As Introduced 1
123rd General Assembly 4
Regular Session H. B. No. 4 5
1999-2000 6
REPRESENTATIVES GARDNER-TIBERI-BUCHY-HARRIS-ALLEN- 8
BARNES-BARRETT-BENDER-BOYD-BRADING-BRITTON- 9
CALLENDER-CAREY-CATES-CORBIN-CORE-COUGHLIN- 10
EVANS-FORD-GOODMAN-GRENDELL-HAINES-HOOD-HOOPS- 11
JACOBSON-JOLIVETTE-KILBANE-KREBS-KRUPINSKI- 12
MAIER-MEAD-METELSKY-METZGER-MOTTLEY-MYERS-O'BRIEN- 13
OGG-OLMAN-OPFER-PADGETT-PATTON-PRINGLE-ROMAN- 14
SALERNO-SCHULER-SCHURING-SMITH-TAYLOR-TERWILLEGER- 15
THOMAS-WILLAMOWSKI-WILLIAMS-WINKLER-WOMER BENJAMIN-YOUNG 16
17
A B I L L
To amend sections 1751.11, 1751.33, 1751.78, 19
1751.81, 1751.82, and 5747.01 and to enact 20
sections 1751.88, 1751.89, 1753.02, and 1753.13 21
of the Revised Code to hold a health insuring 22
corporation responsible for harm to an enrollee 23
proximately caused by the health insuring 24
corporation's failure to exercise ordinary care
in making a health care coverage decision; to 26
make changes to the Health Insuring Corporation 27
Law to provide for speedy review of enrollee
appeals of adverse determinations; to allow 28
female enrollees to obtain health care services 29
from a participating obstetrician or gynecologist 30
without a referral; to require health insuring 31
corporations to name a licensed physician to act
as a corporation's medical director; to require 33
that at least one telephone number provided to
enrollees for health-care-plan information be a 34
toll-free number and to make additional 35
information available to enrollees; and to permit 36
2
personal income tax deductions for certain
medical expenses and long-term care insurance 37
premiums.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 39
Section 1. That sections 1751.11, 1751.33, 1751.78, 41
1751.81, 1751.82, and 5747.01 be amended and sections 1751.88, 42
1751.89, 1753.02, and 1753.13 of the Revised Code be enacted to 45
read as follows:
Sec. 1751.11. (A) Every subscriber of a health insuring 55
corporation is entitled to an evidence of coverage for the health 56
care plan under which health care benefits are provided. 58
(B) Every subscriber of a health insuring corporation that 60
offers basic health care services is entitled to an 61
identification card or similar document that specifies the health 62
insuring corporation's name as stated in its articles of 63
incorporation, and any trade or fictitious names used by the 64
health insuring corporation. The identification card or document 65
shall list at least one TOLL-FREE telephone number that provides 67
the subscriber with access to health care, TO INFORMATION ON THE 68
COVERAGE AVAILABLE UNDER THE SUBSCRIBER'S HEALTH CARE PLAN, AND
TO INFORMATION ON THE HEALTH CARE PLAN'S APPEALS PROCESS, on a 70
twenty-four-hours-per-day, seven-days-per-week basis. 71
(C) No evidence of coverage, or amendment to the evidence 73
of coverage, shall be delivered, issued for delivery, renewed, or 74
used, until the form of the evidence of coverage or amendment has 75
been filed by the health insuring corporation with the 76
superintendent of insurance. If the superintendent does not 77
disapprove the evidence of coverage or amendment within sixty 78
days after it is filed it shall be deemed approved, unless the 79
superintendent sooner gives approval for the evidence of coverage 80
or amendment. With respect to an amendment to an approved 81
evidence of coverage, the superintendent only may disapprove 82
provisions amended or added to the evidence of coverage. If the 83
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superintendent determines within the sixty-day period that any 84
evidence of coverage or amendment fails to meet the requirements 85
of this section, the superintendent shall so notify the health 86
insuring corporation and it shall be unlawful for the health 87
insuring corporation to use such evidence of coverage or 88
amendment. At any time, the superintendent, upon at least thirty 90
days' written notice to a health insuring corporation, may 91
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 92
section. Such disapproval shall be effected by a written order, 93
which shall state the grounds for disapproval and shall be issued 95
in accordance with Chapter 119. of the Revised Code. 97
(D) No evidence of coverage or amendment shall be 99
delivered, issued for delivery, renewed, or used: 100
(1) If it contains provisions or statements that are 102
inequitable, untrue, misleading, or deceptive; 103
(2) Unless it contains a clear, concise, and complete 105
statement of the following: 106
(a) The health care services and insurance or other 109
benefits, if any, to which the enrollee is entitled under the 110
health care plan;
(b) Any exclusions or limitations on the health care 113
services, type of health care services, benefits, or type of 114
benefits to be provided, including copayments; 115
(c) The enrollee's personal financial obligation for 117
noncovered services; 118
(d) Where and in what manner general information and 121
information as to how services may be obtained is available, 122
including the A TOLL-FREE telephone number; 124
(e) The premium rate with respect to individual and 126
conversion contracts, and relevant copayment provisions with 127
respect to all contracts. The statement of the premium rate, 128
however, may be contained in a separate insert. 129
(f) The method utilized by the health insuring corporation 132
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for resolving enrollee complaints; 133
(g) THE AVAILABILITY OF UTILIZATION REVIEW PURSUANT TO 136
SECTIONS 1751.77 TO 1751.86 OF THE REVISED CODE FOR THE 138
DETERMINATION OF THE ELIGIBILITY OF AN ENROLLEE FOR HEALTH CARE 139
SERVICES;
(h) THE ENROLLEE'S RIGHT TO BRING AN ACTION AGAINST THE 142
HEALTH INSURING CORPORATION FOR HARM PROXIMATELY CAUSED BY THE 143
HEALTH INSURING CORPORATION'S FAILURE TO EXERCISE ORDINARY CARE 144
IN MAKING HEALTH CARE COVERAGE DECISIONS. 145
(3) Unless it provides for the continuation of an 147
enrollee's coverage, in the event that the enrollee's coverage 148
under the group policy, contract, certificate, or agreement 149
terminates while the enrollee is receiving inpatient care in a 150
hospital. This continuation of coverage shall terminate at the 151
earliest occurrence of any of the following: 152
(a) The enrollee's discharge from the hospital; 154
(b) The determination by the enrollee's attending 156
physician that inpatient care is no longer medically indicated 157
for the enrollee; however, nothing in division (D)(3)(b) of this 160
section precludes a health insuring corporation from engaging in 161
utilization review as described in the evidence of coverage. 162
(c) The enrollee's reaching the limit for contractual 164
benefits; 165
(d) The effective date of any new coverage. 168
(4) Unless it contains a provision that states, in 170
substance, that the health insuring corporation is not a member 171
of any guaranty fund, and that in the event of the health 172
insuring corporation's insolvency, the enrollee is protected only 174
to the extent that the hold harmless provision required by
section 1751.13 of the Revised Code applies to the health care 176
services rendered; 177
(5) Unless it contains a provision that states, in 179
substance, that in the event of the insolvency of the health 180
insuring corporation, the enrollee may be financially responsible 182
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for health care services rendered by a provider or health care 183
facility that is not under contract to the health insuring 184
corporation, whether or not the health insuring corporation 185
authorized the use of the provider or health care facility; 186
(6) IF IT CONTAINS PROVISIONS THAT LIMIT A SUBSCRIBER'S OR 189
ENROLLEE'S RIGHT TO A RECONSIDERATION OR APPEAL OF AN ADVERSE 190
DETERMINATION PURSUANT TO SECTIONS 1751.77 TO 1751.86 OF THE 191
REVISED CODE. 192
(E) Notwithstanding divisions (C) and (D) of this section, 195
a health insuring corporation may use an evidence of coverage 196
that provides for the coverage of beneficiaries enrolled in Title 198
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 199
U.S.C.A. 301, as amended, pursuant to a medicare contract, or an 201
evidence of coverage that provides for the coverage of 202
beneficiaries enrolled in the federal employees health benefits 203
program pursuant to 5 U.S.C.A. 8905, or an evidence of coverage 205
that provides for the coverage of beneficiaries enrolled in Title 207
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 208
U.S.C.A. 301, as amended, known as the medical assistance program 210
or medicaid, provided by the Ohio department of human services 211
under Chapter 5111. of the Revised Code, or an evidence of 212
coverage that provides for the coverage of beneficiaries under 213
any other federal health care program regulated by a federal 214
regulatory body, or an evidence of coverage that provides for the 215
coverage of beneficiaries under any contract covering officers or 216
employees of the state that has been entered into by the 218
department of administrative services, if both of the following 220
apply: 221
(1) The evidence of coverage has been approved by the 223
United States department of health and human services, the United 225
States office of personnel management, the Ohio department of 226
human services, or the department of administrative services. 227
(2) The evidence of coverage is filed with the 229
superintendent of insurance prior to use and is accompanied by 230
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documentation of approval from the United States department of 232
health and human services, the United States office of personnel 233
management, the Ohio department of human services, or the 234
department of administrative services. 235
Sec. 1751.33. (A) Each health insuring corporation shall 244
provide to its subscribers, by mail, a description of the health 245
insuring corporation, its method of operation, its service area, 246
its most recent provider list, and its complaint procedure 247
established pursuant to section 1751.19 of the Revised Code, ITS 249
UTILIZATION REVIEW PROCESS FOR THE DETERMINATION OF THE 250
ELIGIBILITY OF AN ENROLLEE FOR HEALTH CARE SERVICES, AND ITS 251
PROCEDURES GOVERNING THE STANDARD APPEAL OF AN ADVERSE 252
DETERMINATION. A health insuring corporation providing basic 254
health care services or supplemental health care services shall
provide this information annually. A health insuring corporation 255
providing only specialty health care services shall provide this 256
information biennially.
(B) Each health insuring corporation, upon the request of 259
a subscriber, shall make available its most recent statutory 260
financial statement.
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86 of the 269
Revised Code apply to any health insuring corporation that 271
provides or performs utilization review services in connection 272
with its policies, contracts, and agreements providing basic
health care services and to any designee of the health insuring 273
corporation, or to any utilization review organization that 275
performs utilization review functions on behalf of the health 276
insuring corporation in connection with policies, contracts, or 277
agreements of the health insuring corporation providing basic
health care services. UPON AN ENROLLEE'S REQUEST, THE HEALTH 278
INSURING CORPORATION SHALL PERFORM UTILIZATION REVIEW TO 279
DETERMINE THE ELIGIBILITY OF THE ENROLLEE FOR HEALTH CARE 280
SERVICES THAT ARE REQUESTED BY, OR HAVE BEEN PROVIDED TO, THE 281
ENROLLEE.
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(2) Nothing in sections 1751.77 to 1751.82 or section 283
1751.85 of the Revised Code shall be construed to require a 285
health insuring corporation to provide or perform utilization 286
review services in connection with health care services provided 287
under a policy, plan, or agreement of supplemental health care 288
services or specialty health care services. 289
(B)(1) Each health insuring corporation shall be 292
responsible for monitoring all utilization review activities 293
carried out by, or on behalf of, the health insuring corporation 294
and for ensuring that all requirements of sections 1751.77 to 295
1751.86 of the Revised Code, and any rules adopted thereunder, 297
are met. The health insuring corporation shall also ensure that
appropriate personnel have operational responsibility for the 298
conduct of the health insuring corporation's utilization review 299
program. 300
(2) If a health insuring corporation contracts to have a 302
utilization review organization or other entity perform the 303
utilization review functions required by sections 1751.77 to 304
1751.86 of the Revised Code, and any rules adopted thereunder, 307
the superintendent of insurance shall hold the health insuring 308
corporation responsible for monitoring the activities of the
utilization review organization or other entity and for ensuring 309
that the requirements of those sections and rules are met. 311
Sec. 1751.81. (A) As used in this section: 320
(1) "Enrollee" includes the representative of an enrollee. 322
(2) "Necessary information" includes the results of any 324
face-to-face clinical evaluation or second opinion that may be 326
required.
(B) A health insuring corporation shall maintain written 328
procedures for making utilization review determinations and for 330
notifying enrollees, and participating providers and health care 332
facilities acting on behalf of enrollees, of its determinations. 333
(C) For initial determinations, a health insuring 335
corporation shall make the determination within two business days 337
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after obtaining all necessary information regarding a proposed 339
admission, procedure, or health care service requiring a review 340
determination. 341
(1) In the case of a determination to certify an 343
admission, procedure, or health care service, the health insuring 344
corporation shall notify the provider or health care facility 345
rendering the health care service by telephone or facsimile 346
within three business days after making the initial 347
certification.
(2) In the case of an adverse determination, the health 349
insuring corporation shall notify the provider or health care 351
facility rendering the health care service by telephone within 352
three business days after making the adverse determination, and 353
shall provide written or electronic confirmation of the telephone 354
notification to the enrollee and the provider or health care 355
facility within one business day after making the telephone 356
notification.
(D) For concurrent review determinations, a health 358
insuring corporation shall make the determination within one 360
business day after obtaining all necessary information. 361
(1) In the case of a determination to certify an extended 363
stay or additional health care services, the health insuring 364
corporation shall notify the provider or health care facility 365
rendering the health care service by telephone or facsimile 366
within one business day after making the certification. 368
(2) In the case of an adverse determination, the health 370
insuring corporation shall notify the provider or health care 371
facility rendering the health care service by telephone within 372
one business day after making the adverse determination, and 373
shall provide written or electronic confirmation to the enrollee 374
and the provider or health care facility within one business day 375
after the telephone notification. The health care service to the 376
enrollee shall be continued, with standard copayments and 378
deductibles, if applicable, until the enrollee has been notified 379
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of the determination. 380
(E) For retrospective review determinations, a health 382
insuring corporation shall make the determination within thirty 385
business days after receiving all necessary information. 386
(1) In the case of a certification, the health insuring 388
corporation may notify the enrollee and the provider or health 390
care facility rendering the health care service in writing. 391
(2) In the case of an adverse determination, the health 393
insuring corporation shall notify the enrollee and the provider 395
or health care facility rendering the health care service, in 396
writing, within five business days after making the adverse 397
determination.
(F)(1) The time frames set forth in divisions (C), (D), 400
and (E) of this section for determinations and notifications 401
shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the 402
health insuring corporation. The health insuring corporation 403
shall maintain written procedures for making expedited 405
utilization review determinations and notifications of enrollees 406
and providers or health care facilities when warranted by the 407
medical condition of the enrollee. 408
(2) AN ENROLLEE MAY PROCEED WITH AN APPEAL PURSUANT TO 411
SECTION 1751.82 OF THE REVISED CODE IF A HEALTH INSURING 413
CORPORATION FAILS TO MAKE A DETERMINATION AND NOTIFICATION WITHIN 415
THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND (E) OF THIS 416
SECTION. THE HEALTH INSURING CORPORATION'S FAILURE TO MAKE A 417
DETERMINATION AND NOTIFICATION WITHIN THESE TIME FRAMES SHALL BE 418
DEEMED TO BE AN ADVERSE DETERMINATION BY THE HEALTH INSURING 419
CORPORATION FOR THE PURPOSE OF AN ENROLLEE'S INITIATION OF AN 420
APPEAL.
(G) A written notification of an adverse determination 422
shall include the principal reason or reasons for the 423
determination, instructions for initiating an appeal or 424
reconsideration of the determination, and instructions for 425
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requesting a written statement of the clinical rationale used to 426
make the determination. A health insuring corporation shall
provide the clinical rationale for an adverse determination in 428
writing to any party who received notice of the adverse 430
determination and who follows the instructions for a request. 431
THE INSTRUCTIONS FOR INITIATING AN APPEAL OF AN ADVERSE
DETERMINATION SHALL STATE THAT AN INDEPENDENT PHYSICIAN SHALL 433
CONDUCT THE REVIEW OF, AND ISSUE A DECISION IN, ANY APPEAL MADE 435
PURSUANT TO SECTION 1751.82 OF THE REVISED CODE.
(H)(1) A health insuring corporation shall have written 437
procedures to address the failure or inability of a health care 440
facility, provider, or enrollee to provide all necessary 442
information for review.
(2) A HEALTH INSURING CORPORATION SHALL NOT USE 444
UNREASONABLE REQUESTS FOR INFORMATION IN ORDER TO DELAY MAKING A 445
DETERMINATION. 446
(3) If the health care facility, provider, or enrollee 449
will not release necessary information, the health insuring 450
corporation may deny certification. AN ENROLLEE MAY NOT PROCEED 451
WITH AN APPEAL PURSUANT TO SECTION 1751.82 OF THE REVISED CODE 453
BASED UPON A HEALTH INSURING CORPORATION'S FAILURE TO MAKE A 454
TIMELY DETERMINATION, IF THE HEALTH INSURING CORPORATION'S DELAY 455
IN MAKING A DETERMINATION AND NOTIFICATION IS CAUSED BY THE 456
FAILURE OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO 457
RELEASE ALL NECESSARY INFORMATION. 458
Sec. 1751.82. (A) In a case involving an initial 468
determination or a concurrent review determination, a health 469
insuring corporation shall give the provider or health care 470
facility rendering the health care service an opportunity to 471
request in writing on behalf of the enrollee a reconsideration of 472
an adverse determination by the reviewer making the adverse 473
determination. The reconsideration shall occur within three 474
business days after the health insuring corporation's receipt of 475
the written request for reconsideration, and shall be conducted 476
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between the provider or health care facility rendering the health 477
care service and the reviewer who made the adverse determination. 479
If that reviewer cannot be available within three business days, 480
the reviewer may designate another reviewer.
(B) If the reconsideration process described in division 482
(A) of this section does not resolve the difference of opinion, 484
the adverse determination may be appealed by the enrollee or the 485
provider or health care facility on behalf of the enrollee. 486
(C) Reconsideration is not a prerequisite to a standard or 488
expedited appeal of an adverse determination. 489
(D) The time period allowed by division (A) of this 492
section for a reconsideration of an adverse determination shall 493
not apply if the seriousness of the medical condition of the 494
enrollee requires a more expedited reconsideration. The health 495
insuring corporation shall maintain written procedures for making 496
such an expedited reconsideration. 497
(E)(1) THE SUPERINTENDENT OF INSURANCE SHALL PRESCRIBE, BY 500
RULES ADOPTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED 503
CODE, PROCEDURES GOVERNING THE STANDARD APPEAL OF AN ADVERSE 504
DETERMINATION.
(2) THE PROCEDURES SHALL REQUIRE ALL OF THE FOLLOWING: 507
(a) THE REVIEW OF AN APPEAL SHALL BE CONDUCTED BY A 509
PHYSICIAN THAT HAS BEEN RETAINED FOR THIS PURPOSE. THE PHYSICIAN 510
SHALL HAVE EXPERTISE IN THE TREATMENT OF THE ENROLLEE'S MEDICAL 511
CONDITION. THE PHYSICIAN SHALL NOT HAVE ANY PROFESSIONAL, 512
FAMILIAL, OR FINANCIAL AFFILIATION WITH THE HEALTH INSURING 513
CORPORATION AND SHALL HAVE NO PATIENT-PHYSICIAN RELATIONSHIP OR 514
OTHER AFFILIATION WITH THE ENROLLEE WHO HAS BROUGHT THE APPEAL. 515
THIS NONAFFILIATION PROVISION DOES NOT PRECLUDE THE HEALTH 516
INSURING CORPORATION FROM PAYING THE PHYSICIAN FOR THE CONDUCT OF 518
THE REVIEW.
(b) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE 521
PHYSICIAN'S REVIEW OF THEIR APPEAL. THE COSTS OF THE REVIEW 522
SHALL BE BORNE BY THE HEALTH INSURING CORPORATION. 523
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(c) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE 526
PHYSICIAN CONDUCTING THE REVIEW OF AN APPEAL A COPY OF THOSE 527
MEDICAL RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION 528
THAT ARE RELEVANT TO THE ENROLLEE'S MEDICAL CONDITION AND THE 529
APPEAL. THOSE RECORDS SHALL BE USED SOLELY FOR THE PURPOSE OF 530
THIS DIVISION.
(d) A WRITTEN DECISION SHALL BE ISSUED TO ALL PARTIES TO 533
AN APPEAL INVOLVING A LIFE-THREATENING DISEASE OR CONDITION, 535
WHICH IS A DISEASE OR CONDITION FOR WHICH THE LIKELIHOOD OF DEATH
IS PROBABLE UNLESS THE COURSE OF THE DISEASE OR CONDITION IS 536
INTERRUPTED, WITHIN THREE DAYS AFTER THE FILING OF AN APPEAL. 537
(e) A WRITTEN DECISION SHALL BE ISSUED TO ALL PARTIES TO 540
AN APPEAL NOT INVOLVING A LIFE-THREATENING DISEASE OR CONDITION 541
WITHIN FOURTEEN DAYS AFTER THE FILING OF AN APPEAL.
(3) A HEALTH INSURING CORPORATION SHALL PROVIDE ANY 543
COVERAGE REQUIRED BY A PHYSICIAN'S DECISION IN AN APPEAL OF AN 545
ADVERSE DETERMINATION.
(4) SECTION 1753.24 OF THE REVISED CODE, RATHER THAN THIS 549
DIVISION, SHALL APPLY IF AN ENROLLEE WITH A TERMINAL CONDITION 550
MEETS ALL OF THE CRITERIA LISTED IN DIVISION (A) OF SECTION 552
1753.24 OF THE REVISED CODE. 554
Sec. 1751.88. (A) AS USED IN THIS SECTION: 557
(1) "ORDINARY CARE" MEANS, IN THE CASE OF A HEALTH 559
INSURING CORPORATION, THAT DEGREE OF CARE THAT A HEALTH INSURING 560
CORPORATION OF ORDINARY PRUDENCE WOULD USE UNDER THE SAME OR 561
SIMILAR CIRCUMSTANCES. IN THE CASE OF A DESIGNEE OF A HEALTH 562
INSURING CORPORATION, "ORDINARY CARE" MEANS THAT DEGREE OF CARE 563
THAT A PERSON OF ORDINARY PRUDENCE IN THE SAME PROFESSION, 564
SPECIALTY, OR AREA OF PRACTICE AS SUCH DESIGNEE WOULD USE IN THE 565
SAME OR SIMILAR CIRCUMSTANCES. IN THE CASE OF A UTILIZATION 566
REVIEW ORGANIZATION PERFORMING UTILIZATION REVIEW FUNCTIONS ON 567
BEHALF OF A HEALTH INSURING CORPORATION, "ORDINARY CARE" MEANS 568
THAT DEGREE OF CARE THAT A UTILIZATION REVIEW ORGANIZATION OF 569
ORDINARY PRUDENCE WOULD USE IN THE SAME OR SIMILAR CIRCUMSTANCES. 571
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(2) "UTILIZATION REVIEW" AND "UTILIZATION REVIEW 573
ORGANIZATION" HAVE THE SAME MEANINGS AS IN SECTION 1751.77 OF THE 575
REVISED CODE. 576
(B) EACH HEALTH INSURING CORPORATION THAT IS SUBJECT TO 579
SECTIONS 1751.77 TO 1751.86 OF THE REVISED CODE SHALL EXERCISE 581
ORDINARY CARE WHEN MAKING UTILIZATION REVIEW DETERMINATIONS. 582
A HEALTH INSURING CORPORATION IS LIABLE FOR DAMAGES FOR 584
HARM TO AN ENROLLEE THAT IS PROXIMATELY CAUSED BY THE HEALTH 585
INSURING CORPORATION'S FAILURE TO EXERCISE SUCH ORDINARY CARE. 586
WITH RESPECT TO UTILIZATION REVIEW DETERMINATIONS MADE BY ANY 587
DESIGNEE OF A HEALTH INSURING CORPORATION OR BY ANY UTILIZATION 588
REVIEW ORGANIZATION THAT PERFORMS UTILIZATION REVIEW FUNCTIONS ON 590
BEHALF OF A HEALTH INSURING CORPORATION, THE HEALTH INSURING
CORPORATION IS ALSO LIABLE FOR DAMAGES FOR HARM TO AN ENROLLEE 591
THAT IS PROXIMATELY CAUSED BY THE DESIGNEE'S OR UTILIZATION 592
REVIEW ORGANIZATION'S FAILURE TO EXERCISE SUCH ORDINARY CARE. 594
(C) THIS SECTION DOES NOT CREATE ANY LIABILITY ON THE PART 597
OF AN EMPLOYER OR EMPLOYER GROUP PURCHASING ORGANIZATION THAT 598
PURCHASES COVERAGE OR ASSUMES RISK ON BEHALF OF ITS EMPLOYEES. 599
Sec. 1751.89. NO HEALTH INSURING CORPORATION CONTRACT WITH 602
A PROVIDER OR HEALTH CARE FACILITY SHALL CONTAIN AN
INDEMNIFICATION OR HOLD HARMLESS CLAUSE OR ANY OTHER PROVISION 603
THAT ATTEMPTS TO LIMIT OR ELIMINATE THE HEALTH INSURING 604
CORPORATION'S LIABILITY FOR ANY OMISSION OF OR ANY ACTION TAKEN 605
BY THE HEALTH INSURING CORPORATION THAT AFFECTS THE MEDICAL CARE 606
OF AN ENROLLEE. 607
ANY SUCH INDEMNIFICATION, HOLD HARMLESS, OR SIMILAR 609
PROVISION IN A HEALTH INSURING CORPORATION CONTRACT WITH A 610
PROVIDER OR HEALTH CARE FACILITY, WHICH CONTRACT IS IN FORCE ON 611
THE EFFECTIVE DATE OF THIS SECTION, IS VOID. 612
Sec. 1753.02. A HEALTH INSURING CORPORATION SHALL NAME A 614
PERSON LICENSED TO PRACTICE MEDICINE AND SURGERY OR OSTEOPATHIC 615
MEDICINE AND SURGERY UNDER CHAPTER 4731. OF THE REVISED CODE TO 616
ACT AS THE HEALTH INSURING CORPORATION'S MEDICAL DIRECTOR. 617
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Sec. 1753.13. A HEALTH INSURING CORPORATION THAT DOES NOT 619
ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL PERMIT A FEMALE 620
ENROLLEE TO OBTAIN HEALTH CARE SERVICES FROM AN OBSTETRICIAN OR 621
GYNECOLOGIST PARTICIPATING IN THE ENROLLEE'S HEALTH CARE PLAN 622
WITHOUT OBTAINING A REFERRAL OR ANY OTHER FORM OF PRIOR
AUTHORIZATION FOR THE SERVICES. SUCH OBSTETRICIANS AND 623
GYNECOLOGISTS SHALL BE AUTHORIZED TO PROVIDE HEALTH CARE SERVICES 624
TO A FEMALE ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S PRIMARY 625
CARE PROVIDER.
Sec. 5747.01. Except as otherwise expressly provided or 634
clearly appearing from the context, any term used in this chapter 635
has the same meaning as when used in a comparable context in the 636
Internal Revenue Code, and all other statutes of the United 637
States relating to federal income taxes. 638
As used in this chapter: 640
(A) "Adjusted gross income" or "Ohio adjusted gross 642
income" means adjusted gross income as defined and used in the 643
Internal Revenue Code, adjusted as provided in divisions (A)(1) 645
to (17)(19) of this section:
(1) Add interest or dividends on obligations or securities 647
of any state or of any political subdivision or authority of any 648
state, other than this state and its subdivisions and 649
authorities.
(2) Add interest or dividends on obligations of any 651
authority, commission, instrumentality, territory, or possession 652
of the United States that are exempt from federal income taxes 653
but not from state income taxes. 654
(3) Deduct interest or dividends on obligations of the 656
United States and its territories and possessions or of any 657
authority, commission, or instrumentality of the United States to 658
the extent included in federal adjusted gross income but exempt 659
from state income taxes under the laws of the United States. 660
(4) Deduct disability and survivor's benefits to the 662
extent included in federal adjusted gross income. 663
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(5) Deduct benefits under Title II of the Social Security 665
Act and tier 1 railroad retirement benefits to the extent 666
included in federal adjusted gross income under section 86 of the 667
Internal Revenue Code. 668
(6) Add, in the case of a taxpayer who is a beneficiary of 670
a trust that makes an accumulation distribution as defined in 671
section 665 of the Internal Revenue Code, the portion, if any, of 672
such distribution that does not exceed the undistributed net 673
income of the trust for the three taxable years preceding the 674
taxable year in which the distribution is made. "Undistributed 675
net income of a trust" means the taxable income of the trust 676
increased by (a)(i) the additions to adjusted gross income 677
required under division (A) of this section and (ii) the personal 678
exemptions allowed to the trust pursuant to section 642(b) of the 679
Internal Revenue Code, and decreased by (b)(i) the deductions to 680
adjusted gross income required under division (A) of this 681
section, (ii) the amount of federal income taxes attributable to 682
such income, and (iii) the amount of taxable income that has been 683
included in the adjusted gross income of a beneficiary by reason 684
of a prior accumulation distribution. Any undistributed net 685
income included in the adjusted gross income of a beneficiary 686
shall reduce the undistributed net income of the trust commencing 687
with the earliest years of the accumulation period. 688
(7) Deduct the amount of wages and salaries, if any, not 690
otherwise allowable as a deduction but that would have been 691
allowable as a deduction in computing federal adjusted gross 692
income for the taxable year, had the targeted jobs credit allowed 693
and determined under sections 38, 51, and 52 of the Internal 694
Revenue Code not been in effect. 695
(8) Deduct any interest or interest equivalent on public 697
obligations and purchase obligations to the extent included in 698
federal adjusted gross income. 699
(9) Add any loss or deduct any gain resulting from the 701
sale, exchange, or other disposition of public obligations to the 702
16
extent included in federal adjusted gross income. 703
(10) Regarding tuition credits purchased under Chapter 705
3334. of the Revised Code: 706
(a) Deduct the following: 708
(i) For credits that as of the end of the taxable year 711
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 713
amount of income related to the credits, to the extent included 714
in federal adjusted gross income;
(ii) For credits that during the taxable year have been 717
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 718
the total purchase price of the tuition credits refunded over the 719
amount of refund, to the extent the amount of the excess was not 720
deducted in determining federal adjusted gross income; 721
(b) Add the following: 723
(i) For credits that as of the end of the taxable year 726
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 727
amount of loss related to the credits, to the extent the amount 728
of the loss was deducted in determining federal adjusted gross 729
income;
(ii) For credits that during the taxable year have been 732
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 734
the amount of refund over the purchase price of each tuition 735
credit refunded, to the extent not included in federal adjusted 736
gross income.
(11) Deduct, in the case of a self-employed individual as 738
defined in section 401(c)(1) of the Internal Revenue Code and to 739
the extent not otherwise allowable as a deduction in computing 740
federal adjusted gross income for the taxable year, the amount 741
paid during the taxable year for insurance that constitutes 743
medical care for the taxpayer, the taxpayer's spouse, and
17
dependents. No deduction under division (A)(11) of this section 745
shall be allowed to any taxpayer who is eligible to participate 746
in any subsidized health plan maintained by any employer of the 747
taxpayer or of the spouse of the taxpayer. No IN THE CASE OF A 748
SELF-EMPLOYED INDIVIDUAL AS DEFINED IN SECTION 401(c) OF THE 750
INTERNAL REVENUE CODE, NO deduction under division (A)(11) of 751
this section shall be allowed to the extent that the sum of such 752
deduction and any related deduction allowable in computing 753
federal adjusted gross income for the taxable year exceeds the 754
taxpayer's earned income, within the meaning of section 401(c) of 755
the Internal Revenue Code, derived by the taxpayer from the trade 756
or business with respect to which the A plan providing the 758
medical coverage is established. 759
(12) Deduct any amount included in federal adjusted gross 761
income solely because the amount represents a reimbursement or 762
refund of expenses that in a previous year the taxpayer had 763
deducted as an itemized deduction pursuant to section 63 of the 764
Internal Revenue Code and applicable United States department of 766
the treasury regulations.
(13) Deduct any portion of the deduction described in 768
section 1341(a)(2) of the Internal Revenue Code, for repaying 769
previously reported income received under a claim of right, that 770
meets both of the following requirements: 771
(a) It is allowable for repayment of an item that was 773
included in the taxpayer's adjusted gross income for a prior 774
taxable year and did not qualify for a credit under division (A) 775
or (B) of section 5747.05 of the Revised Code for that year; 776
(b) It does not otherwise reduce the taxpayer's adjusted 778
gross income for the current or any other taxable year. 779
(14) Deduct an amount equal to the deposits made to, and 781
net investment earnings of, a medical savings account during the 782
taxable year, in accordance with section 3924.66 of the Revised 783
Code. The deduction allowed by division (A)(14) of this section 784
does not apply to medical savings account deposits and earnings 785
18
otherwise deducted or excluded for the current or any other 786
taxable year from the taxpayer's federal adjusted gross income. 787
(15)(a) Add an amount equal to the funds withdrawn from a 789
medical savings account during the taxable year, and the net 790
investment earnings on those funds, when the funds withdrawn were 791
used for any purpose other than to reimburse an account holder 792
for, or to pay, eligible medical expenses, in accordance with 793
section 3924.66 of the Revised Code;
(b) Add the amounts distributed from a medical savings 795
account under division (A)(2) of section 3924.68 of the Revised 796
Code during the taxable year. 797
(16) Add any amount claimed as a credit under section 799
5747.059 of the Revised Code to the extent that such amount 800
satisfies either of the following:
(a) The amount was deducted or excluded from the 802
computation of the taxpayer's federal adjusted gross income as 803
required to be reported for the taxpayer's taxable year under the 804
Internal Revenue Code;
(b) The amount resulted in a reduction of the taxpayer's 806
federal adjusted gross income as required to be reported for any 807
of the taxpayer's taxable years under the Internal Revenue Code. 808
(17) Deduct the amount contributed by the taxpayer to an 810
individual development account program established by a county 811
department of human services pursuant to sections 329.11 to 812
329.14 of the Revised Code for the purpose of matching funds 813
deposited by program participants. On request of the tax 814
commissioner, the taxpayer shall provide any information that, in
the tax commissioner's opinion, is necessary to establish the 815
amount deducted under division (A)(17) of this section. 816
(18) DEDUCT EXPENSES PAID DURING THE TAXABLE YEAR FOR 818
MEDICAL CARE OF THE TAXPAYER, THE TAXPAYER'S SPOUSE, AND 819
DEPENDENTS, TO THE EXTENT THAT THE EXPENSES EXCEED SEVEN AND 820
ONE-HALF PER CENT OF THE TAXPAYER'S FEDERAL ADJUSTED GROSS 821
INCOME, THE EXPENSES ARE NOT OTHERWISE ALLOWABLE AS A DEDUCTION
19
IN COMPUTING ADJUSTED GROSS INCOME FOR THE TAXABLE YEAR, THE 822
EXPENSES ARE NOT COMPENSATED FOR BY INSURANCE OR OTHERWISE, AND 823
THE EXPENSES ARE DEDUCTIBLE FOR FEDERAL INCOME TAX PURPOSES UNDER 824
SECTION 213 OF THE INTERNAL REVENUE CODE. 825
(19) DEDUCT THE AMOUNT PAID DURING THE TAXABLE YEAR FOR 827
LONG-TERM CARE INSURANCE, TO THE EXTENT NOT OTHERWISE DEDUCTED IN 828
COMPUTING FEDERAL ADJUSTED GROSS INCOME FOR THE TAXABLE YEAR OR 829
DEDUCTED UNDER DIVISION (A)(18) OF THIS SECTION. 830
(B) "Business income" means income arising from 832
transactions, activities, and sources in the regular course of a 833
trade or business and includes income from tangible and 834
intangible property if the acquisition, rental, management, and 835
disposition of the property constitute integral parts of the 836
regular course of a trade or business operation. 837
(C) "Nonbusiness income" means all income other than 839
business income and may include, but is not limited to, 840
compensation, rents and royalties from real or tangible personal 841
property, capital gains, interest, dividends and distributions, 842
patent or copyright royalties, or lottery winnings, prizes, and 843
awards. 844
(D) "Compensation" means any form of remuneration paid to 846
an employee for personal services. 847
(E) "Fiduciary" means a guardian, trustee, executor, 849
administrator, receiver, conservator, or any other person acting 850
in any fiduciary capacity for any individual, trust, or estate. 851
(F) "Fiscal year" means an accounting period of twelve 853
months ending on the last day of any month other than December. 854
(G) "Individual" means any natural person. 856
(H) "Internal Revenue Code" means the "Internal Revenue 858
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 859
(I) "Resident" means: 861
(1) An individual who is domiciled in this state, subject 863
to section 5747.24 of the Revised Code; 864
(2) The estate of a decedent who at the time of death was 867
20
domiciled in this state. The domicile tests of section 5747.24 868
of the Revised Code and any election under section 5747.25 of the 869
Revised Code are not controlling for purposes of division (I)(2) 870
of this section.
(J) "Nonresident" means an individual or estate that is 872
not a resident. An individual who is a resident for only part of 873
a taxable year is a nonresident for the remainder of that taxable 874
year. 875
(K) "Pass-through entity" has the same meaning as in 877
section 5733.04 of the Revised Code. 878
(L) "Return" means the notifications and reports required 880
to be filed pursuant to this chapter for the purpose of reporting 881
the tax due and includes declarations of estimated tax when so 882
required. 883
(M) "Taxable year" means the calendar year or the 885
taxpayer's fiscal year ending during the calendar year, or 886
fractional part thereof, upon which the adjusted gross income is 887
calculated pursuant to this chapter. 888
(N) "Taxpayer" means any person subject to the tax imposed 890
by section 5747.02 of the Revised Code or any pass-through entity 891
that makes the election under division (D) of section 5747.08 of 892
the Revised Code.
(O) "Dependents" means dependents as defined in the 894
Internal Revenue Code and as claimed in the taxpayer's federal 895
income tax return for the taxable year or which the taxpayer 896
would have been permitted to claim had the taxpayer filed a 897
federal income tax return. 899
(P) "Principal county of employment" means, in the case of 901
a nonresident, the county within the state in which a taxpayer 902
performs services for an employer or, if those services are 903
performed in more than one county, the county in which the major 904
portion of the services are performed. 905
(Q) As used in sections 5747.50 to 5747.55 of the Revised 907
Code:
21
(1) "Subdivision" means any county, municipal corporation, 909
park district, or township. 910
(2) "Essential local government purposes" includes all 912
functions that any subdivision is required by general law to 913
exercise, including like functions that are exercised under a 914
charter adopted pursuant to the Ohio Constitution. 915
(R) "Overpayment" means any amount already paid that 917
exceeds the figure determined to be the correct amount of the 918
tax. 919
(S) "Taxable income" applies to estates only and means 921
taxable income as defined and used in the Internal Revenue Code 922
adjusted as follows: 923
(1) Add interest or dividends on obligations or securities 925
of any state or of any political subdivision or authority of any 926
state, other than this state and its subdivisions and 927
authorities; 928
(2) Add interest or dividends on obligations of any 930
authority, commission, instrumentality, territory, or possession 931
of the United States that are exempt from federal income taxes 932
but not from state income taxes; 933
(3) Add the amount of personal exemption allowed to the 935
estate pursuant to section 642(b) of the Internal Revenue Code; 936
(4) Deduct interest or dividends on obligations of the 938
United States and its territories and possessions or of any 939
authority, commission, or instrumentality of the United States 940
that are exempt from state taxes under the laws of the United 941
States; 942
(5) Deduct the amount of wages and salaries, if any, not 944
otherwise allowable as a deduction but that would have been 945
allowable as a deduction in computing federal taxable income for 946
the taxable year, had the targeted jobs credit allowed under 947
sections 38, 51, and 52 of the Internal Revenue Code not been in 948
effect; 949
(6) Deduct any interest or interest equivalent on public 951
22
obligations and purchase obligations to the extent included in 952
federal taxable income; 953
(7) Add any loss or deduct any gain resulting from sale, 955
exchange, or other disposition of public obligations to the 956
extent included in federal taxable income; 957
(8) Except in the case of the final return of an estate, 959
add any amount deducted by the taxpayer on both its Ohio estate 960
tax return pursuant to section 5731.14 of the Revised Code, and 961
on its federal income tax return in determining either federal 962
adjusted gross income or federal taxable income; 963
(9) Deduct any amount included in federal taxable income 965
solely because the amount represents a reimbursement or refund of 966
expenses that in a previous year the decedent had deducted as an 967
itemized deduction pursuant to section 63 of the Internal Revenue 968
Code and applicable treasury regulations; 969
(10) Deduct any portion of the deduction described in 971
section 1341(a)(2) of the Internal Revenue Code, for repaying 972
previously reported income received under a claim of right, that 973
meets both of the following requirements: 974
(a) It is allowable for repayment of an item that was 976
included in the taxpayer's taxable income or the decedent's 977
adjusted gross income for a prior taxable year and did not 978
qualify for a credit under division (A) or (B) of section 5747.05 979
of the Revised Code for that year. 980
(b) It does not otherwise reduce the taxpayer's taxable 982
income or the decedent's adjusted gross income for the current or 983
any other taxable year. 984
(11) Add any amount claimed as a credit under section 986
5747.059 of the Revised Code to the extent that the amount 987
satisfies either of the following: 988
(a) The amount was deducted or excluded from the 990
computation of the taxpayer's federal taxable income as required 991
to be reported for the taxpayer's taxable year under the Internal 992
Revenue Code;
23
(b) The amount resulted in a reduction in the taxpayer's 994
federal taxable income as required to be reported for any of the 995
taxpayer's taxable years under the Internal Revenue Code. 996
(T) "School district income" and "school district income 998
tax" have the same meanings as in section 5748.01 of the Revised 999
Code. 1,000
(U) As used in divisions (A)(8), (A)(9), (S)(6), and 1,002
(S)(7) of this section, "public obligations," "purchase 1,003
obligations," and "interest or interest equivalent" have the same 1,004
meanings as in section 5709.76 of the Revised Code. 1,005
(V) "Limited liability company" means any limited 1,007
liability company formed under Chapter 1705. of the Revised Code 1,008
or under the laws of any other state. 1,009
(W) "Pass-through entity investor" means any person who, 1,011
during any portion of a taxable year of a pass-through entity, is 1,012
a partner, member, shareholder, or investor in that pass-through 1,013
entity.
(X) "Banking day" has the same meaning as in section 1,015
1304.01 of the Revised Code. 1,016
(Y) "Month" means a calendar month. 1,018
(Z) "Quarter" means the first three months, the second 1,020
three months, the third three months, or the last three months of 1,021
the taxpayer's taxable year.
(AA) Any term used in this chapter that is not otherwise 1,023
defined in this section and that is not used in a comparable 1,024
context in the Internal Revenue Code and other statutes of the 1,025
United States relating to federal income taxes has the same 1,026
meaning as in section 5733.40 of the Revised Code. 1,027
Section 2. That existing sections 1751.11, 1751.33, 1,029
1751.78, 1751.81, 1751.82, and 5747.01 of the Revised Code are 1,031
hereby repealed.
Section 3. The amendment by this act of section 5747.01 of 1,033
the Revised Code applies to taxable years beginning on or after 1,034
January 1, 1999.