As Passed by the House 1
123rd General Assembly 4
Regular Session Sub. H. B. No. 4 5
1999-2000 6
REPRESENTATIVES GARDNER-TIBERI-BUCHY-HARRIS-BRADING- 8
CALLENDER-CAREY-CATES-CORBIN-CORE-COUGHLIN-EVANS- 9
GOODMAN-GRENDELL-HAINES-HOOD-HOOPS-JACOBSON-JOLIVETTE- 10
KILBANE-KREBS-MAIER-MEAD-METZGER-MOTTLEY-MYERS-O'BRIEN- 11
OLMAN-PADGETT-ROMAN-SALERNO-SCHULER-SCHURING-TERWILLEGER- 12
THOMAS-WILLAMOWSKI-WINKLER-WOMER BENJAMIN-YOUNG-VESPER- 13
HOUSEHOLDER-AUSTRIA 14
_________________________________________________________________ 15
A B I L L
To amend sections 1751.11, 1751.19, 1751.33, 17
1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 18
5747.01; to amend, for the purpose of adopting
new section numbers as indicated in parentheses, 19
sections 1751.83 (1751.821), 1751.84 (1751.822), 20
1751.85 (1751.823), and 1753.24 (1751.85); and to
enact new sections 1751.83 and 1751.84 and 21
sections 1751.811, 1751.831, 1751.87, 1751.88, 22
1751.89, 1751.90, 1753.13, and 3923.65 of the
Revised Code to establish procedures for enrollee 24
appeals of health care coverage decisions by
health insuring corporations and to make other 25
changes in the laws related to health insuring 26
corporations.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 28
Section 1. That sections 1751.11, 1751.19, 1751.33, 30
1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 5747.01 be 31
amended, sections 1751.83 (1751.821), 1751.84 (1751.822), 1751.85 32
(1751.823), and 1753.24 (1751.85) be amended for the purpose of 33
adopting new section numbers as indicated in parentheses, and new 34
2
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 35
Revised Code be enacted to read as follows: 37
Sec. 1751.11. (A) Every subscriber of a health insuring 47
corporation is entitled to an evidence of coverage for the health 48
care plan under which health care benefits are provided. 50
(B) Every subscriber of a health insuring corporation that 52
offers basic health care services is entitled to an 53
identification card or similar document that specifies the health 54
insuring corporation's name as stated in its articles of 55
incorporation, and any trade or fictitious names used by the 56
health insuring corporation. The identification card or document 57
shall list at least one TOLL-FREE telephone number that provides 58
the subscriber with access to health care on a 59
twenty-four-hours-per-day, seven-days-per-week basis. THE 60
IDENTIFICATION CARD OR DOCUMENT SHALL ALSO LIST AT LEAST ONE 61
TOLL-FREE NUMBER THAT, DURING NORMAL BUSINESS HOURS, PROVIDES THE 62
SUBSCRIBER WITH ACCESS TO INFORMATION ON THE COVERAGE AVAILABLE
UNDER THE SUBSCRIBER'S HEALTH CARE PLAN AND INFORMATION ON THE 63
HEALTH CARE PLAN'S INTERNAL AND EXTERNAL APPEALS PROCESSES. 64
(C) No evidence of coverage, or amendment to the evidence 66
of coverage, shall be delivered, issued for delivery, renewed, or 67
used, until the form of the evidence of coverage or amendment has 68
been filed by the health insuring corporation with the 69
superintendent of insurance. If the superintendent does not 70
disapprove the evidence of coverage or amendment within sixty 71
days after it is filed it shall be deemed approved, unless the 72
superintendent sooner gives approval for the evidence of coverage 73
or amendment. With respect to an amendment to an approved 74
evidence of coverage, the superintendent only may disapprove 75
provisions amended or added to the evidence of coverage. If the 76
superintendent determines within the sixty-day period that any 77
evidence of coverage or amendment fails to meet the requirements 78
of this section, the superintendent shall so notify the health 79
3
insuring corporation and it shall be unlawful for the health 80
insuring corporation to use such evidence of coverage or 81
amendment. At any time, the superintendent, upon at least thirty 83
days' written notice to a health insuring corporation, may 84
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 85
section. Such disapproval shall be effected by a written order, 86
which shall state the grounds for disapproval and shall be issued 88
in accordance with Chapter 119. of the Revised Code. 90
(D) No evidence of coverage or amendment shall be 92
delivered, issued for delivery, renewed, or used: 93
(1) If it contains provisions or statements that are 95
inequitable, untrue, misleading, or deceptive; 96
(2) Unless it contains a clear, concise, and complete 98
statement of the following: 99
(a) The health care services and insurance or other 102
benefits, if any, to which the AN enrollee is entitled under the 104
health care plan;
(b) Any exclusions or limitations on the health care 107
services, type of health care services, benefits, or type of 108
benefits to be provided, including copayments; 109
(c) The AN enrollee's personal financial obligation for 111
noncovered services; 113
(d) Where and in what manner general information and 116
information as to how services may be obtained is available, 117
including the A TOLL-FREE telephone number; 119
(e) The premium rate with respect to individual and 121
conversion contracts, and relevant copayment provisions with 122
respect to all contracts. The statement of the premium rate, 123
however, may be contained in a separate insert. 124
(f) The method utilized by the health insuring corporation 127
for resolving enrollee complaints; 128
(g) THE UTILIZATION REVIEW, INTERNAL REVIEW, AND EXTERNAL 130
REVIEW PROCEDURES ESTABLISHED UNDER SECTIONS 1751.77 TO 1751.85 132
4
OF THE REVISED CODE. 134
(3) Unless it provides for the continuation of an 136
enrollee's coverage, in the event that the enrollee's coverage 137
under the group policy, contract, certificate, or agreement 138
terminates while the enrollee is receiving inpatient care in a 139
hospital. This continuation of coverage shall terminate at the 140
earliest occurrence of any of the following: 141
(a) The enrollee's discharge from the hospital; 143
(b) The determination by the enrollee's attending 145
physician that inpatient care is no longer medically indicated 146
for the enrollee; however, nothing in division (D)(3)(b) of this 149
section precludes a health insuring corporation from engaging in 150
utilization review as described in the evidence of coverage. 151
(c) The enrollee's reaching the limit for contractual 153
benefits; 154
(d) The effective date of any new coverage. 157
(4) Unless it contains a provision that states, in 159
substance, that the health insuring corporation is not a member 160
of any guaranty fund, and that in the event of the health 161
insuring corporation's insolvency, the AN enrollee is protected 162
only to the extent that the hold harmless provision required by 163
section 1751.13 of the Revised Code applies to the health care 165
services rendered; 166
(5) Unless it contains a provision that states, in 168
substance, that in the event of the insolvency of the health 169
insuring corporation, the AN enrollee may be financially 170
responsible for health care services rendered by a provider or 171
health care facility that is not under contract to the health 172
insuring corporation, whether or not the health insuring 173
corporation authorized the use of the provider or health care 174
facility. 175
(E) Notwithstanding divisions (C) and (D) of this section, 178
a health insuring corporation may use an evidence of coverage 179
that provides for the coverage of beneficiaries enrolled in Title 181
5
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 182
U.S.C.A. 301, as amended, pursuant to a medicare contract, or an 184
evidence of coverage that provides for the coverage of 185
beneficiaries enrolled in the federal employees health benefits 186
program pursuant to 5 U.S.C.A. 8905, or an evidence of coverage 188
that provides for the coverage of beneficiaries enrolled in Title 190
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 191
U.S.C.A. 301, as amended, known as the medical assistance program 193
or medicaid, provided by the Ohio department of human services 194
under Chapter 5111. of the Revised Code, or an evidence of 195
coverage that provides for the coverage of beneficiaries under 196
any other federal health care program regulated by a federal 197
regulatory body, or an evidence of coverage that provides for the 198
coverage of beneficiaries under any contract covering officers or 199
employees of the state that has been entered into by the 201
department of administrative services, if both of the following 203
apply: 204
(1) The evidence of coverage has been approved by the 206
United States department of health and human services, the United 208
States office of personnel management, the Ohio department of 209
human services, or the department of administrative services. 210
(2) The evidence of coverage is filed with the 212
superintendent of insurance prior to use and is accompanied by 213
documentation of approval from the United States department of 215
health and human services, the United States office of personnel 216
management, the Ohio department of human services, or the 217
department of administrative services. 218
Sec. 1751.19. (A) A health insuring corporation shall 228
establish and maintain a complaint system that has been approved 229
by the superintendent of insurance to provide adequate and 230
reasonable procedures for the expeditious resolution of written 231
complaints initiated by subscribers or enrollees concerning any 232
matter relating to services provided, directly or indirectly, by 233
the health insuring corporation, including, but not limited to, 234
6
claims COMPLAINTS regarding the scope of coverage for health care 235
services, and denials, cancellations, or nonrenewals of coverage. 237
COMPLAINTS REGARDING A HEALTH INSURING CORPORATION'S DECISION TO 239
DENY, REDUCE, OR TERMINATE COVERAGE FOR HEALTH CARE SERVICES ARE
SUBJECT TO SECTION 1751.83 OF THE REVISED CODE. 240
(B) A health insuring corporation shall provide a timely 243
written response to each written complaint it receives. 244
Responses to written complaints relating to quality or 245
appropriateness of care shall set forth a statement informing the 246
complainant in detail of any rights the complainant may have to 247
submit such complaint to any professional peer review 248
organization or health insuring corporation peer review committee 249
that has been set up to monitor the quality or appropriateness of 250
provider services rendered. Such statement shall set forth the 251
name of the peer review organization or health insuring 252
corporation peer review committee, its address, telephone number, 253
and any other pertinent data that will enable the complainant to 254
seek further independent review of the complaint. Such appeal 255
shall not be made to the peer review corporation or health 256
insuring corporation peer review committee until the complaint 257
system of the health insuring corporation has been exhausted. 258
(C) Copies of complaints and responses, including medical 261
records related to those complaints, shall be available to the 262
superintendent and the director of health for inspection for 263
three years. Any document or information provided to the 264
superintendent pursuant to this division that contains a medical 265
record is confidential, and is not a public record subject to 266
section 149.43 of the Revised Code.
(D) A health insuring corporation shall establish and 269
maintain a procedure to accept complaints over the telephone or 270
in person. These complaints are not subject to the reporting 271
requirement under division (C) of section 1751.32 of the Revised 273
Code.
(E) A HEALTH INSURING CORPORATION MAY COMPLY WITH THIS 276
7
SECTION AND SECTION 1751.83 OF THE REVISED CODE BY ESTABLISHING 277
ONE SYSTEM FOR RECEIVING AND REVIEWING COMPLAINTS AND APPEALS 278
FROM ENROLLEES AND SUBSCRIBERS IF THE SYSTEM MEETS THE
REQUIREMENTS OF BOTH SECTIONS. 279
Sec. 1751.33. (A) Each health insuring corporation shall 288
provide to its subscribers, by mail, a description of the health 289
insuring corporation, its method of operation, its service area, 290
its most recent provider list, and its complaint procedure 291
established pursuant to section 1751.19 of the Revised Code, AND 293
A DESCRIPTION OF ITS UTILIZATION REVIEW, INTERNAL REVIEW, AND 294
EXTERNAL REVIEW PROCESSES ESTABLISHED UNDER SECTIONS 1751.77 TO 295
1751.85 OF THE REVISED CODE. AT THE REQUEST OF OR WITH THE 296
APPROVAL OF THE SUBSCRIBER, A HEALTH INSURING CORPORATION MAY 298
PROVIDE THIS INFORMATION BY ELECTRONIC MEANS RATHER THAN BY MAIL. 299
A health insuring corporation providing basic health care 301
services or supplemental health care services shall provide this 302
information annually. A health insuring corporation providing
only specialty health care services shall provide this 303
information biennially.
(B) Each health insuring corporation, upon the request of 306
a subscriber, shall make available its most recent statutory 307
financial statement.
Sec. 1751.77. As used in sections 1751.77 to 1751.86 316
1751.90 of the Revised Code, unless otherwise specifically 318
provided:
(A) "Adverse determination" means a determination by a 320
health insuring corporation or its designee utilization review 321
organization that an admission, availability of care, continued 323
stay, or other health care service covered under a policy, 324
contract, or agreement of the health insuring corporation has 326
been reviewed and, based upon the information provided, the 327
health care service does not meet the health insuring 329
corporation's requirements for benefit payment UNDER THE HEALTH 330
INSURING CORPORATION'S POLICY, CONTRACT, OR AGREEMENT, and
8
COVERAGE is therefore denied, reduced, or terminated. 332
(B) "Ambulatory review" means utilization review of health 334
care services performed or provided in an outpatient setting. 335
(C) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 337
PERSON AUTHORIZED TO ACT ON BEHALF OF AN ENROLLEE. 338
(D) "Case management" means a coordinated set of 340
activities conducted for individual patient management of 341
serious, complicated, protracted, or other specified health 342
conditions.
(D)(E) "Certification" means a determination by a health 344
insuring corporation or its designee utilization review 347
organization that an admission, availability of care, continued 348
stay, or other health care service covered under a policy, 349
contract, or agreement of the health insuring corporation has 351
been reviewed and, based upon the information provided, the 352
health care service satisfies the health insuring corporation's 353
requirements for benefit payment UNDER THE HEALTH INSURING 354
CORPORATION'S POLICY, CONTRACT, OR AGREEMENT. 355
(E)(F) "Clinical peer" means a physician when an 358
evaluation is to be made of the clinical appropriateness of 359
health care services provided by a physician. If an evaluation 360
is to be made of the clinical appropriateness of health care 361
services provided by a provider who is not a physician, "clinical 362
peer" means either a physician or a provider holding the same 363
license as the provider who provided the health care services. 364
(F)(G) "Clinical review criteria" means the written 366
screening procedures, decision abstracts, clinical protocols, and 367
practice guidelines used by a health insuring corporation to 368
determine the necessity and appropriateness of health care 370
services.
(G)(H) "Concurrent review" means utilization review 372
conducted during a patient's hospital stay or course of 373
treatment.
(H)(I) "Discharge planning" means the formal process for 375
9
determining, prior to a patient's discharge from a health care 376
facility, the coordination and management of the care that the 378
patient is to receive following discharge from a health care 379
facility.
(I)(J) "Participating provider" means a provider or health 381
care facility that, under a contract with a health insuring 383
corporation or with its contractor or subcontractor, has agreed 385
to provide health care services to enrollees with an expectation
of receiving payment, other than coinsurance, copayments, or 386
deductibles, directly or indirectly from the health insuring 387
corporation.
(J)(K) "Physician" means a provider authorized WHO HOLDS A 390
CERTIFICATE ISSUED under chapter CHAPTER 4731. of the Revised 392
Code to AUTHORIZING THE practice OF medicine and surgery or 394
osteopathic medicine and surgery OR A COMPARABLE LICENSE OR
CERTIFICATE FROM ANOTHER STATE. 395
(K)(L) "Prospective review" means utilization review that 397
is conducted prior to an admission or a course of treatment. 398
(L)(M) "Retrospective review" means utilization review of 400
medical necessity that is conducted after health care services 402
have been provided to a patient. "Retrospective review" does not 404
include the review of a claim that is limited to an evaluation of 405
reimbursement levels, veracity of documentation, accuracy of 406
coding, or adjudication of payment.
(M)(N) "Second opinion" means an opportunity or 408
requirement to obtain a clinical evaluation by a provider other 410
than the provider originally making a recommendation for proposed 411
health care services to assess the clinical necessity and 412
appropriateness of the proposed health care services. 413
(N)(O) "Utilization review" means a process used to 415
monitor the use of, or evaluate the clinical necessity, 417
appropriateness, efficacy, or efficiency of, health care 418
services, procedures, or settings. Areas of review may include 419
ambulatory review, prospective review, second opinion,
10
certification, concurrent review, case management, discharge 420
planning, or retrospective review. 421
(O)(P) "Utilization review organization" means an entity 423
that conducts utilization review, other than a health insuring 424
corporation performing a review of its own health care plans. 426
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86 1751.90 436
of the Revised Code apply to any health insuring corporation that 438
provides or performs utilization review services in connection 439
with its policies, contracts, and agreements providing COVERING 440
basic health care services and to any designee of the health 441
insuring corporation, or to any utilization review organization 444
that performs utilization review functions on behalf of the 445
health insuring corporation in connection with policies,
contracts, or agreements of the health insuring corporation 446
providing COVERING basic health care services. 448
(2) Nothing in sections 1751.77 to 1751.82 or section 450
1751.85 1751.823 of the Revised Code shall be construed to 451
require a health insuring corporation to provide or perform 452
utilization review services in connection with health care 453
services provided under a policy, plan, or agreement of 454
supplemental health care services or specialty health care 455
services. 456
(B)(1) Each health insuring corporation shall be 459
responsible for monitoring all utilization review AND INTERNAL 460
REVIEW activities carried out by, or on behalf of, the health 462
insuring corporation and for ensuring that all requirements of 463
sections 1751.77 to 1751.86 1751.90 of the Revised Code, and any 464
rules adopted thereunder, are met. The health insuring 466
corporation shall also ensure that appropriate personnel have 467
operational responsibility for the conduct of the health insuring 468
corporation's utilization review program. 469
(2) If a health insuring corporation contracts to have a 471
utilization review organization or other entity perform the 472
utilization review functions required by sections 1751.77 to 473
11
1751.86 1751.90 of the Revised Code, and any rules adopted 475
thereunder, the superintendent of insurance shall hold the health 477
insuring corporation responsible for monitoring the activities of
the utilization review organization or other entity and for 478
ensuring that the requirements of those sections and rules are 479
met. 480
Sec. 1751.81. (A) As used in this section: 489
(1) "Enrollee" includes the representative of an enrollee. 491
(2) "Necessary, "NECESSARY information" includes the 494
results of any face-to-face clinical evaluation or second opinion 497
that may be required.
(B) A health insuring corporation shall maintain written 499
procedures for DETERMINING WHETHER A REQUESTED SERVICE IS A 500
SERVICE COVERED UNDER THE TERMS OF AN ENROLLEE'S POLICY, 501
CONTRACT, OR AGREEMENT, making utilization review determinations, 503
and for notifying enrollees, and participating providers, and 504
health care facilities acting on behalf of enrollees, of its 506
determinations.
(C) For initial PROSPECTIVE REVIEW determinations, a 509
health insuring corporation shall make the determination within 511
two business days after obtaining all necessary information 512
regarding a proposed admission, procedure, or health care service 513
requiring a review determination. 515
(1) In the case of a determination to certify an 517
admission, procedure, or health care service, the health insuring 518
corporation shall notify the provider or health care facility 519
rendering the health care service by telephone or facsimile 520
within three business days after making the initial 521
certification.
(2) In the case of an adverse determination, the health 523
insuring corporation shall notify the provider or health care 525
facility rendering the health care service by telephone within 526
three business days after making the adverse determination, and 527
shall provide written or electronic confirmation of the telephone 528
12
notification to the enrollee and the provider or health care 529
facility within one business day after making the telephone 530
notification.
(D) For concurrent review determinations, a health 532
insuring corporation shall make the determination within one 535
business day after obtaining all necessary information. 536
(1) In the case of a determination to certify an extended 538
stay or additional health care services, the health insuring 539
corporation shall notify the provider or health care facility 540
rendering the health care service by telephone or facsimile 541
within one business day after making the certification. 543
(2) In the case of an adverse determination, the health 545
insuring corporation shall notify the provider or health care 546
facility rendering the health care service by telephone within 547
one business day after making the adverse determination, and 548
shall provide written or electronic confirmation to the enrollee 549
and the provider or health care facility within one business day 550
after the telephone notification. The health care service to the 551
enrollee shall be continued, with standard copayments and 553
deductibles, if applicable, until the enrollee has been notified 554
of the determination. 555
(E) For retrospective review determinations, a health 557
insuring corporation shall make the determination within thirty 561
business days after receiving all necessary information. 562
(1) In the case of a certification, the health insuring 564
corporation may notify the enrollee and the provider or health 566
care facility rendering the health care service in writing. 567
(2) In the case of an adverse determination, the health 569
insuring corporation shall notify the enrollee and the provider 571
or health care facility rendering the health care service, in 572
writing, within five business days after making the adverse 573
determination.
(F)(1) The time frames set forth in divisions (C), (D), 576
and (E) of this section for determinations and notifications 578
13
shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the 579
health insuring corporation. The health insuring corporation 580
shall maintain written procedures for making expedited 582
utilization review determinations and notifications of enrollees 583
and providers or health care facilities when warranted by the 584
medical condition of the enrollee. 585
(2) AN ENROLLEE OR AUTHORIZED PERSON MAY PROCEED WITH A 587
REQUEST FOR AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 589
REVISED CODE IF A HEALTH INSURING CORPORATION FAILS TO MAKE A 592
DETERMINATION AND NOTIFICATION WITHIN THE TIME FRAMES SET FORTH 593
IN DIVISIONS (C), (D), AND (E) OF THIS SECTION. THE HEALTH 595
INSURING CORPORATION'S FAILURE TO MAKE A DETERMINATION AND 596
NOTIFICATION WITHIN THESE TIME FRAMES SHALL BE DEEMED TO BE AN 597
ADVERSE DETERMINATION BY THE HEALTH INSURING CORPORATION FOR THE 598
PURPOSE OF INITIATING AN INTERNAL REVIEW.
(G) A written notification of an adverse determination 600
shall include the principal reason or reasons for the 601
determination, instructions for initiating an appeal or A 603
reconsideration OR INTERNAL REVIEW of the determination, and 604
instructions for requesting a written statement of the clinical 605
rationale used to make the determination. A health insuring 606
corporation shall provide the clinical rationale for an adverse 608
determination in writing to any party who received notice of the 610
adverse determination and who follows the instructions for a
request. 611
(H)(1) A health insuring corporation shall have written 613
procedures to address the failure or inability of a health care 615
facility, provider, or enrollee to provide all necessary 616
information for review.
(2) A HEALTH INSURING CORPORATION SHALL NOT USE 618
UNREASONABLE REQUESTS FOR INFORMATION TO DELAY MAKING A 619
DETERMINATION. 620
(3) If the health care facility, provider, or enrollee 623
14
will not release necessary information, the health insuring 624
corporation may deny certification. AN ENROLLEE NEED NOT BE 625
GRANTED AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 626
REVISED CODE BASED ON A HEALTH INSURING CORPORATION'S FAILURE TO 628
MAKE A TIMELY DETERMINATION, IF THE HEALTH INSURING CORPORATION'S 629
DELAY IN MAKING A DETERMINATION AND NOTIFICATION IS CAUSED BY THE 630
FAILURE OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO 631
RELEASE ALL NECESSARY INFORMATION, IN WHICH CASE THE HEALTH 632
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE OF THE REASON FOR 633
THE DELAY.
Sec. 1751.811. A HEALTH INSURING CORPORATION THAT MAKES AN 635
ADVERSE DETERMINATION MAY, IN LIEU OF PROVIDING A RECONSIDERATION 636
UNDER SECTION 1751.82 OF THE REVISED CODE AND AN INTERNAL REVIEW 637
UNDER SECTION 1751.83 OF THE REVISED CODE, AFFORD AN ENROLLEE AN 638
OPPORTUNITY FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 639
1751.85 OF THE REVISED CODE.
Sec. 1751.82. (A) In a case involving an initial A 649
PROSPECTIVE determination or a concurrent review determination, a 651
health insuring corporation shall give the provider or health
care facility rendering the health care service an opportunity to 653
request in writing on behalf of the enrollee a reconsideration of 654
an adverse determination by the reviewer making the adverse 655
determination. The reconsideration shall occur within three 656
business days after the health insuring corporation's receipt of 657
the written request for reconsideration, and shall be conducted 658
between the provider or health care facility rendering the health 659
care service and the reviewer who made the adverse determination. 661
If that reviewer cannot be available within three business days, 662
the reviewer may designate another reviewer.
(B) If the reconsideration process described in division 664
(A) of this section does not resolve the difference of opinion, 666
the adverse determination may be appealed by the enrollee, AN 667
AUTHORIZED PERSON, or the provider or health care facility ACTING 668
on behalf of the enrollee MAY REQUEST AN INTERNAL REVIEW UNDER 669
15
SECTION 1751.83 OF THE REVISED CODE. 670
(C) Reconsideration is not a prerequisite to a standard AN 672
INTERNAL or expedited appeal EXTERNAL REVIEW of an adverse 674
determination.
(D) The time period allowed by division (A) of this 677
section for a reconsideration of an adverse determination shall 678
not apply if the seriousness of the medical condition of the 679
enrollee requires a more expedited reconsideration. The health 680
insuring corporation shall maintain written procedures for making 681
such an expedited reconsideration. 682
Sec. 1751.83 1751.821. A health insuring corporation may 692
present evidence of compliance with the requirements of sections 693
1751.77 to 1751.82 of the Revised Code by submitting evidence to 695
the superintendent of insurance of its accreditation by an
independent, private accrediting organization, such as the 696
national committee on quality assurance, the national quality 697
health council, the joint commission on accreditation of health 699
care organizations, or the American accreditation healthcare
commission/utilization review accreditation commission. The 701
superintendent, upon review of the organization's accreditation 702
process, may determine that such accreditation constitutes 703
compliance by the health insuring corporation with the 704
requirements of these sections.
Sec. 1751.84 1751.822. Each participating provider or 713
health care facility submitting a claim shall cooperate with the 715
utilization review program of a health insuring corporation or 716
utilization review organization and shall provide the health 717
insuring corporation or its designee access to an enrollee's 718
medical records during regular business hours, or copies of those 719
records at a reasonable cost. 720
Sec. 1751.85 1751.823. A health insuring corporation shall 729
annually file a certificate with the superintendent of insurance 731
certifying its compliance with sections 1751.77 to 1751.82 of the 732
Revised Code. 734
16
Sec. 1751.83. A HEALTH INSURING CORPORATION SHALL 736
ESTABLISH AND MAINTAIN AN INTERNAL REVIEW SYSTEM THAT HAS BEEN 737
APPROVED BY THE SUPERINTENDENT OF INSURANCE. THE SYSTEM SHALL 738
PROVIDE FOR REVIEW BY A CLINICAL PEER AND INCLUDE ADEQUATE AND 739
REASONABLE PROCEDURES FOR REVIEW AND RESOLUTION OF APPEALS FROM
ENROLLEES CONCERNING ADVERSE DETERMINATIONS MADE UNDER SECTION 742
1751.81 OF THE REVISED CODE, INCLUDING PROCEDURES FOR VERIFYING 743
AND REVIEWING APPEALS FROM ENROLLEES WHOSE MEDICAL CONDITIONS
REQUIRE EXPEDITED REVIEW. 744
A HEALTH INSURING CORPORATION SHALL CONSIDER AND PROVIDE A 746
WRITTEN RESPONSE TO EACH REQUEST FOR AN INTERNAL REVIEW NOT LATER 748
THAN SIXTY DAYS AFTER RECEIPT OF THE REQUEST, EXCEPT THAT IF THE 749
SERIOUSNESS OF THE ENROLLEE'S MEDICAL CONDITION REQUIRES AN 750
EXPEDITED REVIEW, THE HEALTH INSURING CORPORATION SHALL PROVIDE 751
THE WRITTEN RESPONSE NOT LATER THAN SEVEN DAYS AFTER RECEIPT OF 752
THE REQUEST. THE RESPONSE SHALL STATE THE REASON FOR THE HEALTH 756
INSURING CORPORATION'S DECISION, INFORM THE ENROLLEE OF THE RIGHT
TO PURSUE A FURTHER REVIEW, AND EXPLAIN THE PROCEDURES FOR 758
INITIATING THE REVIEW.
IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 762
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 763
THE SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 764
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, THE RESPONSE SHALL 765
INFORM THE ENROLLEE OF THE RIGHT TO REQUEST A REVIEW BY THE 766
SUPERINTENDENT OF INSURANCE UNDER SECTION 1751.831 OF THE REVISED 767
CODE. IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 768
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 769
THE SERVICE IS NOT MEDICALLY NECESSARY, THE RESPONSE SHALL INFORM 771
THE ENROLLEE OF THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER 772
SECTION 1751.84 OF THE REVISED CODE, EXCEPT THAT IF THE ENROLLEE 774
MEETS THE CRITERIA SET FORTH IN DIVISION (A) OF SECTION 1751.85 775
OF THE REVISED CODE, THE RESPONSE SHALL INFORM THE ENROLLEE OF 776
THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER SECTION 1751.85 OF 777
THE REVISED CODE.
17
THE HEALTH INSURING CORPORATION SHALL MAKE AVAILABLE TO THE 779
SUPERINTENDENT FOR INSPECTION COPIES OF ALL DOCUMENTS IN THE 780
HEALTH INSURING CORPORATION'S POSSESSION RELATED TO REVIEWS 781
CONDUCTED PURSUANT TO THIS SECTION, INCLUDING MEDICAL RECORDS 782
RELATED TO THOSE REVIEWS, AND OF RESPONSES, FOR THREE YEARS 783
FOLLOWING COMPLETION OF THE REVIEW. ANY DOCUMENT OR INFORMATION 784
PROVIDED TO THE SUPERINTENDENT UNDER THIS SECTION IS CONFIDENTIAL 785
AND IS NOT A PUBLIC RECORD UNDER SECTION 149.43 OF THE REVISED 786
CODE.
Sec. 1751.831. THE SUPERINTENDENT OF INSURANCE SHALL 788
ESTABLISH AND MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING 789
REQUESTS FOR REVIEW FROM OR ON BEHALF OF ENROLLEES WHO, UNDER 790
SECTION 1751.83 OF THE REVISED CODE, HAVE BEEN DENIED COVERAGE OF 791
A HEALTH CARE SERVICE OR HAD COVERAGE REDUCED OR TERMINATED WHEN 792
THE GROUNDS FOR THE DENIAL, REDUCTION, OR TERMINATION IS THAT THE 793
SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 794
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT. 795
ON RECEIPT OF A WRITTEN REQUEST FROM AN ENROLLEE OR 797
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 798
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 800
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, EXCEPT THAT THE 801
SUPERINTENDENT SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION 802
UNLESS THE ENROLLEE HAS EXHAUSTED THE HEALTH INSURING 803
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO
SECTION 1751.83 OF THE REVISED CODE. THE HEALTH INSURING 804
CORPORATION AND THE ENROLLEE OR AUTHORIZED PERSON SHALL PROVIDE 805
THE SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 806
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 807
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 809
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 810
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 811
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 812
ENROLLEE'S CONTRACT, POLICY, OR AGREEMENT. THE SUPERINTENDENT 813
18
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION OF 814
ITS DETERMINATION OR THAT IT IS NOT ABLE TO MAKE A DETERMINATION. 815
IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 817
CORPORATION THAT MAKING THE DETERMINATION REQUIRES THE RESOLUTION 818
OF A MEDICAL ISSUE, THE HEALTH INSURING CORPORATION SHALL AFFORD 819
THE ENROLLEE AN OPPORTUNITY FOR EXTERNAL REVIEW UNDER SECTION 820
1751.84 OR 1751.85 OF THE REVISED CODE. IF THE SUPERINTENDENT 821
NOTIFIES THE HEALTH INSURING CORPORATION THAT THE HEALTH SERVICE 822
IS A COVERED SERVICE, THE HEALTH INSURING CORPORATION SHALL 823
EITHER COVER THE SERVICE OR AFFORD THE ENROLLEE AN OPPORTUNITY
FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE 824
REVISED CODE. IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 825
CORPORATION THAT THE HEALTH CARE SERVICE IS NOT A COVERED 826
SERVICE, THE HEALTH INSURING CORPORATION IS NOT REQUIRED TO COVER 827
THE SERVICE OR AFFORD THE ENROLLEE AN EXTERNAL REVIEW. 828
Sec. 1751.84. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 831
(C) OF THIS SECTION, A HEALTH INSURING CORPORATION SHALL AFFORD 833
AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL REVIEW IF BOTH OF THE 834
FOLLOWING ARE THE CASE:
(1) THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, 836
OR TERMINATED COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE 839
SERVICE EXCEPT FOR THE FACT THAT THE HEALTH INSURING CORPORATION 840
HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 841
NECESSARY;
(2) EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, THE 843
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 845
COST THE ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED
SERVICE IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 846
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 848
SECTION, EXCEPT THAT IF AN ENROLLEE WITH A TERMINAL CONDITION 849
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 1751.85 OF 850
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 852
THAT SECTION.
(B) AN ENROLLEE NEED NOT BE AFFORDED A REVIEW UNDER THIS 854
19
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 855
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 857
SECTION 1751.831 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 859
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE ENROLLEE'S 860
POLICY, CONTRACT, OR AGREEMENT. 861
(2) EXCEPT AS PROVIDED IN SECTION 1751.811 OF THE REVISED 863
CODE, THE ENROLLEE HAS FAILED TO EXHAUST THE HEALTH INSURING 864
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO 865
SECTION 1751.83 OF THE REVISED CODE. 866
(3) THE ENROLLEE HAS PREVIOUSLY BEEN AFFORDED AN EXTERNAL 868
REVIEW FOR THE SAME ADVERSE DETERMINATION AND NO NEW CLINICAL 869
INFORMATION HAS BEEN SUBMITTED TO THE HEALTH INSURING 870
CORPORATION.
(C)(1) A HEALTH INSURING CORPORATION MAY DENY A REQUEST 872
FOR AN EXTERNAL REVIEW OF AN ADVERSE DETERMINATION IF IT IS 874
REQUESTED LATER THAN THIRTY DAYS AFTER THE ENROLLEE'S RECEIPT OF 875
NOTICE OF THE RESULT OF AN INTERNAL REVIEW BROUGHT UNDER SECTION 877
1751.83 OF THE REVISED CODE. AN EXTERNAL REVIEW MAY BE REQUESTED 879
BY THE ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S PROVIDER, 881
OR A HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICE TO THE 882
ENROLLEE. THE ENROLLEE MAY REQUEST A REVIEW WITHOUT THE APPROVAL 883
OF THE PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE HEALTH 884
CARE SERVICE. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 885
REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF THE ENROLLEE. 886
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 888
EXCEPT THAT IF THE ENROLLEE HAS A CONDITION THAT REQUIRES 889
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 890
ELECTRONIC MEANS. AN ENROLLEE WHO MAKES AN ORAL OR ELECTRONIC 891
REQUEST FOR REVIEW SHALL SUBMIT TO THE HEALTH INSURING 892
CORPORATION WRITTEN CONFIRMATION OF THE REQUEST NOT LATER THAN 893
FIVE DAYS AFTER MAKING IT.
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 895
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 897
THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 898
20
HEALTH CARE SERVICE TO THE ENROLLEE THAT THE PROPOSED SERVICE,
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 899
ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE 900
IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 901
(3) FOR AN EXPEDITED REVIEW, THE ENROLLEE'S PROVIDER MUST 903
CERTIFY THAT THE ENROLLEE'S CONDITION COULD, IN THE ABSENCE OF 904
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 906
(a) PLACING THE HEALTH OF THE ENROLLEE OR, WITH RESPECT TO 908
A PREGNANT WOMAN, THE HEALTH OF THE ENROLLEE OR THE UNBORN CHILD, 909
IN SERIOUS JEOPARDY; 910
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 912
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 914
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 916
OF AN ADVERSE DETERMINATION SHALL INCLUDE ALL OF THE FOLLOWING: 917
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 919
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 920
DIVISION (C) OF SECTION 1751.90 OF THE REVISED CODE. THE 922
INDEPENDENT REVIEW ORGANIZATION SHALL UTILIZE THE SERVICES OF 923
MEDICAL EXPERTS AND CLINICAL PEERS WHO HAVE EXPERTISE IN THE 924
TREATMENT OF THE ENROLLEE'S MEDICAL CONDITION AND CLINICAL 926
EXPERIENCE IN THE PAST THREE YEARS WITH THE SERVICE REQUESTED OR
RECOMMENDED BY THE ENROLLEE OR THE ENROLLEE'S PROVIDER. THE 928
REVIEW SHALL BE CONDUCTED BY A SINGLE MEDICAL EXPERT OR CLINICAL 929
PEER, UNLESS THE HEALTH INSURING CORPORATION DETERMINES THAT MORE 930
THAN ONE MEDICAL EXPERT OR CLINICAL PEER IS NEEDED. THE MEDICAL 931
EXPERT OR CLINICAL PEER MUST HOLD A LICENSE THAT IS NOT 932
RESTRICTED IN ANY MANNER BY THE STATE IN WHICH THE CLINICAL PEER 933
IS LICENSED. THE MEDICAL EXPERT OR CLINICAL PEER SHALL NOT HAVE
BEEN DISCIPLINED OR SANCTIONED BY A HOSPITAL OR GOVERNMENT ENTITY 935
BASED ON THE QUALITY OF CARE PROVIDED BY THE CLINICAL PEER. IN 936
THE CASE OF A PHYSICIAN, THE CLINICAL PEER MUST BE CERTIFIED BY A 937
NATIONALLY RECOGNIZED MEDICAL SPECIALTY BOARD IN THE AREA THAT IS 938
THE SUBJECT OF THE REVIEW.
(2) EXCEPT AS PROVIDED IN DIVISION (D)(3) AND (4) OF THIS 940
21
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 942
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 944
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 945
FOLLOWING:
(a) THE HEALTH INSURING CORPORATION OR ANY OFFICER, 947
DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING 948
CORPORATION;
(b) THE ENROLLEE, THE ENROLLEE'S PROVIDER, OR THE PRACTICE 950
GROUP OF THE ENROLLEE'S PROVIDER; 951
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 953
SERVICE REQUESTED BY THE ENROLLEE WOULD BE PROVIDED; 954
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 956
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE ENROLLEE. 957
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 959
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 960
CIRCUMSTANCES:
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 962
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 963
THE HEALTH INSURING CORPORATION. 964
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 966
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 967
THE HEALTH INSURING CORPORATION. 968
(c) THE CLINICAL PEER IS A PARTICIPATING PROVIDER BUT WAS 970
NOT INVOLVED WITH THE HEALTH INSURING CORPORATION'S ADVERSE 971
DETERMINATION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 973
HEALTH INSURING CORPORATION FROM PAYING THE INDEPENDENT REVIEW 974
ORGANIZATION FOR THE CONDUCT OF THE REVIEW. 975
(5) AN ENROLLEE SHALL NOT BE REQUIRED TO PAY FOR ANY PART 977
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 978
BY THE HEALTH INSURING CORPORATION. 979
(6)(a) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO 982
THE INDEPENDENT REVIEW ORGANIZATION CONDUCTING THE REVIEW A COPY 983
OF THOSE RECORDS IN ITS POSSESSION THAT ARE RELEVANT TO THE 984
22
ENROLLEE'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL 985
BE USED SOLELY FOR THE PURPOSE OF THIS DIVISION. AT THE REQUEST 986
OF THE INDEPENDENT REVIEW ORGANIZATION, THE HEALTH INSURING 987
CORPORATION, ENROLLEE, OR THE PROVIDER OR HEALTH CARE FACILITY 989
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE SHALL PROVIDE ANY 990
ADDITIONAL INFORMATION THE INDEPENDENT REVIEW ORGANIZATION
REQUESTS TO COMPLETE THE REVIEW. 991
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 993
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 994
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. 996
(7) ON RECEIPT OF ADDITIONAL INFORMATION ON AN ENROLLEE'S 998
MEDICAL CONDITION FROM A PROVIDER OR HEALTH CARE FACILITY, THE 999
HEALTH INSURING CORPORATION MAY ELECT TO COVER THE SERVICE 1,000
REQUESTED AND TERMINATE THE REVIEW. THE HEALTH INSURING 1,001
CORPORATION SHALL NOTIFY THE ENROLLEE AND ALL OTHER PARTIES 1,002
INVOLVED WITH THE DECISION BY MAIL OR, WITH THE CONSENT OR 1,003
APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS.
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 1,005
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 1,006
THE FOLLOWING:
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,008
CORPORATION, THE ENROLLEE, THE ENROLLEE'S PROVIDER, AND THE 1,009
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, INCLUDING 1,011
THE FOLLOWING:
(i) THE ENROLLEE'S MEDICAL RECORDS; 1,013
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 1,015
BY THE HEALTH INSURING CORPORATION TO MAKE ITS DECISION. 1,016
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,017
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,018
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 1,020
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 1,023
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,024
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 1,025
23
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 1,026
AND RESEARCH; 1,027
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,029
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 1,030
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 1,031
RELEVANT NATIONAL MEDICAL SOCIETIES. 1,032
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 1,034
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 1,035
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 1,039
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 1,042
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 1,043
COPY OF ITS DECISION TO THE HEALTH INSURING CORPORATION AND THE 1,044
ENROLLEE. IF THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY 1,045
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE REQUESTED THE 1,046
REVIEW, THE INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A 1,047
COPY OF ITS DECISION TO THE ENROLLEE'S PROVIDER OR THE HEALTH 1,048
CARE FACILITY. 1,049
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 1,051
INCLUDE A DESCRIPTION OF THE ENROLLEE'S CONDITION AND THE 1,053
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 1,054
CLINICAL RATIONALE FOR THE DECISION. 1,055
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 1,057
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 1,058
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 1,059
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 1,060
AND COST EFFECTIVENESS.
(F) THE HEALTH INSURING CORPORATION SHALL PROVIDE ANY 1,062
COVERAGE DETERMINED BY THE INDEPENDENT REVIEW ORGANIZATION'S 1,063
DECISION TO BE MEDICALLY NECESSARY, SUBJECT TO THE OTHER TERMS, 1,064
LIMITATIONS, AND CONDITIONS OF THE ENROLLEE'S CONTRACT. THE 1,065
DECISION SHALL APPLY ONLY TO THE INDIVIDUAL ENROLLEE'S APPEAL. 1,066
Sec. 1753.24 1751.85. (A) Each health insuring 1,075
corporation shall establish a reasonable external, independent 1,078
24
review process to examine the health insuring corporation's 1,079
coverage decisions for enrollees who meet all of the following 1,080
criteria:
(1) The enrollee has a terminal condition that, according 1,082
to the current diagnosis of the enrollee's physician, has a high 1,083
probability of causing death within two years. 1,084
(2) THE ENROLLEE REQUESTS A REVIEW NOT LATER THAN SIXTY 1,087
DAYS AFTER RECEIPT BY THE ENROLLEE OF NOTICE OF THE RESULT OF AN 1,088
INTERNAL REVIEW UNDER SECTION 1751.83 OF THE REVISED CODE. 1,089
(3) The enrollee's physician certifies that the enrollee 1,091
has the condition described in division (A)(1) of this section 1,093
and any of the following situations are applicable: 1,094
(a) Standard therapies have not been effective in 1,096
improving the condition of the enrollee; 1,098
(b) Standard therapies are not medically appropriate for 1,101
the enrollee;
(c) There is no standard therapy covered by the health 1,104
insuring corporation that is more beneficial than therapy 1,105
described in division (A)(3)(4) of this section. 1,106
(3)(4) The enrollee's physician has recommended a drug, 1,108
device, procedure, or other therapy that the physician certifies, 1,110
in writing, is likely to be more beneficial to the enrollee, in 1,111
the physician's opinion, than standard therapies, or, the 1,113
enrollee has requested a therapy that has been found in a
preponderance of peer-reviewed published studies to be associated 1,114
with effective clinical outcomes for the same condition. 1,115
(4)(5) The enrollee has been denied coverage by the health 1,117
insuring corporation for a drug, device, procedure, or other 1,121
therapy recommended or requested pursuant to division (A)(3)(4) 1,122
of this section, and has exhausted all internal appeals. 1,123
(5)(6) The drug, device, procedure, or other therapy, 1,125
recommended or requested pursuant to division (A)(3) of this 1,128
section, FOR WHICH COVERAGE HAS BEEN DENIED would be a covered 1,129
health care service except for the health insuring corporation's 1,131
25
determination that the drug, device, procedure, or other therapy 1,133
is experimental or investigational.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 1,135
THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 1,136
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 1,137
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. AN 1,138
ENROLLEE WHO MAKES AN ORAL OR ELECTRONIC REQUEST FOR REVIEW TO A 1,139
HEALTH INSURING CORPORATION SHALL SUBMIT WRITTEN CONFIRMATION OF 1,140
THE REQUEST NOT LATER THAN FIVE DAYS AFTER MAKING THE REQUEST. 1,141
(C) The external, independent review process established 1,144
by a health insuring corporation shall meet all of the following 1,145
criteria:
(1) Except as provided in division (C)(E) of this section, 1,147
the process shall offer AFFORD all enrollees who meet the 1,149
criteria set forth in division (A) of this section the 1,151
opportunity to have the health insuring corporation's decision to 1,152
deny coverage of the recommended or requested therapy reviewed 1,154
under the process. Each eligible enrollee shall be notified of 1,156
that opportunity within five business days after the health 1,157
insuring corporation denies coverage.
(2) The review of the health insuring corporation's 1,159
decision shall be conducted by experts selected by an independent 1,160
entity that has been retained by the health insuring corporation 1,162
for this purpose REVIEW ORGANIZATION ASSIGNED BY THE 1,163
SUPERINTENDENT OF INSURANCE UNDER DIVISION (C) OF SECTION 1751.90 1,164
OF THE REVISED CODE. The independent entity REVIEW ORGANIZATION 1,165
shall be either an academic medical center or an entity 1,167
ORGANIZATION that has as its primary function, and that receives 1,169
a majority of its revenue from, the provision of expert reviews 1,170
and related services BEEN ACCREDITED IN ACCORDANCE WITH RULES 1,171
ADOPTED BY THE SUPERINTENDENT OF INSURANCE PURSUANT TO SECTION 1,172
1751.90 OF THE REVISED CODE.
The independent entity REVIEW ORGANIZATION shall select a 1,174
panel to conduct the review, which panel shall be composed of at 1,177
26
least three physicians or other providers who, THROUGH CLINICAL 1,178
EXPERIENCE IN THE PAST THREE YEARS, are experts in the treatment 1,179
of the enrollee's medical condition and knowledgeable about the 1,181
recommended or requested therapy. If the independent entity 1,182
REVIEW ORGANIZATION retained by the health insuring corporation 1,184
is an academic medical center, the panel may include experts 1,185
affiliated with or employed by the academic medical center. 1,186
In either of the following circumstances, an exception may 1,189
be made to the requirement that the review be conducted by an 1,190
expert panel composed of a minimum of three physicians or other 1,191
providers:
(a) A review may be conducted by an expert panel composed 1,194
of only two physicians or other providers if an enrollee has 1,195
consented in writing to a review by the smaller panel; 1,196
(b) A review may be conducted by a single expert physician 1,199
or other provider if only one expert physician or other provider 1,200
is available for the review.
(3) Neither the health insuring corporation nor the 1,202
enrollee shall choose, or control the choice of, the physician or 1,204
other provider experts.
(4) Neither the THE SELECTED experts nor, ANY HEALTH CARE 1,207
FACILITY WITH WHICH AN EXPERT IS AFFILIATED, AND the independent 1,208
entity REVIEW ORGANIZATION arranging for the experts' review, 1,209
shall NOT have any professional, familial, or financial 1,210
affiliation with the ANY OF THE FOLLOWING:
(a) THE health insuring corporation, except that OR ANY 1,213
OFFICER, DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING
CORPORATION; 1,214
(b) THE ENROLLEE, THE ENROLLEE'S PHYSICIAN, OR THE 1,216
PRACTICE GROUP OF THE ENROLLEE'S PHYSICIAN; 1,217
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 1,219
REQUESTED THERAPY WOULD BE PROVIDED; 1,220
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,222
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 1,223
27
REQUESTED THERAPY. 1,224
HOWEVER, experts affiliated with academic medical centers 1,227
who provide healthcare services to enrollees of the health 1,228
insuring corporation may serve as experts on the review panel. 1,230
This FURTHER, EXPERTS WITH STAFF PRIVILEGES AT A HEALTH CARE 1,231
FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF THE 1,232
HEALTH INSURING CORPORATION, AS WELL AS EXPERTS WHO ARE 1,233
PARTICIPATING PROVIDERS, BUT WHO WERE NOT INVOLVED WITH THE 1,234
HEALTH INSURING CORPORATION'S DENIAL OF COVERAGE FOR THE THERAPY 1,235
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 1,236
nonaffiliation provision does PROVISIONS DO not preclude a health 1,238
insuring corporation from paying for the experts' review, as
specified in division (B)(5) of this section. The experts shall 1,240
have no patient-physician relationship or other affiliation with 1,241
an enrollee whose request for therapy is under review or with a 1,242
provider whose recommendation for therapy is under review. 1,243
(5) Enrollees shall not be required to pay for ANY PART OF 1,245
the external, independent COST OF THE review. The costs COST of 1,247
the review shall be borne by the health insuring corporation. 1,249
(6) The health insuring corporation shall provide to the 1,251
independent entity REVIEW ORGANIZATION arranging for the experts' 1,252
review and to the enrollee and the enrollee's physician a copy of 1,253
those medical records in the health insuring corporation's 1,254
possession that are relevant to the enrollee's MEDICAL condition 1,257
for which therapy has been recommended or requested AND THE 1,258
REVIEW. The medical records shall be disclosed solely to the 1,261
expert reviewers and shall be used solely for the purpose of this
section. AT THE REQUEST OF THE EXPERT REVIEWERS, THE HEALTH 1,263
INSURING CORPORATION OR THE PHYSICIAN RECOMMENDING THE THERAPY 1,264
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 1,265
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 1,266
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 1,267
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 1,268
NECESSARY TO COMPLETE THE REVIEW. 1,269
28
(7) The IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 1,272
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 1,273
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,275
CORPORATION, THE ENROLLEE, AND THE ENROLLEE'S PHYSICIAN, 1,276
INCLUDING THE ENROLLEE'S MEDICAL RECORDS AND THE STANDARDS, 1,277
CRITERIA, AND CLINICAL RATIONALE USED BY THE HEALTH INSURING 1,278
CORPORATION TO REACH ITS COVERAGE DECISION; 1,279
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,281
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,282
ORGANIZATIONS;
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,284
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 1,285
RECOGNIZED MEDICAL EXPERTS; 1,286
(d) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 1,288
MEDICAL SOCIETIES; 1,289
(e) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 1,291
EFFECTIVENESS.
THE opinions of the experts on the panel shall be rendered 1,294
within thirty days after the enrollee's request for review. If 1,296
the enrollee's physician determines that a therapy would be 1,298
significantly less effective if not promptly initiated, the 1,299
opinions shall be rendered within seven days after the enrollee's 1,300
request for review.
(8) Each expert on the panel shall provide the independent 1,302
entity REVIEW ORGANIZATION with a professional opinion as to 1,304
whether there is sufficient evidence to demonstrate that the 1,305
recommended or requested therapy is likely to be more beneficial
to the enrollee than standard therapies. 1,307
(9) Each expert's opinion shall be presented in written 1,309
form and shall include the following information: 1,311
(a) A description of the enrollee's condition; 1,313
(b) A description of the indicators relevant to 1,315
determining whether there is sufficient evidence to demonstrate 1,316
that the recommended or requested therapy is more likely than not 1,318
29
to be more beneficial to the enrollee than standard therapies; 1,319
(c) A description and analysis of any relevant findings 1,321
published in peer-reviewed medical or scientific literature or 1,322
the published opinions of medical experts or specialty societies; 1,323
(d) A description of the enrollee's suitability to receive 1,325
the recommended or requested therapy according to a treatment 1,326
protocol in a clinical trial, if applicable. 1,328
(10) The independent entity REVIEW ORGANIZATION shall 1,330
provide the health insuring corporation with the opinions of the 1,332
experts. The health insuring corporation shall make the experts' 1,333
opinions available to the enrollee and the enrollee's physician, 1,335
upon request.
(11) The decision OPINION of the majority of the experts 1,337
on the panel, rendered pursuant to division (B)(C)(8) of this 1,339
section, is binding on the health insuring corporation with 1,341
respect to that enrollee. If the opinions of the experts on the 1,342
panel are evenly divided as to whether the therapy should be 1,343
covered, then the health insuring corporation's final decision 1,344
shall be in favor of coverage. If less than a majority of the 1,346
experts on the panel recommend coverage of the therapy, the 1,347
health insuring corporation may, in its discretion, cover the 1,348
therapy. However, any coverage provided pursuant to division 1,349
(B)(C)(11) of this section is subject to the terms, LIMITATIONS, 1,351
and conditions of the enrollee's contract with the health 1,353
insuring corporation.
(12) The health insuring corporation shall have written 1,355
policies describing the external, independent review process. 1,357
The health insuring corporation shall disclose the availability 1,358
of the external, independent review process in the health 1,359
insuring corporation's evidence of coverage and disclosure forms. 1,361
(C)(D) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 1,364
PROCESS, THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,365
RECOMMENDED OR REQUESTED HEALTH CARE SERVICE AND TERMINATE THE 1,366
REVIEW. THE HEALTH INSURING CORPORATION SHALL NOTIFY THE 1,367
30
ENROLLEE AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH THE 1,368
CONSENT OR APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS. 1,369
(E) If a health insuring corporation's initial denial of 1,371
coverage for a therapy recommended or requested pursuant to 1,372
division (A)(3)(4) of this section is based upon an external, 1,373
independent review of that therapy meeting the requirements of 1,374
division (B)(C) of this section, this section shall not be a 1,375
basis for requiring a second external, independent review of the 1,376
recommended or requested therapy. 1,377
(D)(F) The health insuring corporation shall annually file 1,379
a certificate with the superintendent of insurance certifying its 1,380
compliance with the requirements of this section. 1,381
Sec. 1751.87. NOTHING IN SECTIONS 1751.77 TO 1751.85 OF 1,383
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 1,384
AGAINST ANY OF THE FOLLOWING:
AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO EMPLOYEES 1,387
THROUGH A HEALTH INSURING CORPORATION; A CLINICAL PEER OR 1,388
INDEPENDENT REVIEW ORGANIZATION THAT PARTICIPATES IN AN EXTERNAL 1,389
REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE; OR A
HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE FOR BENEFITS 1,390
IN ACCORDANCE WITH DIVISION (F) OF SECTION 1751.84 OR DIVISION 1,391
(C)(11) OF SECTION 1751.85 OF THE REVISED CODE. 1,393
Sec. 1751.88. CONSISTENT WITH THE RULES OF EVIDENCE, A 1,396
WRITTEN DECISION OR OPINION PREPARED BY OR FOR AN INDEPENDENT 1,397
REVIEW ORGANIZATION UNDER SECTION 1751.84 OR 1751.85 OF THE 1,399
REVISED CODE SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO 1,400
THE COVERAGE DECISION THAT WAS THE SUBJECT OF THE DECISION OR 1,401
OPINION. THE INDEPENDENT REVIEW ORGANIZATION'S DECISION OR 1,402
OPINION SHALL BE PRESUMED TO BE A SCIENTIFICALLY VALID AND 1,405
ACCURATE DESCRIPTION OF THE STATE OF MEDICAL KNOWLEDGE AT THE
TIME IT WAS WRITTEN. 1,406
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 1,408
ACTION RELATED TO A HEALTH INSURING CORPORATION'S COVERAGE 1,409
DECISION INVOLVING AN INVESTIGATIONAL OR EXPERIMENTAL DRUG, 1,411
31
DEVICE, OR TREATMENT MAY INTRODUCE INTO EVIDENCE ANY APPLICABLE 1,412
MEDICARE REIMBURSEMENT STANDARDS ESTABLISHED UNDER TITLE XVIII OF 1,413
THE "SOCIAL SECURITY ACT," 49 STAT. 620(1935), 42 U.S.C.A. 301, 1,415
AS AMENDED. 1,416
Sec. 1751.89. (A) AN INDEPENDENT REVIEW ORGANIZATION 1,418
RETAINED BY A HEALTH INSURING CORPORATION TO CONDUCT EXTERNAL 1,420
REVIEWS UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE 1,422
SHALL ANNUALLY REPORT THE FOLLOWING INFORMATION TO THE 1,424
SUPERINTENDENT OF INSURANCE IN A FORMAT PRESCRIBED BY THE
SUPERINTENDENT: 1,425
(1) THE NUMBER OF REVIEWS CONDUCTED; 1,427
(2) THE NUMBER OF REVIEWS DECIDED IN FAVOR OF ENROLLEES 1,429
AND THE NUMBER DECIDED IN FAVOR OF THE HEALTH INSURING 1,430
CORPORATION;
(3) THE AVERAGE TIME REQUIRED TO CONDUCT A REVIEW; 1,432
(4) THE NUMBER AND PERCENTAGE OF REVIEWS IN WHICH A 1,434
DECISION WAS NOT REACHED IN THE TIME REQUIRED UNDER DIVISION (D) 1,435
OF SECTION 1751.84 OR DIVISION (C) OF SECTION 1751.85 OF THE 1,436
REVISED CODE; 1,437
(5) ANY ADDITIONAL INFORMATION REQUIRED BY THE 1,439
SUPERINTENDENT BY RULE ADOPTED PURSUANT TO DIVISION (C) OF THIS 1,440
SECTION;
(6) A SUMMARY OF THE DIAGNOSES, DRUGS, DEVICES, SERVICES, 1,442
PROCEDURES, AND THERAPIES THAT HAVE BEEN THE SUBJECT OF EXTERNAL 1,443
REVIEW.
(B) THE SUPERINTENDENT OF INSURANCE SHALL COMPLY WITH 1,445
APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE CONFIDENTIALITY 1,446
OF MEDICAL RECORDS.
(C) THE SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 1,448
119. OF THE REVISED CODE, ADOPT RULES REQUIRING INDEPENDENT 1,451
REVIEW ORGANIZATIONS TO PROVIDE ADDITIONAL INFORMATION ON THE 1,453
CONSIDERATION AND DISPOSITION OF EXTERNAL REVIEWS BROUGHT UNDER 1,456
SECTION 1751.84 OR 1751.85 OF THE REVISED CODE. 1,457
(D) THE SUPERINTENDENT SHALL COMPILE AND ANNUALLY PUBLISH 1,459
32
THE INFORMATION COLLECTED UNDER THIS SECTION AND REPORT THE 1,462
INFORMATION TO THE GOVERNOR, THE SPEAKER OF THE HOUSE OF 1,463
REPRESENTATIVES, THE PRESIDENT OF THE SENATE, AND THE CHAIRS OF 1,464
THE HOUSE AND SENATE COMMITTEES WITH JURISDICTION OVER HEALTH AND 1,466
INSURANCE ISSUES.
Sec. 1751.90. (A) THE SUPERINTENDENT OF INSURANCE SHALL 1,468
ACCREDIT INDEPENDENT REVIEW ORGANIZATIONS. THE SUPERINTENDENT 1,471
MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE AND IN
CONSULTATION WITH THE DIRECTOR OF HEALTH, ADOPT RULES GOVERNING 1,472
THE ACCREDITATION OF INDEPENDENT REVIEW ORGANIZATIONS. IN 1,473
DEVELOPING THE RULES, THE SUPERINTENDENT MAY TAKE INTO 1,474
CONSIDERATION THE STANDARDS ESTABLISHED BY NATIONAL ORGANIZATIONS 1,475
THAT ACCREDIT ORGANIZATIONS PROVIDING EXPERT REVIEWS AND RELATED 1,477
SERVICES. THE SUPERINTENDENT SHALL ACCEPT ACCREDITATION BY A 1,478
NATIONAL ORGANIZATION RECOGNIZED BY THE SUPERINTENDENT AS
ACCREDITATION BY THE SUPERINTENDENT. THE SUPERINTENDENT SHALL 1,479
NOT ACCREDIT ANY INDEPENDENT REVIEW ORGANIZATION THAT IS OPERATED 1,480
BY A NATIONAL, STATE, OR LOCAL TRADE ASSOCIATION OF HEALTH 1,481
BENEFIT PLANS OR HEALTH CARE PROVIDERS.
(B) EACH INDEPENDENT REVIEW ORGANIZATION SHALL USE THE 1,483
SERVICES OF MEDICAL EXPERTS OR CLINICAL PEERS OUTSIDE THE STAFF 1,485
OF THE INDEPENDENT REVIEW ORGANIZATION TO CONDUCT EXTERNAL 1,486
REVIEWS. NEITHER THE HEALTH INSURING CORPORATION NOR THE
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE CLINICAL 1,487
PEER PHYSICIAN OR OTHER MEDICAL EXPERTS. 1,488
(C) THE SUPERINTENDENT SHALL MAINTAIN A RANDOMLY ORGANIZED 1,490
ROSTER OF EXTERNAL REVIEW ORGANIZATIONS ACCREDITED UNDER THIS 1,491
SECTION FOR PURPOSES OF SELECTING EXTERNAL REVIEW ORGANIZATIONS 1,492
TO CONDUCT EXTERNAL REVIEWS. 1,493
ON RECEIPT OF A REQUEST BY A HEALTH INSURING CORPORATION, 1,495
THE SUPERINTENDENT MUST RANDOMLY ASSIGN TWO EXTERNAL REVIEW 1,496
ORGANIZATIONS THAT ARE ACCREDITED UNDER DIVISION (A) OF THIS 1,498
SECTION AND ARE QUALIFIED UNDER DIVISION (D)(1) OF SECTION 1,499
1751.84 OF THE REVISED CODE TO CONDUCT THE REVIEW. AFTER RECEIPT 1,501
33
OF THE NAMES OF THE TWO EXTERNAL REVIEW ORGANIZATIONS, THE HEALTH 1,502
INSURING CORPORATION SHALL SELECT ONE OF THE ASSIGNED EXTERNAL 1,503
REVIEW ORGANIZATIONS TO CONDUCT THE EXTERNAL REVIEW.
NO HEALTH INSURING CORPORATION SHALL ENGAGE IN A PATTERN OF 1,505
EXCLUDING A PARTICULAR REVIEW ORGANIZATION BASED ON PREVIOUS 1,506
FINDINGS ON BEHALF OF ENROLLEES. IF THE SUPERINTENDENT MAKES 1,507
SUCH A FINDING, IT IS AN UNFAIR TRADE PRACTICE. 1,508
Sec. 1753.13. EVERY INDIVIDUAL OR GROUP HEALTH INSURING 1,510
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES BASIC 1,511
HEALTH CARE SERVICES BUT DOES NOT ALLOW DIRECT ACCESS TO 1,512
OBSTETRICIANS OR GYNECOLOGISTS SHALL PERMIT A FEMALE ENROLLEE TO 1,513
OBTAIN COVERED OBSTETRIC AND GYNECOLOGICAL SERVICES FROM A 1,514
PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST WITHOUT OBTAINING A 1,516
REFERRAL FROM THE ENROLLEE'S PRIMARY CARE PROVIDER. 1,517
NO INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, 1,519
CONTRACT, OR AGREEMENT MAY LIMIT THE NUMBER OF ALLOWABLE VISITS 1,520
TO A PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST. A HEALTH 1,521
INSURING CORPORATION MAY REQUIRE A PARTICIPATING OBSTETRICIAN OR 1,522
GYNECOLOGIST TO COMPLY WITH THE HEALTH INSURING CORPORATION'S 1,523
COVERAGE PROTOCOLS AND PROCEDURES, INCLUDING UTILIZATION REVIEW, 1,524
FOR OBSTETRIC AND GYNECOLOGICAL SERVICES. 1,525
A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 1,527
AGREEMENT MAY NOT IMPOSE ADDITIONAL COPAYMENTS FOR DIRECTLY 1,529
ACCESSED OBSTETRIC AND GYNECOLOGICAL SERVICES, UNLESS THE POLICY, 1,530
CONTRACT, OR AGREEMENT IMPOSES ADDITIONAL COPAYMENTS FOR DIRECT
ACCESS TO ANY PARTICIPATING PROVIDER OTHER THAN A PRIMARY CARE 1,531
PROVIDER.
Sec. 3923.65. (A) AS USED IN THIS SECTION: 1,533
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 1,535
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 1,536
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 1,537
LAYPERSON WITH AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 1,538
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 1,539
RESULT IN ANY OF THE FOLLOWING: 1,540
34
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 1,542
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 1,543
IN SERIOUS JEOPARDY; 1,544
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,546
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,548
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 1,550
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 1,552
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 1,553
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 1,555
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 1,556
MEDICAL CONDITION; 1,557
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 1,559
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 1,560
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND 1,562
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 1,563
BURN CENTER OF THE HOSPITAL.
(B) EVERY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND 1,565
ACCIDENT INSURANCE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL 1,566
EXPENSE COVERAGE SHALL COVER EMERGENCY SERVICES WITHOUT REGARD TO 1,567
THE DAY OR TIME THE EMERGENCY SERVICES ARE RENDERED OR TO WHETHER 1,568
THE POLICYHOLDER, THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE 1,569
SERVICES ARE RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE 1,570
POLICYHOLDER, OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY 1,571
SERVICES.
(C) EVERY INDIVIDUAL POLICY OR CERTIFICATE FURNISHED BY AN 1,573
INSURER IN CONNECTION WITH ANY SICKNESS AND ACCIDENT INSURANCE 1,575
POLICY SHALL PROVIDE INFORMATION REGARDING THE FOLLOWING: 1,576
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 1,578
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 1,580
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 1,581
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 1,582
(3) ANY COPAYMENTS FOR EMERGENCY SERVICES. 1,584
(D) THIS SECTION DOES NOT APPLY TO ANY INDIVIDUAL OR GROUP 1,586
POLICY OF SICKNESS AND ACCIDENT INSURANCE COVERING ONLY ACCIDENT, 1,587
35
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 1,588
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 1,589
DISEASE, OR VISION CARE; COVERAGE UNDER A ONE-TIME LIMITED 1,590
DURATION POLICY OF NO LONGER THAN SIX MONTHS; COVERAGE ISSUED AS 1,591
A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING OUT OF 1,592
WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 1,593
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 1,594
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 1,595
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,596
SELF-INSURANCE.
Sec. 5747.01. Except as otherwise expressly provided or 1,605
clearly appearing from the context, any term used in this chapter 1,606
has the same meaning as when used in a comparable context in the 1,607
Internal Revenue Code, and all other statutes of the United 1,608
States relating to federal income taxes. 1,609
As used in this chapter: 1,611
(A) "Adjusted gross income" or "Ohio adjusted gross 1,613
income" means adjusted gross income as defined and used in the 1,614
Internal Revenue Code, adjusted as provided in divisions (A)(1) 1,616
to (17) of this section:
(1) Add interest or dividends on obligations or securities 1,618
of any state or of any political subdivision or authority of any 1,619
state, other than this state and its subdivisions and 1,620
authorities.
(2) Add interest or dividends on obligations of any 1,622
authority, commission, instrumentality, territory, or possession 1,623
of the United States that are exempt from federal income taxes 1,624
but not from state income taxes. 1,625
(3) Deduct interest or dividends on obligations of the 1,627
United States and its territories and possessions or of any 1,628
authority, commission, or instrumentality of the United States to 1,629
the extent included in federal adjusted gross income but exempt 1,630
from state income taxes under the laws of the United States. 1,631
(4) Deduct disability and survivor's benefits to the 1,633
36
extent included in federal adjusted gross income. 1,634
(5) Deduct benefits under Title II of the Social Security 1,636
Act and tier 1 railroad retirement benefits to the extent 1,637
included in federal adjusted gross income under section 86 of the 1,638
Internal Revenue Code. 1,639
(6) Add, in the case of a taxpayer who is a beneficiary of 1,641
a trust that makes an accumulation distribution as defined in 1,642
section 665 of the Internal Revenue Code, the portion, if any, of 1,643
such distribution that does not exceed the undistributed net 1,644
income of the trust for the three taxable years preceding the 1,645
taxable year in which the distribution is made. "Undistributed 1,646
net income of a trust" means the taxable income of the trust 1,647
increased by (a)(i) the additions to adjusted gross income 1,648
required under division (A) of this section and (ii) the personal 1,649
exemptions allowed to the trust pursuant to section 642(b) of the 1,650
Internal Revenue Code, and decreased by (b)(i) the deductions to 1,651
adjusted gross income required under division (A) of this 1,652
section, (ii) the amount of federal income taxes attributable to 1,653
such income, and (iii) the amount of taxable income that has been 1,654
included in the adjusted gross income of a beneficiary by reason 1,655
of a prior accumulation distribution. Any undistributed net 1,656
income included in the adjusted gross income of a beneficiary 1,657
shall reduce the undistributed net income of the trust commencing 1,658
with the earliest years of the accumulation period. 1,659
(7) Deduct the amount of wages and salaries, if any, not 1,661
otherwise allowable as a deduction but that would have been 1,662
allowable as a deduction in computing federal adjusted gross 1,663
income for the taxable year, had the targeted jobs credit allowed 1,664
and determined under sections 38, 51, and 52 of the Internal 1,665
Revenue Code not been in effect. 1,666
(8) Deduct any interest or interest equivalent on public 1,668
obligations and purchase obligations to the extent included in 1,669
federal adjusted gross income. 1,670
(9) Add any loss or deduct any gain resulting from the 1,672
37
sale, exchange, or other disposition of public obligations to the 1,673
extent included in federal adjusted gross income. 1,674
(10) Regarding tuition credits purchased under Chapter 1,676
3334. of the Revised Code: 1,677
(a) Deduct the following: 1,679
(i) For credits that as of the end of the taxable year 1,682
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 1,684
amount of income related to the credits, to the extent included 1,685
in federal adjusted gross income;
(ii) For credits that during the taxable year have been 1,688
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 1,689
the total purchase price of the tuition credits refunded over the 1,690
amount of refund, to the extent the amount of the excess was not 1,691
deducted in determining federal adjusted gross income;. 1,692
(b) Add the following: 1,694
(i) For credits that as of the end of the taxable year 1,697
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 1,698
amount of loss related to the credits, to the extent the amount 1,699
of the loss was deducted in determining federal adjusted gross 1,700
income;
(ii) For credits that during the taxable year have been 1,703
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 1,705
the amount of refund over the purchase price of each tuition 1,706
credit refunded, to the extent not included in federal adjusted 1,707
gross income.
(11)(a) Deduct, in the case of a self-employed individual 1,709
as defined in section 401(c)(1) of the Internal Revenue Code and 1,710
to the extent not otherwise allowable as a deduction OR EXCLUSION 1,711
in computing federal OR OHIO adjusted gross income for the 1,713
taxable year, the amount THE TAXPAYER paid during the taxable 1,715
38
year for insurance that constitutes medical care INSURANCE AND 1,716
QUALIFIED LONG-TERM CARE INSURANCE for the taxpayer, the 1,717
taxpayer's spouse, and dependents. No deduction FOR MEDICAL CARE 1,719
INSURANCE under division (A)(11) of this section shall be allowed 1,720
EITHER to any taxpayer who is eligible to participate in any 1,721
subsidized health plan maintained by any employer of the taxpayer 1,722
or of the TAXPAYER'S spouse of the taxpayer. No deduction under 1,724
division (A)(11) of this section shall be allowed to the extent 1,726
that the sum of such deduction and any related deduction 1,727
allowable in computing federal adjusted gross income for the 1,728
taxable year exceeds the taxpayer's earned income, within the 1,729
meaning of section 401(c) of the Internal Revenue Code, derived 1,730
by the taxpayer from the trade or business with respect to which 1,731
the plan providing the medical coverage is established., OR TO 1,734
ANY TAXPAYER WHO IS ENTITLED TO, OR ON APPLICATION WOULD BE
ENTITLED TO, BENEFITS UNDER PART A OF TITLE XVIII OF THE "SOCIAL 1,736
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C. 301, AS AMENDED. 1,737
FOR THE PURPOSES OF DIVISION (A)(11)(a) OF THIS SECTION, 1,738
"SUBSIDIZED HEALTH PLAN" MEANS A HEALTH PLAN FOR WHICH THE 1,740
EMPLOYER PAYS ANY PORTION OF THE PLAN'S COST. THE DEDUCTION 1,741
ALLOWED UNDER DIVISION (A)(11)(a) OF THIS SECTION SHALL BE THE 1,744
NET OF ANY RELATED PREMIUM REFUNDS, RELATED PREMIUM
REIMBURSEMENTS, OR RELATED INSURANCE PREMIUM DIVIDENDS RECEIVED 1,747
DURING THE TAXABLE YEAR. 1,748
(b) DEDUCT, TO THE EXTENT NOT OTHERWISE DEDUCTED OR 1,750
EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED GROSS INCOME 1,751
DURING THE TAXABLE YEAR, THE AMOUNT THE TAXPAYER PAID DURING THE 1,752
TAXABLE YEAR, NOT COMPENSATED FOR BY ANY INSURANCE OR OTHERWISE, 1,753
FOR MEDICAL CARE OF THE TAXPAYER, THE TAXPAYER'S SPOUSE, AND 1,754
DEPENDENTS, TO THE EXTENT THE EXPENSES EXCEED SEVEN AND ONE-HALF 1,755
PER CENT OF THE TAXPAYER'S FEDERAL ADJUSTED GROSS INCOME. 1,756
(c) FOR PURPOSES OF DIVISION (A)(11) OF THIS SECTION, 1,758
"MEDICAL CARE" HAS THE MEANING GIVEN IN SECTION 213 OF THE 1,760
INTERNAL REVENUE CODE, SUBJECT TO THE SPECIAL RULES, LIMITATIONS, 1,761
39
AND EXCLUSIONS SET FORTH THEREIN, AND "QUALIFIED LONG-TERM CARE" 1,762
HAS THE SAME MEANING GIVEN IN SECTION 7702(B)(b) OF THE INTERNAL 1,763
REVENUE CODE. 1,764
(12)(a) Deduct any amount included in federal adjusted 1,766
gross income solely because the amount represents a reimbursement 1,767
or refund of expenses that in a previous ANY year the taxpayer 1,768
had deducted as an itemized deduction pursuant to section 63 of 1,769
the Internal Revenue Code and applicable United States department 1,771
of the treasury regulations. THE DEDUCTION OTHERWISE ALLOWED 1,772
UNDER DIVISION (A)(12)(a) OF THIS SECTION SHALL BE REDUCED TO THE 1,774
EXTENT THE REIMBURSEMENT IS ATTRIBUTABLE TO AN AMOUNT THE 1,775
TAXPAYER DEDUCTED UNDER THIS SECTION IN ANY TAXABLE YEAR. 1,776
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO ADJUSTED 1,778
GROSS INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT 1,781
IS ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 1,783
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED 1,784
GROSS INCOME IN ANY TAXABLE YEAR.
(13) Deduct any portion of the deduction described in 1,786
section 1341(a)(2) of the Internal Revenue Code, for repaying 1,787
previously reported income received under a claim of right, that 1,788
meets both of the following requirements: 1,789
(a) It is allowable for repayment of an item that was 1,791
included in the taxpayer's adjusted gross income for a prior 1,792
taxable year and did not qualify for a credit under division (A) 1,793
or (B) of section 5747.05 of the Revised Code for that year; 1,794
(b) It does not otherwise reduce the taxpayer's adjusted 1,796
gross income for the current or any other taxable year. 1,797
(14) Deduct an amount equal to the deposits made to, and 1,799
net investment earnings of, a medical savings account during the 1,800
taxable year, in accordance with section 3924.66 of the Revised 1,801
Code. The deduction allowed by division (A)(14) of this section 1,802
does not apply to medical savings account deposits and earnings 1,803
otherwise deducted or excluded for the current or any other 1,804
taxable year from the taxpayer's federal adjusted gross income. 1,805
40
(15)(a) Add an amount equal to the funds withdrawn from a 1,807
medical savings account during the taxable year, and the net 1,808
investment earnings on those funds, when the funds withdrawn were 1,809
used for any purpose other than to reimburse an account holder 1,810
for, or to pay, eligible medical expenses, in accordance with 1,811
section 3924.66 of the Revised Code;
(b) Add the amounts distributed from a medical savings 1,813
account under division (A)(2) of section 3924.68 of the Revised 1,814
Code during the taxable year. 1,815
(16) Add any amount claimed as a credit under section 1,817
5747.059 of the Revised Code to the extent that such amount 1,818
satisfies either of the following:
(a) The amount was deducted or excluded from the 1,820
computation of the taxpayer's federal adjusted gross income as 1,821
required to be reported for the taxpayer's taxable year under the 1,822
Internal Revenue Code;
(b) The amount resulted in a reduction of the taxpayer's 1,824
federal adjusted gross income as required to be reported for any 1,825
of the taxpayer's taxable years under the Internal Revenue Code. 1,826
(17) Deduct the amount contributed by the taxpayer to an 1,828
individual development account program established by a county 1,829
department of human services pursuant to sections 329.11 to 1,830
329.14 of the Revised Code for the purpose of matching funds 1,831
deposited by program participants. On request of the tax 1,832
commissioner, the taxpayer shall provide any information that, in
the tax commissioner's opinion, is necessary to establish the 1,833
amount deducted under division (A)(17) of this section. 1,834
(B) "Business income" means income arising from 1,836
transactions, activities, and sources in the regular course of a 1,837
trade or business and includes income from tangible and 1,838
intangible property if the acquisition, rental, management, and 1,839
disposition of the property constitute integral parts of the 1,840
regular course of a trade or business operation. 1,841
(C) "Nonbusiness income" means all income other than 1,843
41
business income and may include, but is not limited to, 1,844
compensation, rents and royalties from real or tangible personal 1,845
property, capital gains, interest, dividends and distributions, 1,846
patent or copyright royalties, or lottery winnings, prizes, and 1,847
awards. 1,848
(D) "Compensation" means any form of remuneration paid to 1,850
an employee for personal services. 1,851
(E) "Fiduciary" means a guardian, trustee, executor, 1,853
administrator, receiver, conservator, or any other person acting 1,854
in any fiduciary capacity for any individual, trust, or estate. 1,855
(F) "Fiscal year" means an accounting period of twelve 1,857
months ending on the last day of any month other than December. 1,858
(G) "Individual" means any natural person. 1,860
(H) "Internal Revenue Code" means the "Internal Revenue 1,862
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 1,863
(I) "Resident" means: 1,865
(1) An individual who is domiciled in this state, subject 1,867
to section 5747.24 of the Revised Code; 1,868
(2) The estate of a decedent who at the time of death was 1,871
domiciled in this state. The domicile tests of section 5747.24 1,872
of the Revised Code and any election under section 5747.25 of the 1,873
Revised Code are not controlling for purposes of division (I)(2) 1,874
of this section.
(J) "Nonresident" means an individual or estate that is 1,876
not a resident. An individual who is a resident for only part of 1,877
a taxable year is a nonresident for the remainder of that taxable 1,878
year. 1,879
(K) "Pass-through entity" has the same meaning as in 1,881
section 5733.04 of the Revised Code. 1,882
(L) "Return" means the notifications and reports required 1,884
to be filed pursuant to this chapter for the purpose of reporting 1,885
the tax due and includes declarations of estimated tax when so 1,886
required. 1,887
(M) "Taxable year" means the calendar year or the 1,889
42
taxpayer's fiscal year ending during the calendar year, or 1,890
fractional part thereof, upon which the adjusted gross income is 1,891
calculated pursuant to this chapter. 1,892
(N) "Taxpayer" means any person subject to the tax imposed 1,894
by section 5747.02 of the Revised Code or any pass-through entity 1,895
that makes the election under division (D) of section 5747.08 of 1,896
the Revised Code.
(O) "Dependents" means dependents as defined in the 1,898
Internal Revenue Code and as claimed in the taxpayer's federal 1,899
income tax return for the taxable year or which the taxpayer 1,900
would have been permitted to claim had the taxpayer filed a 1,901
federal income tax return. 1,903
(P) "Principal county of employment" means, in the case of 1,905
a nonresident, the county within the state in which a taxpayer 1,906
performs services for an employer or, if those services are 1,907
performed in more than one county, the county in which the major 1,908
portion of the services are performed. 1,909
(Q) As used in sections 5747.50 to 5747.55 of the Revised 1,911
Code:
(1) "Subdivision" means any county, municipal corporation, 1,913
park district, or township. 1,914
(2) "Essential local government purposes" includes all 1,916
functions that any subdivision is required by general law to 1,917
exercise, including like functions that are exercised under a 1,918
charter adopted pursuant to the Ohio Constitution. 1,919
(R) "Overpayment" means any amount already paid that 1,921
exceeds the figure determined to be the correct amount of the 1,922
tax. 1,923
(S) "Taxable income" applies to estates only and means 1,925
taxable income as defined and used in the Internal Revenue Code 1,926
adjusted as follows: 1,927
(1) Add interest or dividends on obligations or securities 1,929
of any state or of any political subdivision or authority of any 1,930
state, other than this state and its subdivisions and 1,931
43
authorities; 1,932
(2) Add interest or dividends on obligations of any 1,934
authority, commission, instrumentality, territory, or possession 1,935
of the United States that are exempt from federal income taxes 1,936
but not from state income taxes; 1,937
(3) Add the amount of personal exemption allowed to the 1,939
estate pursuant to section 642(b) of the Internal Revenue Code; 1,940
(4) Deduct interest or dividends on obligations of the 1,942
United States and its territories and possessions or of any 1,943
authority, commission, or instrumentality of the United States 1,944
that are exempt from state taxes under the laws of the United 1,945
States; 1,946
(5) Deduct the amount of wages and salaries, if any, not 1,948
otherwise allowable as a deduction but that would have been 1,949
allowable as a deduction in computing federal taxable income for 1,950
the taxable year, had the targeted jobs credit allowed under 1,951
sections 38, 51, and 52 of the Internal Revenue Code not been in 1,952
effect; 1,953
(6) Deduct any interest or interest equivalent on public 1,955
obligations and purchase obligations to the extent included in 1,956
federal taxable income; 1,957
(7) Add any loss or deduct any gain resulting from sale, 1,959
exchange, or other disposition of public obligations to the 1,960
extent included in federal taxable income; 1,961
(8) Except in the case of the final return of an estate, 1,963
add any amount deducted by the taxpayer on both its Ohio estate 1,964
tax return pursuant to section 5731.14 of the Revised Code, and 1,965
on its federal income tax return in determining either federal 1,966
adjusted gross income or federal taxable income; 1,967
(9)(a) Deduct any amount included in federal taxable 1,969
income solely because the amount represents a reimbursement or 1,970
refund of expenses that in a previous year the decedent had 1,971
deducted as an itemized deduction pursuant to section 63 of the 1,972
Internal Revenue Code and applicable treasury regulations;. THE 1,974
44
DEDUCTION OTHERWISE ALLOWED UNDER DIVISION (S)(9)(a) OF THIS 1,976
SECTION SHALL BE REDUCED TO THE EXTENT THE REIMBURSEMENT IS
ATTRIBUTABLE TO AN AMOUNT THE TAXPAYER OR DECEDENT DEDUCTED UNDER 1,977
THIS SECTION IN ANY TAXABLE YEAR. 1,978
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO TAXABLE 1,981
INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT IS 1,982
ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 1,983
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO TAXABLE 1,984
INCOME IN ANY TAXABLE YEAR.
(10) Deduct any portion of the deduction described in 1,986
section 1341(a)(2) of the Internal Revenue Code, for repaying 1,987
previously reported income received under a claim of right, that 1,988
meets both of the following requirements: 1,989
(a) It is allowable for repayment of an item that was 1,991
included in the taxpayer's taxable income or the decedent's 1,992
adjusted gross income for a prior taxable year and did not 1,993
qualify for a credit under division (A) or (B) of section 5747.05 1,994
of the Revised Code for that year. 1,995
(b) It does not otherwise reduce the taxpayer's taxable 1,997
income or the decedent's adjusted gross income for the current or 1,998
any other taxable year. 1,999
(11) Add any amount claimed as a credit under section 2,001
5747.059 of the Revised Code to the extent that the amount 2,002
satisfies either of the following: 2,003
(a) The amount was deducted or excluded from the 2,005
computation of the taxpayer's federal taxable income as required 2,006
to be reported for the taxpayer's taxable year under the Internal 2,007
Revenue Code;
(b) The amount resulted in a reduction in the taxpayer's 2,009
federal taxable income as required to be reported for any of the 2,010
taxpayer's taxable years under the Internal Revenue Code. 2,011
(T) "School district income" and "school district income 2,013
tax" have the same meanings as in section 5748.01 of the Revised 2,014
Code. 2,015
45
(U) As used in divisions (A)(8), (A)(9), (S)(6), and 2,017
(S)(7) of this section, "public obligations," "purchase 2,018
obligations," and "interest or interest equivalent" have the same 2,019
meanings as in section 5709.76 of the Revised Code. 2,020
(V) "Limited liability company" means any limited 2,022
liability company formed under Chapter 1705. of the Revised Code 2,023
or under the laws of any other state. 2,024
(W) "Pass-through entity investor" means any person who, 2,026
during any portion of a taxable year of a pass-through entity, is 2,027
a partner, member, shareholder, or investor in that pass-through 2,028
entity.
(X) "Banking day" has the same meaning as in section 2,030
1304.01 of the Revised Code. 2,031
(Y) "Month" means a calendar month. 2,033
(Z) "Quarter" means the first three months, the second 2,035
three months, the third three months, or the last three months of 2,036
the taxpayer's taxable year.
(AA) Any term used in this chapter that is not otherwise 2,038
defined in this section and that is not used in a comparable 2,039
context in the Internal Revenue Code and other statutes of the 2,040
United States relating to federal income taxes has the same 2,041
meaning as in section 5733.40 of the Revised Code. 2,042
Section 2. That existing sections 1751.11, 1751.19, 2,044
1751.33, 1751.77, 1751.78, 1751.81, 1751.82, 1751.83, 1751.84, 2,045
1751.85, 1753.24, and 5747.01 of the Revised Code are hereby 2,046
repealed.
Section 3. Section 3923.65 of the Revised Code applies 2,048
only to policies issued, issued for delivery, or renewed in this 2,049
state on or after the effective date of this section. 2,050
Section 4. The amendment by this act of section 5747.01 of 2,052
the Revised Code applies to taxable years beginning on or after 2,053
January 1, 1999.
Section 5. It is the intent of the General Assembly that 2,055
sections 1751.84 and 1751.85 of the Revised Code, as enacted or 2,056
46
amendment by this act, provide health insuring corporation 2,057
enrollees with a means for resolving health care coverage 2,058
disputes expeditiously and avoid the need for lengthy and
expensive litigation. 2,059