home-health agencies, hospitals, 10,438
medical clinics, public health agencies, rehabilitation agencies, 10,439
and skilled nursing facilities. 10,440
(P) "Medical professional" means any person licensed or 10,442
certified to provide health care services to natural persons, 10,443
including a chiropractor, clinical dietician, clinical 10,444
psychologist, dentist, nurse, occupational therapist, 10,445
optometrist, pharmacist, physical therapist, physician, 10,446
podiatrist, psychiatric social worker, and speech therapist. 10,447
(Q) "Medical record information" means personal 10,449
information that relates to an individual's physical or mental 10,450
condition, medical history, or medical treatment and that is 10,451
obtained from a medical professional or medical care institution, 10,452
from the individual, or from the individual's spouse, parent, or 10,453
legal guardian. 10,454
(R) "Personal information" means any individually 10,456
identifiable information gathered in connection with an insurance 10,457
transaction from which judgments can be made about an 10,458
individual's character, habits, avocations, finances, occupation, 10,459
general reputation, credit, health, or any other personal 10,460
characteristics. "Personal information" includes an individual's 10,461
name and address and medical record information but does not 10,462
include privileged information. 10,463
(S) "Policyholder" means any person that is a present 10,465
owner of individual life, health, or disability insurance, or a 10,466
present certificate holder under group life, health, or 10,467
disability insurance that is individually underwritten. 10,468
(T) "Pretext interview" means an interview whereby a 10,470
person, in an attempt to obtain information about a natural 10,471
person, performs one or more of the following acts: 10,472
(1) Pretends to be someone he THE INTERVIEWER is not; 10,474
(2) Pretends to represent a person he THE INTERVIEWER is 10,476
235
not in fact representing; 10,478
(3) Misrepresents the true purpose of the interview; 10,480
(4) Refuses to identify himself SELF upon request. 10,482
(U) "Privileged information" means any individually 10,484
identifiable information that relates to a claim for life, 10,485
health, or disability insurance benefits or a civil or criminal 10,486
proceeding involving an individual, and that is collected in 10,487
connection with, or in reasonable anticipation of, a claim for 10,488
life, health, or disability insurance benefits or civil or 10,489
criminal proceeding involving an individual. However, 10,490
information otherwise meeting the requirements of this division 10,491
shall nevertheless be considered personal information if it is 10,492
disclosed in violation of section 3904.13 of the Revised Code. 10,493
(V) "Termination of insurance coverage" or "termination of 10,495
an insurance policy" means either a cancellation or nonrenewal of 10,496
a life, health, or disability insurance policy, in whole or in 10,497
part, for any reason other than the failure to pay a premium as 10,498
required by the policy. 10,499
(W) "Unauthorized insurer" means an insurance institution 10,501
that has not been granted a certificate of authority by the 10,502
superintendent of insurance to transact the business of life, 10,503
health, or disability insurance in this state. 10,504
Sec. 3905.71. As used in sections 3905.71 to 3905.79 of 10,513
the Revised Code: 10,514
(A) "Actuary" means a person who is a member in good 10,516
standing of the American academy of actuaries. 10,517
(B) "Insurer" means any person licensed to do business in 10,519
this state under Chapter 1736., 1737., 1738., 1740., 1742., 1751. 10,521
or 1761. of the Revised Code or Title XXXIX of the Revised Code. 10,522
(C) "Laws of this state relating to insurance" has the 10,524
same meaning as in section 3901.04 of the Revised Code. 10,525
(D)(1) "Managing general agent" means any person that does 10,527
all of the following: 10,528
(a) Manages all or part of the insurance business of an 10,530
236
insurer, including the management of a separate division, 10,531
department, or underwriting office, or negotiates and binds 10,532
ceding reinsurance contracts on behalf of an insurer; 10,533
(b) Acts as an agent for the insurer, whether known as a 10,535
managing general agent, manager, or other similar term; 10,536
(c) With or without the authority of the insurer, 10,538
separately or together with affiliates, does both of the 10,539
following: 10,540
(i) Produces, directly or indirectly, and underwrites an 10,542
amount of gross direct written premium equal to or more than five 10,543
per cent of the policyholder surplus of the insurer as reported 10,544
in the last annual statement of the insurer in any one year; 10,545
(ii) Adjusts or pays claims, or negotiates reinsurance on 10,547
behalf of the insurer. 10,548
(2) "Managing general agent" does not include any of the 10,550
following: 10,551
(a) An employee of the insurer; 10,553
(b) A United States manager of the United States branch of 10,555
an alien insurer; 10,556
(c) An underwriting manager that, pursuant to contract, 10,558
manages all or a part of the insurance operations of the insurer, 10,559
is under common control with the insurer, subject to sections 10,560
3901.32 to 3901.37 of the Revised Code, and whose compensation is 10,561
not based on the volume of premiums written; 10,562
(d) The attorney authorized by and acting for the 10,564
subscribers of a reciprocal insurer or inter-insurance exchange 10,565
under powers of attorney; 10,566
(e) An administrator licensed pursuant to Chapter 3959. of 10,568
the Revised Code whose activities on behalf of an insurer are 10,569
limited to administrative services involving underwriting or the 10,570
payment of claims, and do not include the management of all or 10,571
part of the insurance business of the insurer. 10,572
(E) "Underwrite" or "underwriting" means the authority to 10,574
accept or reject risk on behalf of an insurer. 10,575
237
Sec. 3923.123. (A) As used in this section: 10,584
(1) "Association" means a voluntary unincorporated 10,586
association of insurers formed for the sole purpose of enabling 10,587
cooperative action to provide health coverage in accordance with 10,588
this section. 10,589
(2) "Insurer" includes any insurance company authorized to 10,591
do the business of sickness and accident insurance in this state, 10,592
medical care corporation organized under Chapter 1737. of the 10,593
Revised Code, AND ANY health care INSURING corporation organized 10,595
HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 1751. of 10,596
the Revised Code, dental care corporation organized under Chapter 10,598
1740. of the Revised Code, or hospital maintenance organization 10,599
organized under Chapter 1742. of the Revised Code.
(3) "Insured" means a person covered under a group policy 10,601
or contract issued pursuant to this section. 10,602
(4) "Qualified unemployed person" means one who became 10,604
unemployed while a resident of this state from employment or 10,605
self-employment and has since been continuously unemployed or is 10,606
employed only so that he THE PERSON does not have, or have a 10,607
right to purchase, group health coverage. An individual who is, 10,609
or who becomes, covered by medicare is not a qualified unemployed 10,610
person. A person eligible for coverage under this section, who 10,611
is also eligible for continuation of coverage under section 10,612
1737.30, 1738.26, 1742.34, 1751.53 or 3923.38 of the Revised 10,613
Code, may elect either coverage, but not both. A person who 10,615
elects continuation of coverage under any EITHER of such sections 10,616
may, upon the termination of the continuation of coverage, elect 10,618
any coverage available under this section. 10,619
(B) Any insurer may join with one or more other insurers, 10,621
in an association, to offer, sell, and issue to a policyholder or 10,622
subscriber selected by the association a policy or contract of 10,623
group health coverage, covering residents of this state who are 10,624
qualified unemployed persons and the spouses or dependents of 10,625
such residents. The coverage shall be offered, issued, and 10,626
238
administered in the name of the association. Membership in the 10,627
association shall be open to any insurer and each insurer which 10,628
participates shall be liable for a specified percentage of the 10,629
risks. The policy or contract may be executed on behalf of the 10,630
association by a duly authorized person. 10,631
(C) The persons eligible for coverage under the policy or 10,633
contract shall be all residents of this state who are qualified 10,634
unemployed persons and their spouses and dependents, subject to 10,635
reasonable underwriting restrictions to be set forth in the plan 10,636
of the association. The policy or contract may provide basic 10,637
hospital and surgical coverage, basic medical coverage, major 10,638
medical coverage, and any combination of these; provided that it 10,639
shall not be required as a condition for obtaining major medical 10,640
coverage that any basic coverage be taken. 10,641
(D) The association shall file with the superintendent of 10,643
insurance any policy, contract, certificate, or other evidence of 10,644
coverage, application, or other forms pertaining to such 10,645
insurance together with the premium rates to be charged therefor. 10,646
The superintendent may approve, disapprove, and withdraw approval 10,647
of the forms in accordance with section 3923.02 of the Revised 10,648
Code, or the premium rates if by reasonable assumptions such 10,649
rates are excessive in relation to the benefits provided. In 10,650
determining whether such rates by reasonable assumptions are 10,651
excessive in relation to the benefits provided, the 10,652
superintendent shall give due consideration to past and 10,653
prospective claim experience, within and outside this state, and 10,654
to fluctuations in such claim experience, to a reasonable risk 10,655
charge, to contribution to surplus and contingency funds, to past 10,656
and prospective expenses, both within and outside this state, and 10,657
to all other relevant factors within and outside this state, 10,658
including any differing operating methods of the insurers joining 10,659
in the issuance of the policy or contract. In reviewing the 10,660
forms the superintendent shall not be bound by the requirements 10,661
of sections 3923.04 to 3923.07 of the Revised Code with respect 10,662
239
to standard provisions to be included in sickness and accident 10,663
policies or forms. 10,664
(E) The association may enroll eligible persons for 10,666
coverage under the policy or contract through any person licensed 10,667
by, or authorized under the law of, this state to sell the 10,668
policies or contracts, or to enroll persons in the health plans, 10,669
of any of the insurers participating in the association. 10,670
(F) The association shall file annually with the 10,672
superintendent on such date and in such form as he THE 10,673
SUPERINTENDENT may prescribe, a financial summary of its 10,675
operations.
(G) The association may sue and be sued in its associate 10,677
name and for such purposes only shall be treated as a domestic 10,678
corporation. Service of process against such association made 10,679
upon a managing agent, any member thereof, or any agent 10,680
authorized by appointment to receive service of process, shall 10,681
have the same force and effect as if such service had been made 10,682
upon all members of the association. 10,683
(H) Under any policy issued as provided in this section, 10,685
the policyholder, or such person as the policyholder shall 10,686
designate, shall alone be a member of each domestic mutual 10,687
insurance company joining in the issue of the policy and shall be 10,688
entitled to one vote by virtue of such policy at the meetings of 10,689
each such mutual insurance company. Notice of the annual 10,690
meetings of each such mutual insurance company may be given by 10,691
written notice to the policyholder or as otherwise prescribed in 10,692
said policy. 10,693
Sec. 3923.30. Every person, the state and any of its 10,702
instrumentalities, any county, township, school district, or 10,703
other political subdivisions and any of its instrumentalities, 10,704
and any municipal corporation and any of its instrumentalities, 10,705
which provides payment for health care benefits for any of its 10,706
employees resident in this state, which benefits are not provided 10,707
by contract with an insurer qualified to provide sickness and 10,708
240
accident insurance, or a health maintenance organization INSURING 10,709
CORPORATION, shall include the following benefits in its plan of 10,711
health care benefits commencing on or after January 1, 1979: 10,712
(A) If such plan of health care benefits provides payment 10,714
for the treatment of mental or nervous disorders, then such plan 10,715
shall provide benefits for services on an outpatient basis for 10,716
each eligible employee and dependent for mental or emotional 10,717
disorders, or for evaluations, that are at least equal to the 10,718
following: 10,719
(1) Payments not less than five hundred fifty dollars in a 10,721
twelve-month period, for services legally performed by or under 10,722
the clinical supervision of a licensed physician or a licensed 10,723
psychologist, whether performed in an office, in a hospital, or 10,724
in a community mental health facility so long as the hospital or 10,725
community mental health facility is approved by the joint 10,726
commission on accreditation of hospitals or certified by the 10,727
department of mental health as being in compliance with standards 10,728
established under division (I) of section 5119.01 of the Revised 10,729
Code; 10,730
(2) Such benefit shall be subject to reasonable 10,732
limitations, and may be subject to reasonable deductibles and 10,733
co-insurance costs. 10,734
(3) In order to qualify for participation under this 10,736
division, every facility specified in this division shall have in 10,737
effect a plan for utilization review and a plan for peer review 10,738
and every person specified in this division shall have in effect 10,739
a plan for peer review. Such plans shall have the purpose of 10,740
ensuring high quality patient care and effective and efficient 10,741
utilization of available health facilities and services. 10,742
(4) Such payment for benefits shall not be greater than 10,744
usual, customary, and reasonable. 10,745
(5) For purposes of this division, "community mental 10,747
health facility" means a facility as defined in section 3923.28 10,748
of the Revised Code. 10,749
241
(6)(a) Services performed under the clinical supervision 10,751
of a licensed physician or licensed psychologist, in order to be 10,752
reimbursable under the coverage required in division (A) of this 10,753
section, shall meet both of the following requirements: 10,754
(i) The services shall be performed in accordance with a 10,756
treatment plan that describes the expected duration, frequency, 10,757
and type of services to be performed; 10,758
(ii) The plan shall be reviewed and approved by a licensed 10,760
physician or licensed psychologist every three months. 10,761
(b) Payment of benefits for services reimbursable under 10,763
division (A)(6)(a) of the section shall not be restricted to 10,764
services described in the treatment plan or conditioned upon 10,765
standards of a licensed physician or licensed psychologist, which 10,766
at least equal the requirements of division (A)(6)(a) of this 10,767
section. 10,768
(B) Payment for benefits for alcoholism treatment for 10,770
outpatient, inpatient, and intermediate primary care for each 10,771
eligible employee and dependent that are at least equal to the 10,772
following: 10,773
(1) Payments not less than five hundred fifty dollars in a 10,775
twelve-month period for services legally performed by or under 10,776
the clinical supervision of a licensed physician or licensed 10,777
psychologist, whether performed in an office, or in a hospital or 10,778
a community mental health facility or alcoholism treatment 10,779
facility so long as the hospital, community mental health 10,780
facility, or alcoholism treatment facility is approved by the 10,781
joint commission on accreditation of hospitals or certified by 10,782
the department of health; 10,783
(2) The benefits provided under this division shall be 10,785
subject to reasonable limitations and may be subject to 10,786
reasonable deductibles and co-insurance costs. 10,787
(3) A licensed physician or licensed psychologist shall 10,789
every three months certify a patient's need for continued 10,790
services performed by such facilities. 10,791
242
(4) In order to qualify for participation under this 10,793
division, every facility specified in this division shall have in 10,794
effect a plan for utilization review and a plan for peer review 10,795
and every person specified in this division shall have in effect 10,796
a plan for peer review. Such plans shall have the purpose of 10,797
ensuring high quality patient care and efficient utilization of 10,798
available health facilities and services. Such person or 10,799
facilities shall also have in effect a program of rehabilitation 10,800
or a program of rehabilitation and detoxification. 10,801
(5) Nothing in this section shall be construed to require 10,803
reimbursement for benefits which is greater than usual, 10,804
customary, and reasonable. 10,805
Sec. 3923.301. Every person, the state and any of its 10,814
instrumentalities, any county, township, school district, or 10,815
other political subdivision and any of its instrumentalities, and 10,816
any municipal corporation and any of its instrumentalities that 10,818
provides payment for health care benefits for any of its
employees resident in this state, which benefits are not provided 10,819
by contract with an insurer qualified to provide sickness and 10,820
accident insurance or a health maintenance organization INSURING 10,821
CORPORATION, and THAT includes reimbursement for any service that 10,823
may be legally performed by a certified nurse-midwife who is 10,824
authorized under section 4723.42 of the Revised Code to practice 10,826
nurse-midwifery, shall not deny reimbursement to a certified 10,827
nurse-midwife performing the service if the service is performed 10,829
in collaboration with a licensed physician. The collaborating 10,832
physician shall be identified on the claim form.
The cost of collaboration with a certified nurse-midwife by 10,835
a licensed physician as required under section 4723.43 of the 10,836
Revised Code is a reimbursable expense. 10,837
The division of any reimbursement payment for services 10,839
performed by a certified nurse-midwife between the nurse-midwife 10,840
and the nurse-midwife's collaborating physician shall be 10,841
determined and mutually agreed upon by the certified 10,843
243
nurse-midwife and the physician. The division of fees shall not 10,844
be considered a violation of division (B)(17) of section 4731.22 10,845
of the Revised Code. In no case shall the total fees charged 10,846
exceed the fee the physician would have charged had the physician 10,847
provided the entire service.
Sec. 3923.33. As used in section 3923.33 and sections 10,857
3923.331 to 3923.339 of the Revised Code: 10,858
(A) "Applicant" means: 10,860
(1) In the case of an individual medicare supplement 10,862
policy, the person who seeks to contract for insurance benefits; 10,863
and 10,864
(2) In the case of a group medicare supplement policy, the 10,866
proposed certificate holder. 10,867
(B) "Certificate" means, for purposes of section 3923.33 10,869
and sections 3923.331 to 3923.339 of the Revised Code, any 10,870
certificate delivered or issued for delivery in this state under 10,871
a group medicare supplement policy. 10,872
(C) "Certificate form" means the form on which the 10,874
certificate is delivered or issued for delivery by the issuer. 10,875
(D) "Direct response insurance policy" means a medicare 10,877
supplement policy or certificate marketed without the direct 10,878
involvement of an insurance agent. 10,879
(E) "Issuer" includes insurance companies, fraternal 10,881
benefit societies, health maintenance organizations INSURING 10,882
CORPORATIONS, and any other entities delivering or issuing for 10,884
delivery in this state medicare supplement policies or 10,885
certificates.
(F) "Medicare" means the "Health Insurance for the Aged 10,887
Act," Title XVIII of the Social Security Amendments of 1965, 79 10,888
Stat. 291, 42 U.S.C.A. 1395, as then constituted or later 10,889
amended. 10,890
(G) "Medicare supplement policy" means a group or 10,892
individual policy of sickness and accident insurance or a 10,893
subscriber contract of health maintenance organizations INSURING 10,894
244
CORPORATIONS or any other issuers, other than a policy issued 10,896
pursuant to a contract under section 1876 of the "Social Security 10,897
Act," 49 Stat. 620 (1935), 42 U.S.C.A., 1395mm, as amended, or an 10,898
issued policy under any demonstration project specified in 42 10,899
U.S.C.A. 1395ss(g)(1), which is advertised, marketed, or designed 10,901
primarily as a supplement to reimbursements under medicare for 10,902
the hospital, medical, or surgical expenses of persons eligible 10,903
for medicare.
(H) "Policy form" means the form on which the policy is 10,905
delivered or issued for delivery by the issuer. 10,906
Sec. 3923.333. Medicare supplement policies shall return 10,915
to policyholders benefits that are reasonable in relation to the 10,916
premium charged. The superintendent of insurance shall issue 10,917
reasonable rules to establish minimum standards for loss ratios 10,918
of medicare supplement policies on the basis of incurred claims 10,919
experience, or incurred health care expenses where coverage is
provided by a health maintenance organization INSURING 10,920
CORPORATION on a service rather than reimbursement basis, and 10,922
earned premiums in accordance with accepted actuarial principles 10,923
and practices.
Sec. 3923.38. (A) As used in this section: 10,932
(1) "Group policy" includes any group sickness and 10,934
accident policy or contract delivered, issued for delivery, or 10,935
renewed in this state on or after June 28, 1984, and any private 10,936
or public employer self-insurance plan or other plan that 10,937
provides, or provides payment for, health care benefits for 10,938
employees resident in this state other than through an insurer, 10,939
OR health care INSURING corporation, or health maintenance 10,941
organization, to which both of the following apply: 10,943
(a) The policy insures employees for hospital, surgical, 10,945
or major medical insurance on an expense incurred or service 10,946
basis, other than for specified diseases or for accidental 10,947
injuries only. 10,948
(b) The policy is in effect and covers an eligible 10,950
245
employee at the time the employee's employment is terminated. 10,951
(2) "Eligible employee" includes only an employee to whom 10,953
all of the following apply: 10,954
(a) The employee has been continuously insured under a 10,956
group policy or under the policy and any prior similar group 10,957
coverage replaced by the policy, during the entire three-month 10,958
period preceding the termination of the employee's employment. 10,959
(b) The employee is entitled, at the time of the 10,961
termination of his THE EMPLOYEE'S employment, to unemployment 10,962
compensation benefits under Chapter 4141. of the Revised Code. 10,964
(c) The employee is not, and does not become, covered by 10,966
or eligible for coverage by medicare under Title XVIII of the 10,967
Social Security Act, as amended. 10,968
(d) The employee is not, and does not become, covered by 10,970
or eligible for coverage by any other insured or uninsured 10,971
arrangement that provides hospital, surgical, or medical coverage 10,972
for individuals in a group and under which the person was not 10,973
covered immediately prior to such termination. A person eligible 10,974
for continuation of coverage under this section, who is also 10,975
eligible for coverage under section 3923.123 of the Revised Code, 10,976
may elect either coverage, but not both. A person who elects 10,977
continuation of coverage may elect any coverage available under 10,978
section 3923.123 of the Revised Code upon the termination of the 10,979
continuation of coverage. 10,980
(3) "Group rate" means, in the case of an employer 10,982
self-insurance or other health benefits plan, the average monthly 10,983
cost per employee, over a period of at least twelve months, of 10,984
the operation of the plan that would represent a group insurance 10,985
rate if the same coverage had been provided under a group 10,986
sickness and accident insurance policy. 10,987
(B) A group policy shall provide that any eligible 10,989
employee may continue the employee's hospital, surgical, and 10,990
medical insurance under the policy, for the employee and the 10,991
employee's eligible dependents, for a period of six months after 10,992
246
the date that the insurance coverage would otherwise terminate by 10,993
reason of the termination of his THE EMPLOYEE'S employment. Each 10,995
certificate of coverage, or other notice of coverage, issued to 10,996
employees under the policy shall include a notice of the 10,997
employee's privilege of continuation. 10,998
(C) All of the following apply to the continuation of 11,000
coverage required under division (B) of this section: 11,001
(1) Continuation need not include dental, vision care, 11,003
prescription drug benefits, or any other benefits provided under 11,004
the policy in addition to its hospital, surgical, or major 11,005
medical benefits. 11,006
(2) The employer shall notify the employee of the right of 11,008
continuation at the time the employer notifies the employee of 11,009
the termination of employment. The notice shall inform the 11,010
employee of the amount of contribution required by the employer 11,011
under division (C)(4) of this section. 11,012
(3) The employee shall file a written election of 11,014
continuation with the employer and pay the employer the first 11,015
contribution required under division (C)(4) of this section. The 11,016
request and payment must be received by the employer no later 11,017
than the earlier of any of the following dates: 11,018
(a) Thirty-one days after the date on which the employee's 11,020
coverage would otherwise terminate; 11,021
(b) Ten days after the date on which the employee's 11,023
coverage would otherwise terminate, if the employer has notified 11,024
the employee of the right of continuation prior to such date; 11,025
(c) Ten days after the employer notifies the employee of 11,027
the right of continuation, if the notice is given after the date 11,028
on which the employee's coverage would otherwise terminate. 11,029
(4) The employee must pay to the employer, on a monthly 11,031
basis, in advance, the amount of contribution required by the 11,032
employer. The amount required shall not exceed the group rate 11,033
for the insurance being continued under the policy on the due 11,034
date of each payment. 11,035
247
(5) The employee's privilege to continue coverage and the 11,037
coverage under any continuation ceases if any of the following 11,038
occurs: 11,039
(a) The employee ceases to be an eligible employee under 11,041
division (A)(2)(c) or (d) of this section; 11,042
(b) A period of six months expires after the date that the 11,044
employee's insurance under the policy would otherwise have 11,045
terminated because of the termination of employment; 11,046
(c) The employee fails to make a timely payment of a 11,048
required contribution, in which event the coverage shall cease at 11,049
the end of the coverage for which contributions were made; 11,050
(d) The policy is terminated, or the employer terminates 11,052
participation under the policy, unless the employer replaces the 11,053
coverage by similar coverage under another group policy or other 11,054
group health arrangement. 11,055
If the employer replaces the policy with similar group 11,057
health coverage, all of the following apply: 11,058
(i) The member shall be covered under the replacement 11,060
coverage, for the balance of the period that he THE MEMBER would 11,061
have remained covered under the terminated coverage if it had not 11,063
been terminated. 11,064
(ii) The minimum level of benefits under the replacement 11,066
coverage shall be the applicable level of benefits of the policy 11,067
replaced reduced by any benefits payable under the policy 11,068
replaced. 11,069
(iii) The policy replaced shall continue to provide 11,071
benefits to the extent of its accrued liabilities and extensions 11,072
of benefits as if the replacement had not occurred. 11,073
(D) This section does not apply to an employer's 11,075
self-insurance plan if federal law supersedes, preempts, 11,076
prohibits, or otherwise precludes its application to such plans. 11,077
Sec. 3923.382. (A) As used in this section: 11,086
(1) "Eligible person" means any person who, at the time a 11,088
reservist is called or ordered to active duty, is covered under a 11,089
248
group plan and is either of the following: 11,090
(a) An employee who is a reservist called or ordered to 11,092
active duty; 11,093
(b) The spouse or a dependent child of an employee 11,095
described in division (A)(1)(a) of this section. 11,096
(2) "Group plan" includes any private or public employer 11,098
self-insurance plan that satisfies all of the following: 11,099
(a) The plan is established or modified in this state on 11,101
or after the effective date of this section APRIL 17, 1991. 11,103
(b) The plan provides, or provides payment for, health 11,105
benefits for employees resident in this state other than through 11,106
an insurer, OR health maintenance organization, health care 11,108
INSURING corporation, or medical care corporation. 11,109
(c) The plan is in effect and covers an eligible person at 11,111
the time a reservist is called or ordered to active duty. 11,112
(3) "Group rate" means the average monthly cost per 11,114
employee, over a period of at least twelve months of the 11,115
operation of a group plan, that would represent a group insurance 11,116
rate if the same coverage had been provided under a group 11,117
sickness and accident insurance policy. 11,118
(4) "Reservist" means a member of a reserve component of 11,120
the armed forces of the United States. "Reservist" includes a 11,121
member of the Ohio national guard and the Ohio air national 11,122
guard. 11,123
(B) Every group plan shall provide that any eligible 11,125
person may continue the coverage under the plan for a period of 11,126
eighteen months after the date on which the coverage would 11,127
otherwise terminate because the reservist is called or ordered to 11,128
active duty. 11,129
(C)(1) An eligible person may extend the eighteen-month 11,131
period of continuation of coverage to a thirty-six-month period 11,132
of continuation of coverage, if any of the following occurs 11,133
during the eighteen-month period: 11,134
(a) The death of the reservist; 11,136
249
(b) The divorce or separation of a reservist from the 11,138
reservist's spouse; 11,139
(c) The cessation of dependency of a child pursuant to the 11,141
terms of the plan. 11,142
(2) The thirty-six-month period of continuation of 11,144
coverage is deemed to begin on the date on which the coverage 11,145
would otherwise terminate because the reservist is called or 11,146
ordered to active duty. 11,147
(3) The employer may begin the thirty-six-month period on 11,149
the date of any occurrence described in division (C)(1) of this 11,150
section. 11,151
(D) All of the following apply to any continuation of 11,153
coverage, or the extension of any continuation of coverage, 11,154
provided under division (B) or (C) of this section: 11,155
(1) The continuation of coverage shall provide the same 11,157
benefits as those provided to any similarly situated eligible 11,158
person who is covered under the same group plan and an employee 11,159
who has not been called or ordered to active duty. 11,160
(2) An employer shall notify each employee of the right of 11,162
continuation of coverage at the time of employment. At the time 11,163
the reservist is called or ordered to active duty, the employer 11,164
shall notify each eligible person of the requirements for the 11,165
continuation of coverage. 11,166
(3) Each certificate or other evidence of coverage issued 11,168
by an employer to an employee under the group plan shall include 11,169
a notice of the eligible person's right of continuation of 11,170
coverage. 11,171
(4) An eligible person shall file a written election of 11,173
continuation of coverage with the employer and pay the employer 11,174
the first contribution required under division (D)(5) of this 11,175
section. The written election and payment must be received by 11,176
the employer no later than thirty-one days after the date on 11,177
which the eligible person's coverage would otherwise terminate. 11,178
If the employer notifies the eligible person of the right of 11,179
250
continuation of coverage after the date on which the eligible 11,180
person's coverage would otherwise terminate, the written election 11,181
and payment must be received by the employer no later than 11,182
thirty-one days after the date of the notification. 11,183
(5)(a) Except as provided in division (D)(5)(b) of this 11,185
section, the eligible person shall pay to the employer, on a 11,186
monthly basis and in advance, the amount of contribution required 11,187
by the employer. The amount shall not exceed one hundred two per 11,188
cent of the group rate for the coverage being continued under the 11,189
group plan on the due date of each payment. 11,190
(b) The employer may pay a portion or all of the eligible 11,192
person's contribution. 11,193
(E) The eligible person's right to any continuation of 11,195
coverage, or the extension of any continuation of coverage, 11,196
provided under division (B) or (C) of this section ceases on the 11,197
date on which any of the following occurs: 11,198
(1) The eligible person, whether as an employee or 11,200
otherwise, enrolls in another group plan or other group health 11,201
plan or arrangement that does not contain any exclusion or 11,202
limitation with respect to any preexisting condition of that 11,203
eligible person. For purposes of division (E)(1) of this 11,204
section, a group plan or other group health plan or arrangement 11,205
does not include the civilian health and medical program of the 11,206
uniformed services as defined in Public Law 99-661, 100 Stat. 11,207
3898 (1986), 10 U.S.C.A. 1072. 11,208
(2) The period of either eighteen months provided under 11,210
division (B) of this section or thirty-six months provided under 11,211
division (C) of this section expires. 11,212
(3) The eligible person fails to make a timely payment of 11,214
a required contribution, in which case the coverage ceases at the 11,215
end of the period of coverage for which contributions were made. 11,216
(4) The group plan, or participation under the group plan, 11,218
is terminated, unless the employer, in accordance with division 11,219
(F) of this section, replaces the coverage with similar coverage 11,220
251
under another group plan or other group health plan or 11,221
arrangement. 11,222
(F) If the employer replaces the group plan with similar 11,224
coverage as described in division (E)(4) of this section, both of 11,225
the following apply: 11,226
(1) The eligible person is covered under the replacement 11,228
coverage for the balance of the period that he THE PERSON would 11,229
have remained covered under the terminated coverage if it had not 11,231
been terminated. 11,232
(2) The level of benefits under the replacement coverage 11,234
is the same as the level of benefits provided to any similarly 11,235
situated eligible person who is covered under the group plan and 11,236
an employee who has not been called or ordered to active duty. 11,237
(G) Upon the reservist's release from active duty and his 11,239
THE RESERVIST'S return to employment for the employer by whom he 11,241
THE RESERVIST was employed at the time he THE RESERVIST was 11,243
called or ordered to active duty, both of the following apply: 11,245
(1) Every eligible person is entitled, without any waiting 11,247
period, to coverage under the employer's group plan that is in 11,248
effect at the time of the reservist's return to employment. 11,249
(2) Every eligible person is entitled to all benefits 11,251
under the group plan described in division (G)(1) of this section 11,252
from the date of the original coverage under the plan. 11,253
(H)(1) No employer shall fail to provide for a 11,255
continuation of coverage, or an extension of a continuation of 11,256
coverage, in a group plan as required by and in accordance with 11,257
the terms and conditions set forth under this section. 11,258
(2) No employer shall fail to issue a certificate or other 11,260
evidence of coverage in compliance with division (D)(3) of this 11,261
section. 11,262
(3) No employer shall fail to provide an employee or 11,264
eligible person with notice of the right to a continuation of 11,265
coverage under a group plan in accordance with division (D)(2) of 11,266
this section. 11,267
252
(I) Whoever violates division (H)(1), (2), or (3) of this 11,269
section is deemed to have engaged in an unfair and deceptive act 11,270
or practice in the business of insurance under sections 3901.19 11,271
to 3901.26 of the Revised Code. 11,272
(J) This section does not apply to a group plan under 11,274
either of the following circumstances: 11,275
(1) The group plan is subject to section 5923.051 of the 11,277
Revised Code. 11,278
(2) The application of this section is superseded, 11,280
preempted, prohibited, or otherwise precluded by federal law. 11,281
Sec. 3923.41. As used in sections 3923.41 to 3923.48 of 11,290
the Revised Code: 11,291
(A) "Long-term care insurance" means any insurance policy 11,293
or rider advertised, marketed, offered, or designed to provide 11,294
coverage for not less than one year for each covered person on an 11,295
expense incurred, indemnity, prepaid, or other basis, for one or 11,296
more necessary or medically necessary diagnostic, preventive, 11,297
therapeutic, rehabilitative, maintenance, or personal care 11,298
services, provided in a setting other than an acute care unit of 11,299
a hospital. "Long-term care insurance" includes group and 11,300
individual annuities and life insurance policies or riders that 11,301
provide directly or supplement long-term care benefits, and 11,302
policies or riders that provide for payment of benefits based on 11,303
cognitive impairment or the loss of functional capacity. 11,304
"Long-term care insurance" includes group and individual policies 11,305
or riders whether issued by insurers, fraternal benefit 11,306
societies, OR health and medical care INSURING corporations, 11,308
prepaid health plans, or health maintenance organizations. 11,309
"Long-term care insurance" does not include any insurance policy 11,310
that is offered primarily to provide basic medicare supplement 11,311
coverage, basic hospital expense coverage, basic medical-surgical 11,312
expense coverage, hospital confinement indemnity coverage, major 11,313
medical expense coverage, disability income protection coverage, 11,314
accident only coverage, specified disease or specified accident 11,315
253
coverage, or limited benefit health coverage. 11,316
With regard to life insurance, "long-term care insurance" 11,318
does not include life insurance policies that accelerate the 11,319
death benefits specifically for one or more of the qualifying 11,320
events of terminal illness, medical conditions requiring 11,321
extraordinary medical intervention, or permanent institutional 11,322
confinement; that provide the option of a lump sum payment for 11,323
those benefits; and in which neither the benefits nor the 11,324
eligibility for the benefits is conditioned upon the receipt of 11,325
long-term care. 11,326
Notwithstanding any other provision contained in sections 11,328
3923.41 to 3923.48 of the Revised Code, any product advertised, 11,329
marketed, or offered as long-term care insurance shall be subject 11,330
to sections 3923.41 to 3923.48 of the Revised Code. 11,331
(B) "Applicant" means either of the following: 11,333
(1) In the case of an individual long-term care insurance 11,335
policy, the person who seeks to contract for benefits; 11,336
(2) In the case of a group long-term care insurance 11,338
policy, the proposed certificate holder. 11,339
(C) "Certificate" means any certificate issued under a 11,341
group long-term care insurance policy that has been delivered, 11,342
issued for delivery, or used in or outside this state. 11,343
(D) "Group long-term care insurance" means a form of 11,345
long-term care insurance covering any group of two or more 11,346
employees, members, or other persons, with or without one or more 11,347
of their dependents and members of their immediate families. Such 11,349
insurance may be offered to groups without regard to the purpose 11,350
or type of group or the occupation of the employees, members, and 11,351
other persons insured under the policy.
(E) "Policy" means any policy, contract, rider, or 11,353
endorsement delivered, issued for delivery, or used in or outside 11,354
this state by an insurer, fraternal benefit society, OR health or 11,355
medical care INSURING corporation, prepaid health plan, or health 11,357
maintenance organization. 11,358
254
Sec. 3923.51. (A) As used in this section, "official 11,367
poverty line" means the poverty line as defined by the United 11,368
States office of management and budget and revised by the 11,369
secretary of health and human services under 95 Stat. 511, 42 11,370
U.S.C.A. 9902, as amended. 11,371
(B) Every insurer that is authorized to write sickness and 11,373
accident insurance in this state may offer group contracts of 11,374
sickness and accident insurance to any charitable foundation that 11,375
is certified as exempt from taxation under section 501(c)(3) of 11,376
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 11,377
1, as amended, and that has the sole purpose of issuing 11,378
certificates of coverage under these contracts to persons under 11,379
the age of nineteen who are members of families that have incomes 11,380
that are no greater than three hundred per cent of the official 11,381
poverty line. 11,382
(C) Contracts offered pursuant to division (B) of this 11,384
section are not subject to any of the following: 11,385
(1) Sections 3923.122, 3923.24, and 3923.29 of the Revised 11,387
Code; 11,388
(2) Any other sickness and accident insurance coverage 11,390
required under this chapter on the effective date of this section 11,392
AUGUST 3, 1989. Any requirement of sickness and accident 11,393
insurance coverage enacted after that date applies to this 11,394
section only if the subsequent enactment specifically refers to 11,395
this section.
(3) Chapter 1742. 1751. of the Revised Code. 11,397
Sec. 3923.54. (A) As used in this section, "screening 11,406
mammography" means a radiologic examination utilized to detect 11,407
unsuspected breast cancer at an early stage in asymptomatic women 11,408
and includes the x-ray examination of the breast using equipment 11,409
that is dedicated specifically for mammography including, but not 11,410
limited to, the x-ray tube, filter, compression device, screens, 11,411
film, and cassettes, and that has an average radiation exposure 11,412
delivery of less than one rad mid-breast. "Screening 11,413
255
mammography" includes two views for each breast. The term also 11,415
includes the professional interpretation of the film. 11,416
"Screening mammography" does not include diagnostic 11,418
mammography.
(B) Each employer in this state that provides, in whole or 11,420
in part, health care benefits for its employees under a policy of 11,421
sickness and accident insurance issued in accordance with Chapter 11,422
3923. of the Revised Code shall also provide to its employees 11,423
benefits for the expenses of both of the following: 11,424
(1) Screening mammography to detect the presence of breast 11,426
cancer in adult women; 11,427
(2) Cytologic screening for the presence of cervical 11,429
cancer. 11,430
(C) An employer may comply with division (B) of this 11,432
section in any of the following ways: 11,433
(1) By providing the benefits under a health maintenance 11,435
organization INSURING CORPORATION contract issued in accordance 11,436
with Chapter 1742. 1751. of the Revised Code or a policy of 11,438
sickness and accident insurance issued in accordance with Chapter 11,439
3923. of the Revised Code;
(2) By reimbursing the employee for the direct health care 11,441
provider charges associated with receipt of the covered service; 11,442
(3) By making any other arrangement that provides the 11,444
benefits described in division (B) of this section. 11,445
(D) The benefits provided under division (B)(1) of this 11,447
section shall cover expenses in accordance with all of the 11,448
following: 11,449
(1) If a woman is at least thirty-five years of age but 11,451
under forty years of age, one screening mammography; 11,452
(2) If a woman is at least forty years of age but under 11,454
fifty years of age, either of the following: 11,455
(a) One screening mammography every two years; 11,457
(b) If a licensed physician has determined that the woman 11,459
has risk factors to breast cancer, one screening mammography 11,460
256
every year. 11,461
(3) If a woman is at least fifty years of age but under 11,463
sixty-five years of age, one screening mammography every year. 11,464
(E)(1) The benefits provided under division (B)(1) of this 11,466
section need not exceed eighty-five dollars per year. 11,467
(2) The benefit paid in accordance with division (E)(1) of 11,469
this section shall constitute full payment. No institutional or 11,470
professional health care provider shall seek or receive 11,471
compensation in excess of the payment made in accordance with 11,472
division (E)(1) of this section, except for approved deductibles 11,473
and copayments. 11,474
(F) The benefits provided under division (B)(1) of this 11,476
section shall be provided only for screening mammographies that 11,477
are performed in a facility or mobile mammography screening unit 11,478
that is accredited under the American college of radiology 11,480
mammography accreditation program or in a hospital as defined in 11,481
section 3727.01 of the Revised Code.
(G) The benefits provided under division (B)(2) of this 11,483
section shall be provided only for cytologic screenings that are 11,484
processed and interpreted in a laboratory certified by the 11,485
college of American pathologists or in a hospital as defined in 11,486
section 3727.01 of the Revised Code. 11,487
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 11,496
of the Revised Code: 11,497
(1) "Case characteristics," "eligible employee," "health 11,499
benefit plan," "late enrollee," "MEWA," and "pre-existing 11,500
conditions provision" have the same meanings as in section 11,501
3924.01 of the Revised Code. 11,502
(2) "Insurer" means any sickness and accident insurance 11,504
company authorized to issue health benefit plans in this state, 11,505
or MEWA authorized to issue insured health benefit plans in this 11,506
state. "Insurer" does not include any health maintenance 11,507
organization INSURING CORPORATION that is owned or operated by an 11,508
insurer. 11,509
257
(3) "Small employer" means any person, firm, corporation, 11,511
or partnership actively engaged in business whose total employed 11,512
work force, on at least fifty per cent of its working days during 11,513
the preceding year, consisted of at least two unrelated eligible 11,514
employees but no more than twenty-five eligible employees, the 11,515
majority of whom were employed within this state. In determining 11,516
the number of eligible employees, companies that are affiliated 11,517
companies or that are eligible to file a combined tax return for 11,518
purposes of state taxation shall be considered one employer. In 11,519
determining whether the members of an association are small 11,520
employers, each member of the association shall be considered as 11,521
a separate person, firm, corporation, or partnership. 11,522
(4) "Small employer group" means any group consisting of 11,524
all of the eligible employees of a small employer, except those 11,525
employees who are covered, or are eligible for coverage, under 11,526
any other private or public health benefits arrangement, 11,527
including the medicare program established under Title XVIII of 11,528
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 11,529
as amended, or any other act of congress or law of this or any 11,530
other state of the United States that provides benefits 11,531
comparable to the benefits provided under this section. 11,532
(B) Beginning in January of each year, insurers shall 11,534
accept applicants for open enrollment coverage, as set forth in 11,535
divisions (B)(1) and (2) of this section, in the order in which 11,536
they apply for coverage and subject to the limitation set forth 11,537
in division (G) of this section: 11,538
(1) Insurers in the business of issuing health benefit 11,540
plans to small employer groups shall accept small employer groups 11,541
for which coverage is not otherwise available and for whom 11,542
coverage had not been terminated by the employer or by an insurer 11,543
or, health maintenance organization, OR HEALTH INSURING 11,545
CORPORATION during the preceding twelve-month period; 11,548
(2) Insurers in the business of issuing individual 11,550
policies of sickness and accident insurance as contemplated by 11,551
258
section 3923.021 of the Revised Code, except individual policies 11,552
issued pursuant to section 3923.122 of the Revised Code, shall 11,553
either accept individuals pursuant to the open enrollment 11,554
requirements of section 3941.53 of the Revised Code, if subject 11,555
to that section, or accept for coverage pursuant to this section 11,557
individuals to whom both of the following conditions apply: 11,558
(a) The individual is not applying for coverage as an 11,560
employee of an employer, as a member of an association, or as a 11,561
member of any other group. 11,562
(b) The individual is not covered, and is not eligible for 11,564
coverage, under any other private or public health benefits 11,565
arrangement, including the medicare program established under 11,566
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 11,567
U.S.C.A. 301, as amended, or any other act of congress or law of 11,568
this or any other state of the United States that provides 11,569
benefits comparable to the benefits provided under this section, 11,570
any medicare supplement policy, or any conversion or continuation 11,571
of coverage policy under state or federal law. 11,572
(C) An insurer shall offer to any individual or small 11,574
employer group accepted under this section the small employer 11,575
health care plan established by the board of directors of the 11,576
Ohio small employer health reinsurance program under division (A) 11,577
of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care 11,578
plan in benefit plan design and scope of covered services. 11,579
An insurer may offer other health benefit plans in addition 11,581
to, but not in lieu of, the plan required to be offered under 11,582
this division. These additional health benefit plans shall 11,583
provide, at a minimum, the coverage provided by the small 11,584
employer health care plan or any health benefit plan that is 11,585
substantially similar to the small employer health care plan in
benefit plan design and scope of covered services. 11,586
For purposes of this division, the superintendent of 11,588
insurance shall determine whether a health benefit plan is 11,589
259
substantially similar to the small employer health care plan in 11,590
benefit plan design and scope of covered services. 11,591
(D) Health benefit plans issued under this section may 11,593
establish pre-existing conditions provisions that exclude or 11,594
limit coverage for a period of up to twelve months following the 11,595
individual's effective date of coverage and that may relate only 11,596
to conditions during the six months immediately preceding the 11,597
effective date of coverage. However, an insurer may exclude a 11,598
late enrollee for a period of up to eighteen months following the 11,599
individual's date of application for coverage. 11,600
(E) Premiums charged to groups or individuals under this 11,602
section may not exceed an amount that is two and one-half times 11,603
the highest rate charged any other group with similar case 11,604
characteristics or any other individual to which the insurer is 11,605
currently accepting new business, and for which similar 11,606
copayments and deductibles are applied. 11,607
(F) In offering health benefit plans under this section, 11,609
an insurer may require the purchase of health benefit plans that 11,610
condition the reimbursement of health services upon the use of a 11,611
specific network of providers. 11,612
(G)(1) In no event shall an insurer be required to accept 11,614
annually under this section either individuals or small employer 11,615
groups that, in the aggregate, would cause the insurer to have a 11,616
total number of new insureds that is more than one-half per cent 11,617
of its total number of insured individuals in this state per 11,618
year, as contemplated by section 3923.021 of the Revised Code, 11,619
and small group certificate holders of health benefit plans in 11,620
this state per year, calculated as of the immediately preceding 11,622
thirty-first day of December and excluding the insurer's medicare 11,623
supplement policies and conversion or continuation of coverage 11,625
policies under state or federal law and any policies described in 11,626
division (N) of this section. If an insurer is subject to, and 11,628
elects to operate under, the individual open enrollment 11,629
requirements of section 3941.53 of the Revised Code, in no event 11,630
260
shall the insurer be required to accept annually under this 11,631
section small employer groups that would cause the insurer to 11,632
have a total number of new insureds that is more than one-half 11,633
per cent of its total number of small group certificate holders 11,634
calculated as set forth in division (G)(1) of this section. 11,635
(2) An officer of the insurer shall certify to the 11,637
department of insurance when it has met the enrollment limit set 11,638
forth in division (G)(1) of this section. Upon providing such 11,639
certification, the insurer shall be relieved of its open 11,640
enrollment requirement under this section for the remainder of 11,641
the calendar year. 11,642
(H) An insurer shall not be required to accept under this 11,644
section applicants who, at the time of enrollment, are confined 11,645
to a health care facility because of chronic illness, permanent 11,646
injury, or other infirmity that would cause economic impairment 11,647
to the insurer if the applicants were accepted, or to make the 11,648
effective date of benefits for individuals or groups accepted 11,649
under this section earlier than ninety days after the date of 11,650
acceptance. 11,651
(I) The requirements of this section do not apply to any 11,653
insurer that is currently in a state of supervision, insolvency, 11,654
or liquidation. If an insurer demonstrates to the satisfaction 11,655
of the superintendent that the requirements of this section would 11,657
place the insurer in a state of supervision, insolvency, or 11,658
liquidation, the superintendent may waive or modify the 11,659
requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be effective for 11,661
a period of not more than one year. At the expiration of such 11,662
time, a new showing of need for a waiver or modification by the 11,663
insurer shall be made before a new waiver or modification is 11,664
issued or imposed.
(J) No hospital, health care facility, or health care 11,666
practitioner, and no person who employs any health care 11,667
practitioner, shall balance bill any individual or dependent of 11,668
261
an individual or any eligible employee or dependent of an 11,669
employee for any health care supplies or services provided to the 11,670
individual or dependent or the eligible employee or dependent, 11,671
who is insured under a policy or enrolled under a health benefit 11,673
plan issued under this section. The hospital, health care 11,674
facility, or health care practitioner, or any person that employs 11,675
the health care practitioner, shall accept payments made to it by 11,676
the insurer under the terms of the policy or contract insuring or 11,678
covering such individual as payment in full for such health care 11,679
supplies or services. 11,680
As used in this division, "hospital" has the same meaning 11,682
as in section 3727.01 of the Revised Code; "health care 11,683
practitioner" has the same meaning as in section 4769.01 of the 11,684
Revised Code; and "balance bill" means charging or collecting an 11,685
amount in excess of the amount reimbursable or payable under the 11,686
policy or health care service contract issued to an individual or 11,687
group under this section for such health care supply or service. 11,688
"Balance bill" does not include charging for or collecting 11,689
copayments or deductibles required by the policy or contract. 11,690
(K) An insurer shall pay an agent a commission in the 11,692
amount of five per cent of the premium charged for initial 11,693
placement or for otherwise securing the issuance of a policy or 11,694
contract issued to an individual or small employer group under 11,695
this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may 11,696
adopt, in accordance with Chapter 119. of the Revised Code, such 11,697
rules as are necessary to enforce this division. 11,698
(L) Except as otherwise provided in this section, sections 11,700
3924.01 to 3924.06 of the Revised Code apply to all health 11,701
benefit plans issued under this section. 11,702
(M) Individuals accepted for coverage under this section 11,704
may be issued contracts and certificates subject to the 11,705
requirements of section 3923.12 of the Revised Code. The 11,706
coverage issued to such individuals is not subject to the 11,707
262
requirements of section 3923.021 of the Revised Code. 11,708
(N) This section does not apply to any policy that 11,710
provides coverage for specific diseases or accidents only, or to 11,712
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer 11,714
than six months, or other policy that offers only supplemental 11,715
benefits.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of 11,724
the Revised Code: 11,725
(A) "Actuarial certification" means a written statement 11,727
prepared by a member of the American academy of actuaries, or by 11,728
any other person acceptable to the superintendent of insurance, 11,729
that states that, based upon the person's examination, a carrier 11,730
offering health benefit plans to small employers is in compliance 11,731
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial 11,732
certification" shall include a review of the appropriate records 11,733
of, and the actuarial assumptions and methods used by, the 11,734
carrier relative to establishing premium rates for the health 11,735
benefit plans. 11,736
(B) "Adjusted average market premium price" means the 11,738
average market premium price as determined by the board of 11,740
directors of the Ohio small employer health reinsurance program 11,741
either on the basis of the arithmetic mean of all carriers' 11,742
premium rates for an SEHC plan sold to groups with similar case 11,743
characteristics by all carriers selling SEHC plans in the state, 11,745
or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit 11,747
plan that is issued by a carrier and that covers at least two but 11,748
no more than fifty employees of a small employer, the lowest 11,750
premium rate for a new or existing business prescribed by the 11,751
carrier for the same or similar coverage under a plan or 11,752
arrangement covering any small employer with similar case 11,753
characteristics.
(D) "Carrier" means any sickness and accident insurance 11,755
263
company or health maintenance organization INSURING CORPORATION 11,756
authorized to issue health benefit plans in this state or a MEWA. 11,758
A sickness and accident insurance company that owns or operates a 11,760
health maintenance organization INSURING CORPORATION, either as a 11,761
separate corporation or as a line of business, shall be 11,763
considered as a separate carrier from that health maintenance 11,764
organization INSURING CORPORATION for purposes of sections 11,766
3924.01 to 3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small 11,768
employer, the geographic area in which the employees work; the 11,769
age and sex of the individual employees and their dependents; the 11,770
appropriate industry classification as determined by the carrier; 11,771
the number of employees and dependents; and such other objective 11,772
criteria as may be established by the carrier. "Case 11,773
characteristics" does not include claims experience, health 11,774
status, or duration of coverage from the date of issue. 11,775
(F) "Dependent" means the spouse or child of an eligible 11,777
employee, subject to applicable terms of the health benefits plan 11,778
covering the employee. 11,779
(G) "Eligible employee" means an employee who works a 11,781
normal work week of twenty-five or more hours. "Eligible 11,782
employee" does not include a temporary or substitute employee, or 11,784
a seasonal employee who works only part of the calendar year on 11,785
the basis of natural or suitable times or circumstances. 11,786
(H) "Financially impaired" means a program member that, 11,788
after April 14, 1993, is not insolvent but is determined by the 11,791
superintendent to be potentially unable to fulfill its 11,792
contractual obligations, or is placed under an order of 11,793
rehabilitation or conservation by a court of competent 11,794
jurisdiction or under an order of supervision by the 11,795
superintendent.
(I) "Health benefit plan" means any hospital or medical 11,797
expense policy or certificate or any health plan provided by a 11,799
carrier, that is delivered, issued for delivery, renewed, or used 11,801
264
in this state on or after the date occurring six months after the 11,802
effective date of this amendment NOVEMBER 24, 1995. "Health 11,803
benefit plan" does not include policies covering only accident, 11,805
credit, dental, disability income, long-term care, hospital 11,806
indemnity, medicare supplement, specified disease, or vision 11,807
care; coverage under a one-time-limited-duration policy of no 11,808
longer than six months; coverage issued by a health care 11,809
corporation; coverage issued by a prepaid dental plan 11,811
organization solely or in conjunction with a carrier; coverage 11,812
issued as a supplement to liability insurance; insurance arising 11,813
out of a workers' compensation or similar law; automobile 11,814
medical-payment insurance; or insurance under which benefits are 11,815
payable with or without regard to fault and which is statutorily 11,816
required to be contained in any liability insurance policy or 11,817
equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day 11,819
period immediately following any service waiting period 11,820
established by an employer. 11,821
(K) "Late enrollee" means an eligible employee or 11,823
dependent who requests enrollment in a small employer's health 11,824
benefit plan following the initial enrollment period provided 11,825
under the terms of the first plan for which the employee or 11,826
dependent was eligible through the small employer, unless any of 11,827
the following apply: 11,828
(1) The individual: 11,830
(a) Was covered under another health benefit plan at the 11,833
time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that 11,835
coverage under another health benefit plan was the reason for 11,838
declining enrollment;
(c) Has lost coverage under another health benefit plan as 11,841
a result of the termination of employment, a reduction of hours 11,842
worked per week, the termination of the other plan's coverage, 11,843
death of a spouse, or divorce; and 11,844
265
(d) Requests enrollment within thirty days after the 11,846
termination of coverage under another health benefit plan. 11,847
(2) The individual is employed by an employer who offers 11,849
multiple health benefit plans and the individual elects a 11,850
different health benefit plan during an open enrollment period. 11,851
(3) A court has ordered coverage to be provided for a 11,853
spouse or minor child under a covered employee's plan and a 11,854
request for enrollment is made within thirty days after issuance 11,855
of the court order. 11,856
(L) "MEWA" means any "multiple employer welfare 11,858
arrangement" as defined in section 3 of the "Federal Employee 11,859
Retirement Income Security Act of 1974," 88 Stat. 832, 29 11,860
U.S.C.A. 1001, as amended, except for any arrangement which is 11,861
fully insured as defined in division (b)(6)(D) of section 514 of 11,862
that act. 11,863
(M) "Midpoint rate" means, for small employers with 11,865
similar case characteristics and plan designs and as determined 11,866
by the applicable carrier for a rating period, the arithmetic 11,867
average of the applicable base premium rate and the corresponding 11,868
highest premium rate. 11,869
(N) "Pre-existing conditions provision" means a policy 11,871
provision that excludes or limits coverage for charges or 11,872
expenses incurred during a specified period following the 11,873
insured's effective date of coverage as to a condition which, 11,874
during a specified period immediately preceding the effective 11,875
date of coverage, had manifested itself in such a manner as would 11,876
cause an ordinarily prudent person to seek medical advice, 11,877
diagnosis, care, or treatment or for which medical advice, 11,878
diagnosis, care, or treatment was recommended or received, or a 11,879
pregnancy existing on the effective date of coverage. 11,880
(O) "Service waiting period" means the period of time 11,882
after employment begins before an eligible employee may enroll in 11,883
any applicable health benefit plan offered by the small employer. 11,884
(P)(1) "Small employer" means any person, firm, 11,887
266
corporation, partnership, or association actively engaged in 11,888
business whose total employed work force consisted of, on at 11,889
least fifty per cent of its working days during the preceding 11,890
year, at least two but no more than fifty eligible employees, the 11,891
majority of whom were employed within the state. 11,892
(2) In determining the number of eligible employees for 11,894
purposes of division (P)(1) of this section, companies which are 11,895
affiliated companies or which are eligible to file a combined tax 11,896
return for purposes of state taxation shall be considered one 11,897
employer. Except as otherwise specifically provided, provisions 11,898
of sections 3924.01 to 3924.14 of the Revised Code that apply to 11,899
a small employer that has a health benefit plan shall continue to 11,900
apply until the plan anniversary following the date the employer 11,901
no longer meets the requirements of this division. 11,902
(Q) "SEHC plan" means an Ohio small employer health care 11,905
plan, which is a health benefit plan for small employers
established by the board in accordance with section 3924.10 of 11,906
the Revised Code. 11,907
Sec. 3924.02. (A) An individual or group health benefit 11,916
plan is subject to sections 3924.01 to 3924.14 of the Revised 11,917
Code if it provides health care benefits covering at least two 11,919
but no more than fifty employees of a small employer, and if it 11,920
meets either of the following conditions: 11,921
(1) Any portion of the premium or benefits is paid by a 11,923
small employer, or any covered individual is reimbursed, whether 11,924
through wage adjustments or otherwise, by a small employer for 11,925
any portion of the premium. 11,926
(2) The health benefit plan is treated by the employer or 11,928
any of the covered individuals as part of a plan or program for 11,929
purposes of section 106 or 162 of the "Internal Revenue Code of 11,930
1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 11,931
(B) Notwithstanding division (A) of this section, 11,933
divisions (G) to (J) of section 3924.03 of the Revised Code and 11,935
section 3924.04 of the Revised Code do not apply to health 11,936
267
benefit policies that are not sold to owners of small businesses 11,937
as an employment benefit plan. Such policies shall clearly state 11,938
that they are not being sold as an employment benefit plan and 11,939
that the owner of the business is not responsible, either 11,940
directly or indirectly, for paying the premium or benefits. 11,941
(C) Every health benefit plan offered or delivered by a 11,943
carrier, other than a health maintenance organization INSURING 11,944
CORPORATION, to a small employer is subject to sections 3923.23, 11,946
3923.231, 3923.232, 3923.233, and 3923.234 of the Revised Code 11,947
and any other provision of the Revised Code that requires the 11,948
reimbursement, utilization, or consideration of a specific 11,949
category of a licensed or certified health care practitioner. 11,950
(D) Except as expressly provided in sections 3924.01 to 11,952
3924.14 of the Revised Code, no health benefit plan offered to a 11,953
small employer is subject to any of the following: 11,954
(1) Any law that would inhibit any carrier from 11,956
contracting with providers or groups of providers with respect to 11,957
health care services or benefits; 11,958
(2) Any law that would impose any restriction on the 11,960
ability to negotiate with providers regarding the level or method 11,961
of reimbursing care or services provided under the health benefit 11,962
plan; 11,963
(3) Any law that would require any carrier to either 11,965
include a specific provider or class of provider when contracting 11,966
for health care services or benefits, or to exclude any class of 11,967
provider that is generally authorized by statute to provide such 11,968
care. 11,969
Sec. 3924.08. (A) The board of directors of the Ohio 11,978
small employer health reinsurance program shall consist of nine 11,979
appointed members who shall serve staggered terms as determined 11,980
by the initial board for its members and by the plan of operation 11,981
of the program for members of subsequent boards. Within thirty 11,982
days after April 14, 1993, the members of the board shall be 11,983
appointed, as follows: 11,984
268
(1) The chairperson of the senate committee having 11,986
jurisdiction over insurance shall appoint the following members: 11,987
(a) Two member carriers that are small employer carriers; 11,989
(b) One member carrier that is a health maintenance 11,991
organization INSURING CORPORATION predominantly in the small 11,992
employer market; 11,993
(c) One representative of providers of health care. 11,995
(2) The chairperson of the committee in the house of 11,997
representatives having jurisdiction over insurance shall appoint 11,998
the following members: 11,999
(a) One member carrier that is a small employer carrier; 12,001
(b) One member carrier whose principal health insurance 12,003
business is in the large employer market; 12,004
(c) One representative of an employer with fifty or fewer 12,006
employees; 12,007
(d) One representative of consumers in this state. 12,009
(3) The superintendent shall appoint a representative of a 12,011
member carrier operating in the small employer market who is a 12,012
fellow of the society of actuaries. 12,013
The superintendent, a member of the house of 12,015
representatives appointed by the speaker of the house of 12,016
representatives, and a member of the senate appointed by the 12,017
president of the senate, shall be ex-officio members of the 12,018
board. The membership of all boards subsequent to the initial 12,019
board shall reflect the distribution described in division (A) of 12,021
this section.
The chairperson of the initial board and each subsequent 12,023
board shall represent a small employer member carrier and shall 12,024
be elected by a majority of the voting members of the board. 12,025
Each chairperson shall serve for the maximum duration established 12,026
in the plan of operation. 12,027
(B) Within one hundred eighty days after the appointment 12,029
of the initial board, the board shall establish a plan of 12,030
operation and, thereafter, any amendments to the plan that are 12,031
269
necessary or suitable, to assure the fair, reasonable, and 12,032
equitable administration of the program. The board shall, 12,033
immediately upon adoption, provide to the superintendent copies 12,034
of the plan of operation and all subsequent amendments to it. 12,035
(C) The plan of operation shall establish rules, 12,037
conditions, and procedures for all of the following: 12,038
(1) The handling and accounting of assets and moneys of 12,040
the program and for an annual fiscal reporting to the 12,041
superintendent; 12,042
(2) Filling vacancies on the board; 12,044
(3) Selecting an administering insurer, which shall be a 12,046
carrier as defined in section 3924.01 of the Revised Code, and 12,047
setting forth the powers and duties of the administering insurer; 12,048
(4) Reinsuring risks in accordance with sections 3924.07 12,050
to 3924.14 of the Revised Code; 12,051
(5) Collecting assessments subject to section 3924.13 of 12,053
the Revised Code from all members to provide for claims reinsured 12,054
by the program and for administrative expenses incurred or 12,055
estimated to be incurred during the period for which the 12,056
assessment is made; 12,057
(6) Providing protection for carriers from the financial 12,059
risk associated with small employers that present poor credit 12,060
risks; 12,061
(7) Establishing standards for the coverage of small 12,063
employers that have a high turnover of employees; 12,064
(8) Establishing an appeals process for carriers to seek 12,066
relief when a carrier has experienced an unfair share of 12,067
administrative and credit risks; 12,068
(9) Establishing the adjusted average market premium 12,070
prices for use by the SEHC plan for groups of two to twenty-five 12,071
employees and for groups of twenty-six to fifty employees that 12,072
are offered in the state; 12,073
(10) Establishing participation standards at issue and 12,075
renewal for reinsured cases; 12,076
270
(11) Reinsuring risks and collecting assessments in 12,078
accordance with division (G) of section 3924.11 of the Revised 12,079
Code; 12,080
(12) Any additional matters as determined by the board. 12,082
Sec. 3924.10. (A) The board of directors of the Ohio 12,091
small employer health reinsurance program shall design the SEHC 12,092
plan which, when offered by a carrier, is eligible for 12,093
reinsurance under the program. The board shall establish the 12,094
form and level of coverage to be made available by carriers in 12,095
their SEHC plan. In designing the plan the board shall also 12,097
establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels 12,098
of coverage established by the board shall specify which 12,099
components of a health benefit plan offered by a small employer 12,100
carrier may be reinsured. The SEHC plan is subject to division 12,102
(C) of section 3924.02 of the Revised Code and to the provisions 12,103
in Chapters 1742. 1751., 3923., and any other chapter of the 12,105
Revised Code that require coverage or the offer of coverage of a 12,106
health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 12,109
eighty days after its appointment. The plan may include cost 12,110
containment features including any of the following:
(1) Utilization review of health care services, including 12,112
review of the medical necessity of hospital and physician 12,113
services; 12,114
(2) Case management benefit alternatives; 12,116
(3) Selective contracting with hospitals, physicians, and 12,118
other health care providers; 12,119
(4) Reasonable benefit differentials applicable to 12,121
participating and nonparticipating providers; 12,122
(5) Employee assistance program options that provide 12,124
preventive and early intervention mental health and substance 12,125
abuse services; 12,126
(6) Other provisions for the cost-effective management of 12,128
271
the plan. 12,129
(C) An SEHC plan established for use by health maintenance 12,132
organizations INSURING CORPORATIONS shall be consistent with the 12,133
basic method of operation of such organizations CORPORATIONS. 12,134
(D) Each carrier shall certify to the superintendent of 12,136
insurance, in the form and manner prescribed by the 12,137
superintendent, that the SEHC plan filed by the carrier is in 12,139
substantial compliance with the provisions of the board SEHC 12,140
plan. Upon receipt by the superintendent of the certification, 12,141
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 12,143
date that the program becomes operational and as a condition of 12,144
transacting business in this state, renew coverage provided to 12,145
any individual or group under its SEHC plan. 12,146
(F) A carrier shall not be required to renew coverage 12,148
where the superintendent finds that renewal of coverage would 12,149
place the carrier in a financially impaired condition. The 12,150
superintendent shall determine when the carrier is no longer 12,151
financially impaired and is, therefore, subject to the guaranteed 12,152
renewability requirements. 12,153
Sec. 3924.12. (A) Except as provided in division (B) of 12,162
this section, premium rates charged for coverage reinsured by the 12,163
Ohio small employer health reinsurance program shall be 12,164
established as follows: 12,165
(1) For whole group reinsurance coverage, one and one-half 12,167
times the adjusted average market premium price established by 12,168
the program for that classification or group with similar 12,169
characteristics and coverage, with respect to the eligible 12,170
employees of a small employer and their dependents, all of whose 12,171
coverage is reinsured with the program, minus a ceding expense 12,172
factor determined by the board of directors of the program; 12,173
(2) For individual reinsurance coverage, five times the 12,175
adjusted average market premium price established by the program 12,176
for an individual in that classification or group with similar 12,177
272
characteristics and coverage, with respect to an eligible 12,178
employee or his THE EMPLOYEE'S dependents, minus a ceding expense 12,180
factor determined by the board. 12,181
(B) Premium rates charged for reinsurance by the program 12,183
to a health maintenance organization INSURING CORPORATION that is 12,185
approved by the secretary of health and human services as a 12,186
federally qualified health maintenance organization pursuant to 12,187
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, 12,188
as amended, and as such is subject to requirements that limit the 12,189
amount of risk that may be ceded to the program, may be modified 12,190
to reflect the portion of risk that may be ceded to the program. 12,191
Sec. 3924.13. (A) Following the close of each calendar 12,200
year, the administering insurer of the Ohio small employer health 12,201
reinsurance program shall determine the net premiums, the program 12,202
expenses for administration, and the incurred losses, if any, for 12,203
the year, taking into account investment income and other 12,204
appropriate gains and losses. For purposes of this section, 12,205
health benefit plan premiums earned by MEWAs shall be established 12,206
by adding paid claim losses and administrative expenses of the 12,207
MEWA. Health benefit plan premiums and benefits paid by a 12,209
carrier that are less than an amount determined by the board of 12,210
directors of the program to justify the cost of collection shall 12,211
not be considered for purposes of determining assessments. For 12,212
purposes of this division, "net premiums" means health benefit 12,213
plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by 12,215
assessments of carriers in accordance with this division. 12,216
Assessments shall be apportioned by the board among all carriers 12,217
participating in the program in proportion to their respective 12,218
shares of the total premiums, net of reinsurance premiums paid 12,219
for coverage under this program earned in the state from health 12,220
benefit plans covering small employers that are issued by 12,221
participating members during the calendar year coinciding with or 12,222
ending during the fiscal year of the program, or on any other 12,223
273
equitable basis reflecting coverage of small employers as may be 12,224
provided in the plan of operation. An assessment shall be made 12,225
pursuant to this division against a health maintenance 12,226
organization INSURING CORPORATION that is approved by the 12,227
secretary of health and human services as a federally qualified 12,229
health maintenance organization pursuant to the "Social Security 12,230
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, subject 12,231
to an assessment adjustment formula adopted by the board for such 12,232
health maintenance organizations INSURING CORPORATIONS that 12,233
recognizes the restrictions imposed on the organizations ENTITIES 12,235
by federal law. The adjustment formula shall be adopted by the 12,237
board prior to the first anniversary of the program's operation. 12,238
In no event shall the assessment made pursuant to this division 12,239
exceed, on an annual basis, one per cent of the carrier's Ohio 12,241
small employer group premium as reported on its most recent 12,242
annual statement filed with the superintendent of insurance. If 12,243
an excess is actuarially projected, the superintendent may take 12,244
any action necessary to lower the assessment to the maximum level 12,245
of one per cent.
(C) If assessments exceed actual losses and administrative 12,247
expenses of the program, the excess shall be held at interest and 12,248
used by the board to offset future losses or to reduce program 12,249
premiums. As used in this division, "future losses" includes 12,250
reserves for incurred but not reported claims. 12,251
(D) Each carrier's proportion of participation in the 12,253
program shall be determined annually by the board based on annual 12,255
statements and other reports deemed necessary by the board and 12,256
filed by the carrier with the board. MEWAs shall report to the 12,257
board claims payments made and administrative expenses incurred 12,258
in this state on an annual basis on a form prescribed by the 12,259
superintendent.
(E) Provision shall be made in the plan of operation for 12,261
the imposition of an interest penalty for late payment of 12,262
assessments. 12,263
274
(F) A carrier may seek from the superintendent a 12,265
deferment, in whole or in part, from any assessment issued by the 12,266
board. The superintendent may defer, in whole or in part, the 12,267
assessment of a carrier if, in the opinion of the superintendent, 12,268
payment of the assessment would endanger the carrier's ability to 12,269
fulfill its contractual obligations. 12,270
(G) In the event an assessment against a carrier is 12,272
deferred in whole or in part, the amount by which the assessment 12,273
is deferred may be assessed against the other carriers in a 12,274
manner consistent with the basis for assessments set forth in 12,275
this section. In such event, the other carriers assessed shall 12,276
have a claim in the amount of the assessment against the carrier 12,277
receiving the deferment. The carrier receiving the deferment 12,278
shall remain liable to the program for the amount deferred. The 12,279
superintendent may attach appropriate conditions to any 12,280
deferment. 12,281
Sec. 3924.41. (A) As used in sections 3924.41 and 3924.42 12,290
of the Revised Code, "health insurer" means any sickness and 12,291
accident insurer, health maintenance organization, preferred 12,292
provider organization, OR health care INSURING corporation, 12,294
medical care corporation, dental care corporation, or prepaid 12,295
dental plan organization. "Health insurer" also includes any 12,296
group health plan as defined in section 607 of the federal 12,297
"Employee Retirement Income Security Act of 1974," 88 Stat. 832, 12,298
29 U.S.C.A. 1167. 12,299
(B) Notwithstanding any other provision of the Revised 12,301
Code, no health insurer shall take into consideration the 12,302
availability of, or eligibility for, medical assistance in this 12,303
state under Chapter 5111. of the Revised Code or in any other 12,304
state pursuant to Title XIX of the "Social Security Act," 49 12,305
Stat. 620 (1935), 42 U.S.C.A. 301, as amended, when determining 12,306
an individual's eligibility for coverage or when making payments 12,307
to or on behalf of an enrollee, subscriber, policyholder, or 12,308
certificate holder. 12,309
275
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of 12,318
the Revised Code: 12,319
(A) "Account holder" means the natural person who opens a 12,322
medical savings account or on whose behalf a medical savings 12,323
account is opened.
(B) "Eligible medical expense" means any expense for a 12,326
service rendered by a licensed health care provider or a 12,327
christian science CHRISTIAN SCIENCE practitioner, or for an 12,328
article, device, or drug prescribed by a licensed health care 12,329
provider or provided by a christian science CHRISTIAN SCIENCE 12,331
practitioner, when intended for use in the mitigation, treatment, 12,333
or prevention of disease; or premiums paid for comprehensive 12,334
sickness and accident insurance, coverage under a health care 12,335
plan of a health maintenance organization INSURING CORPORATION 12,336
organized under Chapter 1742. 1751. of the Revised Code, 12,338
long-term care insurance as defined in section 3923.41 of the
Revised Code, Medicare supplemental coverage as defined in 12,339
section 3923.33 of the Revised Code, or payments made pursuant to 12,341
cost sharing agreements under comprehensive sickness and accident 12,342
plans. An "eligible medical expense" does not include expenses 12,343
otherwise paid or reimbursed, including medical expenses paid or 12,344
reimbursed under an automobile or motor vehicle insurance policy, 12,345
a workers' compensation insurance policy or plan, or an
employer-sponsored health coverage policy, plan, or contract. 12,346
(C) "Qualified dependent" means a child of an account 12,349
holder when any of the following applies:
(1) The child is under nineteen years of age, or is under 12,352
twenty-three years of age and a full-time student at an
accredited college or university; 12,353
(2) The child is not self-sufficient due to physical or 12,355
mental disorders or impairments; 12,356
(3) The child is legally entitled to the provision of 12,358
proper or necessary subsistence, education, medical care, or 12,359
other care necessary for the child's health, guidance, or 12,360
276
well-being and is not otherwise emancipated, self-supporting, 12,361
married, or a member of the armed forces of the United States. 12,363
Sec. 3924.62. (A) A medical savings account may be opened 12,372
by or on behalf of any natural person, to pay the person's 12,373
eligible medical expenses and the eligible medical expenses of 12,374
that person's spouse or qualified dependent. A medical savings 12,375
account may be opened by or on behalf of a person only if that 12,377
person participates in a sickness or accident insurance plan, a 12,378
plan offered by a health maintenance organization INSURING
CORPORATION organized under Chapter 1742. 1751. of the Revised 12,380
Code, or a self-funded, employer-sponsored health benefit plan
established pursuant to the "Employee Retirement Income Security 12,381
Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. While 12,382
the medical savings account is open, the account holder shall 12,383
continue to participate in such a plan.
(B) A person who refuses to participate in a policy, plan, 12,386
or contract of health coverage that is funded by the person's 12,387
employer, and who receives additional monetary compensation by 12,388
virtue of refusing that coverage, may not open a medical savings 12,389
account unless the medical savings account also is sponsored by 12,390
the person's employer. 12,391
Sec. 3924.64. (A) At the time a medical savings account 12,401
is opened, an administrator for the account shall be designated. 12,402
If an employer opens an account for an employee, the employer may 12,403
designate the administrator. If an account is opened by any 12,404
person other than an employer, or if an employer chooses not to 12,405
designate an administrator for an account opened for an employee, 12,406
the account holder shall designate the administrator. The 12,407
administrator shall manage the account in a fiduciary capacity 12,408
for the benefit of the account holder.
(B) Medical savings accounts shall be administered by one 12,411
of the following:
(1) A federally or state-chartered bank, savings and loan 12,414
association, savings bank, or credit union;
277
(2) A trust company authorized to act as a fiduciary; 12,416
(3) An insurer authorized under Title XXXIX of the Revised 12,419
Code to engage in the business of sickness and accident 12,420
insurance;
(4) A dealer or salesperson licensed under Chapter 1707. 12,423
of the Revised Code;
(5) An administrator licensed under Chapter 3959. of the 12,426
Revised Code;
(6) A certified public accountant; 12,428
(7) An employer that administers an employee benefit plan 12,431
subject to regulation under the "Employee Retirement Income 12,432
Security Act of 1974," 88 Stat. 829, 29 U.S.C.A. 1001, as 12,434
amended, or that maintains medical savings accounts for its 12,435
employees;
(8) Health maintenance organizations INSURING CORPORATIONS 12,437
organized under Chapter 1742. 1751. of the Revised Code. 12,438
(C) Each administrator shall send to the account holder, 12,441
at least annually, a statement setting forth the balance 12,442
remaining in the account holder's account and detailing the 12,443
activity in the account since the last statement was issued. 12,444
Upon an administrator's receipt of a written request from an 12,445
account holder for a current statement, the administrator shall 12,446
promptly send the statement to the account holder.
(D) When an account holder documents to the administrator 12,449
of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the 12,450
account holder, the account holder's spouse, or qualified 12,451
dependents, the administrator shall reimburse the account holder 12,452
for, or shall pay for, the eligible medical expense with funds 12,453
from the account holder's account, if sufficient funds are 12,454
available in the account holder's account. If there are not 12,455
sufficient funds in the account to fully reimburse the account 12,456
holder or pay the expenses, the administrator shall reimburse the 12,458
account holder or pay the expenses using whatever funds are in 12,459
278
the account. The reimbursement or payment shall be made within 12,460
thirty days of the administrator's receipt of the documentation. 12,461
At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical 12,462
expense does not count toward meeting the deductible or other 12,463
obligation for the receipt of benefits that is required by the 12,464
insurer or other third-party payer providing health coverage to 12,465
the account holder. The administrator shall keep a record of the 12,466
amounts disbursed from the account for documented eligible 12,467
medical expenses and of the dates on which the expenses were 12,468
incurred. This record shall be made available to any sickness 12,469
and accident insurer or other third-party payer providing health 12,470
coverage to the account holder, for use by the insurer or 12,471
third-party payer in determining whether the account holder has 12,472
met the deductible or other obligation required for the receipt 12,473
of benefits from the insurer or third-party payer. 12,474
(E) When an account is opened, the administrator shall 12,477
give written notice to the account holder of the date of the last 12,478
business day of the administrator's business year. 12,479
Sec. 3924.73. (A) As used in this section: 12,488
(1) "Health care insurer" means any person legally engaged 12,490
in the business of providing sickness and accident insurance 12,491
contracts in this state, a health maintenance organization 12,492
INSURING CORPORATION organized under Chapter 1742. 1751. of the 12,493
Revised Code, or any legal entity that is self-insured and 12,494
provides health care benefits to its employees or members. 12,495
(2) "Small employer" has the same meaning as in division 12,497
(P) of section 3924.01 of the Revised Code. 12,498
(B)(1) Subject to division (B)(2) of this section, nothing 12,501
in sections 3924.61 to 3924.74 of the Revised Code shall be 12,502
construed to limit the rights, privileges, or protections of 12,503
employees or small employers under sections 3924.01 to 3924.14 of 12,504
the Revised Code. 12,505
(2) If any account holder enrolls or applies to enroll in 12,507
279
a policy or contract offered by a health care insurer providing 12,508
sickness and accident coverage that is more comprehensive than, 12,509
and has a deductible amount that is less than, the coverage and 12,510
deductible amount of the policy under which the account holder 12,511
currently is enrolled, the health care insurer to which the 12,512
account holder applies may subject the account holder to the same 12,514
medical review, waiting periods, and underwriting requirements to 12,515
which the health care insurer generally subjects other enrollees 12,516
or applicants, unless the account holder enrolls or applies to 12,517
enroll during a designated period of open enrollment. 12,518
Sec. 3929.77. The joint underwriting association shall be 12,527
governed by a board of governors consisting of nine members seven 12,528
of whom shall be selected from the members of the joint 12,529
underwriting association and appointed by the superintendent of 12,530
insurance. Five members shall be selected from insurers and
corporations domiciled in this state. Two members shall be 12,531
selected from insurers and corporations domiciled outside this 12,532
state. One member shall be an insurance agent licensed and 12,533
writing insurance in this state. One member shall represent the 12,534
interests of consumers and shall neither be a member of, or 12,535
associated with, a health care provider or profession nor
associated with an insurance company or an association organized 12,536
A HEALTH INSURING CORPORATION HOLDING A CERTIFICATE OF AUTHORITY 12,537
under Chapter 1737., 1738., or 1740. 1751. of the Revised Code. 12,538
The directors of the stabilization reserve fund shall serve as ex 12,540
officio members of the board of governors.
Sec. 3956.01. As used in this chapter: 12,549
(A) "Account" means either of the two accounts created 12,551
under section 3956.06 of the Revised Code. 12,552
(B) "Contractual obligation" means any obligation under a 12,554
policy, contract, or certificate under a group policy or 12,555
contract, or portion of the policy or contract, for which 12,556
coverage is provided under section 3956.04 of the Revised Code. 12,557
(C) "Covered policy or contract" means any policy, 12,559
280
contract, or group certificate within the scope of section 12,560
3956.04 of the Revised Code. 12,561
(D) "Impaired insurer" means a member insurer that, after 12,563
the effective date of this section NOVEMBER 20, 1989, is not an 12,565
insolvent insurer, and to which either of the following applies: 12,566
(1) The insurer is considered by the superintendent to be 12,568
potentially unable to fulfill its contractual obligations; 12,569
(2) The insurer is placed under an order of rehabilitation 12,571
or conservation by a court of competent jurisdiction. 12,572
(E) "Insolvent insurer" means a member insurer that, after 12,574
the effective date of this section NOVEMBER 20, 1989, is placed 12,576
under an order of liquidation by a court of competent 12,577
jurisdiction with a finding of insolvency. 12,578
(F)(1) "Member insurer" means any insurer that holds a 12,580
certificate of authority or is licensed to transact in this state 12,581
any kind of insurance for which coverage is provided under 12,582
section 3956.04 of the Revised Code, and includes any insurer 12,583
whose certificate of authority or license in this state may have 12,584
been suspended, revoked, not renewed, or voluntarily withdrawn 12,585
after the effective date of this section NOVEMBER 20, 1989. 12,587
(2) "Member insurer" does not include any of the 12,589
following: 12,590
(a) A medical care corporation; 12,592
(b) A health care corporation; 12,594
(c) A dental care corporation; 12,596
(d) A prepaid dental plan; 12,598
(e) A health maintenance organization INSURING 12,601
CORPORATION;
(f) A preferred provider organization; 12,603
(g)(b) A fraternal benefit society; 12,605
(h)(c) A self-insurance or joint self-insurance pool or 12,607
plan of the state or any political subdivision of the state; 12,608
(i)(d) A mutual protective association; 12,610
(j)(e) An insurance exchange; 12,612
281
(k)(f) Any person who qualifies as a "member insurer" 12,614
under section 3955.01 of the Revised Code and who does not 12,616
receive premiums on covered policies or contracts;
(l)(g) Any entity similar to any of those described in 12,618
divisions (F)(2)(a) to (k)(f) of this section. 12,619
(3) "Member insurer" includes any insurer that operates 12,621
any of the entities described in division (F)(2) of this section 12,622
as a line of business, and not as a separate, affiliated legal 12,623
entity, and otherwise qualifies as a member insurer. 12,624
(G) "Premiums" means amounts received on covered policies 12,626
or contracts, less premiums, considerations, and deposits 12,627
returned on the policies or contracts, and less dividends and 12,628
experience credits on the policies and contracts. "Premiums" 12,629
does not include either of the following: 12,630
(1) Any amounts in excess of one million dollars received 12,632
on any unallocated annuity contract not issued under a 12,633
governmental retirement plan established under Section 401, 12,634
403(b), or 457 of the "Internal Revenue Code of 1986," 100 Stat. 12,635
2085, 26 U.S.C.A. 1, as amended; 12,636
(2) Any amounts received for any policies or contracts or 12,638
for the portions of any policies or contracts for which coverage 12,639
is not provided under section 3956.04 of the Revised Code. 12,640
Division (G)(2) of this section shall not be construed to require 12,641
the exclusion, from assessable premiums, of premiums paid for 12,642
coverages in excess of the interest limitations specified in 12,643
division (B)(2)(c) of section 3956.04 of the Revised Code or of 12,644
premiums paid for coverages in excess of the limitations with 12,645
respect to any one individual, any one participant, or any one 12,646
contract holder specified in division (C)(2) of section 3956.04 12,647
of the Revised Code. 12,648
(H) "Resident" means any person who resides in this state 12,650
at the time a member insurer is determined to be an impaired or 12,651
insolvent insurer and to whom a contractual obligation is owed. 12,652
A person may be a resident of only one state, which, in the case 12,653
282
of a person other than a natural person, shall be its principal 12,654
place of business. 12,655
(I) "Subaccount" means any of the three subaccounts 12,657
created under division (A) of section 3956.06 of the Revised 12,658
Code. 12,659
(J) "Supplemental contract" means any agreement entered 12,661
into for the distribution of policy or contract proceeds. 12,662
(K) "Unallocated annuity contract" means any annuity 12,664
contract or group annuity certificate that is not issued to and 12,665
owned by an individual, except to the extent of any annuity 12,666
benefits guaranteed to an individual by an insurer under that 12,667
contract or certificate. 12,668
Sec. 3959.01. (A) "Administration fees" means any amount 12,677
charged a covered person for services rendered. "Administration 12,678
fees" includes commissions earned or paid by any person relative 12,679
to services performed by an administrator. 12,680
(B) "Administrator" means any person who adjusts or 12,682
settles claims on, residents of this state in connection with 12,683
life, dental, health, or disability insurance or self-insurance 12,684
programs. "Administrator" does not include any of the following: 12,685
(1) An insurance agent or solicitor licensed in this state 12,687
whose activities are limited exclusively to the sale of insurance 12,688
and who does not provide any administrative services; 12,689
(2) Any person who administers or operates the workers' 12,691
compensation program of a self-insuring employer under Chapter 12,692
4123. of the Revised Code; 12,693
(3) Any person who administers pension plans for the 12,695
benefit of the person's own members or employees or administers 12,697
pension plans for the benefit of the members or employees of any 12,698
other person; 12,699
(4) Any person that administers an insured plan or a 12,701
self-insured plan that provides life, dental, health, or 12,702
disability benefits exclusively for the person's own members or 12,703
employees; 12,704
283
(5) Any medical care corporation organized under Chapter 12,706
1737. of the Revised Code, prepaid dental plan organization 12,707
organized under Chapter 1736. of the Revised Code, health care 12,708
INSURING corporation organized HOLDING A CERTIFICATE OF AUTHORITY 12,710
under Chapter 1738. 1751. of the Revised Code, dental care 12,712
corporation organized under Chapter 1740. of the Revised Code, 12,713
health maintenance organization organized under Chapter 1742. of 12,714
the Revised Code, or an insurance company that is authorized to 12,715
write life or sickness and accident insurance in this state. 12,716
(C) "Aggregate excess insurance" means that type of 12,718
coverage whereby the insurer agrees to reimburse the insured 12,719
employer or trust for all benefits or claims paid during an 12,720
agreement period on behalf of all covered persons under the plan 12,721
or trust which exceed a stated deductible amount and subject to a 12,722
stated maximum. 12,723
(D) "Contributions" means any amount collected from a 12,725
covered person to fund the self-insured portion of any plan in 12,726
accordance with the plan's provisions, summary plan descriptions, 12,727
and contracts of insurance. 12,728
(E) "Fiduciary" has the meaning set forth in section 12,730
1002(21)(A) of the "Employee Retirement Income Security Act of 12,731
1974," 88 Stat. 829, 29 U.S.C. 1001, as amended. 12,732
(F) "Fiscal year" means the twelve-month accounting period 12,734
commencing on the date the plan is established and ending twelve 12,735
months following that date, and each corresponding twelve-month 12,736
accounting period thereafter as provided for in the summary plan 12,737
description. 12,738
(G) "Plan" means any arrangement in written form for the 12,740
payment of life, dental, health, or disability benefits to 12,741
covered persons defined by the summary plan description. 12,742
(H) "Plan sponsor" means the person who establishes the 12,744
plan. 12,745
(I) "Self-insurance program" means a program whereby an 12,747
employer provides a plan of benefits for its employees without 12,748
284
involving an intermediate insurance carrier to assume risk or pay 12,749
claims. "Self-insurance program" includes but is not limited to 12,750
employer programs that pay claims up to a prearranged limit 12,751
beyond which they purchase insurance coverage to protect against 12,752
unpredictable or catastrophic losses. 12,753
(J) "Specific excess insurance" means that type of 12,755
coverage whereby the insurer agrees to reimburse the insured 12,756
employer or trust for all benefits or claims paid during an 12,757
agreement period on behalf of a covered person in excess of a 12,758
stated deductible amount and subject to a stated maximum. 12,759
(K) "Summary plan description" means the written document 12,761
adopted by the plan sponsor which outlines the plan of benefits, 12,762
conditions, limitations, exclusions, and other pertinent details 12,763
relative to the benefits provided to covered persons thereunder. 12,764
Sec. 3999.32. (A) As used in this section: 12,774
(1) "Certificate holder" means any person whose employment 12,776
or retirement status is the basis of eligibility for coverage 12,777
under a group policy of sickness and accident insurance or for 12,778
enrollment under a group contract of a prepaid dental plan 12,779
organization, medical care corporation, health care INSURING 12,780
corporation, dental care corporation, or health maintenance 12,782
organization.
(2) "Health insurer" means any sickness and accident 12,784
insurer, prepaid dental plan organization, medical care 12,785
corporation, OR health care INSURING corporation, dental care, 12,787
corporation, or health maintenance organization. 12,788
(B) Each person to whom a group policy or contract of 12,790
sickness and accident insurance or other health care coverage has 12,791
been delivered or issued for delivery in this state by a health 12,792
insurer shall make a reasonable effort to notify every 12,793
certificate holder, or his CERTIFICATE HOLDER'S designee, who is 12,795
covered under that policy or contract whenever the person fails 12,796
to make a required premium payment or contribution on behalf of 12,797
the certificate holder and that failure results in the 12,798
285
termination of coverage. The person shall mail or present the 12,799
notice to the certificate holder or his CERTIFICATE HOLDER'S 12,800
designee no later than five days after the date on which the 12,802
person receives the notice from the health insurer as required 12,803
under division (D) of this section. If a person other than the 12,804
policyholder or contract holder is obligated to make the required 12,805
premium payment or contribution on behalf of the certificate 12,806
holder, that person shall mail or present the notice as required 12,807
by this section.
(C) The notice required by division (B) of this section 12,809
shall be in writing and shall clearly state that the person 12,810
failed to make the required premium payment or contribution, the 12,811
reasons for the failure, and the effect of the failure on the 12,812
coverage of the certificate holder under the policy or contract. 12,813
(D) If a person described in division (B) of this section 12,815
fails to make a required premium payment or contribution on 12,816
behalf of a certificate holder and that failure results in the 12,817
termination of the coverage, the health insurer providing the 12,818
coverage shall notify the person in writing of that person's 12,819
duties as described in divisions (B) and (C) of this section. If 12,820
a person other than the policyholder or contract holder if IS 12,821
obligated to make the required premium payment or contribution on 12,822
behalf of the certificate holder, the insurer shall notify the 12,823
person in writing of that person's duties as described in 12,824
divisions (B) and (C) of this section. 12,825
(E) A certificate holder may designate any person to 12,827
receive on his THE CERTIFICATE HOLDER'S behalf the notice 12,828
required by division (B) of this section. The certificate holder 12,830
shall furnish the name and address of the person so designated to 12,831
the person to whom the group policy or contract has been 12,832
delivered or issued for delivery. 12,833
(F) No person shall knowingly fail to comply with division 12,835
(B) or (C) of this section. 12,836
Sec. 3999.36. (A) As used in this section and sections 12,846
286
3999.37 and 3999.38 of the Revised Code: 12,847
(1) "Insurer" means any person that is authorized to 12,849
engage in the business of insurance in this state under title 12,851
TITLE XXXIX of the Revised Code;, any prepaid dental plan 12,852
organization, medical care corporation, health care INSURING 12,853
corporation, dental care corporation, or health maintenance 12,855
organization; or any other person engaging either directly or 12,856
indirectly in this state in the business of insurance or entering 12,857
into contracts substantially amounting to insurance under section 12,858
3905.42 of the Revised Code. 12,859
(2) "Impaired" or "impairment" means a financial situation 12,861
in which the insurer's assets are less than the sum of the 12,862
insurer's minimum required capital, minimum required surplus, and 12,863
all liabilities, as determined in accordance with the 12,864
requirements for the preparation and filing of the insurer's 12,865
annual financial statement. 12,866
(3) "Chief executive officer" means the person, 12,868
irrespective of his THE PERSON'S title, designated by the board 12,869
of directors or trustees of an insurer as the person charged with 12,871
the responsibility of administering and implementing the 12,872
insurer's policies and procedures. 12,873
(B) Whenever a chief executive officer of an insurer knows 12,875
or has reason to know that the insurer is impaired, he THE CHIEF 12,876
EXECUTIVE OFFICER shall provide written notice of the impairment 12,878
to the superintendent of insurance and to each member of the 12,879
board of directors or trustees of the insurer. The chief 12,880
executive officer shall provide the notice as soon as reasonably 12,881
possible, but no later than thirty days after he THE CHIEF 12,882
EXECUTIVE OFFICER knows or has reason to know of the impairment. 12,884
No chief executive officer shall fail to provide notice in 12,885
compliance with this division.
(C) The notice received by the superintendent under 12,887
division (B) of this section is not a public record under section 12,888
149.43 of the Revised Code. 12,889
287
Sec. 4582.041. (A) Any port authority created under 12,898
section 4582.02 of the Revised Code may procure and pay all or 12,899
any part of the cost of group hospitalization, surgical, major 12,900
medical, sickness and accident insurance, or group life 12,901
insurance, or a combination of any of the foregoing types of 12,902
insurance or coverage for full-time employees and their immediate 12,903
dependents, whether issued by an insurance company or a medical 12,904
care corporation, duly authorized to do business in this state. 12,905
(B) Any port authority also may procure and pay all or any 12,907
part of the cost of a plan of group hospitalization, surgical, or 12,908
major medical insurance with a health care INSURING corporation 12,909
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,911
1751. of the Revised Code, provided that each full-time employee 12,913
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,915
insurance company or medical care corporation as provided in 12,916
division (A) of this section and such a plan offered by a health 12,917
care INSURING corporation under this division, on the condition 12,918
that the full-time employee shall pay any amount by which the 12,920
cost of the plan offered in this division exceeds the cost of the 12,921
plan offered under division (A) of this section; and 12,922
(2) Change from one of the two plans to the other at a 12,924
time each year as determined by the port authority. 12,925
Sec. 4582.29. (A) Any port authority created under 12,934
section 4582.22 of the Revised Code may procure and pay all or 12,935
any part of the cost of group hospitalization, surgical, major 12,936
medical, sickness and accident insurance, or group life 12,937
insurance, or a combination of any of the foregoing types of 12,938
insurance or coverage for full-time employees and their immediate 12,939
dependents, whether issued by an insurance company or a medical 12,940
care corporation, duly authorized to do business in this state. 12,941
(B) Any port authority also may procure and pay all or any 12,943
part of the cost of a plan of group hospitalization, surgical, or 12,944
major medical insurance with a health care INSURING corporation 12,945
288
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1738. 12,947
1751. of the Revised Code, provided that each full-time employee 12,949
shall be permitted to:
(1) Exercise an option between a plan offered by an 12,951
insurance company, hospital service association, or medical care 12,952
corporation as provided in division (A) of this section and a 12,953
plan offered by a health care INSURING corporation under this 12,954
division, on the condition that the full-time employee shall pay 12,956
any amount by which the cost of the plan offered in this division 12,957
exceeds the cost of the plan offered under division (A) of this 12,958
section; and
(2) Change from one of the two plans to the other at a 12,960
time each year as determined by the port authority. 12,961
Sec. 4715.02. The governor, with the advice and consent of 12,970
the senate, shall appoint a state dental board consisting of 12,971
seven persons, five of whom shall be graduates of a reputable 12,972
dental college, a citizen CITIZENS of the United States, and 12,973
shall have been in the legal and reputable practice of dentistry 12,974
in the state at least five years next preceding his THEIR 12,975
appointment; one of whom shall be a graduate of a reputable 12,976
school of dental hygiene, a citizen of the United States, and 12,977
shall have been in the legal and reputable practice of dental 12,978
hygiene in the state at least five years next preceding his THE 12,979
PERSON'S appointment; and one of whom shall be a member of the 12,981
public at large who is not associated with or financially 12,982
interested in the practice of dentistry. Terms of office shall 12,983
be for five years, commencing on the seventh day of April and 12,984
ending on the sixth day of April, except that upon expiration of 12,985
the term ending April 25, 1978, the new term which succeeds it 12,986
shall commence on April 26, 1978 and end on April 6, 1983; upon 12,987
expiration of the term ending July 23, 1974, the new term which 12,988
succeeds it shall commence on July 24, 1974 and end on April 6, 12,989
1979; and upon expiration of the term ending June 24, 1975, the 12,990
new term which succeeds it shall commence on June 25, 1975 and 12,991
289
end on April 6, 1980. Each member shall hold office from the 12,992
date of his THE MEMBER'S appointment until the end of the term 12,994
for which he THE MEMBER was appointed. Any member appointed to 12,996
fill a vacancy occurring prior to the expiration of the term for 12,997
which his THE MEMBER'S predecessor was appointed shall hold 12,999
office for the remainder of such term. Any member shall continue 13,000
in office subsequent to the expiration date of his THE MEMBER'S 13,001
term until his THE MEMBER'S successor takes office, or until a 13,002
period of sixty days has elapsed, whichever occurs first. No 13,004
person so appointed shall serve to exceed two terms. The Ohio 13,005
dental association may submit to the governor the names of five 13,006
nominees for each position to be filled by a dentist and from the 13,007
names so submitted or from others, at his THE GOVERNOR'S 13,008
discretion, the governor shall make such appointments; provided 13,010
that all such appointees shall possess the required 13,011
qualifications. The Ohio dental hygienists association, inc. 13,012
may submit to the governor the names of five nominees for each 13,013
position to be filled by a dental hygienist and from the names so 13,014
submitted or from others, at his THE GOVERNOR'S discretion, the 13,016
governor shall make such appointments; provided that all such
appointees shall possess the required qualifications. No person 13,017
shall be appointed to the state dental board who is employed by 13,018
or practices in a partnership, association, or corporation 13,019
organized HOLDING A CERTIFICATE OF AUTHORITY under Chapter 1740. 13,021
1751. of the Revised Code with a person who is a member of the 13,022
board.
Sec. 4719.01. (A) As used in sections 4719.01 to 4719.18 13,031
of the Revised Code: 13,032
(1) "Affiliate" means a business entity that is owned by, 13,034
operated by, controlled by, or under common control with another 13,035
business entity.
(2) "Communication" means a written or oral notification 13,037
or advertisement that meets both of the following criteria, as 13,038
applicable:
290
(a) The notification or advertisement is transmitted by or 13,040
on behalf of the seller of goods or services and by or through 13,041
any printed, audio, video, cinematic, telephonic, or electronic 13,042
means.
(b) In the case of a notification or advertisement other 13,044
than by telephone, either of the following conditions is met: 13,045
(i) The notification or advertisement is followed by a 13,047
telephone call from a telephone solicitor or salesperson. 13,048
(ii) The notification or advertisement invites a response 13,050
by telephone, and, during the course of that response, a 13,051
telephone solicitor or salesperson attempts to make or makes a 13,052
sale of goods or services. As used in division (A)(2)(b)(ii) of 13,053
this section, "invites a response by telephone" excludes the mere 13,054
listing or inclusion of a telephone number in a notification or 13,055
advertisement.
(3) "Gift, award, or prize" means anything of value that 13,058
is offered or purportedly offered, or given or purportedly given 13,059
by chance, at no cost to the receiver and with no obligation to 13,060
purchase goods or services. As used in this division, "chance"
includes a situation in which a person is guaranteed to receive 13,062
an item and, at the time of the offer or purported offer, the 13,063
telephone solicitor does not identify the specific item that the
person will receive. 13,064
(4) "Goods or services" means any real property or any 13,067
tangible or intangible personal property, or services of any kind 13,068
provided or offered to a person. "Goods or services" includes,
but is not limited to, advertising; labor performed for the 13,069
benefit of a person; personal property intended to be attached to 13,070
or installed in any real property, regardless of whether it is so 13,071
attached or installed; timeshare estates or licenses; and 13,072
extended service contracts.
(5) "Purchaser" means a person that is solicited to become 13,075
or does become financially obligated as a result of a telephone 13,076
solicitation.
291
(6) "Salesperson" means an individual who is employed, 13,078
appointed, or authorized by a telephone solicitor to make 13,080
telephone solicitations but does not mean any of the following:
(a) An individual who comes within one of the exemptions 13,082
in division (B) of this section; 13,083
(b) An individual employed, appointed, or authorized by a 13,085
person who comes within one of the exemptions in division (B) of 13,086
this section; 13,087
(c) An individual under a written contract with a person 13,089
who comes within one of the exemptions in division (B) of this 13,090
section, if liability for all transactions with purchasers is 13,091
assumed by the person so exempted. 13,092
(7) "Telephone solicitation" means a communication to a 13,094
person that meets both of the following criteria: 13,095
(a) The communication is initiated by or on behalf of a 13,097
telephone solicitor or by a salesperson. 13,098
(b) The communication either represents a price or the 13,100
quality or availability of goods or services or is used to induce 13,101
the person to purchase goods or services, including, but not 13,102
limited to, inducement through the offering of a gift, award, or 13,103
prize.
(8) "Telephone solicitor" means a person that engages in 13,105
telephone solicitation directly or through one or more 13,106
salespersons either from a location in this state or from a 13,107
location outside this state to persons in this state. "Telephone 13,108
solicitor" includes, but is not limited to, any such person that 13,109
is an owner, operator, officer, or director of, partner in, or 13,110
other individual engaged in the management activities of, a 13,111
business.
(B) A telephone solicitor is exempt from the provisions of 13,114
sections 4719.02 to 4719.18 and section 4719.99 of the Revised
Code if the telephone solicitor is any one of the following: 13,115
(1) A person engaging in a telephone solicitation that is 13,117
a one-time or infrequent transaction not done in the course of a 13,118
292
pattern of repeated transactions of a like nature; 13,119
(2) A person engaged in telephone solicitation solely for 13,121
religious or political purposes; a charitable organization, 13,122
fund-raising counsel, or professional solicitor in compliance 13,123
with the registration and reporting requirements of Chapter 1716. 13,124
of the Revised Code; or any person or other entity exempt under 13,125
section 1716.03 of the Revised Code from filing a registration 13,126
statement under section 1716.02 of the Revised Code; 13,128
(3) A person, making a telephone solicitation involving a 13,130
home solicitation sale as defined in section 1345.21 of the 13,131
Revised Code, that makes the sales presentation and completes the 13,132
sale at a later, face-to-face meeting between the seller and the 13,134
purchaser rather than during the telephone solicitation. 13,135
However, if the person, following the telephone solicitation, 13,136
causes another person to collect the payment of any money, this 13,137
exemption does not apply.
(4) A licensed securities, commodities, or investment 13,139
broker, dealer, investment advisor, or associated person when 13,140
making a telephone solicitation within the scope of the person's 13,141
license. As used in division (B)(4) of this section, "licensed 13,142
securities, commodities, or investment broker, dealer, investment 13,143
advisor, or associated person" means a person subject to 13,144
licensure or registration as such by the securities and exchange 13,145
commission; the National Association of Securities Dealers or 13,146
other self-regulatory organization, as defined by 15 U.S.C.A. 13,147
78c; by the division of securities under Chapter 1707. Revised 13,148
Code; or by an official or agency of any other state of the 13,149
United States.
(5)(a) A person primarily engaged in soliciting the sale 13,151
of a newspaper of general circulation; 13,152
(b) As used in division (B)(5)(a) of this section, 13,154
"newspaper of general circulation" includes, but is not limited 13,155
to, both of the following:
(i) A newspaper that is a daily law journal designated as 13,157
293
an official publisher of court calendars pursuant to section 13,158
2701.09 of the Revised Code;
(ii) A newspaper or publication that has at least 13,160
twenty-five per cent editorial, non-advertising content, 13,161
exclusive of inserts, measured relative to total publication 13,162
space, and an audited circulation to at least fifty per cent of 13,163
the households in the newspaper's retail trade zone as defined by
the audit. 13,164
(6)(a) An issuer, or its subsidiary, that has a class of 13,166
securities to which all of the following apply: 13,167
(i) The class of securities is subject to section 12 of 13,169
the "Securities Exchange Act of 1934," 15 U.S.C.A. 78l, and is 13,170
registered or is exempt from registration under 15 U.S.C.A. 13,172
78l(g)(2)(A), (B), (C), (E), (F), (G), or (H);
(ii) The class of securities is listed on the New York 13,175
stock exchange, the American stock exchange, or the NASDAQ 13,176
national market system;
(iii) The class of securities is a reported security as 13,178
defined in 17 C.F.R. 240.11Aa3-1(a)(4). 13,179
(b) An issuer, or its subsidiary, that formerly had a 13,181
class of securities that met the criteria set forth in division 13,182
(B)(6)(a) of this section if the issuer, or its subsidiary, has a 13,184
net worth in excess of one hundred million dollars, files or its 13,185
parent files with the securities and exchange commission an 13,186
S.E.C. form 10-K, and has continued in substantially the same 13,187
business since it had a class of securities that met the criteria
in division (B)(6)(a) of this section. As used in division 13,188
(B)(6)(b) of this section, "issuer" and "subsidiary" include the 13,189
successor to an issuer or subsidiary. 13,191
(7) A person soliciting a transaction regulated by the 13,193
commodity futures trading commission, if the person is registered 13,194
or temporarily registered for that activity with the commission 13,195
under 7 U.S.C.A. 1 et. seq. and the registration or temporary 13,196
registration has not expired or been suspended or revoked; 13,197
294
(8) A person soliciting the sale of any book, record, 13,199
audio tape, compact disc, or video, if the person allows the 13,200
purchaser to review the merchandise for at least seven days and 13,202
provides a full refund within thirty days to a purchaser who 13,203
returns the merchandise or if the person solicits the sale on 13,204
behalf of a membership club operating in compliance with 13,205
regulations adopted by the federal trade commission in 16 C.F.R. 13,206
425;
(9) A supervised financial institution or its subsidiary. 13,208
As used in division (B)(9) of this section, "supervised financial 13,210
institution" means a bank, trust company, savings and loan 13,211
association, savings bank, credit union, industrial loan company,
consumer finance lender, commercial finance lender, or 13,212
institution described in section 2(c)(2)(F) of the "Bank Holding 13,213
Company Act of 1956," 12 U.S.C.A. 1841(c)(2)(F), as amended, 13,214
supervised by an official or agency of the United States, this 13,215
state, or any other state of the United States; or a licensee or 13,216
registrant under sections 1321.01 to 1321.19, 1321.51 to 1321.60, 13,217
or 1321.71 to 1321.83 of the Revised Code. 13,218
(10)(a) An insurance company, association, or other 13,220
organization that is licensed or authorized to conduct business 13,221
in this state by the superintendent of insurance pursuant to 13,222
Title XXXIX of the Revised Code or Chapter 1736., 1737., 1738., 13,223
1739., 1740., or 1742. 1751. of the Revised Code, when soliciting 13,224
within the scope of its license or authorization. 13,225
(b) A licensed insurance broker, agent, or solicitor when 13,228
soliciting within the scope of the person's license. As used in 13,229
division (B)(10)(b) of this section, "licensed insurance broker, 13,230
agent, or solicitor" means any person licensed as an insurance 13,231
broker, agent, or solicitor by the superintendent of insurance 13,232
pursuant to Title XXXIX of the Revised Code.
(11) A person soliciting the sale of services provided by 13,234
a cable television system operating under authority of a 13,235
governmental franchise or permit; 13,236
295
(12) A person soliciting a business-to-business sale under 13,238
which any of the following conditions are met: 13,239
(a) The telephone solicitor has been operating 13,241
continuously for at least three years under the same business 13,242
name under which it solicits purchasers, and at least fifty-one 13,243
per cent of its gross dollar volume of sales consists of repeat 13,244
sales to existing customers to whom it has made sales under the 13,245
same business name.
(b) The purchaser business intends to resell the goods 13,248
purchased.
(c) The purchaser business intends to use the goods or 13,251
services purchased in a recycling, reuse, manufacturing, or
remanufacturing process. 13,252
(d) The telephone solicitor is a publisher of a periodical 13,254
or of magazineS distributed as controlled circulation 13,255
publicationS as defined in division (CC) of section 5739.01 of 13,256
the Revised Code and is soliciting sales of advertising, 13,257
subscriptions, reprints, lists, information databases, conference 13,258
participation or sponsorships, trade shows or media products 13,259
related to the periodical or magazine, or other publishing
services provided by the controlled circulation publication. 13,260
(13) A person that, not less often than once each year, 13,262
publishes and delivers to potential purchasers a catalog that 13,263
complies with both of the following: 13,264
(a) It includes all of the following: 13,266
(i) The business address of the seller; 13,268
(ii) A written description or illustration of each good or 13,271
service offered for sale;
(iii) A clear and conspicuous disclosure of the sale price 13,273
of each good or service; shipping, handling, and other charges; 13,275
and return policy;
(b) One of the following applies: 13,277
(i) The catalog includes at least twenty-four pages of 13,279
written material and illustrations, is distributed in more than 13,280
296
one state, and has an annual postage-paid mail circulation of not 13,281
less than two hundred fifty thousand households; 13,282
(ii) The catalog includes at least ten pages of written 13,284
material or an equivalent amount of material in electronic form 13,285
on the internet or an on-line computer service, the person does 13,286
not solicit customers by telephone but solely receives telephone 13,287
calls made in response to the catalog, and during the calls the 13,289
person takes orders but does not engage in further solicitation
of the purchaser. As used in division (B)(13)(b)(ii) of this 13,290
section, "further solicitation" does not include providing the 13,291
purchaser with information about, or attempting to sell, any 13,292
other item in the catalog that prompted the purchaser's call or 13,293
in a substantially similar catalog issued by the seller. 13,294
(14) A political subdivision or instrumentality of the 13,296
United States, this state, or any state of the United States; 13,298
(15) A college or university or any other public or 13,300
private institution of higher education in this state; 13,301
(16) A public utility, as defined in section 4905.02 of 13,303
the Revised Code, that is subject to regulation by the public 13,304
utilities commission, or its affiliate; 13,305
(17) A travel agency or tour promoter that is registered 13,307
in compliance with section 1333.96 of the Revised Code when 13,308
soliciting within the scope of the agency's or promoter's 13,309
registration;
(18) A person that solicits sales through a television 13,311
program or advertisement that is presented in the same market 13,312
area no fewer than twenty days per month or offers for sale no 13,313
fewer than ten distinct items of goods or services; and offers to 13,314
the purchaser an unconditional right to return any good or 13,315
service purchased within a period of at least seven days and to 13,316
receive a full refund within thirty days after the purchaser
returns the good or cancels the service; 13,317
(19)(a) A person that, for at least one year, has been 13,319
operating a retail business under the same name as that used in 13,320
297
connection with telephone solicitation and both of the following 13,321
occur on a continuing basis: 13,322
(i) The person either displays goods and offers them for 13,324
retail sale at the person's business premises or offers services 13,325
for sale and provides them at the person's business premises. 13,326
(ii) At least fifty-one per cent of the person's gross 13,329
dollar volume of retail sales involves purchases of goods or
services at the person's business premises. 13,330
(b) An affiliate of a person that meets the requirements 13,332
in division (B)(19)(a) of this section if the affiliate meets all 13,334
of the following requirements:
(i) The affiliate has operated a retail business for a 13,336
period of less than one year; 13,337
(ii) The affiliate either displays goods and offers them 13,339
for retail sale at the affiliate's business premises or offers 13,340
services for sale and provides them at the affiliate's business 13,341
premises;
(iii) At least fifty-one per cent of the affiliate's gross 13,343
dollar volume of retail sales involves purchases of goods or 13,344
services at the affiliate's business premises. 13,345
(c) A person that, for a period of less than one year, has 13,347
been operating a retail business in this state under the same 13,348
name as that used in connection with telephone solicitation, as 13,349
long as all of the following requirements are met: 13,350
(i) The person either displays goods and offers them for 13,352
retail sale at the person's business premises or offers services 13,353
for sale and provides them at the person's business premises; 13,354
(ii) The goods or services that are the subject of 13,356
telephone solicitation are sold at the person's business 13,357
premises, and at least sixty-five per cent of the person's gross 13,358
dollar volume of retail sales involves purchases of goods or 13,359
services at the person's business premises;
(iii) The person conducts all telephone solicitation 13,361
activities according to sections 310.3, 310.4, and 310.5 of the 13,362
298
telemarketing sales rule adopted by the federal trade commission 13,363
in 16 C.F.R. part 310.
(20) A person who performs telephone solicitation sales 13,365
services on behalf of other persons and to whom one of the 13,366
following applies:
(a) The person has operated under the same ownership, 13,368
control, and business name for at least five years, and the 13,369
person receives at least seventy-five per cent of its gross 13,370
revenues from written telephone solicitation contracts with 13,371
persons who come within one of the exemptions in division (B) of
this section. 13,372
(b) The person is an affiliate of one or more exempt 13,374
persons and makes telephone solicitations on behalf of only the 13,375
exempt persons of which it is an affiliate. 13,376
(c) The person makes telephone solicitations on behalf of 13,378
only exempt persons, the person and each exempt person on whose 13,379
behalf telephone solicitations are made have entered into a 13,380
written contract that specifies the manner in which the telephone 13,381
solicitations are to be conducted and that at a minimum requires 13,382
compliance with the telemarketing sales rule adopted by the
federal trade commission in 16 C.F.R. part 310, and the person 13,384
conducts the telephone solicitations in the manner specified in 13,385
the written contract.
(d) The person performs telephone solicitation for 13,387
religious or political purposes, a charitable organization, a 13,388
fund-raising council, or a professional solicitor in compliance 13,389
with the registration and reporting requirements of Chapter 1716. 13,390
of the Revised Code; and meets all of the following requirements: 13,391
(i) The person has operated under the same ownership, 13,393
control, and business name for at least five years, and the 13,394
person receives at least fifty-one per cent of its gross revenues 13,395
from written telephone solicitation contracts with persons who 13,396
come within the exemption in division (B)(2) of this section; 13,397
(ii) The person does not conduct a prize promotion or 13,399
299
offer the sale of an investment opportunity; and 13,400
(iii) The person conducts all telephone solicitation 13,402
activities according to sections 310.3, 310.4, and 310.5 of the 13,403
telemarketing sales rules adopted by the federal trade commission 13,404
in 16 C.F.R. part 310. 13,405
(21) A person that is a licensed real estate salesperson 13,407
or broker under Chapter 4735. of the Revised Code when soliciting 13,408
within the scope of the person's license; 13,409
(22) A publisher that solicits the sale of the publisher's 13,411
periodical or magazine of general, paid circulation, or a person 13,412
that solicits a sale of that nature on behalf of a publisher 13,413
under a written agreement directly between the publisher and the 13,414
person. As used in division (B)(22) of this section, "periodical 13,415
or magazine of general, paid circulation" excludes a periodical 13,416
or magazine circulated only as part of a membership package or 13,417
given as a free gift or prize from the publisher or person. 13,418
(23) A person that solicits the sale of food, as defined 13,420
in section 3715.01 of the Revised Code, or the sale of products 13,421
of horticulture, as defined in section 5739.01 of the Revised 13,422
Code, if the person does not intend the solicitation to result 13,423
in, or the solicitation actually does not result in, a sale that 13,424
costs the purchaser an amount greater than five hundred dollars.
(24) A funeral director licensed pursuant to Chapter 4717. 13,426
of the Revised Code when soliciting within the scope of that 13,427
license, if both of the following apply: 13,428
(a) The solicitation and sale are conducted in compliance 13,430
with 16 C.F.R. part 453, as adopted by the federal trade 13,431
commission, and with sections 1107.33 and 1345.21 to 1345.28 of 13,432
the Revised Code;
(b) The person provides to the purchaser of any preneed 13,434
funeral contract a notice that clearly and conspicuously sets 13,435
forth the cancellation rights specified in division (G) of 13,436
section 1107.33 of the Revised Code, and retains a copy of the 13,437
that notice signed by the purchaser.
300
(25) A person, or affiliate thereof, licensed to sell or 13,439
issue Ohio instruments designated as travelers checks pursuant to 13,440
sections 1315.01 to 1315.11 of the Revised Code. 13,441
(26) A person that solicits sales from its previous 13,443
purchasers and meets all of the following requirements: 13,444
(a) The solicitation is made under the same business name 13,446
that was previously used to sell goods or services to the 13,447
purchaser;
(b) The person has, for a period of not less than three 13,449
years, operated a business under the same business name as that 13,450
used in connection with telephone solicitation; 13,451
(c) The person does not conduct a prize promotion or offer 13,453
the sale of an investment opportunity; 13,454
(d) The person conducts all telephone solicitation 13,456
activities according to sections 310.3, 310.4, and 310.5 of the 13,457
telemarketing sales rules adopted by the federal trade commission 13,458
in 16 C.F.R. part 310;
(e) Neither the person nor any of its principals has been 13,460
convicted of, pleaded guilty to, or has entered a plea of no 13,461
contest for a felony or a theft offense as defined in sections 13,462
2901.02 and 2913.01 of the Revised Code or similar law of another 13,463
state or of the United States;
(f) Neither the person nor any of its principals has had 13,465
entered against them an injunction or a final judgment or order, 13,466
including an agreed judgment or order, an assurance of voluntary 13,467
compliance, or any similar instrument, in any civil or 13,468
administrative action involving engaging in a pattern of corrupt 13,469
practices, fraud, theft, embezzlement, fraudulent conversion, or 13,470
misappropriation of property; the use of any untrue, deceptive,
or misleading representation; or the use of any unfair, unlawful, 13,471
deceptive, or unconscionable trade act or practice. 13,472
(27) An institution defined as a home health agency in 13,474
section 3701.88 of the Revised Code, that conducts all telephone 13,475
solicitation activities according to sections 310.3, 310.4, and 13,476
301
310.5 of the telemarketing sales rules adopted by the federal 13,477
trade commission in 16 C.F.R. part 310, and engages in telephone 13,478
solicitation only within the scope of the institution's 13,479
certification, accreditation, contract with the department of
aging, or status as a home health agency; and that meets one of 13,480
the following requirements: 13,481
(a) The institution is certified as a provider of home 13,483
health services under Title XVIII of the Social Security Act, 49 13,485
Stat. 620, 42 U.S.C. 301, as amended; and is registered with the 13,486
department of health pursuant to division (B) of section 3701.88 13,487
of the Revised Code; 13,488
(b) The institution is accredited by either the joint 13,490
commission on accreditation of health care organizations or the 13,491
community health accreditation program; 13,492
(c) The institution is providing PASSPORT services under 13,495
the direction of the Ohio department of aging under section
173.40 of the Revised Code; 13,496
(d) An affiliate of an institution that meets the 13,498
requirements of division (B)(27)(a), (b), or (c) of this section 13,500
when offering for sale substantially the same goods and services 13,501
as those that are offered by the institution that meets the
requirements of division (B)(27)(a), (b), or (c) of this section. 13,503
(28) A person licensed to provide a hospice care program 13,505
by the department of health pursuant to section 3712.04 of the 13,506
Revised Code when conducting telephone solicitations within the 13,507
scope of the person's license and according to sections 310.3, 13,508
310.4, and 310.5 of the telemarketing sales rules adopted by the 13,509
federal trade commission in 16 C.F.R. part 310.
Sec. 4729.381. No licensed pharmacist shall be liable for 13,518
civil damages or in any criminal prosecution arising from the 13,519
dispensing of a drug based upon a formulary established by a 13,520
practitioner in a hospital, health maintenance organization 13,521
INSURING CORPORATION, or long-term care facility and requiring 13,522
the pharmacist to dispense the particular drug. 13,523
302
Sec. 4731.67. Section 4731.66 of the Revised Code does not 13,532
apply to any of the following referrals by the holder of a 13,533
certificate under this chapter: 13,534
(A) Referrals for physicians' services that are performed 13,536
by or under the personal supervision of a physician in the same 13,537
group practice as the referring physician; 13,538
(B) Referrals for clinical laboratory services by a 13,540
certificate holder specializing in the practice of pathology if 13,541
those services are provided by or under the supervision of the 13,542
pathologist pursuant to a consultation requested by another 13,543
physician; 13,544
(C) Referrals for in-office ancillary services to which 13,546
all of the following apply: 13,547
(1) The services are furnished by the referring physician, 13,549
a physician in the same group practice as the referring 13,550
physician, or individuals who are employed by the referring 13,551
physician or the group practice and who are supervised by the 13,552
referring physician or a physician in the group practice, and are 13,553
furnished either: 13,554
(a) In a building in which the referring physician, or 13,556
another physician in the same group practice as the referring 13,557
physician, furnishes physicians' services unrelated to the 13,558
furnishing of designated health services; 13,559
(b) In another building used by the referring physician's 13,561
group practice for the centralized provision of the group's 13,562
designated health services. 13,563
(2) The services are billed by the physician performing or 13,565
supervising the services, the physician's group practice, or an 13,566
entity wholly owned by the group practice. 13,567
(3) The physician's ownership or investment interest in 13,569
the services described in this division meets any other 13,570
requirements that the state medical board applies in rules 13,571
adopted under section 4731.70 of the Revised Code. 13,572
(D) "Referrals for in-office ancillary services if the 13,574
303
third-party payer is aware of and has agreed in writing to 13,575
reimburse the services notwithstanding the financial arrangement 13,576
between the physician and the provider of such ancillary 13,577
services. 13,578
(E) Referrals for services furnished by a health 13,580
maintenance organization INSURING CORPORATION to an enrollee of 13,581
the organization CORPORATION; 13,582
(F) Referrals to a hospital for designated health 13,585
services, if all of the following apply:
(1) The financial arrangement between the referring 13,587
physician or immediate family member and the hospital consists of 13,588
an ownership or investment interest described in division (A)(1) 13,589
of section 4731.66 of the Revised Code and not a compensation 13,590
arrangement described in division (A)(2) of that section. 13,591
(2) The referring physician is authorized to perform 13,593
services at the hospital. 13,594
(3) The ownership or investment interest is in the 13,596
hospital itself and not merely in a subdivision of the hospital. 13,597
(G) Referrals to a hospital with which the certificate 13,599
holder's or immediate family member's financial relationship does 13,600
not relate to the provision of designated health services; 13,602
(H) Referrals to a laboratory located in a rural area as 13,604
defined in section 1886(d)(2)(D) of the "Social Security Act," 49 13,605
Stat. 620 (1935), 42 U.S.C.A. 1395ww(d)(2)(D), as amended, if the 13,606
financial relationship consists of an ownership or investment 13,607
interest described in division (A)(1) of section 4731.66 of the 13,608
Revised Code, and not a compensation arrangement described in 13,609
division (A)(2) of that section; 13,610
(I) Any other referrals in which the financial 13,612
relationship between the certificate holder or immediate family 13,613
member and the person furnishing services has been specified in 13,614
rules adopted by the state medical board under section 4731.70 of 13,615
the Revised Code. 13,616
Sec. 5111.02. (A) Under the medical assistance program: 13,625
304
(1) Reimbursement by the department of human services to a 13,627
medical provider for any medical service rendered under the 13,628
program shall not exceed the authorized reimbursement level for 13,629
the same service under the medicare program established under 13,630
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 13,631
U.S.C.A. 301, as amended. 13,632
(2) Reimbursement for freestanding medical laboratory 13,634
charges shall not exceed the customary and usual fee for 13,635
laboratory profiles. 13,636
(3) The department may deduct from payments for services 13,638
rendered by a medicaid provider under the medical assistance 13,639
program any amounts the provider owes the state as the result of 13,640
incorrect medical assistance payments the department has made to 13,641
the provider. 13,642
(4) The department may conduct final fiscal audits in 13,644
accordance with the applicable requirements set forth in federal 13,645
laws and regulations and determine any amounts the provider may 13,646
owe the state. When conducting final fiscal audits, the 13,647
department shall consider generally accepted auditing standards, 13,648
which include the use of statistical sampling. 13,649
(5) To the maximum extent that federal laws and 13,651
regulations permit the implementation of such a policy, the 13,652
department may institute a copayment program for all services 13,653
provided under the medical assistance program. The program shall 13,654
be administered in accordance with the applicable requirements 13,655
set forth in federal laws and regulations. 13,656
(6) The number of days of inpatient hospital care for 13,658
which reimbursement is made on behalf of a recipient of medical 13,659
assistance to a hospital that is not paid under a 13,660
diagnostic-related-group prospective payment system shall not 13,661
exceed thirty days during a period beginning on the day of the 13,662
recipient's admission to the hospital and ending sixty days after 13,663
the termination of that hospital stay, except that the department 13,664
may make exceptions to this limitation. The limitation does not 13,665
305
apply to children participating in the program for medically 13,666
handicapped children established under section 3701.023 of the 13,667
Revised Code. 13,668
(B) The director of human services may adopt, amend, or 13,670
rescind rules under Chapter 119. of the Revised Code establishing 13,671
the amount, duration, and scope of medical services to be 13,672
included in the medical assistance program. Such rules shall 13,673
establish the conditions under which services are covered and 13,674
reimbursed, the method of reimbursement applicable to each 13,675
covered service, and the amount of reimbursement or, in lieu of 13,676
such amounts, methods by which such amounts are to be determined 13,677
for each covered service. Any rules that pertain to nursing 13,678
facilities or intermediate care facilities for the mentally 13,679
retarded shall be consistent with sections 5111.20 to 5111.33 of 13,680
the Revised Code. 13,681
(C) No health maintenance organization INSURING 13,683
CORPORATION that has a contract to provide health care services 13,685
to recipients of medical assistance shall restrict the 13,686
availability to its enrollees of any prescription drugs included 13,687
in the Ohio medicaid drug formulary as established under rules of 13,688
the department.
(D) The division of any reimbursement between a 13,690
collaborating physician or podiatrist and a clinical nurse 13,691
specialist, certified nurse-midwife, or certified nurse 13,692
practitioner for services performed by the nurse shall be 13,693
determined and agreed on by the nurse and collaborating physician 13,694
or podiatrist. In no case shall reimbursement exceed the payment
that the physician or podiatrist would have received had the 13,695
physician or podiatrist provided the entire service. 13,697
Sec. 5111.17. (A) As used in this section, 13,706
"community-based clinic" means a clinic that provides prenatal, 13,707
family planning, well child, or primary care services and is 13,708
funded in whole or in part by the state or federal government. 13,709
(B) On receipt of a waiver from the United States 13,711
306
department of health and human services of any federal 13,712
requirement that would otherwise be violated, the department of 13,713
human services shall establish in Franklin, Hamilton, and Lucas 13,714
counties a managed care system under which designated recipients 13,715
of medical assistance are required to obtain medical services 13,716
from providers designated by the department. The department may 13,717
stagger implementation of the managed care system, but the system 13,718
shall be implemented in at least one county not later than 13,719
January 1, 1995, and in all three counties not later than July 1, 13,720
1996.
(B)(C) The department, by rule adopted under this section, 13,722
may require any recipients in any other county to receive all or 13,723
some of their care through managed care organizations that 13,724
contract with the department and are paid by the department 13,725
pursuant to a capitation or other risk-based methodology 13,726
prescribed in the rules, and to receive their care only from 13,727
providers designated by the organizations.
(C)(D) In accordance with rules adopted under division 13,730
(E)(G) of this section, the department may issue requests for 13,731
proposals from managed care organizations interested in 13,732
contracting with the department to provide managed care to
participating medical assistance recipients. 13,733
(E) A health maintenance organization INSURING CORPORATION 13,736
under contract with the department under this section may enter 13,738
into an agreement with any community-based clinic for the 13,739
provision of medical services to medical assistance recipients
participating in the managed care system if the clinic is willing 13,740
to accept the terms, conditions, and payment procedures 13,741
established by the health maintenance organization INSURING 13,742
CORPORATION.
(D)(F) For the purpose of determining the amount the 13,744
department pays hospitals under section 5112.08 of the Revised 13,746
Code and the amount of disproportionate share hospital payments 13,747
paid by the medicare program established under Title XVIII of the 13,748
307
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as 13,749
amended, each managed care organization under contract with the 13,750
department to provide managed care to participating medical
assistance recipients shall keep detailed records for each 13,751
hospital with which it contracts about the cost to the hospital 13,752
of providing the care, payments made by the organization to the 13,753
hospital for the care, utilization of hospital services by 13,754
medical assistance recipients participating in managed care, and
other utilization data required by the department. 13,755
(E)(G) The department shall adopt rules in accordance with 13,757
Chapter 119. of the Revised Code to implement this section. The 13,759
rules shall include all of the following: 13,760
(1) A monthly capitation or other risk-based payment rate 13,762
system for managed care organizations under contract to provide 13,763
managed care to participating medical assistance recipients; 13,765
(2) The method by which the department will issue requests 13,767
for proposals from managed care organizations interested in 13,768
providing managed care to participating medical assistance 13,769
recipients, including all of the following: 13,770
(a) Public notice of the department's intent to issue a 13,772
request for proposals within a county; 13,773
(b) The process for managed care organizations to submit 13,775
letters of interest;
(c) The procurement, selection, and implementation 13,777
timetable within each county; 13,778
(d) The time by which the department will furnish 13,780
interested managed care organizations with demographic, cost, and 13,781
utilization data about medical assistance recipients required or 13,782
permitted to enroll in a managed care organization in a county. 13,783
(3) Performance standards of managed care organizations 13,785
under contract with the department governing all of the 13,786
following:
(a) Scope of coverage and benefits; 13,788
(b) Quality assurance performance indicators for services 13,790
308
including prenatal care, immunizations, screenings that are part 13,791
of the early and periodic screening, diagnostic, and treatment 13,792
program, and any other service specified by the department; 13,793
(c) Service delivery system capacity; 13,795
(d) Reporting requirements; 13,797
(e) Grievance and complaint procedures; 13,799
(f) Enrollment and disenrollment procedures; 13,801
(g) Stop-loss arrangements; 13,803
(h) Marketing; 13,805
(i) Consumer and provider advisory councils; 13,807
(j) Any other requirement established by the department. 13,809
(4) A review process for any managed care organization 13,811
that has submitted a proposal to have the department reconsider 13,812
the denial of a contract under this section or termination of a 13,813
contract entered into under this section;
(5) Any other procedures or requirements the department 13,815
considers necessary to implement managed care. 13,816
Sec. 5111.171. On receipt of a waiver from the United 13,825
States department of health and human services of any federal 13,826
requirement that would be violated by implementation of this 13,827
section, the department shall establish a case management system 13,828
to ensure that recipients of medical assistance under this 13,829
chapter whose medical treatment and care is exceptionally 13,830
expensive receive medical services in a cost-effective manner. 13,831
Recipients identified by the department as being subject to this 13,832
division shall comply with the requirements of the case 13,833
management system as a condition of continued eligibility for 13,834
medical assistance. The department shall reimburse a hospital 13,835
under the medical assistance program for emergency services 13,836
covered by the medical assistance program provided to a medical 13,837
assistance recipient pursuant to section 1867 of the "Social 13,838
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 1395dd, as 13,839
amended, regardless of whether the hospital is participating in 13,840
the case management system. 13,841
309
A hospital's participation in the case management system 13,843
does not prevent its participation in the hospital care assurance 13,844
program established by sections 5112.01 to 5112.21 of the Revised 13,845
Code unless the hospital is operated by a health maintenance 13,846
organization INSURING CORPORATION. 13,847
Sec. 5111.19. The department of human services shall adopt 13,856
rules governing the calculation and payment of graduate medical 13,857
education costs associated with services rendered to recipients 13,858
of the medical assistance program after June 30, 1994. The rules 13,859
shall provide for reimbursement of graduate medical education 13,860
costs associated with services rendered to medical assistance 13,861
recipients, including recipients enrolled in health maintenance 13,862
organizations INSURING CORPORATIONS, that the department 13,863
determines are allowable and reasonable. 13,865
If the department requires a health maintenance 13,867
organization INSURING CORPORATION to pay a provider for graduate 13,868
medical education costs associated with the delivery of services 13,870
to medical assistance recipients enrolled in the organization 13,871
CORPORATION, the department shall include in its payment to the 13,873
organization CORPORATION an amount sufficient for the 13,875
organization CORPORATION to pay such costs. If the department 13,877
does not include in its payments to the organization HEALTH 13,878
INSURING CORPORATION amounts for graduate medical education costs 13,879
of providers, all of the following apply: 13,880
(A) The department shall pay the provider for graduate 13,882
medical education costs associated with the delivery of services 13,883
to medical assistance recipients enrolled in the organization 13,884
CORPORATION; 13,885
(B) No provider shall seek reimbursement from the 13,887
organization CORPORATION for such costs; 13,888
(C) The organization CORPORATION is not required to pay 13,890
providers for such costs. 13,892
Sec. 5111.74. (A) Not later than July 1, 1995, the 13,901
department of human services shall establish a fair share 13,902
310
demonstration project in Butler county for two years. The 13,903
demonstration project shall be administered by the Butler county 13,904
health care management board created under division (B) of this 13,905
section. In establishing the project, the department shall enter 13,906
into an agreement with the board, which shall provide that 13,907
medical assistance services be given to designated medical 13,908
assistance recipients who elect or are required by the department 13,909
to receive their services from or through the board or at least 13,910
one other managed care arrangement designated and approved by the 13,911
department.
The demonstration project shall demonstrate the viability 13,913
of delivering health care services to Butler county medical 13,914
assistance recipients through a cooperative health care 13,915
purchasing plan involving the organization of a managed care 13,916
network by physicians practicing medicine in Butler county and 13,917
hospitals located there. The demonstration project shall 13,918
restructure the medical assistance delivery system to improve the 13,919
delivery of cost effective, quality health care with an emphasis 13,920
on primary and preventive care, and shall prevent cost shifting 13,921
to the private sector. The demonstration project shall 13,922
demonstrate all of the following: 13,923
(1) A cost savings through prevention, the use of 13,925
appropriate levels of care, reduced administrative costs, and 13,926
utilization of the demonstration project through primary provider 13,927
reimbursement policies that encourage the delivery of primary and 13,928
preventive care; 13,929
(2) The effectiveness of local collaboration and autonomy 13,931
in managing medical assistance expenditures in Butler county; 13,932
(3) Improved access to quality health care for Butler 13,934
county's medical assistance recipients, while containing health 13,935
care costs. 13,936
The department shall make a grant of two hundred fifty 13,938
thousand dollars to the board on its establishment for operating 13,939
and project expenses. These funds shall be transferred from the 13,940
311
department's medical assistance account. 13,941
(B)(1) There is hereby created the Butler county health 13,943
care management board to administer the fair share demonstration 13,944
project in that county. The board shall consist of the county 13,945
director of human services and the following members: 13,946
(a) One representative of each hospital system located in 13,948
Butler county, selected by the hospital; 13,949
(b) Two physicians who specialize in pediatrics; two 13,951
family practice physicians; a physician who specializes in 13,952
obstetrics; an emergency department physician; a primary care 13,953
physician; a physician who is a medical specialist; a physician 13,954
who is a surgical specialist; a psychiatrist; and one physician 13,955
selected at large. The physicians shall be selected by the 13,956
county medical society or a similar organization of physicians in 13,957
the county. 13,958
(c) A chiropractor selected by an association of 13,960
chiropractors in the county; 13,961
(d) A licensed registered nurse who is an advanced 13,963
practice nurse selected by an organization of nurses in the 13,964
county; 13,965
(e) A dentist selected by an organization of dentists in 13,967
the county; 13,968
(f) An optometrist selected by an organization of 13,970
optometrists in the county; 13,971
(g) A psychologist selected by an organization of 13,973
psychologists in the county; 13,974
(h) A representative of child and family health services 13,976
clinics selected by the child health service consortium of Butler 13,977
county; 13,978
(i) A podiatrist selected by an organization of 13,980
podiatrists in the county. 13,981
(2) All members of the board shall be selected on the 13,983
basis of their experience with the delivery of health care 13,984
services to medical assistance recipients. If more than one 13,985
312
physician is to be selected from a specialty area, the order of 13,986
preference for determining board membership shall first be those 13,987
physicians that have significant experience in providing health 13,988
care services to medical assistance recipients. 13,989
(3) Each member of the board shall serve for the duration 13,991
of the demonstration project. In the event of a vacancy on the 13,992
board, a member shall be selected in the same manner as the 13,993
member he replaces REPLACED. Members shall not be compensated, 13,995
but may be reimbursed by the board for their actual and necessary 13,996
expenses. A majority of the members constitutes a quorum, and 13,997
the board may take official action only by affirmative vote of a 13,998
quorum.
(4) Not later than thirty days after July 1, 1993, the 14,000
representatives of the hospital systems in Butler county shall 14,002
select a temporary chairman CHAIRPERSON, who shall convene the 14,004
board not later than ninety days after July 1, 1993. Once
convened, the board shall elect a chairman CHAIRPERSON by a 14,006
majority vote from among its members, and all further meetings 14,008
shall be convened by the chairman CHAIRPERSON. The board may 14,010
elect officers and shall establish rules and procedures for its 14,011
governance and a schedule of meetings. The board may establish 14,012
an executive committee and such other subcommittees as it 14,013
determines necessary to act on behalf of the board. The county 14,014
department shall provide the board with any clerical,
professional, or technical assistance it requests. 14,015
(C) The Butler county health care management board shall 14,017
develop and implement a plan for the fair share demonstration 14,018
project. The board shall establish educational and case 14,019
management programs as it determines necessary to facilitate 14,020
access to and encourage appropriate utilization of essential 14,021
preventive medicine and primary care services. The board shall 14,022
have limited immunity from antitrust actions in developing and 14,023
implementing the project. The board shall apply for a 14,024
certificate of authority to establish and operate a health 14,025
313
maintenance organization INSURING CORPORATION under Chapter 1742. 14,027
1751. of the Revised Code. On application of the board, the 14,028
superintendent of insurance shall issue a certificate of 14,029
authority to the board for a two-year period, notwithstanding the 14,030
fact that the board may not meet the requirements of Chapter 14,031
1742. 1751. of the Revised Code. The certificate of authority 14,033
shall be void if the agreement with the department is not 14,034
executed. The superintendent shall retain powers and duties 14,035
under Chapter 3903. of the Revised Code with regard to the Butler 14,036
county health care management board and the demonstration 14,037
project.
The board may do any of the following: 14,039
(1) Enter into contracts with any person organized to do 14,041
business in this state on behalf of the board; 14,042
(2) Accept and spend donations, grants, and other funds 14,044
received by the board; 14,045
(3) Employ personnel and professionals that may be needed 14,047
to assess the feasibility and to develop the demonstration 14,048
project; 14,049
(4) Establish provider agreements in Butler county that 14,051
will organize a managed health care delivery system for medical 14,052
assistance recipients and will establish provider reimbursement 14,053
policies to encourage the delivery of primary health care 14,054
services; 14,055
(5) Monitor the quality of health care delivered to 14,057
medical assistance recipients in Butler county; 14,058
(6) Establish provider agreements with physicians and 14,060
other health care practitioners that set forth the terms, 14,061
conditions, and payment procedures for the provision of health 14,062
care services to medical assistance recipients. Any provider 14,063
willing to accept such terms and conditions shall be eligible for 14,064
participation in the project. 14,065
(7) Establish, in cooperation with the county medical 14,067
society, voluntary participation guidelines for the project for 14,068
314
physicians in Butler county to ensure that they provide health 14,069
care services to their fair share of medical assistance 14,070
recipients in the county. Such guidelines shall be communicated 14,071
to all medical providers providing services in Butler county. 14,072
(8) Require that all medical assistance recipients, other 14,074
than those described in division (A)(2) of section 5111.01 of the 14,075
Revised Code, who elect or are required by the department to 14,076
receive their medical assistance services through the board 14,077
choose a physician who is participating in the demonstration 14,079
project to provide all health care services to the recipient, and 14,080
adopt standards for changing physicians, including disenrollment 14,081
as provided by federal law;
(9) So long as it is consistent with federal law, 14,083
establish a co-pay system for the following: 14,084
(a) Provision of medical services under the demonstration 14,086
project; 14,087
(b) Inappropriate utilization of medical services; 14,089
(c) Over-utilization of medical services; 14,091
(d) Failure of a medical assistance recipient to appear 14,093
for a scheduled medical appointment. 14,094
(10) Enter into agreements with the board of nursing 14,096
authorizing advanced practice nurses, certified nurse 14,098
practitioners, clinical nurse specialists, and certified 14,099
nurse-midwives in Butler county to have prescription powers and 14,101
perform primary care services in collaboration with or under the
supervision of a physician or podiatrist in accordance with 14,103
division (D) of this section; 14,105
(11) Enter into agreements with the state medical board 14,107
authorizing physician assistants in Butler county to have 14,108
prescription powers and perform primary care services under the 14,109
general supervision and authority of a physician in accordance 14,110
with division (D) of this section.;
(12) Assign medical assistance recipients, other than 14,112
those described in division (A)(2) of section 5111.01 of the 14,113
315
Revised Code, who elect or are required by the department to 14,114
receive their medical assistance services through the board, to 14,115
providers who have entered into provider agreements with the 14,117
board.
(D) The Butler county health care management board shall 14,119
pass a resolution by a majority vote establishing the terms and 14,120
conditions under which the scope of practice of advanced practice 14,121
nurses, certified nurse practitioners, clinical nurse 14,122
specialists, certified nurse-midwives, and physician assistants 14,123
in Butler county may be expanded. The expansion of practice for 14,125
advanced practice nurses shall comply with section 4723.56 of the 14,126
Revised Code. The expansion of practice for certified nurse 14,128
practitioners, clinical nurse specialists, and certified
nurse-midwives shall comply with Chapter 4723. of the Revised 14,129
Code. The expansion of practice for physician assistants shall 14,131
comply with sections 4730.06 and 4730.07 of the Revised Code. 14,132
The resolution shall be sent to the board of nursing and the Ohio 14,133
state medical board with a request that the scope of practice of 14,134
the practitioners be amended in accordance with the resolution. 14,135
On receipt of the resolution and request, the board of nursing 14,136
and the Ohio state medical board shall, without amendment, adopt 14,137
rules establishing the terms and conditions for expansion of the 14,138
scope of practice of advanced practice nurses, certified nurse 14,139
practitioners, clinical nurse specialists, certified 14,140
nurse-midwives, and physician assistants in Butler county in 14,142
accordance with the resolution. Such rules shall apply only to 14,143
such practitioners performing their duties in Butler county in 14,144
conjunction with and in accordance with the fair share 14,145
demonstration project.
(E) The department of human services may negotiate and 14,147
enter into an agreement with the board establishing a 14,148
comprehensive capitated fee for purposes of delivering health 14,149
care services to persons receiving benefits under Chapter 5107. 14,150
and section 5111.013 of the Revised Code, if the department 14,151
316
obtains a waiver from the secretary of the United States 14,152
department of health and human services of any federal regulation 14,153
that would prohibit or restrict the use of federal funds. The 14,154
department may include those persons described in division (A)(2) 14,155
of section 5111.01 of the Revised Code in the project as it 14,156
considers necessary. The capitated fee shall be based on 14,157
historic and expected utilization of the medical assistance 14,158
program by the Butler county medical assistance population, 14,159
adjusted by the current inflation rate, and shall be sufficient 14,160
to ensure that all Butler county primary care physicians 14,161
participating in the demonstration project are reimbursed for 14,162
office visits at a rate of not less than thirty dollars per 14,163
patient during the first year of the project, and not less than 14,164
thirty-five dollars per patient for the second year of the 14,165
project. Any savings of state funds the department of human 14,166
services receives as the result of the demonstration project 14,167
shall be distributed as follows: 14,168
(1) One-third of the savings to Butler county for 14,170
children's health programs; 14,171
(2) One-third of the savings to the department of human 14,173
services; 14,174
(3) One-third of the savings to providers participating in 14,176
the demonstration project. 14,177
(F) All provider agreements or any contracts entered into 14,179
or negotiated by the board shall be exempt from any contract 14,180
provision contained in a contract between medical providers and 14,181
health insurers or indemnity insurers licensed to do business in 14,182
this state that provides for a lower payment for the services. 14,184
(G) The Butler county health care management board shall, 14,186
at the end of each year of the demonstration project, issue a 14,187
report listing every medical provider practicing in Butler 14,188
county, the degree to which such provider has participated in the 14,189
demonstration project, and the extent to which such provider has 14,190
met the voluntary guidelines adopted by the board under division 14,191
317
(C)(7) of this section. 14,192
(H) The department of human services shall apply for any 14,194
federal waiver needed to implement the Butler county fair share 14,195
demonstration project. 14,196
Sec. 5115.10. (A) The disability assistance medical 14,205
assistance program shall consist of a system of managed primary 14,206
care. Until July 1, 1992, the program shall also include limited 14,207
hospital services, except that if prior to that date hospitals 14,208
are required by section 5112.17 of the Revised Code to provide 14,209
medical services without charge to persons specified in that 14,210
section, the program shall cease to include hospital services at 14,211
the time the requirement of section 5112.17 of the Revised Code 14,212
takes effect. 14,213
The state department of human services may require 14,215
disability assistance medical assistance recipients to enroll in 14,216
health maintenance organizations, preferred provider 14,218
organizations, INSURING CORPORATIONS or other managed care 14,219
programs, or may limit the number or type of health care 14,221
providers from which a recipient may receive services. 14,222
The state department shall adopt rules governing the 14,224
disability assistance medical assistance program established 14,225
under this division. The rules shall specify all of the 14,226
following: 14,227
(1) Services that will be provided under the system of 14,229
managed primary care; 14,230
(2) Hospital services that will be provided during the 14,232
period that hospital services are provided under the program; 14,233
(3) The maximum authorized amount, scope, duration, or 14,235
limit of payment for services. 14,236
(B) The director of human services shall designate medical 14,238
services providers for the disability assistance medical 14,239
assistance program. The first such designation shall be made not 14,240
later than September 30, 1991. Services under the program shall 14,241
be provided only by providers designated by the director. The 14,242
318
director may require that, as a condition of being designated a 14,243
disability assistance medical assistance provider, a provider 14,244
enter into a provider agreement with the state department. 14,245
(C) As long as the disability assistance medical 14,247
assistance program continues to include hospital services, the 14,248
state department or a county director of human services may, 14,249
pursuant to rules adopted by the state department under this 14,250
section, approve an application for disability assistance medical 14,251
assistance for emergency inpatient hospital services when care 14,252
has been given to a person who had not completed a sworn 14,253
application for disability assistance at the time the care was 14,254
rendered, if all of the following apply: 14,255
(1) The person files an application for disability 14,257
assistance within sixty days after being discharged from the 14,258
hospital or, if the conditions of division (D) of this section 14,259
are met, while in the hospital; 14,260
(2) The person met all eligibility requirements for 14,262
disability assistance at the time the care was rendered; 14,263
(3) The care given to the person was a medical service 14,265
within the scope of disability assistance medical assistance as 14,266
established under rules adopted by the department of human 14,267
services. 14,268
(D) If a person files an application for disability 14,270
assistance medical assistance for emergency inpatient hospital 14,271
services while in the hospital, a face-to-face interview shall be 14,272
conducted with the applicant while he THE APPLICANT is in the 14,273
hospital to determine whether he THE APPLICANT is eligible for 14,275
the assistance. If the hospital agrees to reimburse the county 14,277
department of human services for all actual costs incurred by the 14,278
department in conducting the interview, the interview shall be 14,279
conducted by an employee of the county department. If, at the 14,280
request of the hospital, the county department designates an 14,281
employee of the hospital to conduct the interview, the interview 14,282
shall be conducted by the hospital employee. 14,283
319
(E) The state department of human services may assume 14,285
responsibility for peer review of expenditures for disability 14,286
assistance medical assistance. 14,287
Sec. 5119.01. The director of mental health is the chief 14,300
executive and administrative officer of the department of mental 14,301
health. The director may establish procedures for the governance 14,302
of the department, conduct of its employees and officers, 14,303
performance of its business, and custody, use, and preservation 14,304
of departmental records, papers, books, documents, and property. 14,305
Whenever the Revised Code imposes a duty upon or requires an 14,306
action of the department or any of its institutions, the director 14,307
shall perform the action or duty in the name of the department, 14,308
except that the medical director appointed pursuant to section 14,309
5119.07 of the Revised Code shall be responsible for decisions 14,310
relating to medical diagnosis, treatment, rehabilitation, quality 14,311
assurance, and the clinical aspects of the following: licensure 14,312
of hospitals and residential facilities, research, community 14,313
mental health plans, and delivery of mental health services. 14,314
The director shall: 14,316
(A) Adopt rules for the proper execution of the powers and 14,318
duties of the department with respect to the institutions under 14,319
its control, and require the performance of additional duties by 14,320
the officers of the institutions as necessary to fully meet the 14,321
requirements, intents, and purposes of this chapter. In case of 14,322
an apparent conflict between the powers conferred upon any 14,323
managing officer and those conferred by such sections upon the 14,324
department, the presumption shall be conclusive in favor of the 14,325
department. 14,326
(B) Adopt rules for the nonpartisan management of the 14,328
institutions under the department's control. An officer or 14,329
employee of the department or any officer or employee of any 14,331
institution under its control who, by solicitation or otherwise, 14,332
exerts influence directly or indirectly to induce any other 14,333
officer or employee of the department or any of its institutions 14,334
320
to adopt the exerting officer's or employee's political views or 14,335
to favor any particular person, issue, or candidate for office 14,337
shall be removed from the exerting officer's or employee's office 14,338
or position, by the department in case of an officer or employee, 14,339
and by the governor in case of the director. 14,340
(C) Appoint such employees, including the medical 14,342
director, as are necessary for the efficient conduct of the 14,343
department, and prescribe their titles and duties; 14,344
(D) Prescribe the forms of affidavits, applications, 14,346
medical certificates, orders of hospitalization and release, and 14,347
all other forms, reports, and records that are required in the 14,348
hospitalization or admission and release of all persons to the 14,349
institutions under the control of the department, or are 14,350
otherwise required under this chapter or Chapter 5122. of the 14,351
Revised Code; 14,352
(E) Contract with hospitals licensed by the department 14,354
under section 5119.20 of the Revised Code for the care and 14,355
treatment of mentally ill patients, or with persons, 14,356
organizations, or agencies for the custody, supervision, care, or 14,357
treatment of mentally ill persons receiving services elsewhere 14,358
than within the enclosure of a hospital operated under section 14,359
5119.02 of the Revised Code; 14,360
(F) Exercise the powers and perform the duties relating to 14,362
community mental health facilities and services that are assigned 14,363
to the director under this chapter and Chapter 340. of the 14,364
Revised Code; 14,365
(G) Adopt rules under Chapter 119. of the Revised Code for 14,367
the establishment of minimum standards, including standards for 14,368
use of seclusion and restraint, of mental health services that 14,369
are not inconsistent with nationally recognized applicable 14,370
standards and that facilitate participation in federal assistance 14,371
programs; 14,372
(H) Develop and implement clinical evaluation and 14,374
monitoring of services that are operated by the department; 14,375
321
(I) At the director's discretion, adopt rules establishing 14,377
standards for the adequacy of services provided by community 14,379
mental health facilities, and certify the compliance of such 14,380
facilities with the standards for the purpose of authorizing 14,381
their participation in the health care plans of medical care 14,382
corporations under Chapter 1737., health care INSURING 14,383
corporations under Chapter 1738., 1751. and sickness and accident 14,385
insurance policies issued under Chapter 3923. of the Revised 14,386
Code;
(J) Adopt rules establishing standards for the performance 14,388
of evaluations by a forensic center or other psychiatric program 14,389
or facility of the mental condition of defendants ordered by the 14,390
court under section 2919.271, or 2945.371 of the Revised Code, 14,392
and for the treatment of defendants who have been found 14,393
incompetent to stand trial and ordered by the court under section 14,394
2945.38, 2945.39, 2945.401, or 2945.402 of the Revised Code to
receive treatment in facilities; 14,395
(K) On behalf of the department, have the authority and 14,397
responsibility for entering into contracts and other agreements; 14,398
(L) Prepare and publish regularly a state mental health 14,400
plan that describes the department's philosophy, current 14,401
activities, and long-term and short-term goals and activities.; 14,402
(M) Adopt rules in accordance with Chapter 119. of the 14,404
Revised Code specifying the supplemental services that may be 14,405
provided through a trust authorized by section 1339.51 of the 14,406
Revised Code; 14,407
(N) Adopt rules in accordance with Chapter 119. of the 14,409
Revised Code establishing standards for the maintenance and 14,410
distribution to a beneficiary of assets of a trust authorized by 14,411
section 1339.51 of the Revised Code; 14,412
(O) As used in division (I) of this section: 14,414
(1) "Community mental health facility" means a facility 14,416
that provides community mental health services and is included in 14,418
the community mental health plan for the alcohol, drug addiction, 14,419
322
and mental health service district in which it is located. 14,420
(2) "Community mental health service" means services, 14,422
other than inpatient services, provided by a community mental 14,423
health facility. 14,424
Sec. 5119.202. No third-party payer shall directly or 14,434
indirectly reimburse, nor shall any person be obligated to pay 14,435
any hospital for psychiatric services for which a license is 14,436
required under section 5119.20 of the Revised Code unless the 14,437
hospital is licensed by the department of mental health.
As used in this section, "third-party payer" means a 14,439
medical care corporation licensed under Chapter 1737. of the 14,441
Revised Code, a health care INSURING corporation licensed under 14,443
Chapter 1738. 1751. of the Revised Code, an insurance company 14,444
that issues sickness and accident insurance in conformity with 14,445
Chapter 3923. of the Revised Code, a state-financed health 14,446
insurance program under Chapter 3701., 4123., or 5101. of the 14,447
Revised Code, or any self-insurance plan.
Sec. 5505.28. (A) The state highway patrol retirement 14,456
board may enter into an agreement with insurance companies, 14,457
medical or health care INSURING corporations, health maintenance 14,459
organizations, or government agencies authorized to do business 14,460
in the state for issuance of a policy or contract of health, 14,461
medical, hospital, or surgical benefits, or any combination 14,462
thereof, for those persons receiving pensions and subscribing to 14,464
the plan. Notwithstanding any other provision of this chapter, 14,465
the policy or contract may also include coverage for any eligible 14,466
individual's spouse and dependent children and for any of the 14,468
individual's sponsored dependents as the board considers 14,469
appropriate.
If all or any portion of the policy or contract premium is 14,471
to be paid by any individual receiving a service, disability, or 14,473
survivor pension or benefit, the individual shall, by written 14,475
authorization, instruct the board to deduct from the individual's 14,477
pension or benefit the premium agreed to be paid by the 14,478
323
individual to the company, corporation, or agency. 14,480
The board may contract for coverage on the basis of part or 14,483
all of the cost of the coverage to be paid from appropriate funds 14,484
of the state highway patrol retirement system. The cost paid 14,485
from the funds of the system shall be included in the employer's 14,487
contribution rate as provided by section 5505.15 of the Revised 14,488
Code.
(B) If the board provides health, medical, hospital, or 14,490
surgical benefits through any means other than a health 14,491
maintenance organization INSURING CORPORATION, it shall offer to 14,492
each individual eligible for the benefits the alternative of 14,495
receiving benefits through enrollment in a health maintenance 14,497
organization INSURING CORPORATION, if all of the following apply: 14,499
(1) The health maintenance organization INSURING 14,501
CORPORATION provides HEALTH CARE services in the geographical 14,503
area in which the individual lives; 14,504
(2) The eligible individual was receiving health care 14,506
benefits through a health maintenance organization OR A HEALTH 14,508
INSURING CORPORATION before retirement; 14,509
(3) The rate and coverage provided by the health 14,511
maintenance organization INSURING CORPORATION to eligible 14,512
individuals is comparable to that currently provided by the board 14,515
under division (A) of this section. If the rate or coverage 14,516
provided by the health maintenance organization INSURING 14,517
CORPORATION is not comparable to that currently provided by the 14,519
board under division (A) of this section, the board may deduct 14,520
the additional cost from the eligible individual's monthly 14,522
benefit.
The health maintenance organization INSURING CORPORATION 14,524
shall accept as an enrollee any eligible individual who requests 14,526
enrollment.
The board shall permit each eligible individual to change 14,528
from one plan to another at least once a year at a time 14,530
determined by the board. 14,531
324
(C) The board shall, beginning the month following receipt 14,533
of satisfactory evidence of the payment for coverage, pay monthly 14,534
to each recipient of a pension under the state highway patrol 14,536
retirement system who is eligible for medical insurance coverage 14,537
under part B of "The Social Security Amendments of 1965," 79 14,538
Stat. 301, 42 U.S.C.A. 1395j, as amended, the lesser of an 14,539
amount equal to the basic premium for such coverage or an amount 14,541
equal to the basic premium for such coverage in effect on January 14,543
1, 1994.
(D) The board shall establish by rule requirements for the 14,545
coordination of any coverage, payment, or benefit provided under 14,547
this section with any similar coverage, payment, or benefit made 14,548
available to the same individual by the public employees 14,549
retirement system, police and firemen's disability and pension 14,550
fund, state teachers retirement system, or school employees 14,551
retirement system. 14,552
(E) The board shall make all other necessary rules 14,554
pursuant to the purpose and intent of this section. 14,555
Sec. 5505.33. (A) As used in this section: 14,564
(1) "Long-term care insurance" has the same meaning as in 14,566
section 3923.41 of the Revised Code. 14,567
(2) "Retirement systems" has the same meaning as in 14,569
division (A) of section 145.581 of the Revised Code. 14,570
(B) The state highway patrol retirement board shall 14,572
establish a program under which members of the retirement system, 14,573
employers on behalf of members, and persons receiving service or 14,574
disability pensions or survivor benefits are permitted to 14,575
participate in contracts for long-term care insurance. 14,576
Participation may include dependents and family members. If a 14,577
participant in a contract for long-term care insurance leaves his 14,578
employment, he THE PERSON and his THE PERSON'S dependents and 14,580
family members may, at their election, continue to participate in 14,581
a program established under this section in the same manner as if 14,582
he THE PERSON had not left his employment, except that no part of 14,584
325
the cost of the insurance shall be paid by his THE PERSON'S 14,585
former employer. Such program may be established independently 14,587
or jointly with one or more of the retirement systems. 14,588
(C) The board may enter into an agreement with insurance 14,590
companies, medical or health care INSURING corporations, health 14,592
maintenance organizations, or government agencies authorized to 14,593
do business in the state for issuance of a long-term care 14,594
insurance policy or contract. However, prior to entering into 14,595
such an agreement with an insurance company, medical or health 14,596
care INSURING corporation, or health maintenance organization, 14,598
the board shall request the superintendent of insurance to 14,599
certify the financial condition of the company, OR corporation, 14,600
or organization. The board shall not enter into the agreement 14,602
if, according to that certification, the company, OR corporation, 14,603
or organization is insolvent, is determined by the superintendent 14,605
to be potentially unable to fulfill its contractual obligations, 14,606
or is placed under an order of rehabilitation or conservation by 14,607
a court of competent jurisdiction or under an order of 14,608
supervision by the superintendent. 14,609
(D) The board shall adopt rules in accordance with section 14,611
111.15 of the Revised Code governing the program. The rules 14,612
shall establish methods of payment for participation under this 14,613
section, which may include establishment of a payroll deduction 14,614
plan under section 5505.203 of the Revised Code, deduction of the 14,615
full premium charged from a person's service or disability 14,616
pension or survivor benefit, or any other method of payment 14,617
considered appropriate by the board. If the program is 14,618
established jointly with one or more of the other retirement 14,619
systems, the rules also shall establish the terms and conditions 14,620
of such joint participation. 14,621
Sec. 5923.051. Notwithstanding any collective bargaining 14,630
agreement or other agreement or law to the contrary, the state 14,631
and any agency, authority, commission, or board thereof, shall, 14,632
at the request of any person employed by the entity who is called 14,633
326
to active duty as specified in division (B) of section 5923.05 of 14,634
the Revised Code, or at the request of the spouse or dependent of 14,635
that person, continue or reactivate the health, medical, 14,636
hospital, dental, vision, and surgical benefits coverage, whether 14,637
provided by an insurance company, medical care corporation, 14,638
health care INSURING corporation, health maintenance 14,639
organization, or other health plan or entity, of that person for 14,641
the duration of the time the person is on active duty as 14,642
described in that division. The person or the spouse or 14,643
dependent thereof who requests the continuation or reactivation 14,644
of the coverage and the employing state or agency, authority, 14,645
commission, or board thereof, each are liable for payment of the 14,646
same costs for the coverage as if the person were not on a leave 14,647
of absence.
Section 2. That existing sections 101.271, 124.81, 124.82, 14,649
124.822, 124.84, 124.841, 124.92, 124.93, 145.58, 145.581, 14,650
305.171, 306.48, 307.86, 339.16, 351.08, 505.60, 742.45, 742.53, 14,651
1319.12, 1337.16, 1545.071, 1731.01, 1731.06, 1739.05, 1901.111, 14,652
1901.312, 2133.12, 2305.25, 2913.47, 3105.71, 3111.241, 3113.217, 14,653
3307.74, 3307.741, 3309.69, 3309.691, 3313.202, 3375.40, 3381.14, 14,654
3501.141, 3701.24, 3701.76, 3702.51, 3702.62, 3709.16, 3729.12, 14,655
3901.04, 3901.041, 3901.043, 3901.071, 3901.16, 3901.19, 3901.31, 14,656
3901.32, 3901.38, 3901.40, 3901.41, 3901.48, 3901.72, 3902.01, 14,657
3902.02, 3902.11, 3902.13, 3904.01, 3905.71, 3923.123, 3923.30, 14,658
3923.301, 3923.33, 3923.333, 3923.38, 3923.382, 3923.41, 3923.51, 14,659
3923.54, 3923.58, 3924.01, 3924.02, 3924.08, 3924.10, 3924.12, 14,660
3924.13, 3924.41, 3924.61, 3924.62, 3924.64, 3924.73, 3929.77, 14,662
3956.01, 3959.01, 3999.32, 3999.36, 4582.041, 4582.29, 4715.02, 14,663
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 14,665
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, 14,666
1736.12, 1736.13, 1736.14, 1736.15, 1736.16, 1736.17, 1736.18, 14,667
1736.19, 1736.20, 1736.21, 1736.22, 1736.23, 1736.24, 1736.25, 14,668
327
1736.26, 1736.27, 1736.28, 1737.01, 1737.02, 1737.03, 1737.04, 14,669
1737.05, 1737.06, 1737.07, 1737.08, 1737.09, 1737.10, 1737.11, 14,670
1737.12, 1737.13, 1737.14, 1737.15, 1737.16, 1737.17, 1737.18, 14,671
1737.19, 1737.20, 1737.21, 1737.22, 1737.23, 1737.24, 1737.25, 14,672
1737.26, 1737.27, 1737.28, 1737.29, 1737.30, 1737.301, 1737.31, 14,673
1737.32, 1737.99, 1738.01, 1738.02, 1738.03, 1738.04, 1738.05, 14,674
1738.06, 1738.07, 1738.08, 1738.09, 1738.10, 1738.11, 1738.12, 14,675
1738.13, 1738.14, 1738.15, 1738.16, 1738.17, 1738.18, 1738.19, 14,676
1738.20, 1738.21, 1738.22, 1738.23, 1738.24, 1738.25, 1738.26, 14,677
1738.261, 1738.27, 1738.28, 1738.29, 1738.30, 1738.99, 1740.01, 14,678
1740.02, 1740.03, 1740.04, 1740.05, 1740.06, 1740.07, 1740.08, 14,679
1740.09, 1740.10, 1740.11, 1740.12, 1740.13, 1740.14, 1740.15, 14,680
1740.16, 1740.17, 1740.18, 1740.19, 1740.20, 1740.21, 1740.22, 14,681
1740.23, 1740.24, 1740.25, 1740.26, 1740.99, 1742.01, 1742.02, 14,682
1742.03, 1742.04, 1742.05, 1742.06, 1742.07, 1742.08, 1742.09, 14,683
1742.10, 1742.11, 1742.12, 1742.13, 1742.131, 1742.14, 1742.141, 14,684
1742.15, 1742.151, 1742.16, 1742.17, 1742.171, 1742.18, 1742.19, 14,685
1742.20, 1742.21, 1742.22, 1742.23, 1742.24, 1742.25, 1742.26, 14,686
1742.27, 1742.28, 1742.29, 1742.30, 1742.301, 1742.31, 1742.32, 14,687
1742.33, 1742.34, 1742.341, 1742.35, 1742.36, 1742.37, 1742.38, 14,688
1742.39, 1742.40, 1742.41, 1742.42, 1742.43, 1742.44, and 1742.45 14,689
of the Revised Code are hereby repealed. 14,690
Section 3. (A) The certificate of authority of every 14,692
prepaid dental plan organization, health care corporation, dental 14,693
care corporation, and health maintenance organization licensed to 14,695
operate under Chapter 1736., 1738., 1740., or 1742. of the 14,697
Revised Code, respectively, shall renew, by operation of law, on
January 1, 1998, as a certificate of authority to operate under 14,700
Chapter 1751. of the Revised Code. All assets and liabilities of 14,701
the prepaid dental plan organization, health care corporation, 14,702
dental care corporation, or health maintenance organization, 14,703
including all obligations under subscriber contracts delivered, 14,704
issued for delivery, or renewed prior to the effective date of 14,705
this section, shall be assumed by the successor entity. Except 14,706
328
as otherwise provided in division (B) of this section, such 14,707
entity shall, no later than January 1, 1998, comply with Chapter 14,708
1751. of the Revised Code. 14,709
(B)(1) Each entity described in division (A) of this 14,711
section shall do both of the following: 14,712
(a) Comply with sections 1751.19 and 1751.26 of the 14,715
Revised Code no later than six months after the effective date of
this section. 14,716
(b) Comply with section 1751.28 of the Revised Code by 14,719
making annual deposits with the Superintendent of Insurance, no 14,720
later than the first day of January of each year, for up to three 14,721
years, beginning the first day of January immediately following 14,722
the effective date of this section. 14,723
(2) Every contract delivered, issued for delivery, or 14,725
renewed by an entity described in division (A) of this section 14,726
prior to the effective date of this section shall comply with 14,727
section 1751.13 of the Revised Code no later than the contract's 14,729
first renewal date after the first day of January immediately 14,730
following the effective date of this section. 14,732
(3) Every contract delivered, issued for delivery, or 14,735
renewed by an entity described in division (A) of this section 14,736
prior to the effective date of this section shall comply with 14,737
section 1751.31 of the Revised Code no later than three months 14,738
after the effective date of this section. 14,739
(4) An entity described in division (A) of this section 14,741
may comply with section 1751.27 of the Revised Code by making 14,742
annual deposits with the Superintendent of Insurance, not later 14,743
than the first day of January of each year, for up to three years 14,744
beginning the first day of January immediately following the 14,745
effective date of this section. An equal amount shall be 14,746
deposited each year until the total amount required under section 14,747
1751.27 of the Revised Code has been deposited. 14,748
Section 4. On and after the effective date of this 14,750
section, the Department of Insurance shall no longer accept new 14,751
329
applications for certificates of authority to operate under 14,752
Chapter 1736., 1737., 1738., 1740., or 1742. of the Revised Code, 14,753
and shall not issue any such certificates of authority. Any such 14,754
application received by the Department of Insurance that is 14,755
pending on the effective date of this section shall be considered 14,756
an application for a certificate of authority to operate under 14,757
Chapter 1751. of the Revised Code, and the review period for that 14,758
application shall begin to run on the effective date of this 14,759
section.
Section 5. The member of the Board of Directors of the 14,761
Ohio Small Employer Health Reinsurance Program who, on the 14,762
effective date of this section, is serving pursuant to section 14,763
3924.08 of the Revised Code as the member carrier that is a 14,764
health maintenance organization predominantly in the small 14,765
employer market, shall continue in office until the end of the 14,766
term for which the member was appointed. Thereafter, that 14,767
appointment shall be filled by a member carrier that is a health 14,768
insuring corporation predominantly in the small employer market. 14,769
Section 6. Section 1751.64 of the Revised Code is hereby 14,771
repealed, effective February 9, 2004. The repeal of that section 14,773
shall apply only to contracts that are delivered, issued for 14,774
delivery, or renewed in this state on or after that date.
Section 7. Every provision for mandated health benefits, 14,776
as defined in section 3901.71 of the Revised Code, that is 14,777
contained in Chapter 1751. of the Revised Code, shall be applied 14,779
to every policy, contract, certificate, or agreement of a health 14,780
insuring corporation on the effective date of the section in 14,781
which the provision is contained, notwithstanding section 3901.71 14,782
of the Revised Code.
Section 8. Section 5119.01 of the Revised Code is 14,784
presented in this act as a composite of the section as amended by 14,785
both Sub. H.B. 670 and Am. Sub. S.B. 285 of the 121st General 14,786
Assembly, with the new language of neither of the acts shown in 14,788
capital letters. This is in recognition of the principle stated 14,789
330
in division (B) of section 1.52 of the Revised Code that such 14,790
amendments are to be harmonized where not substantively 14,791
irreconcilable and constitutes a legislative finding that such is 14,792
the resulting version in effect prior to the effective date of 14,793
this act.
Section 9. This act is hereby declared to be an emergency 14,795
measure necessary for the immediate preservation of the public 14,796
peace, health, and safety. The reason for such necessity is that 14,797
current laws governing the regulation of prepaid dental plan 14,798
organizations, medical care corporations, health care
corporations, dental care corporations, and health maintenance 14,799
organizations do not grant the Superintendent of Insurance the 14,800
authority to regulate all forms of managed care corporations 14,802
currently insuring substantial numbers of Ohio citizens, thereby 14,803
threatening the public health and safety. In order to protect 14,804
the public health and safety of the citizens of this state, the
Superintendent must have the immediate authority to regulate 14,805
these currently unregulated forms of managed care corporations 14,806
and to strengthen the financial regulation of all corporations 14,807
engaged in managed care in Ohio. Therefore, this act shall go 14,808
into immediate effect.