As Reported by House Health, Retirement and Aging Committee 1
123rd General Assembly 4
Regular Session Sub. H. B. No. 4 5
1999-2000 6
REPRESENTATIVES GARDNER-TIBERI-BUCHY-HARRIS-ALLEN-BARNES- 8
BARRETT-BENDER-BOYD-BRADING-BRITTON-CALLENDER-CAREY-CATES- 9
CORBIN-CORE-COUGHLIN-EVANS-FORD-GOODMAN-GRENDELL-HAINES- 10
HOOD-HOOPS-JACOBSON-JOLIVETTE-KILBANE-KREBS-KRUPINSKI- 11
MAIER-MEAD-METELSKY-METZGER-MOTTLEY-MYERS-O'BRIEN-OGG- 12
OLMAN-OPFER-PADGETT-PATTON-PRINGLE-ROMAN-SALERNO-SCHULER- 13
SCHURING-SMITH-TAYLOR-TERWILLEGER-THOMAS-WILLAMOWSKI-WINKLER- 14
WOMER BENJAMIN-YOUNG 15
_________________________________________________________________ 16
A B I L L
To amend sections 1751.11, 1751.19, 1751.33, 18
1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 19
5747.01; to amend, for the purpose of adopting
new section numbers as indicated in parentheses, 20
sections 1751.83 (1751.821), 1751.84 (1751.822), 21
1751.85 (1751.823), and 1753.24 (1751.85); and to
enact new sections 1751.83 and 1751.84 and 22
sections 1751.811, 1751.831, 1751.87, 1751.88, 23
1751.89, 1751.90, 1753.13, and 3923.65 of the
Revised Code to establish procedures for enrollee 25
appeals of health care coverage decisions by
health insuring corporations and to make other 26
changes in the laws related to health insuring 27
corporations.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 29
Section 1. That sections 1751.11, 1751.19, 1751.33, 31
1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 5747.01 be 32
amended, sections 1751.83 (1751.821), 1751.84 (1751.822), 1751.85 33
(1751.823), and 1753.24 (1751.85) be amended for the purpose of 34
2
adopting new section numbers as indicated in parentheses, and new 35
sections 1751.83 and 1751.84 and sections 1751.811, 1751.831,
1751.87, 1751.88, 1751.89, 1751.90, 1753.13, and 3923.65 of the 36
Revised Code be enacted to read as follows: 38
Sec. 1751.11. (A) Every subscriber of a health insuring 48
corporation is entitled to an evidence of coverage for the health 49
care plan under which health care benefits are provided. 51
(B) Every subscriber of a health insuring corporation that 53
offers basic health care services is entitled to an 54
identification card or similar document that specifies the health 55
insuring corporation's name as stated in its articles of 56
incorporation, and any trade or fictitious names used by the 57
health insuring corporation. The identification card or document 58
shall list at least one TOLL-FREE telephone number that provides 59
the subscriber with access to health care on a 60
twenty-four-hours-per-day, seven-days-per-week basis. THE 61
IDENTIFICATION CARD OR DOCUMENT SHALL ALSO LIST AT LEAST ONE 62
TOLL-FREE NUMBER THAT, DURING NORMAL BUSINESS HOURS, PROVIDES THE 63
SUBSCRIBER WITH ACCESS TO INFORMATION ON THE COVERAGE AVAILABLE
UNDER THE SUBSCRIBER'S HEALTH CARE PLAN AND INFORMATION ON THE 64
HEALTH CARE PLAN'S INTERNAL AND EXTERNAL APPEALS PROCESSES. 65
(C) No evidence of coverage, or amendment to the evidence 67
of coverage, shall be delivered, issued for delivery, renewed, or 68
used, until the form of the evidence of coverage or amendment has 69
been filed by the health insuring corporation with the 70
superintendent of insurance. If the superintendent does not 71
disapprove the evidence of coverage or amendment within sixty 72
days after it is filed it shall be deemed approved, unless the 73
superintendent sooner gives approval for the evidence of coverage 74
or amendment. With respect to an amendment to an approved 75
evidence of coverage, the superintendent only may disapprove 76
provisions amended or added to the evidence of coverage. If the 77
superintendent determines within the sixty-day period that any 78
evidence of coverage or amendment fails to meet the requirements 79
3
of this section, the superintendent shall so notify the health 80
insuring corporation and it shall be unlawful for the health 81
insuring corporation to use such evidence of coverage or 82
amendment. At any time, the superintendent, upon at least thirty 84
days' written notice to a health insuring corporation, may 85
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 86
section. Such disapproval shall be effected by a written order, 87
which shall state the grounds for disapproval and shall be issued 89
in accordance with Chapter 119. of the Revised Code. 91
(D) No evidence of coverage or amendment shall be 93
delivered, issued for delivery, renewed, or used: 94
(1) If it contains provisions or statements that are 96
inequitable, untrue, misleading, or deceptive; 97
(2) Unless it contains a clear, concise, and complete 99
statement of the following: 100
(a) The health care services and insurance or other 103
benefits, if any, to which the AN enrollee is entitled under the 105
health care plan;
(b) Any exclusions or limitations on the health care 108
services, type of health care services, benefits, or type of 109
benefits to be provided, including copayments; 110
(c) The AN enrollee's personal financial obligation for 112
noncovered services; 114
(d) Where and in what manner general information and 117
information as to how services may be obtained is available, 118
including the A TOLL-FREE telephone number; 120
(e) The premium rate with respect to individual and 122
conversion contracts, and relevant copayment provisions with 123
respect to all contracts. The statement of the premium rate, 124
however, may be contained in a separate insert. 125
(f) The method utilized by the health insuring corporation 128
for resolving enrollee complaints; 129
(g) THE UTILIZATION REVIEW, INTERNAL REVIEW, AND EXTERNAL 131
4
REVIEW PROCEDURES ESTABLISHED UNDER SECTIONS 1751.77 TO 1751.85 133
OF THE REVISED CODE. 135
(3) Unless it provides for the continuation of an 137
enrollee's coverage, in the event that the enrollee's coverage 138
under the group policy, contract, certificate, or agreement 139
terminates while the enrollee is receiving inpatient care in a 140
hospital. This continuation of coverage shall terminate at the 141
earliest occurrence of any of the following: 142
(a) The enrollee's discharge from the hospital; 144
(b) The determination by the enrollee's attending 146
physician that inpatient care is no longer medically indicated 147
for the enrollee; however, nothing in division (D)(3)(b) of this 150
section precludes a health insuring corporation from engaging in 151
utilization review as described in the evidence of coverage. 152
(c) The enrollee's reaching the limit for contractual 154
benefits; 155
(d) The effective date of any new coverage. 158
(4) Unless it contains a provision that states, in 160
substance, that the health insuring corporation is not a member 161
of any guaranty fund, and that in the event of the health 162
insuring corporation's insolvency, the AN enrollee is protected 163
only to the extent that the hold harmless provision required by 164
section 1751.13 of the Revised Code applies to the health care 166
services rendered; 167
(5) Unless it contains a provision that states, in 169
substance, that in the event of the insolvency of the health 170
insuring corporation, the AN enrollee may be financially 171
responsible for health care services rendered by a provider or 172
health care facility that is not under contract to the health 173
insuring corporation, whether or not the health insuring 174
corporation authorized the use of the provider or health care 175
facility. 176
(E) Notwithstanding divisions (C) and (D) of this section, 179
a health insuring corporation may use an evidence of coverage 180
5
that provides for the coverage of beneficiaries enrolled in Title 182
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 183
U.S.C.A. 301, as amended, pursuant to a medicare contract, or an 185
evidence of coverage that provides for the coverage of 186
beneficiaries enrolled in the federal employees health benefits 187
program pursuant to 5 U.S.C.A. 8905, or an evidence of coverage 189
that provides for the coverage of beneficiaries enrolled in Title 191
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 192
U.S.C.A. 301, as amended, known as the medical assistance program 194
or medicaid, provided by the Ohio department of human services 195
under Chapter 5111. of the Revised Code, or an evidence of 196
coverage that provides for the coverage of beneficiaries under 197
any other federal health care program regulated by a federal 198
regulatory body, or an evidence of coverage that provides for the 199
coverage of beneficiaries under any contract covering officers or 200
employees of the state that has been entered into by the 202
department of administrative services, if both of the following 204
apply: 205
(1) The evidence of coverage has been approved by the 207
United States department of health and human services, the United 209
States office of personnel management, the Ohio department of 210
human services, or the department of administrative services. 211
(2) The evidence of coverage is filed with the 213
superintendent of insurance prior to use and is accompanied by 214
documentation of approval from the United States department of 216
health and human services, the United States office of personnel 217
management, the Ohio department of human services, or the 218
department of administrative services. 219
Sec. 1751.19. (A) A health insuring corporation shall 229
establish and maintain a complaint system that has been approved 230
by the superintendent of insurance to provide adequate and 231
reasonable procedures for the expeditious resolution of written 232
complaints initiated by subscribers or enrollees concerning any 233
matter relating to services provided, directly or indirectly, by 234
6
the health insuring corporation, including, but not limited to, 235
claims COMPLAINTS regarding the scope of coverage for health care 236
services, and denials, cancellations, or nonrenewals of coverage. 238
COMPLAINTS REGARDING A HEALTH INSURING CORPORATION'S DECISION TO 240
DENY, REDUCE, OR TERMINATE COVERAGE FOR HEALTH CARE SERVICES ARE
SUBJECT TO SECTION 1751.83 OF THE REVISED CODE. 241
(B) A health insuring corporation shall provide a timely 244
written response to each written complaint it receives. 245
Responses to written complaints relating to quality or 246
appropriateness of care shall set forth a statement informing the 247
complainant in detail of any rights the complainant may have to 248
submit such complaint to any professional peer review 249
organization or health insuring corporation peer review committee 250
that has been set up to monitor the quality or appropriateness of 251
provider services rendered. Such statement shall set forth the 252
name of the peer review organization or health insuring 253
corporation peer review committee, its address, telephone number, 254
and any other pertinent data that will enable the complainant to 255
seek further independent review of the complaint. Such appeal 256
shall not be made to the peer review corporation or health 257
insuring corporation peer review committee until the complaint 258
system of the health insuring corporation has been exhausted. 259
(C) Copies of complaints and responses, including medical 262
records related to those complaints, shall be available to the 263
superintendent and the director of health for inspection for 264
three years. Any document or information provided to the 265
superintendent pursuant to this division that contains a medical 266
record is confidential, and is not a public record subject to 267
section 149.43 of the Revised Code.
(D) A health insuring corporation shall establish and 270
maintain a procedure to accept complaints over the telephone or 271
in person. These complaints are not subject to the reporting 272
requirement under division (C) of section 1751.32 of the Revised 274
Code.
7
(E) A HEALTH INSURING CORPORATION MAY COMPLY WITH THIS 277
SECTION AND SECTION 1751.83 OF THE REVISED CODE BY ESTABLISHING 278
ONE SYSTEM FOR RECEIVING AND REVIEWING COMPLAINTS AND APPEALS 279
FROM ENROLLEES AND SUBSCRIBERS IF THE SYSTEM MEETS THE
REQUIREMENTS OF BOTH SECTIONS. 280
Sec. 1751.33. (A) Each health insuring corporation shall 289
provide to its subscribers, by mail, a description of the health 290
insuring corporation, its method of operation, its service area, 291
its most recent provider list, and its complaint procedure 292
established pursuant to section 1751.19 of the Revised Code, AND 294
A DESCRIPTION OF ITS UTILIZATION REVIEW, INTERNAL REVIEW, AND 295
EXTERNAL REVIEW PROCESSES ESTABLISHED UNDER SECTIONS 1751.77 TO 296
1751.85 OF THE REVISED CODE. AT THE REQUEST OF OR WITH THE 297
APPROVAL OF THE SUBSCRIBER, A HEALTH INSURING CORPORATION MAY 299
PROVIDE THIS INFORMATION BY ELECTRONIC MEANS RATHER THAN BY MAIL. 300
A health insuring corporation providing basic health care 302
services or supplemental health care services shall provide this 303
information annually. A health insuring corporation providing
only specialty health care services shall provide this 304
information biennially.
(B) Each health insuring corporation, upon the request of 307
a subscriber, shall make available its most recent statutory 308
financial statement.
Sec. 1751.77. As used in sections 1751.77 to 1751.86 317
1751.90 of the Revised Code, unless otherwise specifically 319
provided:
(A) "Adverse determination" means a determination by a 321
health insuring corporation or its designee utilization review 322
organization that an admission, availability of care, continued 324
stay, or other health care service covered under a policy, 325
contract, or agreement of the health insuring corporation has 327
been reviewed and, based upon the information provided, the 328
health care service does not meet the health insuring 330
corporation's requirements for benefit payment UNDER THE HEALTH 331
8
INSURING CORPORATION'S POLICY, CONTRACT, OR AGREEMENT, and
COVERAGE is therefore denied, reduced, or terminated. 333
(B) "Ambulatory review" means utilization review of health 335
care services performed or provided in an outpatient setting. 336
(C) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 338
PERSON AUTHORIZED TO ACT ON BEHALF OF AN ENROLLEE. 339
(D) "Case management" means a coordinated set of 341
activities conducted for individual patient management of 342
serious, complicated, protracted, or other specified health 343
conditions.
(D)(E) "Certification" means a determination by a health 345
insuring corporation or its designee utilization review 348
organization that an admission, availability of care, continued 349
stay, or other health care service covered under a policy, 350
contract, or agreement of the health insuring corporation has 352
been reviewed and, based upon the information provided, the 353
health care service satisfies the health insuring corporation's 354
requirements for benefit payment UNDER THE HEALTH INSURING 355
CORPORATION'S POLICY, CONTRACT, OR AGREEMENT. 356
(E)(F) "Clinical peer" means a physician when an 359
evaluation is to be made of the clinical appropriateness of 360
health care services provided by a physician. If an evaluation 361
is to be made of the clinical appropriateness of health care 362
services provided by a provider who is not a physician, "clinical 363
peer" means either a physician or a provider holding the same 364
license as the provider who provided the health care services. 365
(F)(G) "Clinical review criteria" means the written 367
screening procedures, decision abstracts, clinical protocols, and 368
practice guidelines used by a health insuring corporation to 369
determine the necessity and appropriateness of health care 371
services.
(G)(H) "Concurrent review" means utilization review 373
conducted during a patient's hospital stay or course of 374
treatment.
9
(H)(I) "Discharge planning" means the formal process for 376
determining, prior to a patient's discharge from a health care 377
facility, the coordination and management of the care that the 379
patient is to receive following discharge from a health care 380
facility.
(I)(J) "Participating provider" means a provider or health 382
care facility that, under a contract with a health insuring 384
corporation or with its contractor or subcontractor, has agreed 386
to provide health care services to enrollees with an expectation
of receiving payment, other than coinsurance, copayments, or 387
deductibles, directly or indirectly from the health insuring 388
corporation.
(J)(K) "Physician" means a provider authorized WHO HOLDS A 391
CERTIFICATE ISSUED under chapter CHAPTER 4731. of the Revised 393
Code to AUTHORIZING THE practice OF medicine and surgery or 395
osteopathic medicine and surgery OR A COMPARABLE LICENSE OR
CERTIFICATE FROM ANOTHER STATE. 396
(K)(L) "Prospective review" means utilization review that 398
is conducted prior to an admission or a course of treatment. 399
(L)(M) "Retrospective review" means utilization review of 401
medical necessity that is conducted after health care services 403
have been provided to a patient. "Retrospective review" does not 405
include the review of a claim that is limited to an evaluation of 406
reimbursement levels, veracity of documentation, accuracy of 407
coding, or adjudication of payment.
(M)(N) "Second opinion" means an opportunity or 409
requirement to obtain a clinical evaluation by a provider other 411
than the provider originally making a recommendation for proposed 412
health care services to assess the clinical necessity and 413
appropriateness of the proposed health care services. 414
(N)(O) "Utilization review" means a process used to 416
monitor the use of, or evaluate the clinical necessity, 418
appropriateness, efficacy, or efficiency of, health care 419
services, procedures, or settings. Areas of review may include 420
10
ambulatory review, prospective review, second opinion,
certification, concurrent review, case management, discharge 421
planning, or retrospective review. 422
(O)(P) "Utilization review organization" means an entity 424
that conducts utilization review, other than a health insuring 425
corporation performing a review of its own health care plans. 427
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86 1751.90 437
of the Revised Code apply to any health insuring corporation that 439
provides or performs utilization review services in connection 440
with its policies, contracts, and agreements providing COVERING 441
basic health care services and to any designee of the health 442
insuring corporation, or to any utilization review organization 445
that performs utilization review functions on behalf of the 446
health insuring corporation in connection with policies,
contracts, or agreements of the health insuring corporation 447
providing COVERING basic health care services. 449
(2) Nothing in sections 1751.77 to 1751.82 or section 451
1751.85 1751.823 of the Revised Code shall be construed to 452
require a health insuring corporation to provide or perform 453
utilization review services in connection with health care 454
services provided under a policy, plan, or agreement of 455
supplemental health care services or specialty health care 456
services. 457
(B)(1) Each health insuring corporation shall be 460
responsible for monitoring all utilization review AND INTERNAL 461
REVIEW activities carried out by, or on behalf of, the health 463
insuring corporation and for ensuring that all requirements of 464
sections 1751.77 to 1751.86 1751.90 of the Revised Code, and any 465
rules adopted thereunder, are met. The health insuring 467
corporation shall also ensure that appropriate personnel have 468
operational responsibility for the conduct of the health insuring 469
corporation's utilization review program. 470
(2) If a health insuring corporation contracts to have a 472
utilization review organization or other entity perform the 473
11
utilization review functions required by sections 1751.77 to 474
1751.86 1751.90 of the Revised Code, and any rules adopted 476
thereunder, the superintendent of insurance shall hold the health 478
insuring corporation responsible for monitoring the activities of
the utilization review organization or other entity and for 479
ensuring that the requirements of those sections and rules are 480
met. 481
Sec. 1751.81. (A) As used in this section: 490
(1) "Enrollee" includes the representative of an enrollee. 492
(2) "Necessary, "NECESSARY information" includes the 495
results of any face-to-face clinical evaluation or second opinion 498
that may be required.
(B) A health insuring corporation shall maintain written 500
procedures for DETERMINING WHETHER A REQUESTED SERVICE IS A 501
SERVICE COVERED UNDER THE TERMS OF AN ENROLLEE'S POLICY, 502
CONTRACT, OR AGREEMENT, making utilization review determinations, 504
and for notifying enrollees, and participating providers, and 505
health care facilities acting on behalf of enrollees, of its 507
determinations.
(C) For initial PROSPECTIVE REVIEW determinations, a 510
health insuring corporation shall make the determination within 512
two business days after obtaining all necessary information 513
regarding a proposed admission, procedure, or health care service 514
requiring a review determination. 516
(1) In the case of a determination to certify an 518
admission, procedure, or health care service, the health insuring 519
corporation shall notify the provider or health care facility 520
rendering the health care service by telephone or facsimile 521
within three business days after making the initial 522
certification.
(2) In the case of an adverse determination, the health 524
insuring corporation shall notify the provider or health care 526
facility rendering the health care service by telephone within 527
three business days after making the adverse determination, and 528
12
shall provide written or electronic confirmation of the telephone 529
notification to the enrollee and the provider or health care 530
facility within one business day after making the telephone 531
notification.
(D) For concurrent review determinations, a health 533
insuring corporation shall make the determination within one 536
business day after obtaining all necessary information. 537
(1) In the case of a determination to certify an extended 539
stay or additional health care services, the health insuring 540
corporation shall notify the provider or health care facility 541
rendering the health care service by telephone or facsimile 542
within one business day after making the certification. 544
(2) In the case of an adverse determination, the health 546
insuring corporation shall notify the provider or health care 547
facility rendering the health care service by telephone within 548
one business day after making the adverse determination, and 549
shall provide written or electronic confirmation to the enrollee 550
and the provider or health care facility within one business day 551
after the telephone notification. The health care service to the 552
enrollee shall be continued, with standard copayments and 554
deductibles, if applicable, until the enrollee has been notified 555
of the determination. 556
(E) For retrospective review determinations, a health 558
insuring corporation shall make the determination within thirty 562
business days after receiving all necessary information. 563
(1) In the case of a certification, the health insuring 565
corporation may notify the enrollee and the provider or health 567
care facility rendering the health care service in writing. 568
(2) In the case of an adverse determination, the health 570
insuring corporation shall notify the enrollee and the provider 572
or health care facility rendering the health care service, in 573
writing, within five business days after making the adverse 574
determination.
(F)(1) The time frames set forth in divisions (C), (D), 577
13
and (E) of this section for determinations and notifications 579
shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the 580
health insuring corporation. The health insuring corporation 581
shall maintain written procedures for making expedited 583
utilization review determinations and notifications of enrollees 584
and providers or health care facilities when warranted by the 585
medical condition of the enrollee. 586
(2) AN ENROLLEE OR AUTHORIZED PERSON MAY PROCEED WITH A 588
REQUEST FOR AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 590
REVISED CODE IF A HEALTH INSURING CORPORATION FAILS TO MAKE A 593
DETERMINATION AND NOTIFICATION WITHIN THE TIME FRAMES SET FORTH 594
IN DIVISIONS (C), (D), AND (E) OF THIS SECTION. THE HEALTH 596
INSURING CORPORATION'S FAILURE TO MAKE A DETERMINATION AND 597
NOTIFICATION WITHIN THESE TIME FRAMES SHALL BE DEEMED TO BE AN 598
ADVERSE DETERMINATION BY THE HEALTH INSURING CORPORATION FOR THE 599
PURPOSE OF INITIATING AN INTERNAL REVIEW.
(G) A written notification of an adverse determination 601
shall include the principal reason or reasons for the 602
determination, instructions for initiating an appeal or A 604
reconsideration OR INTERNAL REVIEW of the determination, and 605
instructions for requesting a written statement of the clinical 606
rationale used to make the determination. A health insuring 607
corporation shall provide the clinical rationale for an adverse 609
determination in writing to any party who received notice of the 611
adverse determination and who follows the instructions for a
request. 612
(H)(1) A health insuring corporation shall have written 614
procedures to address the failure or inability of a health care 616
facility, provider, or enrollee to provide all necessary 617
information for review.
(2) A HEALTH INSURING CORPORATION SHALL NOT USE 619
UNREASONABLE REQUESTS FOR INFORMATION TO DELAY MAKING A 620
DETERMINATION. 621
14
(3) If the health care facility, provider, or enrollee 624
will not release necessary information, the health insuring 625
corporation may deny certification. AN ENROLLEE NEED NOT BE 626
GRANTED AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 627
REVISED CODE BASED ON A HEALTH INSURING CORPORATION'S FAILURE TO 629
MAKE A TIMELY DETERMINATION, IF THE HEALTH INSURING CORPORATION'S 630
DELAY IN MAKING A DETERMINATION AND NOTIFICATION IS CAUSED BY THE 631
FAILURE OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO 632
RELEASE ALL NECESSARY INFORMATION, IN WHICH CASE THE HEALTH 633
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE OF THE REASON FOR 634
THE DELAY.
Sec. 1751.811. A HEALTH INSURING CORPORATION THAT MAKES AN 636
ADVERSE DETERMINATION MAY, IN LIEU OF PROVIDING A RECONSIDERATION 637
UNDER SECTION 1751.82 OF THE REVISED CODE AND AN INTERNAL REVIEW 638
UNDER SECTION 1751.83 OF THE REVISED CODE, AFFORD AN ENROLLEE AN 639
OPPORTUNITY FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 640
1751.85 OF THE REVISED CODE.
Sec. 1751.82. (A) In a case involving an initial A 650
PROSPECTIVE determination or a concurrent review determination, a 652
health insuring corporation shall give the provider or health
care facility rendering the health care service an opportunity to 654
request in writing on behalf of the enrollee a reconsideration of 655
an adverse determination by the reviewer making the adverse 656
determination. The reconsideration shall occur within three 657
business days after the health insuring corporation's receipt of 658
the written request for reconsideration, and shall be conducted 659
between the provider or health care facility rendering the health 660
care service and the reviewer who made the adverse determination. 662
If that reviewer cannot be available within three business days, 663
the reviewer may designate another reviewer.
(B) If the reconsideration process described in division 665
(A) of this section does not resolve the difference of opinion, 667
the adverse determination may be appealed by the enrollee, AN 668
AUTHORIZED PERSON, or the provider or health care facility ACTING 669
15
on behalf of the enrollee MAY REQUEST AN INTERNAL REVIEW UNDER 670
SECTION 1751.83 OF THE REVISED CODE. 671
(C) Reconsideration is not a prerequisite to a standard AN 673
INTERNAL or expedited appeal EXTERNAL REVIEW of an adverse 675
determination.
(D) The time period allowed by division (A) of this 678
section for a reconsideration of an adverse determination shall 679
not apply if the seriousness of the medical condition of the 680
enrollee requires a more expedited reconsideration. The health 681
insuring corporation shall maintain written procedures for making 682
such an expedited reconsideration. 683
Sec. 1751.83 1751.821. A health insuring corporation may 693
present evidence of compliance with the requirements of sections 694
1751.77 to 1751.82 of the Revised Code by submitting evidence to 696
the superintendent of insurance of its accreditation by an
independent, private accrediting organization, such as the 697
national committee on quality assurance, the national quality 698
health council, the joint commission on accreditation of health 700
care organizations, or the American accreditation healthcare
commission/utilization review accreditation commission. The 702
superintendent, upon review of the organization's accreditation 703
process, may determine that such accreditation constitutes 704
compliance by the health insuring corporation with the 705
requirements of these sections.
Sec. 1751.84 1751.822. Each participating provider or 714
health care facility submitting a claim shall cooperate with the 716
utilization review program of a health insuring corporation or 717
utilization review organization and shall provide the health 718
insuring corporation or its designee access to an enrollee's 719
medical records during regular business hours, or copies of those 720
records at a reasonable cost. 721
Sec. 1751.85 1751.823. A health insuring corporation shall 730
annually file a certificate with the superintendent of insurance 732
certifying its compliance with sections 1751.77 to 1751.82 of the 733
16
Revised Code. 735
Sec. 1751.83. A HEALTH INSURING CORPORATION SHALL 737
ESTABLISH AND MAINTAIN AN INTERNAL REVIEW SYSTEM THAT HAS BEEN 738
APPROVED BY THE SUPERINTENDENT OF INSURANCE. THE SYSTEM SHALL 739
PROVIDE FOR REVIEW BY A CLINICAL PEER AND INCLUDE ADEQUATE AND 740
REASONABLE PROCEDURES FOR REVIEW AND RESOLUTION OF APPEALS FROM
ENROLLEES CONCERNING ADVERSE DETERMINATIONS MADE UNDER SECTION 743
1751.81 OF THE REVISED CODE, INCLUDING PROCEDURES FOR VERIFYING 744
AND REVIEWING APPEALS FROM ENROLLEES WHOSE MEDICAL CONDITIONS
REQUIRE EXPEDITED REVIEW. 745
A HEALTH INSURING CORPORATION SHALL CONSIDER AND PROVIDE A 747
WRITTEN RESPONSE TO EACH REQUEST FOR AN INTERNAL REVIEW NOT LATER 749
THAN SIXTY DAYS AFTER RECEIPT OF THE REQUEST, EXCEPT THAT IF THE 750
SERIOUSNESS OF THE ENROLLEE'S MEDICAL CONDITION REQUIRES AN 751
EXPEDITED REVIEW, THE HEALTH INSURING CORPORATION SHALL PROVIDE 752
THE WRITTEN RESPONSE NOT LATER THAN SEVEN DAYS AFTER RECEIPT OF 753
THE REQUEST. THE RESPONSE SHALL STATE THE REASON FOR THE HEALTH 757
INSURING CORPORATION'S DECISION, INFORM THE ENROLLEE OF THE RIGHT
TO PURSUE A FURTHER REVIEW, AND EXPLAIN THE PROCEDURES FOR 759
INITIATING THE REVIEW.
IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 763
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 764
THE SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 765
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, THE RESPONSE SHALL 766
INFORM THE ENROLLEE OF THE RIGHT TO REQUEST A REVIEW BY THE 767
SUPERINTENDENT OF INSURANCE UNDER SECTION 1751.831 OF THE REVISED 768
CODE. IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 769
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 770
THE SERVICE IS NOT MEDICALLY NECESSARY, THE RESPONSE SHALL INFORM 772
THE ENROLLEE OF THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER 773
SECTION 1751.84 OF THE REVISED CODE, EXCEPT THAT IF THE ENROLLEE 775
MEETS THE CRITERIA SET FORTH IN DIVISION (A) OF SECTION 1751.85 776
OF THE REVISED CODE, THE RESPONSE SHALL INFORM THE ENROLLEE OF 777
THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER SECTION 1751.85 OF 778
17
THE REVISED CODE.
THE HEALTH INSURING CORPORATION SHALL MAKE AVAILABLE TO THE 780
SUPERINTENDENT FOR INSPECTION COPIES OF ALL DOCUMENTS IN THE 781
HEALTH INSURING CORPORATION'S POSSESSION RELATED TO REVIEWS 782
CONDUCTED PURSUANT TO THIS SECTION, INCLUDING MEDICAL RECORDS 783
RELATED TO THOSE REVIEWS, AND OF RESPONSES, FOR THREE YEARS 784
FOLLOWING COMPLETION OF THE REVIEW. ANY DOCUMENT OR INFORMATION 785
PROVIDED TO THE SUPERINTENDENT UNDER THIS SECTION IS CONFIDENTIAL 786
AND IS NOT A PUBLIC RECORD UNDER SECTION 149.43 OF THE REVISED 787
CODE.
Sec. 1751.831. THE SUPERINTENDENT OF INSURANCE SHALL 789
ESTABLISH AND MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING 790
REQUESTS FOR REVIEW FROM OR ON BEHALF OF ENROLLEES WHO, UNDER 791
SECTION 1751.83 OF THE REVISED CODE, HAVE BEEN DENIED COVERAGE OF 792
A HEALTH CARE SERVICE OR HAD COVERAGE REDUCED OR TERMINATED WHEN 793
THE GROUNDS FOR THE DENIAL, REDUCTION, OR TERMINATION IS THAT THE 794
SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 795
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT. 796
ON RECEIPT OF A WRITTEN REQUEST FROM AN ENROLLEE OR 798
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 799
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 801
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, EXCEPT THAT THE 802
SUPERINTENDENT SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION 803
UNLESS THE ENROLLEE HAS EXHAUSTED THE HEALTH INSURING 804
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO
SECTION 1751.83 OF THE REVISED CODE. THE HEALTH INSURING 805
CORPORATION AND THE ENROLLEE OR AUTHORIZED PERSON SHALL PROVIDE 806
THE SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 807
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 808
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 810
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 811
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 812
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 813
18
ENROLLEE'S CONTRACT, POLICY, OR AGREEMENT. THE SUPERINTENDENT 814
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION OF 815
ITS DETERMINATION OR THAT IT IS NOT ABLE TO MAKE A DETERMINATION. 816
IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 818
CORPORATION THAT MAKING THE DETERMINATION REQUIRES THE RESOLUTION 819
OF A MEDICAL ISSUE, THE HEALTH INSURING CORPORATION SHALL AFFORD 820
THE ENROLLEE AN OPPORTUNITY FOR EXTERNAL REVIEW UNDER SECTION 821
1751.84 OR 1751.85 OF THE REVISED CODE. IF THE SUPERINTENDENT 822
NOTIFIES THE HEALTH INSURING CORPORATION THAT THE HEALTH SERVICE 823
IS A COVERED SERVICE, THE HEALTH INSURING CORPORATION SHALL 824
EITHER COVER THE SERVICE OR AFFORD THE ENROLLEE AN OPPORTUNITY
FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE 825
REVISED CODE. IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 826
CORPORATION THAT THE HEALTH CARE SERVICE IS NOT A COVERED 827
SERVICE, THE HEALTH INSURING CORPORATION IS NOT REQUIRED TO COVER 828
THE SERVICE OR AFFORD THE ENROLLEE AN EXTERNAL REVIEW. 829
Sec. 1751.84. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 832
(C) OF THIS SECTION, A HEALTH INSURING CORPORATION SHALL AFFORD 834
AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL REVIEW IF BOTH OF THE 835
FOLLOWING ARE THE CASE:
(1) THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, 837
OR TERMINATED COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE 840
SERVICE EXCEPT FOR THE FACT THAT THE HEALTH INSURING CORPORATION 841
HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 842
NECESSARY;
(2) EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, THE 844
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 846
COST THE ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED
SERVICE IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 847
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 849
SECTION, EXCEPT THAT IF AN ENROLLEE WITH A TERMINAL CONDITION 850
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 1751.85 OF 851
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 853
THAT SECTION.
19
(B) AN ENROLLEE NEED NOT BE AFFORDED A REVIEW UNDER THIS 855
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 856
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 858
SECTION 1751.831 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 860
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE ENROLLEE'S 861
POLICY, CONTRACT, OR AGREEMENT. 862
(2) EXCEPT AS PROVIDED IN SECTION 1751.811 OF THE REVISED 864
CODE, THE ENROLLEE HAS FAILED TO EXHAUST THE HEALTH INSURING 865
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO 866
SECTION 1751.83 OF THE REVISED CODE. 867
(3) THE ENROLLEE HAS PREVIOUSLY BEEN AFFORDED AN EXTERNAL 869
REVIEW FOR THE SAME ADVERSE DETERMINATION AND NO NEW CLINICAL 870
INFORMATION HAS BEEN SUBMITTED TO THE HEALTH INSURING 871
CORPORATION.
(C)(1) A HEALTH INSURING CORPORATION MAY DENY A REQUEST 873
FOR AN EXTERNAL REVIEW OF AN ADVERSE DETERMINATION IF IT IS 875
REQUESTED LATER THAN THIRTY DAYS AFTER THE ENROLLEE'S RECEIPT OF 876
NOTICE OF THE RESULT OF AN INTERNAL REVIEW BROUGHT UNDER SECTION 878
1751.83 OF THE REVISED CODE. AN EXTERNAL REVIEW MAY BE REQUESTED 880
BY THE ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S PROVIDER, 882
OR A HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICE TO THE 883
ENROLLEE. THE ENROLLEE MAY REQUEST A REVIEW WITHOUT THE APPROVAL 884
OF THE PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE HEALTH 885
CARE SERVICE. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 886
REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF THE ENROLLEE. 887
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 889
EXCEPT THAT IF THE ENROLLEE HAS A CONDITION THAT REQUIRES 890
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 891
ELECTRONIC MEANS. AN ENROLLEE WHO MAKES AN ORAL OR ELECTRONIC 892
REQUEST FOR REVIEW SHALL SUBMIT TO THE HEALTH INSURING 893
CORPORATION WRITTEN CONFIRMATION OF THE REQUEST NOT LATER THAN 894
FIVE DAYS AFTER MAKING IT.
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 896
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 898
20
THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 899
HEALTH CARE SERVICE TO THE ENROLLEE THAT THE PROPOSED SERVICE,
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 900
ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE 901
IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 902
(3) FOR AN EXPEDITED REVIEW, THE ENROLLEE'S PROVIDER MUST 904
CERTIFY THAT THE ENROLLEE'S CONDITION COULD, IN THE ABSENCE OF 905
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 907
(a) PLACING THE HEALTH OF THE ENROLLEE OR, WITH RESPECT TO 909
A PREGNANT WOMAN, THE HEALTH OF THE ENROLLEE OR THE UNBORN CHILD, 910
IN SERIOUS JEOPARDY; 911
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 913
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 915
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 917
OF AN ADVERSE DETERMINATION SHALL INCLUDE ALL OF THE FOLLOWING: 918
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 920
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 921
DIVISION (C) OF SECTION 1751.90 OF THE REVISED CODE. THE 923
INDEPENDENT REVIEW ORGANIZATION SHALL UTILIZE THE SERVICES OF 924
MEDICAL EXPERTS AND CLINICAL PEERS WHO HAVE EXPERTISE IN THE 925
TREATMENT OF THE ENROLLEE'S MEDICAL CONDITION AND CLINICAL 927
EXPERIENCE IN THE PAST THREE YEARS WITH THE SERVICE REQUESTED OR
RECOMMENDED BY THE ENROLLEE OR THE ENROLLEE'S PROVIDER. THE 929
REVIEW SHALL BE CONDUCTED BY A SINGLE MEDICAL EXPERT OR CLINICAL 930
PEER, UNLESS THE HEALTH INSURING CORPORATION DETERMINES THAT MORE 931
THAN ONE MEDICAL EXPERT OR CLINICAL PEER IS NEEDED. THE MEDICAL 932
EXPERT OR CLINICAL PEER MUST HOLD A LICENSE THAT IS NOT 933
RESTRICTED IN ANY MANNER BY THE STATE IN WHICH THE CLINICAL PEER 934
IS LICENSED. THE MEDICAL EXPERT OR CLINICAL PEER SHALL NOT HAVE
BEEN DISCIPLINED OR SANCTIONED BY A HOSPITAL OR GOVERNMENT ENTITY 936
BASED ON THE QUALITY OF CARE PROVIDED BY THE CLINICAL PEER. IN 937
THE CASE OF A PHYSICIAN, THE CLINICAL PEER MUST BE CERTIFIED BY A 938
NATIONALLY RECOGNIZED MEDICAL SPECIALTY BOARD IN THE AREA THAT IS 939
THE SUBJECT OF THE REVIEW.
21
(2) EXCEPT AS PROVIDED IN DIVISION (D)(3) AND (4) OF THIS 941
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 943
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 945
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 946
FOLLOWING:
(a) THE HEALTH INSURING CORPORATION OR ANY OFFICER, 948
DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING 949
CORPORATION;
(b) THE ENROLLEE, THE ENROLLEE'S PROVIDER, OR THE PRACTICE 951
GROUP OF THE ENROLLEE'S PROVIDER; 952
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 954
SERVICE REQUESTED BY THE ENROLLEE WOULD BE PROVIDED; 955
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 957
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE ENROLLEE. 958
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 960
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 961
CIRCUMSTANCES:
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 963
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 964
THE HEALTH INSURING CORPORATION. 965
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 967
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 968
THE HEALTH INSURING CORPORATION. 969
(c) THE CLINICAL PEER IS A PARTICIPATING PROVIDER BUT WAS 971
NOT INVOLVED WITH THE HEALTH INSURING CORPORATION'S ADVERSE 972
DETERMINATION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 974
HEALTH INSURING CORPORATION FROM PAYING THE INDEPENDENT REVIEW 975
ORGANIZATION FOR THE CONDUCT OF THE REVIEW. 976
(5) AN ENROLLEE SHALL NOT BE REQUIRED TO PAY FOR ANY PART 978
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 979
BY THE HEALTH INSURING CORPORATION. 980
(6)(a) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO 983
THE INDEPENDENT REVIEW ORGANIZATION CONDUCTING THE REVIEW A COPY 984
22
OF THOSE RECORDS IN ITS POSSESSION THAT ARE RELEVANT TO THE 985
ENROLLEE'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL 986
BE USED SOLELY FOR THE PURPOSE OF THIS DIVISION. AT THE REQUEST 987
OF THE INDEPENDENT REVIEW ORGANIZATION, THE HEALTH INSURING 988
CORPORATION, ENROLLEE, OR THE PROVIDER OR HEALTH CARE FACILITY 990
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE SHALL PROVIDE ANY 991
ADDITIONAL INFORMATION THE INDEPENDENT REVIEW ORGANIZATION
REQUESTS TO COMPLETE THE REVIEW. 992
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 994
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 995
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. 997
(7) ON RECEIPT OF ADDITIONAL INFORMATION ON AN ENROLLEE'S 999
MEDICAL CONDITION FROM A PROVIDER OR HEALTH CARE FACILITY, THE 1,000
HEALTH INSURING CORPORATION MAY ELECT TO COVER THE SERVICE 1,001
REQUESTED AND TERMINATE THE REVIEW. THE HEALTH INSURING 1,002
CORPORATION SHALL NOTIFY THE ENROLLEE AND ALL OTHER PARTIES 1,003
INVOLVED WITH THE DECISION BY MAIL OR, WITH THE CONSENT OR 1,004
APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS.
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 1,006
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 1,007
THE FOLLOWING:
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,009
CORPORATION, THE ENROLLEE, THE ENROLLEE'S PROVIDER, AND THE 1,010
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, INCLUDING 1,012
THE FOLLOWING:
(i) THE ENROLLEE'S MEDICAL RECORDS; 1,014
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 1,016
BY THE HEALTH INSURING CORPORATION TO MAKE ITS DECISION. 1,017
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,018
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,019
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 1,021
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 1,024
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,025
23
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 1,026
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 1,027
AND RESEARCH; 1,028
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,030
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 1,031
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 1,032
RELEVANT NATIONAL MEDICAL SOCIETIES. 1,033
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 1,035
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 1,036
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 1,040
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 1,043
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 1,044
COPY OF ITS DECISION TO THE HEALTH INSURING CORPORATION AND THE 1,045
ENROLLEE. IF THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY 1,046
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE REQUESTED THE 1,047
REVIEW, THE INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A 1,048
COPY OF ITS DECISION TO THE ENROLLEE'S PROVIDER OR THE HEALTH 1,049
CARE FACILITY. 1,050
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 1,052
INCLUDE A DESCRIPTION OF THE ENROLLEE'S CONDITION AND THE 1,054
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 1,055
CLINICAL RATIONALE FOR THE DECISION. 1,056
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 1,058
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 1,059
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 1,060
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 1,061
AND COST EFFECTIVENESS.
(F) THE HEALTH INSURING CORPORATION SHALL PROVIDE ANY 1,063
COVERAGE DETERMINED BY THE INDEPENDENT REVIEW ORGANIZATION'S 1,064
DECISION TO BE MEDICALLY NECESSARY, SUBJECT TO THE OTHER TERMS, 1,065
LIMITATIONS, AND CONDITIONS OF THE ENROLLEE'S CONTRACT. THE 1,066
DECISION SHALL APPLY ONLY TO THE INDIVIDUAL ENROLLEE'S APPEAL. 1,067
Sec. 1753.24 1751.85. (A) Each health insuring 1,076
24
corporation shall establish a reasonable external, independent 1,079
review process to examine the health insuring corporation's 1,080
coverage decisions for enrollees who meet all of the following 1,081
criteria:
(1) The enrollee has a terminal condition that, according 1,083
to the current diagnosis of the enrollee's physician, has a high 1,084
probability of causing death within two years. 1,085
(2) THE ENROLLEE REQUESTS A REVIEW NOT LATER THAN SIXTY 1,088
DAYS AFTER RECEIPT BY THE ENROLLEE OF NOTICE OF THE RESULT OF AN 1,089
INTERNAL REVIEW UNDER SECTION 1751.83 OF THE REVISED CODE. 1,090
(3) The enrollee's physician certifies that the enrollee 1,092
has the condition described in division (A)(1) of this section 1,094
and any of the following situations are applicable: 1,095
(a) Standard therapies have not been effective in 1,097
improving the condition of the enrollee; 1,099
(b) Standard therapies are not medically appropriate for 1,102
the enrollee;
(c) There is no standard therapy covered by the health 1,105
insuring corporation that is more beneficial than therapy 1,106
described in division (A)(3)(4) of this section. 1,107
(3)(4) The enrollee's physician has recommended a drug, 1,109
device, procedure, or other therapy that the physician certifies, 1,111
in writing, is likely to be more beneficial to the enrollee, in 1,112
the physician's opinion, than standard therapies, or, the 1,114
enrollee has requested a therapy that has been found in a
preponderance of peer-reviewed published studies to be associated 1,115
with effective clinical outcomes for the same condition. 1,116
(4)(5) The enrollee has been denied coverage by the health 1,118
insuring corporation for a drug, device, procedure, or other 1,122
therapy recommended or requested pursuant to division (A)(3)(4) 1,123
of this section, and has exhausted all internal appeals. 1,124
(5)(6) The drug, device, procedure, or other therapy, 1,126
recommended or requested pursuant to division (A)(3) of this 1,129
section, FOR WHICH COVERAGE HAS BEEN DENIED would be a covered 1,130
25
health care service except for the health insuring corporation's 1,132
determination that the drug, device, procedure, or other therapy 1,134
is experimental or investigational.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 1,136
THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 1,137
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 1,138
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. AN 1,139
ENROLLEE WHO MAKES AN ORAL OR ELECTRONIC REQUEST FOR REVIEW TO A 1,140
HEALTH INSURING CORPORATION SHALL SUBMIT WRITTEN CONFIRMATION OF 1,141
THE REQUEST NOT LATER THAN FIVE DAYS AFTER MAKING THE REQUEST. 1,142
(C) The external, independent review process established 1,145
by a health insuring corporation shall meet all of the following 1,146
criteria:
(1) Except as provided in division (C)(E) of this section, 1,148
the process shall offer AFFORD all enrollees who meet the 1,150
criteria set forth in division (A) of this section the 1,152
opportunity to have the health insuring corporation's decision to 1,153
deny coverage of the recommended or requested therapy reviewed 1,155
under the process. Each eligible enrollee shall be notified of 1,157
that opportunity within five business days after the health 1,158
insuring corporation denies coverage.
(2) The review of the health insuring corporation's 1,160
decision shall be conducted by experts selected by an independent 1,161
entity that has been retained by the health insuring corporation 1,163
for this purpose REVIEW ORGANIZATION ASSIGNED BY THE 1,164
SUPERINTENDENT OF INSURANCE UNDER DIVISION (C) OF SECTION 1751.90 1,165
OF THE REVISED CODE. The independent entity REVIEW ORGANIZATION 1,166
shall be either an academic medical center or an entity 1,168
ORGANIZATION that has as its primary function, and that receives 1,170
a majority of its revenue from, the provision of expert reviews 1,171
and related services BEEN ACCREDITED IN ACCORDANCE WITH RULES 1,172
ADOPTED BY THE SUPERINTENDENT OF INSURANCE PURSUANT TO SECTION 1,173
1751.90 OF THE REVISED CODE.
The independent entity REVIEW ORGANIZATION shall select a 1,175
26
panel to conduct the review, which panel shall be composed of at 1,178
least three physicians or other providers who, THROUGH CLINICAL 1,179
EXPERIENCE IN THE PAST THREE YEARS, are experts in the treatment 1,180
of the enrollee's medical condition and knowledgeable about the 1,182
recommended or requested therapy. If the independent entity 1,183
REVIEW ORGANIZATION retained by the health insuring corporation 1,185
is an academic medical center, the panel may include experts 1,186
affiliated with or employed by the academic medical center. 1,187
In either of the following circumstances, an exception may 1,190
be made to the requirement that the review be conducted by an 1,191
expert panel composed of a minimum of three physicians or other 1,192
providers:
(a) A review may be conducted by an expert panel composed 1,195
of only two physicians or other providers if an enrollee has 1,196
consented in writing to a review by the smaller panel; 1,197
(b) A review may be conducted by a single expert physician 1,200
or other provider if only one expert physician or other provider 1,201
is available for the review.
(3) Neither the health insuring corporation nor the 1,203
enrollee shall choose, or control the choice of, the physician or 1,205
other provider experts.
(4) Neither the THE SELECTED experts nor, ANY HEALTH CARE 1,208
FACILITY WITH WHICH AN EXPERT IS AFFILIATED, AND the independent 1,209
entity REVIEW ORGANIZATION arranging for the experts' review, 1,210
shall NOT have any professional, familial, or financial 1,211
affiliation with the ANY OF THE FOLLOWING:
(a) THE health insuring corporation, except that OR ANY 1,214
OFFICER, DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING
CORPORATION; 1,215
(b) THE ENROLLEE, THE ENROLLEE'S PHYSICIAN, OR THE 1,217
PRACTICE GROUP OF THE ENROLLEE'S PHYSICIAN; 1,218
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 1,220
REQUESTED THERAPY WOULD BE PROVIDED; 1,221
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,223
27
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 1,224
REQUESTED THERAPY. 1,225
HOWEVER, experts affiliated with academic medical centers 1,228
who provide healthcare services to enrollees of the health 1,229
insuring corporation may serve as experts on the review panel. 1,231
This FURTHER, EXPERTS WITH STAFF PRIVILEGES AT A HEALTH CARE 1,232
FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF THE 1,233
HEALTH INSURING CORPORATION, AS WELL AS EXPERTS WHO ARE 1,234
PARTICIPATING PROVIDERS, BUT WHO WERE NOT INVOLVED WITH THE 1,235
HEALTH INSURING CORPORATION'S DENIAL OF COVERAGE FOR THE THERAPY 1,236
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 1,237
nonaffiliation provision does PROVISIONS DO not preclude a health 1,239
insuring corporation from paying for the experts' review, as
specified in division (B)(5) of this section. The experts shall 1,241
have no patient-physician relationship or other affiliation with 1,242
an enrollee whose request for therapy is under review or with a 1,243
provider whose recommendation for therapy is under review. 1,244
(5) Enrollees shall not be required to pay for ANY PART OF 1,246
the external, independent COST OF THE review. The costs COST of 1,248
the review shall be borne by the health insuring corporation. 1,250
(6) The health insuring corporation shall provide to the 1,252
independent entity REVIEW ORGANIZATION arranging for the experts' 1,253
review and to the enrollee and the enrollee's physician a copy of 1,254
those medical records in the health insuring corporation's 1,255
possession that are relevant to the enrollee's MEDICAL condition 1,258
for which therapy has been recommended or requested AND THE 1,259
REVIEW. The medical records shall be disclosed solely to the 1,262
expert reviewers and shall be used solely for the purpose of this
section. AT THE REQUEST OF THE EXPERT REVIEWERS, THE HEALTH 1,264
INSURING CORPORATION OR THE PHYSICIAN RECOMMENDING THE THERAPY 1,265
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 1,266
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 1,267
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 1,268
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 1,269
28
NECESSARY TO COMPLETE THE REVIEW. 1,270
(7) The IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 1,273
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 1,274
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,276
CORPORATION, THE ENROLLEE, AND THE ENROLLEE'S PHYSICIAN, 1,277
INCLUDING THE ENROLLEE'S MEDICAL RECORDS AND THE STANDARDS, 1,278
CRITERIA, AND CLINICAL RATIONALE USED BY THE HEALTH INSURING 1,279
CORPORATION TO REACH ITS COVERAGE DECISION; 1,280
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,282
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,283
ORGANIZATIONS;
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,285
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 1,286
RECOGNIZED MEDICAL EXPERTS; 1,287
(d) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 1,289
MEDICAL SOCIETIES; 1,290
(e) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 1,292
EFFECTIVENESS.
THE opinions of the experts on the panel shall be rendered 1,295
within thirty days after the enrollee's request for review. If 1,297
the enrollee's physician determines that a therapy would be 1,299
significantly less effective if not promptly initiated, the 1,300
opinions shall be rendered within seven days after the enrollee's 1,301
request for review.
(8) Each expert on the panel shall provide the independent 1,303
entity REVIEW ORGANIZATION with a professional opinion as to 1,305
whether there is sufficient evidence to demonstrate that the 1,306
recommended or requested therapy is likely to be more beneficial
to the enrollee than standard therapies. 1,308
(9) Each expert's opinion shall be presented in written 1,310
form and shall include the following information: 1,312
(a) A description of the enrollee's condition; 1,314
(b) A description of the indicators relevant to 1,316
determining whether there is sufficient evidence to demonstrate 1,317
29
that the recommended or requested therapy is more likely than not 1,319
to be more beneficial to the enrollee than standard therapies; 1,320
(c) A description and analysis of any relevant findings 1,322
published in peer-reviewed medical or scientific literature or 1,323
the published opinions of medical experts or specialty societies; 1,324
(d) A description of the enrollee's suitability to receive 1,326
the recommended or requested therapy according to a treatment 1,327
protocol in a clinical trial, if applicable. 1,329
(10) The independent entity REVIEW ORGANIZATION shall 1,331
provide the health insuring corporation with the opinions of the 1,333
experts. The health insuring corporation shall make the experts' 1,334
opinions available to the enrollee and the enrollee's physician, 1,336
upon request.
(11) The decision OPINION of the majority of the experts 1,338
on the panel, rendered pursuant to division (B)(C)(8) of this 1,340
section, is binding on the health insuring corporation with 1,342
respect to that enrollee. If the opinions of the experts on the 1,343
panel are evenly divided as to whether the therapy should be 1,344
covered, then the health insuring corporation's final decision 1,345
shall be in favor of coverage. If less than a majority of the 1,347
experts on the panel recommend coverage of the therapy, the 1,348
health insuring corporation may, in its discretion, cover the 1,349
therapy. However, any coverage provided pursuant to division 1,350
(B)(C)(11) of this section is subject to the terms, LIMITATIONS, 1,352
and conditions of the enrollee's contract with the health 1,354
insuring corporation.
(12) The health insuring corporation shall have written 1,356
policies describing the external, independent review process. 1,358
The health insuring corporation shall disclose the availability 1,359
of the external, independent review process in the health 1,360
insuring corporation's evidence of coverage and disclosure forms. 1,362
(C)(D) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 1,365
PROCESS, THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,366
RECOMMENDED OR REQUESTED HEALTH CARE SERVICE AND TERMINATE THE 1,367
30
REVIEW. THE HEALTH INSURING CORPORATION SHALL NOTIFY THE 1,368
ENROLLEE AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH THE 1,369
CONSENT OR APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS. 1,370
(E) If a health insuring corporation's initial denial of 1,372
coverage for a therapy recommended or requested pursuant to 1,373
division (A)(3)(4) of this section is based upon an external, 1,374
independent review of that therapy meeting the requirements of 1,375
division (B)(C) of this section, this section shall not be a 1,376
basis for requiring a second external, independent review of the 1,377
recommended or requested therapy. 1,378
(D)(F) The health insuring corporation shall annually file 1,380
a certificate with the superintendent of insurance certifying its 1,381
compliance with the requirements of this section. 1,382
Sec. 1751.87. NOTHING IN SECTIONS 1751.77 TO 1751.85 OF 1,384
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 1,385
AGAINST ANY OF THE FOLLOWING:
AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO EMPLOYEES 1,388
THROUGH A HEALTH INSURING CORPORATION; A CLINICAL PEER OR 1,389
INDEPENDENT REVIEW ORGANIZATION THAT PARTICIPATES IN AN EXTERNAL 1,390
REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE; OR A
HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE FOR BENEFITS 1,391
IN ACCORDANCE WITH DIVISION (F) OF SECTION 1751.84 OR DIVISION 1,392
(C)(11) OF SECTION 1751.85 OF THE REVISED CODE. 1,394
Sec. 1751.88. CONSISTENT WITH THE RULES OF EVIDENCE, A 1,397
WRITTEN DECISION OR OPINION PREPARED BY OR FOR AN INDEPENDENT 1,398
REVIEW ORGANIZATION UNDER SECTION 1751.84 OR 1751.85 OF THE 1,400
REVISED CODE SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO 1,401
THE COVERAGE DECISION THAT WAS THE SUBJECT OF THE DECISION OR 1,402
OPINION. THE INDEPENDENT REVIEW ORGANIZATION'S DECISION OR 1,403
OPINION SHALL BE PRESUMED TO BE A SCIENTIFICALLY VALID AND 1,406
ACCURATE DESCRIPTION OF THE STATE OF MEDICAL KNOWLEDGE AT THE
TIME IT WAS WRITTEN. 1,407
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 1,409
ACTION RELATED TO A HEALTH INSURING CORPORATION'S COVERAGE 1,410
31
DECISION INVOLVING AN INVESTIGATIONAL OR EXPERIMENTAL DRUG, 1,412
DEVICE, OR TREATMENT MAY INTRODUCE INTO EVIDENCE ANY APPLICABLE 1,413
MEDICARE REIMBURSEMENT STANDARDS ESTABLISHED UNDER TITLE XVIII OF 1,414
THE "SOCIAL SECURITY ACT," 49 STAT. 620(1935), 42 U.S.C.A. 301, 1,416
AS AMENDED. 1,417
Sec. 1751.89. (A) AN INDEPENDENT REVIEW ORGANIZATION 1,419
RETAINED BY A HEALTH INSURING CORPORATION TO CONDUCT EXTERNAL 1,421
REVIEWS UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE 1,423
SHALL ANNUALLY REPORT THE FOLLOWING INFORMATION TO THE 1,425
SUPERINTENDENT OF INSURANCE IN A FORMAT PRESCRIBED BY THE
SUPERINTENDENT: 1,426
(1) THE NUMBER OF REVIEWS CONDUCTED; 1,428
(2) THE NUMBER OF REVIEWS DECIDED IN FAVOR OF ENROLLEES 1,430
AND THE NUMBER DECIDED IN FAVOR OF THE HEALTH INSURING 1,431
CORPORATION;
(3) THE AVERAGE TIME REQUIRED TO CONDUCT A REVIEW; 1,433
(4) THE NUMBER AND PERCENTAGE OF REVIEWS IN WHICH A 1,435
DECISION WAS NOT REACHED IN THE TIME REQUIRED UNDER DIVISION (D) 1,436
OF SECTION 1751.84 OR DIVISION (C) OF SECTION 1751.85 OF THE 1,437
REVISED CODE; 1,438
(5) ANY ADDITIONAL INFORMATION REQUIRED BY THE 1,440
SUPERINTENDENT BY RULE ADOPTED PURSUANT TO DIVISION (C) OF THIS 1,441
SECTION;
(6) A SUMMARY OF THE DIAGNOSES, DRUGS, DEVICES, SERVICES, 1,443
PROCEDURES, AND THERAPIES THAT HAVE BEEN THE SUBJECT OF EXTERNAL 1,444
REVIEW.
(B) THE SUPERINTENDENT OF INSURANCE SHALL COMPLY WITH 1,446
APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE CONFIDENTIALITY 1,447
OF MEDICAL RECORDS.
(C) THE SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 1,449
119. OF THE REVISED CODE, ADOPT RULES REQUIRING INDEPENDENT 1,452
REVIEW ORGANIZATIONS TO PROVIDE ADDITIONAL INFORMATION ON THE 1,454
CONSIDERATION AND DISPOSITION OF EXTERNAL REVIEWS BROUGHT UNDER 1,457
SECTION 1751.84 OR 1751.85 OF THE REVISED CODE. 1,458
32
(D) THE SUPERINTENDENT SHALL COMPILE AND ANNUALLY PUBLISH 1,460
THE INFORMATION COLLECTED UNDER THIS SECTION AND REPORT THE 1,463
INFORMATION TO THE GOVERNOR, THE SPEAKER OF THE HOUSE OF 1,464
REPRESENTATIVES, THE PRESIDENT OF THE SENATE, AND THE CHAIRS OF 1,465
THE HOUSE AND SENATE COMMITTEES WITH JURISDICTION OVER HEALTH AND 1,467
INSURANCE ISSUES.
Sec. 1751.90. (A) THE SUPERINTENDENT OF INSURANCE SHALL 1,469
ACCREDIT INDEPENDENT REVIEW ORGANIZATIONS. THE SUPERINTENDENT 1,472
MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE AND IN
CONSULTATION WITH THE DIRECTOR OF HEALTH, ADOPT RULES GOVERNING 1,473
THE ACCREDITATION OF INDEPENDENT REVIEW ORGANIZATIONS. IN 1,474
DEVELOPING THE RULES, THE SUPERINTENDENT MAY TAKE INTO 1,475
CONSIDERATION THE STANDARDS ESTABLISHED BY NATIONAL ORGANIZATIONS 1,476
THAT ACCREDIT ORGANIZATIONS PROVIDING EXPERT REVIEWS AND RELATED 1,478
SERVICES. THE SUPERINTENDENT SHALL ACCEPT ACCREDITATION BY A 1,479
NATIONAL ORGANIZATION RECOGNIZED BY THE SUPERINTENDENT AS
ACCREDITATION BY THE SUPERINTENDENT. THE SUPERINTENDENT SHALL 1,480
NOT ACCREDIT ANY INDEPENDENT REVIEW ORGANIZATION THAT IS OPERATED 1,481
BY A NATIONAL, STATE, OR LOCAL TRADE ASSOCIATION OF HEALTH 1,482
BENEFIT PLANS OR HEALTH CARE PROVIDERS.
(B) EACH INDEPENDENT REVIEW ORGANIZATION SHALL USE THE 1,484
SERVICES OF MEDICAL EXPERTS OR CLINICAL PEERS OUTSIDE THE STAFF 1,486
OF THE INDEPENDENT REVIEW ORGANIZATION TO CONDUCT EXTERNAL 1,487
REVIEWS. NEITHER THE HEALTH INSURING CORPORATION NOR THE
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE CLINICAL 1,488
PEER PHYSICIAN OR OTHER MEDICAL EXPERTS. 1,489
(C) THE SUPERINTENDENT SHALL MAINTAIN A RANDOMLY ORGANIZED 1,491
ROSTER OF EXTERNAL REVIEW ORGANIZATIONS ACCREDITED UNDER THIS 1,492
SECTION FOR PURPOSES OF SELECTING EXTERNAL REVIEW ORGANIZATIONS 1,493
TO CONDUCT EXTERNAL REVIEWS. 1,494
ON RECEIPT OF A REQUEST BY A HEALTH INSURING CORPORATION, 1,496
THE SUPERINTENDENT MUST RANDOMLY ASSIGN TWO EXTERNAL REVIEW 1,497
ORGANIZATIONS THAT ARE ACCREDITED UNDER DIVISION (A) OF THIS 1,499
SECTION AND ARE QUALIFIED UNDER DIVISION (D)(1) OF SECTION 1,500
33
1751.84 OF THE REVISED CODE TO CONDUCT THE REVIEW. AFTER RECEIPT 1,502
OF THE NAMES OF THE TWO EXTERNAL REVIEW ORGANIZATIONS, THE HEALTH 1,503
INSURING CORPORATION SHALL SELECT ONE OF THE ASSIGNED EXTERNAL 1,504
REVIEW ORGANIZATIONS TO CONDUCT THE EXTERNAL REVIEW.
NO HEALTH INSURING CORPORATION SHALL ENGAGE IN A PATTERN OF 1,506
EXCLUDING A PARTICULAR REVIEW ORGANIZATION BASED ON PREVIOUS 1,507
FINDINGS ON BEHALF OF ENROLLEES. IF THE SUPERINTENDENT MAKES 1,508
SUCH A FINDING, IT IS AN UNFAIR TRADE PRACTICE. 1,509
Sec. 1753.13. EVERY INDIVIDUAL OR GROUP HEALTH INSURING 1,511
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES BASIC 1,512
HEALTH CARE SERVICES BUT DOES NOT ALLOW DIRECT ACCESS TO 1,513
OBSTETRICIANS OR GYNECOLOGISTS SHALL PERMIT A FEMALE ENROLLEE TO 1,514
OBTAIN COVERED OBSTETRIC AND GYNECOLOGICAL SERVICES FROM A 1,515
PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST WITHOUT OBTAINING A 1,517
REFERRAL FROM THE ENROLLEE'S PRIMARY CARE PROVIDER. 1,518
NO INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, 1,520
CONTRACT, OR AGREEMENT MAY LIMIT THE NUMBER OF ALLOWABLE VISITS 1,521
TO A PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST. A HEALTH 1,522
INSURING CORPORATION MAY REQUIRE A PARTICIPATING OBSTETRICIAN OR 1,523
GYNECOLOGIST TO COMPLY WITH THE HEALTH INSURING CORPORATION'S 1,524
COVERAGE PROTOCOLS AND PROCEDURES, INCLUDING UTILIZATION REVIEW, 1,525
FOR OBSTETRIC AND GYNECOLOGICAL SERVICES. 1,526
A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 1,528
AGREEMENT MAY NOT IMPOSE ADDITIONAL COPAYMENTS FOR DIRECTLY 1,530
ACCESSED OBSTETRIC AND GYNECOLOGICAL SERVICES, UNLESS THE POLICY, 1,531
CONTRACT, OR AGREEMENT IMPOSES ADDITIONAL COPAYMENTS FOR DIRECT
ACCESS TO ANY PARTICIPATING PROVIDER OTHER THAN A PRIMARY CARE 1,532
PROVIDER.
Sec. 3923.65. (A) AS USED IN THIS SECTION: 1,534
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 1,536
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 1,537
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 1,538
LAYPERSON WITH AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 1,539
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 1,540
34
RESULT IN ANY OF THE FOLLOWING: 1,541
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 1,543
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 1,544
IN SERIOUS JEOPARDY; 1,545
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,547
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,549
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 1,551
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 1,553
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 1,554
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 1,556
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 1,557
MEDICAL CONDITION; 1,558
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 1,560
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 1,561
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND 1,563
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 1,564
BURN CENTER OF THE HOSPITAL.
(B) EVERY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND 1,566
ACCIDENT INSURANCE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL 1,567
EXPENSE COVERAGE SHALL COVER EMERGENCY SERVICES WITHOUT REGARD TO 1,568
THE DAY OR TIME THE EMERGENCY SERVICES ARE RENDERED OR TO WHETHER 1,569
THE POLICYHOLDER, THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE 1,570
SERVICES ARE RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE 1,571
POLICYHOLDER, OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY 1,572
SERVICES.
(C) EVERY INDIVIDUAL POLICY OR CERTIFICATE FURNISHED BY AN 1,574
INSURER IN CONNECTION WITH ANY SICKNESS AND ACCIDENT INSURANCE 1,576
POLICY SHALL PROVIDE INFORMATION REGARDING THE FOLLOWING: 1,577
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 1,579
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 1,581
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 1,582
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 1,583
(3) ANY COPAYMENTS FOR EMERGENCY SERVICES. 1,585
(D) THIS SECTION DOES NOT APPLY TO ANY INDIVIDUAL OR GROUP 1,587
35
POLICY OF SICKNESS AND ACCIDENT INSURANCE COVERING ONLY ACCIDENT, 1,588
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 1,589
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 1,590
DISEASE, OR VISION CARE; COVERAGE UNDER A ONE-TIME LIMITED 1,591
DURATION POLICY OF NO LONGER THAN SIX MONTHS; COVERAGE ISSUED AS 1,592
A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING OUT OF 1,593
WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 1,594
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 1,595
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 1,596
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,597
SELF-INSURANCE.
Sec. 5747.01. Except as otherwise expressly provided or 1,606
clearly appearing from the context, any term used in this chapter 1,607
has the same meaning as when used in a comparable context in the 1,608
Internal Revenue Code, and all other statutes of the United 1,609
States relating to federal income taxes. 1,610
As used in this chapter: 1,612
(A) "Adjusted gross income" or "Ohio adjusted gross 1,614
income" means adjusted gross income as defined and used in the 1,615
Internal Revenue Code, adjusted as provided in divisions (A)(1) 1,617
to (17) of this section:
(1) Add interest or dividends on obligations or securities 1,619
of any state or of any political subdivision or authority of any 1,620
state, other than this state and its subdivisions and 1,621
authorities.
(2) Add interest or dividends on obligations of any 1,623
authority, commission, instrumentality, territory, or possession 1,624
of the United States that are exempt from federal income taxes 1,625
but not from state income taxes. 1,626
(3) Deduct interest or dividends on obligations of the 1,628
United States and its territories and possessions or of any 1,629
authority, commission, or instrumentality of the United States to 1,630
the extent included in federal adjusted gross income but exempt 1,631
from state income taxes under the laws of the United States. 1,632
36
(4) Deduct disability and survivor's benefits to the 1,634
extent included in federal adjusted gross income. 1,635
(5) Deduct benefits under Title II of the Social Security 1,637
Act and tier 1 railroad retirement benefits to the extent 1,638
included in federal adjusted gross income under section 86 of the 1,639
Internal Revenue Code. 1,640
(6) Add, in the case of a taxpayer who is a beneficiary of 1,642
a trust that makes an accumulation distribution as defined in 1,643
section 665 of the Internal Revenue Code, the portion, if any, of 1,644
such distribution that does not exceed the undistributed net 1,645
income of the trust for the three taxable years preceding the 1,646
taxable year in which the distribution is made. "Undistributed 1,647
net income of a trust" means the taxable income of the trust 1,648
increased by (a)(i) the additions to adjusted gross income 1,649
required under division (A) of this section and (ii) the personal 1,650
exemptions allowed to the trust pursuant to section 642(b) of the 1,651
Internal Revenue Code, and decreased by (b)(i) the deductions to 1,652
adjusted gross income required under division (A) of this 1,653
section, (ii) the amount of federal income taxes attributable to 1,654
such income, and (iii) the amount of taxable income that has been 1,655
included in the adjusted gross income of a beneficiary by reason 1,656
of a prior accumulation distribution. Any undistributed net 1,657
income included in the adjusted gross income of a beneficiary 1,658
shall reduce the undistributed net income of the trust commencing 1,659
with the earliest years of the accumulation period. 1,660
(7) Deduct the amount of wages and salaries, if any, not 1,662
otherwise allowable as a deduction but that would have been 1,663
allowable as a deduction in computing federal adjusted gross 1,664
income for the taxable year, had the targeted jobs credit allowed 1,665
and determined under sections 38, 51, and 52 of the Internal 1,666
Revenue Code not been in effect. 1,667
(8) Deduct any interest or interest equivalent on public 1,669
obligations and purchase obligations to the extent included in 1,670
federal adjusted gross income. 1,671
37
(9) Add any loss or deduct any gain resulting from the 1,673
sale, exchange, or other disposition of public obligations to the 1,674
extent included in federal adjusted gross income. 1,675
(10) Regarding tuition credits purchased under Chapter 1,677
3334. of the Revised Code: 1,678
(a) Deduct the following: 1,680
(i) For credits that as of the end of the taxable year 1,683
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 1,685
amount of income related to the credits, to the extent included 1,686
in federal adjusted gross income;
(ii) For credits that during the taxable year have been 1,689
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 1,690
the total purchase price of the tuition credits refunded over the 1,691
amount of refund, to the extent the amount of the excess was not 1,692
deducted in determining federal adjusted gross income;. 1,693
(b) Add the following: 1,695
(i) For credits that as of the end of the taxable year 1,698
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 1,699
amount of loss related to the credits, to the extent the amount 1,700
of the loss was deducted in determining federal adjusted gross 1,701
income;
(ii) For credits that during the taxable year have been 1,704
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 1,706
the amount of refund over the purchase price of each tuition 1,707
credit refunded, to the extent not included in federal adjusted 1,708
gross income.
(11)(a) Deduct, in the case of a self-employed individual 1,710
as defined in section 401(c)(1) of the Internal Revenue Code and 1,711
to the extent not otherwise allowable as a deduction OR EXCLUSION 1,712
in computing federal OR OHIO adjusted gross income for the 1,714
38
taxable year, the amount THE TAXPAYER paid during the taxable 1,716
year for insurance that constitutes medical care INSURANCE AND 1,717
QUALIFIED LONG-TERM CARE INSURANCE for the taxpayer, the 1,718
taxpayer's spouse, and dependents. No deduction FOR MEDICAL CARE 1,720
INSURANCE under division (A)(11) of this section shall be allowed 1,721
EITHER to any taxpayer who is eligible to participate in any 1,722
subsidized health plan maintained by any employer of the taxpayer 1,723
or of the TAXPAYER'S spouse of the taxpayer. No deduction under 1,725
division (A)(11) of this section shall be allowed to the extent 1,727
that the sum of such deduction and any related deduction 1,728
allowable in computing federal adjusted gross income for the 1,729
taxable year exceeds the taxpayer's earned income, within the 1,730
meaning of section 401(c) of the Internal Revenue Code, derived 1,731
by the taxpayer from the trade or business with respect to which 1,732
the plan providing the medical coverage is established., OR TO 1,735
ANY TAXPAYER WHO IS ENTITLED TO, OR ON APPLICATION WOULD BE
ENTITLED TO, BENEFITS UNDER PART A OF TITLE XVIII OF THE "SOCIAL 1,737
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C. 301, AS AMENDED. 1,738
FOR THE PURPOSES OF DIVISION (A)(11)(a) OF THIS SECTION, 1,739
"SUBSIDIZED HEALTH PLAN" MEANS A HEALTH PLAN FOR WHICH THE 1,741
EMPLOYER PAYS ANY PORTION OF THE PLAN'S COST. THE DEDUCTION 1,742
ALLOWED UNDER DIVISION (A)(11)(a) OF THIS SECTION SHALL BE THE 1,745
NET OF ANY RELATED PREMIUM REFUNDS, RELATED PREMIUM
REIMBURSEMENTS, OR RELATED INSURANCE PREMIUM DIVIDENDS RECEIVED 1,748
DURING THE TAXABLE YEAR. 1,749
(b) DEDUCT, TO THE EXTENT NOT OTHERWISE DEDUCTED OR 1,751
EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED GROSS INCOME 1,752
DURING THE TAXABLE YEAR, THE AMOUNT THE TAXPAYER PAID DURING THE 1,753
TAXABLE YEAR, NOT COMPENSATED FOR BY ANY INSURANCE OR OTHERWISE, 1,754
FOR MEDICAL CARE OF THE TAXPAYER, THE TAXPAYER'S SPOUSE, AND 1,755
DEPENDENTS, TO THE EXTENT THE EXPENSES EXCEED SEVEN AND ONE-HALF 1,756
PER CENT OF THE TAXPAYER'S FEDERAL ADJUSTED GROSS INCOME. 1,757
(c) FOR PURPOSES OF DIVISION (A)(11) OF THIS SECTION, 1,759
"MEDICAL CARE" HAS THE MEANING GIVEN IN SECTION 213 OF THE 1,761
39
INTERNAL REVENUE CODE, SUBJECT TO THE SPECIAL RULES, LIMITATIONS, 1,762
AND EXCLUSIONS SET FORTH THEREIN, AND "QUALIFIED LONG-TERM CARE" 1,763
HAS THE SAME MEANING GIVEN IN SECTION 7702(B)(b) OF THE INTERNAL 1,764
REVENUE CODE. 1,765
(12)(a) Deduct any amount included in federal adjusted 1,767
gross income solely because the amount represents a reimbursement 1,768
or refund of expenses that in a previous ANY year the taxpayer 1,769
had deducted as an itemized deduction pursuant to section 63 of 1,770
the Internal Revenue Code and applicable United States department 1,772
of the treasury regulations. THE DEDUCTION OTHERWISE ALLOWED 1,773
UNDER DIVISION (A)(12)(a) OF THIS SECTION SHALL BE REDUCED TO THE 1,775
EXTENT THE REIMBURSEMENT IS ATTRIBUTABLE TO AN AMOUNT THE 1,776
TAXPAYER DEDUCTED UNDER THIS SECTION IN ANY TAXABLE YEAR. 1,777
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO ADJUSTED 1,779
GROSS INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT 1,782
IS ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 1,784
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED 1,785
GROSS INCOME IN ANY TAXABLE YEAR.
(13) Deduct any portion of the deduction described in 1,787
section 1341(a)(2) of the Internal Revenue Code, for repaying 1,788
previously reported income received under a claim of right, that 1,789
meets both of the following requirements: 1,790
(a) It is allowable for repayment of an item that was 1,792
included in the taxpayer's adjusted gross income for a prior 1,793
taxable year and did not qualify for a credit under division (A) 1,794
or (B) of section 5747.05 of the Revised Code for that year; 1,795
(b) It does not otherwise reduce the taxpayer's adjusted 1,797
gross income for the current or any other taxable year. 1,798
(14) Deduct an amount equal to the deposits made to, and 1,800
net investment earnings of, a medical savings account during the 1,801
taxable year, in accordance with section 3924.66 of the Revised 1,802
Code. The deduction allowed by division (A)(14) of this section 1,803
does not apply to medical savings account deposits and earnings 1,804
otherwise deducted or excluded for the current or any other 1,805
40
taxable year from the taxpayer's federal adjusted gross income. 1,806
(15)(a) Add an amount equal to the funds withdrawn from a 1,808
medical savings account during the taxable year, and the net 1,809
investment earnings on those funds, when the funds withdrawn were 1,810
used for any purpose other than to reimburse an account holder 1,811
for, or to pay, eligible medical expenses, in accordance with 1,812
section 3924.66 of the Revised Code;
(b) Add the amounts distributed from a medical savings 1,814
account under division (A)(2) of section 3924.68 of the Revised 1,815
Code during the taxable year. 1,816
(16) Add any amount claimed as a credit under section 1,818
5747.059 of the Revised Code to the extent that such amount 1,819
satisfies either of the following:
(a) The amount was deducted or excluded from the 1,821
computation of the taxpayer's federal adjusted gross income as 1,822
required to be reported for the taxpayer's taxable year under the 1,823
Internal Revenue Code;
(b) The amount resulted in a reduction of the taxpayer's 1,825
federal adjusted gross income as required to be reported for any 1,826
of the taxpayer's taxable years under the Internal Revenue Code. 1,827
(17) Deduct the amount contributed by the taxpayer to an 1,829
individual development account program established by a county 1,830
department of human services pursuant to sections 329.11 to 1,831
329.14 of the Revised Code for the purpose of matching funds 1,832
deposited by program participants. On request of the tax 1,833
commissioner, the taxpayer shall provide any information that, in
the tax commissioner's opinion, is necessary to establish the 1,834
amount deducted under division (A)(17) of this section. 1,835
(B) "Business income" means income arising from 1,837
transactions, activities, and sources in the regular course of a 1,838
trade or business and includes income from tangible and 1,839
intangible property if the acquisition, rental, management, and 1,840
disposition of the property constitute integral parts of the 1,841
regular course of a trade or business operation. 1,842
41
(C) "Nonbusiness income" means all income other than 1,844
business income and may include, but is not limited to, 1,845
compensation, rents and royalties from real or tangible personal 1,846
property, capital gains, interest, dividends and distributions, 1,847
patent or copyright royalties, or lottery winnings, prizes, and 1,848
awards. 1,849
(D) "Compensation" means any form of remuneration paid to 1,851
an employee for personal services. 1,852
(E) "Fiduciary" means a guardian, trustee, executor, 1,854
administrator, receiver, conservator, or any other person acting 1,855
in any fiduciary capacity for any individual, trust, or estate. 1,856
(F) "Fiscal year" means an accounting period of twelve 1,858
months ending on the last day of any month other than December. 1,859
(G) "Individual" means any natural person. 1,861
(H) "Internal Revenue Code" means the "Internal Revenue 1,863
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 1,864
(I) "Resident" means: 1,866
(1) An individual who is domiciled in this state, subject 1,868
to section 5747.24 of the Revised Code; 1,869
(2) The estate of a decedent who at the time of death was 1,872
domiciled in this state. The domicile tests of section 5747.24 1,873
of the Revised Code and any election under section 5747.25 of the 1,874
Revised Code are not controlling for purposes of division (I)(2) 1,875
of this section.
(J) "Nonresident" means an individual or estate that is 1,877
not a resident. An individual who is a resident for only part of 1,878
a taxable year is a nonresident for the remainder of that taxable 1,879
year. 1,880
(K) "Pass-through entity" has the same meaning as in 1,882
section 5733.04 of the Revised Code. 1,883
(L) "Return" means the notifications and reports required 1,885
to be filed pursuant to this chapter for the purpose of reporting 1,886
the tax due and includes declarations of estimated tax when so 1,887
required. 1,888
42
(M) "Taxable year" means the calendar year or the 1,890
taxpayer's fiscal year ending during the calendar year, or 1,891
fractional part thereof, upon which the adjusted gross income is 1,892
calculated pursuant to this chapter. 1,893
(N) "Taxpayer" means any person subject to the tax imposed 1,895
by section 5747.02 of the Revised Code or any pass-through entity 1,896
that makes the election under division (D) of section 5747.08 of 1,897
the Revised Code.
(O) "Dependents" means dependents as defined in the 1,899
Internal Revenue Code and as claimed in the taxpayer's federal 1,900
income tax return for the taxable year or which the taxpayer 1,901
would have been permitted to claim had the taxpayer filed a 1,902
federal income tax return. 1,904
(P) "Principal county of employment" means, in the case of 1,906
a nonresident, the county within the state in which a taxpayer 1,907
performs services for an employer or, if those services are 1,908
performed in more than one county, the county in which the major 1,909
portion of the services are performed. 1,910
(Q) As used in sections 5747.50 to 5747.55 of the Revised 1,912
Code:
(1) "Subdivision" means any county, municipal corporation, 1,914
park district, or township. 1,915
(2) "Essential local government purposes" includes all 1,917
functions that any subdivision is required by general law to 1,918
exercise, including like functions that are exercised under a 1,919
charter adopted pursuant to the Ohio Constitution. 1,920
(R) "Overpayment" means any amount already paid that 1,922
exceeds the figure determined to be the correct amount of the 1,923
tax. 1,924
(S) "Taxable income" applies to estates only and means 1,926
taxable income as defined and used in the Internal Revenue Code 1,927
adjusted as follows: 1,928
(1) Add interest or dividends on obligations or securities 1,930
of any state or of any political subdivision or authority of any 1,931
43
state, other than this state and its subdivisions and 1,932
authorities; 1,933
(2) Add interest or dividends on obligations of any 1,935
authority, commission, instrumentality, territory, or possession 1,936
of the United States that are exempt from federal income taxes 1,937
but not from state income taxes; 1,938
(3) Add the amount of personal exemption allowed to the 1,940
estate pursuant to section 642(b) of the Internal Revenue Code; 1,941
(4) Deduct interest or dividends on obligations of the 1,943
United States and its territories and possessions or of any 1,944
authority, commission, or instrumentality of the United States 1,945
that are exempt from state taxes under the laws of the United 1,946
States; 1,947
(5) Deduct the amount of wages and salaries, if any, not 1,949
otherwise allowable as a deduction but that would have been 1,950
allowable as a deduction in computing federal taxable income for 1,951
the taxable year, had the targeted jobs credit allowed under 1,952
sections 38, 51, and 52 of the Internal Revenue Code not been in 1,953
effect; 1,954
(6) Deduct any interest or interest equivalent on public 1,956
obligations and purchase obligations to the extent included in 1,957
federal taxable income; 1,958
(7) Add any loss or deduct any gain resulting from sale, 1,960
exchange, or other disposition of public obligations to the 1,961
extent included in federal taxable income; 1,962
(8) Except in the case of the final return of an estate, 1,964
add any amount deducted by the taxpayer on both its Ohio estate 1,965
tax return pursuant to section 5731.14 of the Revised Code, and 1,966
on its federal income tax return in determining either federal 1,967
adjusted gross income or federal taxable income; 1,968
(9)(a) Deduct any amount included in federal taxable 1,970
income solely because the amount represents a reimbursement or 1,971
refund of expenses that in a previous year the decedent had 1,972
deducted as an itemized deduction pursuant to section 63 of the 1,973
44
Internal Revenue Code and applicable treasury regulations;. THE 1,975
DEDUCTION OTHERWISE ALLOWED UNDER DIVISION (S)(9)(a) OF THIS 1,977
SECTION SHALL BE REDUCED TO THE EXTENT THE REIMBURSEMENT IS
ATTRIBUTABLE TO AN AMOUNT THE TAXPAYER OR DECEDENT DEDUCTED UNDER 1,978
THIS SECTION IN ANY TAXABLE YEAR. 1,979
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO TAXABLE 1,982
INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT IS 1,983
ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 1,984
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO TAXABLE 1,985
INCOME IN ANY TAXABLE YEAR.
(10) Deduct any portion of the deduction described in 1,987
section 1341(a)(2) of the Internal Revenue Code, for repaying 1,988
previously reported income received under a claim of right, that 1,989
meets both of the following requirements: 1,990
(a) It is allowable for repayment of an item that was 1,992
included in the taxpayer's taxable income or the decedent's 1,993
adjusted gross income for a prior taxable year and did not 1,994
qualify for a credit under division (A) or (B) of section 5747.05 1,995
of the Revised Code for that year. 1,996
(b) It does not otherwise reduce the taxpayer's taxable 1,998
income or the decedent's adjusted gross income for the current or 1,999
any other taxable year. 2,000
(11) Add any amount claimed as a credit under section 2,002
5747.059 of the Revised Code to the extent that the amount 2,003
satisfies either of the following: 2,004
(a) The amount was deducted or excluded from the 2,006
computation of the taxpayer's federal taxable income as required 2,007
to be reported for the taxpayer's taxable year under the Internal 2,008
Revenue Code;
(b) The amount resulted in a reduction in the taxpayer's 2,010
federal taxable income as required to be reported for any of the 2,011
taxpayer's taxable years under the Internal Revenue Code. 2,012
(T) "School district income" and "school district income 2,014
tax" have the same meanings as in section 5748.01 of the Revised 2,015
45
Code. 2,016
(U) As used in divisions (A)(8), (A)(9), (S)(6), and 2,018
(S)(7) of this section, "public obligations," "purchase 2,019
obligations," and "interest or interest equivalent" have the same 2,020
meanings as in section 5709.76 of the Revised Code. 2,021
(V) "Limited liability company" means any limited 2,023
liability company formed under Chapter 1705. of the Revised Code 2,024
or under the laws of any other state. 2,025
(W) "Pass-through entity investor" means any person who, 2,027
during any portion of a taxable year of a pass-through entity, is 2,028
a partner, member, shareholder, or investor in that pass-through 2,029
entity.
(X) "Banking day" has the same meaning as in section 2,031
1304.01 of the Revised Code. 2,032
(Y) "Month" means a calendar month. 2,034
(Z) "Quarter" means the first three months, the second 2,036
three months, the third three months, or the last three months of 2,037
the taxpayer's taxable year.
(AA) Any term used in this chapter that is not otherwise 2,039
defined in this section and that is not used in a comparable 2,040
context in the Internal Revenue Code and other statutes of the 2,041
United States relating to federal income taxes has the same 2,042
meaning as in section 5733.40 of the Revised Code. 2,043
Section 2. That existing sections 1751.11, 1751.19, 2,045
1751.33, 1751.77, 1751.78, 1751.81, 1751.82, 1751.83, 1751.84, 2,046
1751.85, 1753.24, and 5747.01 of the Revised Code are hereby 2,047
repealed.
Section 3. Section 3923.65 of the Revised Code applies 2,049
only to policies issued, issued for delivery, or renewed in this 2,050
state on or after the effective date of this section. 2,051
Section 4. The amendment by this act of section 5747.01 of 2,053
the Revised Code applies to taxable years beginning on or after 2,054
January 1, 1999.
Section 5. It is the intent of the General Assembly that 2,056
46
sections 1751.84 and 1751.85 of the Revised Code, as enacted or 2,057
amendment by this act, provide health insuring corporation 2,058
enrollees with a means for resolving health care coverage 2,059
disputes expeditiously and avoid the need for lengthy and
expensive litigation. 2,060