As Introduced

126th General Assembly Regular Session 2005-2006

S. B. No. 116

Senators Spada, Gardner, Schuring, Hottinger, Fedor, Fingerhut, Miller, Hagan, Dann, Zurz 

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A BILL

To amend sections 1739.05, 1751.01, 1751.02, 3923.28,

1

3923.30, and 3923.51 and to enact sections

2

3923.281 and 3923.282 of the Revised Code to

3

prohibit, subject to certain exceptions,

4

discrimination in group health care policies,

5

contracts, and agreements in the coverage provided

6

for the diagnosis, care, and treatment of

7

biologically based mental illnesses.

8

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1.  That sections 1739.05, 1751.01, 1751.02, 3923.28,	9
3923.30, and 3923.51 be amended and sections 3923.281 and 3923.282	10
of the Revised Code be enacted to read as follows:	11

Sec. 1739.05.  (A) A multiple employer welfare arrangement	12
that is created pursuant to sections 1739.01 to 1739.22 of the	13
Revised Code and that operates a group self-insurance program may	14
be established only if any of the following applies:	15

(1) The arrangement has and maintains a minimum enrollment of	16
three hundred employees of two or more employers.	17

(2) The arrangement has and maintains a minimum enrollment of	18
three hundred self-employed individuals.	19

(3) The arrangement has and maintains a minimum enrollment of	20
three hundred employees or self-employed individuals in any	21
combination of divisions (A)(1) and (2) of this section.	22

(B) A multiple employer welfare arrangement that is created	23
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	24
that operates a group self-insurance program shall comply with all	25
laws applicable to self-funded programs in this state, including	26
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	27
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	28
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3924.031,	29
3924.032, and 3924.27 of the Revised Code.	30

(C) A multiple employer welfare arrangement created pursuant	31
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	32
enrollments only through agents or solicitors licensed pursuant to	33
Chapter 3905. of the Revised Code to sell or solicit sickness and	34
accident insurance.	35

(D) A multiple employer welfare arrangement created pursuant	36
to sections 1739.01 to 1739.22 of the Revised Code shall provide	37
benefits only to individuals who are members, employees of	38
members, or the dependents of members or employees, or are	39
eligible for continuation of coverage under section 1751.53 or	40
3923.38 of the Revised Code or under Title X of the "Consolidated	41
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	42
U.S.C.A. 1161, as amended.	43

Sec. 1751.01.  As used in this chapter:

44

(A)(1) "Basic health care services" means the following	45
services when medically necessary:	46

(1)(a) Physician's services, except when such services are	47
supplemental under division (B) of this section;	48

(2)(b) Inpatient hospital services;

49

(3)(c) Outpatient medical services;

50

(4)(d) Emergency health services;

51

(5)(e) Urgent care services;

52

(6)(f) Diagnostic laboratory services and diagnostic and	53
therapeutic radiologic services;	54

(7)(g) Diagnostic and treatment services, other than	55
prescription drug services, for biologically based mental	56
illnesses;	57

(h) Preventive health care services, including, but not	58
limited to, voluntary family planning services, infertility	59
services, periodic physical examinations, prenatal obstetrical	60
care, and well-child care.	61

"Basic health care services" does not include experimental	62
procedures.	63

AExcept as provided by divisions (A)(2) and (3) of this	64
section in connection with the offering of coverage for diagnostic	65
and treatment services for biologically based mental illnesses, a	66
health insuring corporation shall not offer coverage for a health	67
care service, defined as a basic health care service by this	68
division, unless it offers coverage for all listed basic health	69
care services. However, this requirement does not apply to the	70
coverage of beneficiaries enrolled in Title XVIII of the "Social	71
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended,	72
pursuant to a medicare contract, or to the coverage of	73
beneficiaries enrolled in the federal employee health benefits	74
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	75
beneficiaries enrolled in Title XIX of the "Social Security Act,"	76
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	77
medical assistance program or medicaid, provided by the department	78
of job and family services under Chapter 5111. of the Revised	79
Code, or to the coverage of beneficiaries under any federal health	80
care program regulated by a federal regulatory body, or to the	81
coverage of beneficiaries under any contract covering officers or	82
employees of the state that has been entered into by the	83
department of administrative services.	84

(2) A health insuring corporation may offer coverage for	85
diagnostic and treatment services for biologically based mental	86
illnesses without offering coverage for all other basic health	87
care services. A health insuring corporation may offer coverage	88
for diagnostic and treatment services for biologically based	89
mental illnesses alone or in combination with one or more	90
supplemental health care services. However, a health insuring	91
corporation that offers coverage for any other basic health care	92
service shall offer coverage for diagnostic and treatment services	93
for biologically based mental illnesses in combination with the	94
offer of coverage for all other listed basic health care services.	95

(3) A health insuring corporation that offers coverage for	96
basic health care services is not required to offer coverage for	97
diagnostic and treatment services for biologically based mental	98
illnesses in combination with the offer of coverage for all other	99
listed basic health care services if all of the following apply:	100

(a) The health insuring corporation submits documentation	101
certified by an independent member of the American academy of	102
actuaries to the superintendent of insurance showing that actual	103
claims for diagnostic and treatment services for biologically	104
based mental illnesses incurred for a period of at least six	105
months independently caused the health insuring corporation's	106
costs for claims and administrative expenses for the coverage of	107
basic health care services to increase by more than one per cent	108
per year.	109

(b) The health insuring corporation submits a signed letter	110
from an independent member of the American academy of actuaries to	111
the superintendent of insurance opining that the increase in costs	112
described in division (A)(3)(a) of this section could reasonably	113
justify an increase of more than one per cent in the annual	114
premiums or rates charged by the health insuring corporation for	115
the coverage of basic health care services.	116

(c) The superintendent of insurance makes the following	117
determinations from the documentation and opinion submitted	118
pursuant to divisions (A)(3)(a) and (b) of this section:	119

(i) Actual claims for diagnostic and treatment services for	120
biologically based mental illnesses incurred for a period of at	121
least six months independently caused the health insuring	122
corporation's costs for claims and administrative expenses for the	123
coverage of basic health care services to increase by more than	124
one per cent per year.	125

(ii) The increase in costs reasonably justifies an increase	126
of more than one per cent in the annual premiums or rates charged	127
by the health insuring corporation for the coverage of basic	128
health care services.	129

Any determination made by the superintendent under this	130
division is final.	131

(B) "Supplemental health care services" means any health care	132
services other than basic health care services that a health	133
insuring corporation may offer, alone or in combination with	134
either basic health care services or other supplemental health	135
care services, and includes:	136

(1) Services of facilities for intermediate or long-term	137
care, or both;	138

(2) Dental care services;

139

(3) Vision care and optometric services including lenses and	140
frames;	141

(4) Podiatric care or foot care services;

142

(5) Mental health services including psychological services,	143
excluding diagnostic and treatment services for biologically based	144
mental illnesses;	145

(6) Short-term outpatient evaluative and crisis-intervention	146
mental health services;	147

(7) Medical or psychological treatment and referral services	148
for alcohol and drug abuse or addiction;	149

(8) Home health services;

150

(9) Prescription drug services;

151

(10) Nursing services;

152

(11) Services of a dietitian licensed under Chapter 4759. of	153
the Revised Code;	154

(12) Physical therapy services;

155

(13) Chiropractic services;

156

(14) Any other category of services approved by the	157
superintendent of insurance.	158

(C) "Specialty health care services" means one of the	159
supplemental health care services listed in division (B)(1) to	160
(13) of this section, when provided by a health insuring	161
corporation on an outpatient-only basis and not in combination	162
with other supplemental health care services.	163

(D) "Biologically based mental illnesses" means	164
schizophrenia, schizoaffective disorder, major depressive	165
disorder, bipolar disorder, paranoia and other psychotic	166
disorders, obsessive-compulsive disorder, and panic disorder, as	167
these terms are defined in the most recent edition of the	168
diagnostic and statistical manual of mental disorders published by	169
the American psychiatric association.	170

(E) "Closed panel plan" means a health care plan that	171
requires enrollees to use participating providers.	172

(E)(F) "Compensation" means remuneration for the provision of	173
health care services, determined on other than a fee-for-service	174
or discounted-fee-for-service basis.	175

(F)(G) "Contractual periodic prepayment" means the formula	176
for determining the premium rate for all subscribers of a health	177
insuring corporation.	178

(G)(H) "Corporation" means a corporation formed under Chapter	179
1701. or 1702. of the Revised Code or the similar laws of another	180
state.	181

(H)(I) "Emergency health services" means those health care	182
services that must be available on a seven-days-per-week,	183
twenty-four-hours-per-day basis in order to prevent jeopardy to an	184
enrollee's health status that would occur if such services were	185
not received as soon as possible, and includes, where appropriate,	186
provisions for transportation and indemnity payments or service	187
agreements for out-of-area coverage.	188

(I)(J) "Enrollee" means any natural person who is entitled to	189
receive health care benefits provided by a health insuring	190
corporation.	191

(J)(K) "Evidence of coverage" means any certificate,	192
agreement, policy, or contract issued to a subscriber that sets	193
out the coverage and other rights to which such person is entitled	194
under a health care plan.	195

(K)(L) "Health care facility" means any facility, except a	196
health care practitioner's office, that provides preventive,	197
diagnostic, therapeutic, acute convalescent, rehabilitation,	198
mental health, mental retardation, intermediate care, or skilled	199
nursing services.	200

(L)(M) "Health care services" means basic, supplemental, and	201
specialty health care services.	202

(M)(N) "Health delivery network" means any group of providers	203
or health care facilities, or both, or any representative thereof,	204
that have entered into an agreement to offer health care services	205
in a panel rather than on an individual basis.	206

(N)(O) "Health insuring corporation" means a corporation, as	207
defined in division (G)(H) of this section, that, pursuant to a	208
policy, contract, certificate, or agreement, pays for, reimburses,	209
or provides, delivers, arranges for, or otherwise makes available,	210
basic health care services, supplemental health care services, or	211
specialty health care services, or a combination of basic health	212
care services and either supplemental health care services or	213
specialty health care services, through either an open panel plan	214
or a closed panel plan.	215

"Health insuring corporation" does not include a limited	216
liability company formed pursuant to Chapter 1705. of the Revised	217
Code, an insurer licensed under Title XXXIX of the Revised Code if	218
that insurer offers only open panel plans under which all	219
providers and health care facilities participating receive their	220
compensation directly from the insurer, a corporation formed by or	221
on behalf of a political subdivision or a department, office, or	222
institution of the state, or a public entity formed by or on	223
behalf of a board of county commissioners, a county board of	224
mental retardation and developmental disabilities, an alcohol and	225
drug addiction services board, a board of alcohol, drug addiction,	226
and mental health services, or a community mental health board, as	227
those terms are used in Chapters 340. and 5126. of the Revised	228
Code. Except as provided by division (D) of section 1751.02 of the	229
Revised Code, or as otherwise provided by law, no board,	230
commission, agency, or other entity under the control of a	231
political subdivision may accept insurance risk in providing for	232
health care services. However, nothing in this division shall be	233
construed as prohibiting such entities from purchasing the	234
services of a health insuring corporation or a third-party	235
administrator licensed under Chapter 3959. of the Revised Code.	236

(O)(P) "Intermediary organization" means a health delivery	237
network or other entity that contracts with licensed health	238
insuring corporations or self-insured employers, or both, to	239
provide health care services, and that enters into contractual	240
arrangements with other entities for the provision of health care	241
services for the purpose of fulfilling the terms of its contracts	242
with the health insuring corporations and self-insured employers.	243

(P)(Q) "Intermediate care" means residential care above the	244
level of room and board for patients who require personal	245
assistance and health-related services, but who do not require	246
skilled nursing care.	247

(Q)(R) "Medical record" means the personal information that	248
relates to an individual's physical or mental condition, medical	249
history, or medical treatment.	250

(R)(S)(1) "Open panel plan" means a health care plan that	251
provides incentives for enrollees to use participating providers	252
and that also allows enrollees to use providers that are not	253
participating providers.	254

(2) No health insuring corporation may offer an open panel	255
plan, unless the health insuring corporation is also licensed as	256
an insurer under Title XXXIX of the Revised Code, the health	257
insuring corporation, on June 4, 1997, holds a certificate of	258
authority or license to operate under Chapter 1736. or 1740. of	259
the Revised Code, or an insurer licensed under Title XXXIX of the	260
Revised Code is responsible for the out-of-network risk as	261
evidenced by both an evidence of coverage filing under section	262
1751.11 of the Revised Code and a policy and certificate filing	263
under section 3923.02 of the Revised Code.	264

(S)(T) "Panel" means a group of providers or health care	265
facilities that have joined together to deliver health care	266
services through a contractual arrangement with a health insuring	267
corporation, employer group, or other payor.	268

(T)(U) "Person" has the same meaning as in section 1.59 of	269
the Revised Code, and, unless the context otherwise requires,	270
includes any insurance company holding a certificate of authority	271
under Title XXXIX of the Revised Code, any subsidiary and	272
affiliate of an insurance company, and any government agency.	273

(U)(V) "Premium rate" means any set fee regularly paid by a	274
subscriber to a health insuring corporation. A "premium rate" does	275
not include a one-time membership fee, an annual administrative	276
fee, or a nominal access fee, paid to a managed health care system	277
under which the recipient of health care services remains solely	278
responsible for any charges accessed for those services by the	279
provider or health care facility.	280

(V)(W) "Primary care provider" means a provider that is	281
designated by a health insuring corporation to supervise,	282
coordinate, or provide initial care or continuing care to an	283
enrollee, and that may be required by the health insuring	284
corporation to initiate a referral for specialty care and to	285
maintain supervision of the health care services rendered to the	286
enrollee.	287

(W)(X) "Provider" means any natural person or partnership of	288
natural persons who are licensed, certified, accredited, or	289
otherwise authorized in this state to furnish health care	290
services, or any professional association organized under Chapter	291
1785. of the Revised Code, provided that nothing in this chapter	292
or other provisions of law shall be construed to preclude a health	293
insuring corporation, health care practitioner, or organized	294
health care group associated with a health insuring corporation	295
from employing certified nurse practitioners, certified nurse	296
anesthetists, clinical nurse specialists, certified nurse	297
midwives, dietitians, physicians' assistants, dental assistants,	298
dental hygienists, optometric technicians, or other allied health	299
personnel who are licensed, certified, accredited, or otherwise	300
authorized in this state to furnish health care services.	301

(X)(Y) "Provider sponsored organization" means a corporation,	302
as defined in division (G) of this section, that is at least	303
eighty per cent owned or controlled by one or more hospitals, as	304
defined in section 3727.01 of the Revised Code, or one or more	305
physicians licensed to practice medicine or surgery or osteopathic	306
medicine and surgery under Chapter 4731. of the Revised Code, or	307
any combination of such physicians and hospitals. Such control is	308
presumed to exist if at least eighty per cent of the voting rights	309
or governance rights of a provider sponsored organization are	310
directly or indirectly owned, controlled, or otherwise held by any	311
combination of the physicians and hospitals described in this	312
division.	313

(Y)(Z) "Solicitation document" means the written materials	314
provided to prospective subscribers or enrollees, or both, and	315
used for advertising and marketing to induce enrollment in the	316
health care plans of a health insuring corporation.	317

(Z)(AA) "Subscriber" means a person who is responsible for	318
making payments to a health insuring corporation for participation	319
in a health care plan, or an enrollee whose employment or other	320
status is the basis of eligibility for enrollment in a health	321
insuring corporation.	322

(AA)(BB) "Urgent care services" means those health care	323
services that are appropriately provided for an unforeseen	324
condition of a kind that usually requires medical attention	325
without delay but that does not pose a threat to the life, limb,	326
or permanent health of the injured or ill person, and may include	327
such health care services provided out of the health insuring	328
corporation's approved service area pursuant to indemnity payments	329
or service agreements.	330

Sec. 1751.02.  (A) Notwithstanding any law in this state to	331
the contrary, any corporation, as defined in section 1751.01 of	332
the Revised Code, may apply to the superintendent of insurance for	333
a certificate of authority to establish and operate a health	334
insuring corporation. If the corporation applying for a	335
certificate of authority is a foreign corporation domiciled in a	336
state without laws similar to those of this chapter, the	337
corporation must form a domestic corporation to apply for, obtain,	338
and maintain a certificate of authority under this chapter.	339

(B) No person shall establish, operate, or perform the	340
services of a health insuring corporation in this state without	341
obtaining a certificate of authority under this chapter.	342

(C) Except as provided by division (D) of this section, no	343
political subdivision or department, office, or institution of	344
this state, or corporation formed by or on behalf of any political	345
subdivision or department, office, or institution of this state,	346
shall establish, operate, or perform the services of a health	347
insuring corporation. Nothing in this section shall be construed	348
to preclude a board of county commissioners, a county board of	349
mental retardation and developmental disabilities, an alcohol and	350
drug addiction services board, a board of alcohol, drug addiction,	351
and mental health services, or a community mental health board, or	352
a public entity formed by or on behalf of any of these boards,	353
from using managed care techniques in carrying out the board's or	354
public entity's duties pursuant to the requirements of Chapters	355
307., 329., 340., and 5126. of the Revised Code. However, no such	356
board or public entity may operate so as to compete in the private	357
sector with health insuring corporations holding certificates of	358
authority under this chapter.	359

(D) A corporation formed by or on behalf of a publicly owned,	360
operated, or funded hospital or health care facility may apply to	361
the superintendent for a certificate of authority under division	362
(A) of this section to establish and operate a health insuring	363
corporation.	364

(E) A health insuring corporation shall operate in this state	365
in compliance with this chapter and Chapter 1753. of the Revised	366
Code, and with sections 3702.51 to 3702.62 of the Revised Code,	367
and shall operate in conformity with its filings with the	368
superintendent under this chapter, including filings made pursuant	369
to sections 1751.03, 1751.11, 1751.12, and 1751.31 of the Revised	370
Code.	371

(F) An insurer licensed under Title XXXIX of the Revised Code	372
need not obtain a certificate of authority as a health insuring	373
corporation to offer an open panel plan as long as the providers	374
and health care facilities participating in the open panel plan	375
receive their compensation directly from the insurer. If the	376
providers and health care facilities participating in the open	377
panel plan receive their compensation from any person other than	378
the insurer, or if the insurer offers a closed panel plan, the	379
insurer must obtain a certificate of authority as a health	380
insuring corporation.	381

(G) An intermediary organization need not obtain a	382
certificate of authority as a health insuring corporation,	383
regardless of the method of reimbursement to the intermediary	384
organization, as long as a health insuring corporation or a	385
self-insured employer maintains the ultimate responsibility to	386
assure delivery of all health care services required by the	387
contract between the health insuring corporation and the	388
subscriber and the laws of this state or between the self-insured	389
employer and its employees.	390

Nothing in this section shall be construed to require any	391
health care facility, provider, health delivery network, or	392
intermediary organization that contracts with a health insuring	393
corporation or self-insured employer, regardless of the method of	394
reimbursement to the health care facility, provider, health	395
delivery network, or intermediary organization, to obtain a	396
certificate of authority as a health insuring corporation under	397
this chapter, unless otherwise provided, in the case of contracts	398
with a self-insured employer, by operation of the "Employee	399
Retirement Income Security Act of 1974," 88 Stat. 829, 29 U.S.C.A.	400
1001, as amended.	401

(H) Any health delivery network doing business in this state,	402
including any health delivery network that is functioning as an	403
intermediary organization doing business in this state, that is	404
not required to obtain a certificate of authority under this	405
chapter shall certify to the superintendent annually, not later	406
than the first day of July, and shall provide a statement signed	407
by the highest ranking official which includes the following	408
information:	409

(1) The health delivery network's full name and the address	410
of its principal place of business;	411

(2) A statement that the health delivery network is not	412
required to obtain a certificate of authority under this chapter	413
to conduct its business.	414

(I) The superintendent shall not issue a certificate of	415
authority to a health insuring corporation that is a provider	416
sponsored organization unless all health care plans to be offered	417
by the health insuring corporation provide basic health care	418
services. Substantially all of the physicians and hospitals with	419
ownership or control of the provider sponsored organization, as	420
defined in division (X) of section 1751.01 of the Revised Code,	421
shall also be participating providers for the provision of basic	422
health care services for health care plans offered by the provider	423
sponsored organization. If a health insuring corporation that is a	424
provider sponsored organization offers health care plans that do	425
not provide basic health care services, the health insuring	426
corporation shall be deemed, for purposes of section 1751.35 of	427
the Revised Code, to have failed to substantially comply with this	428
chapter.	429

Except as specifically provided in this division and in	430
division (A) of section 1751.28 of the Revised Code, the	431
provisions of this chapter shall apply to all health insuring	432
corporations that are provider sponsored organizations in the same	433
manner that these provisions apply to all health insuring	434
corporations that are not provider sponsored organizations.	435

(J) Nothing in this section shall be construed to apply to	436
any multiple employer welfare arrangement operating pursuant to	437
Chapter 1739. of the Revised Code.	438

(K) Any person who violates division (B) of this section, and	439
any health delivery network that fails to comply with division (H)	440
of this section, is subject to the penalties set forth in section	441
1751.45 of the Revised Code.	442

Sec. 3923.28.  (A) Every policy of group sickness and	443
accident insurance providing hospital, surgical, or medical	444
expense coverage for other than specific diseases or accidents	445
only, and delivered, issued for delivery, or renewed in this state	446
on or after January 1, 1979, and that provides coverage for mental	447
or emotional disorders, shall provide benefits for services on an	448
outpatient basis for each eligible person under the policy who	449
resides in this state for mental or emotional disorders, or for	450
evaluations, that are at least equal to five hundred fifty dollars	451
in any calendar year or twelve-month period. The services shall be	452
legally performed by or under the clinical supervision of a	453
licensed physician or licensedauthorized under Chapter 4731. of	454
the Revised Code to practice medicine and surgery or osteopathic	455
medicine and surgery; a psychologist licensed under Chapter 4732.	456
of the Revised Code; a professional clinical counselor,	457
professional counselor, or independent social worker licensed	458
under Chapter 4757. of the Revised Code; or a clinical nurse	459
specialist licensed under Chapter 4723. of the Revised Code whose	460
nursing specialty is mental health, whether performed in an	461
office, in a hospital, or in a community mental health facility so	462
long as the hospital or community mental health facility is	463
approved by the joint commission on accreditation of healthcare	464
organizations, the council on accreditation for children and	465
family services, the rehabilitation accreditation commission, or,	466
until two years after the effective date of this amendmentJune 6,	467
2001, certified by the department of mental health as being in	468
compliance with standards established under division (H) of	469
section 5119.01 of the Revised Code.	470

(B) Outpatient benefits offered under division (A) of this	471
section shall be subject to reasonable contract limitations and	472
may be subject to reasonable deductibles and co-insurance costs.	473
Persons entitled to such benefit under more than one service or	474
insurance contract may be limited to a single	475
five-hundred-fifty-dollar outpatient benefit for services under	476
all contracts.	477

(C) In order to qualify for participation under division (A)	478
of this section, every facility specified in such division shall	479
have in effect a plan for utilization review and a plan for peer	480
review and every person specified in such division shall have in	481
effect a plan for peer review. Such plans shall have the purpose	482
of ensuring high quality patient care and effective and efficient	483
utilization of available health facilities and services.	484

(D) Nothing in this section shall be construed to require an	485
insurer to pay benefits which are greater than usual, customary,	486
and reasonable.	487

(E)(1) Services performed under the clinical supervision of a	488
licensed physician or licensed psychologisthealth care	489
professional identified in division (A) of this section, in order	490
to be reimbursable under the coverage required in division (A) of	491
this section, shall meet both of the following requirements:	492

(a) The services shall be performed in accordance with a	493
treatment plan that describes the expected duration, frequency,	494
and type of services to be performed;	495

(b) The plan shall be reviewed and approved by a licensed	496
physician or licensed psychologistthe health care professional	497
every three months.	498

(2) Payment of benefits for services reimbursable under	499
division (E)(1) of this section shall not be restricted to	500
services described in the treatment plan or conditioned upon	501
standards of clinical supervision that are more restrictive than	502
standards of a licensed physician or licensed psychologisthealth	503
care professional described in division (A) of this section, which	504
at least equal the requirements of division (E)(1) of this	505
section.	506

(F) The benefits provided by this section for mental and	507
emotional disorders shall not be reduced by the cost of benefits	508
provided pursuant to section 3923.281 of the Revised Code for	509
diagnostic and treatment services for biologically based mental	510
illnesses. This section does not provide benefits for diagnostic	511
and treatment services for biologically based mental illnesses.	512

Sec. 3923.281.  (A) As used in this section:

513

(1) "Biologically based mental illness" means schizophrenia,	514
schizoaffective disorder, major depressive disorder, bipolar	515
disorder, paranoia and other psychotic disorders,	516
obsessive-compulsive disorder, and panic disorder, as these terms	517
are defined in the most recent edition of the diagnostic and	518
statistical manual of mental disorders published by the American	519
psychiatric association.	520

(2) "Policy of sickness and accident insurance" excludes any	521
hospital indemnity, medicare supplement, long-term care,	522
disability income, one-time-limited-duration policy of not longer	523
than six months, supplemental benefit, or other policy that	524
provides coverage for specific diseases or accidents only; any	525
policy or certificate of sickness and accident insurance that is	526
underwritten by an insurer on an individual basis; any policy that	527
provides coverage for workers' compensation claims compensable	528
pursuant to Chapters 4121. and 4123. of the Revised Code; and any	529
policy that provides coverage to beneficiaries enrolled in Title	530
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A.	531
301, as amended, known as the medical assistance program or	532
medicaid, as provided by the Ohio department of job and family	533
services under Chapter 5111. of the Revised Code.	534

(B) Notwithstanding section 3901.71 of the Revised Code, and	535
subject to division (E) of this section, each group policy of	536
sickness and accident insurance shall provide benefits for the	537
diagnosis and treatment of biologically based mental illnesses on	538
the same terms and conditions as, and shall provide benefits no	539
less extensive than, those provided under the policy of sickness	540
and accident insurance for the treatment and diagnosis of all	541
other physical diseases and disorders, if both of the following	542
apply:	543

(1) The biologically based mental illness is clinically	544
diagnosed by a physician authorized under Chapter 4731. of the	545
Revised Code to practice medicine and surgery or osteopathic	546
medicine and surgery; a psychologist licensed under Chapter 4732.	547
of the Revised Code; a professional clinical counselor,	548
professional counselor, or independent social worker licensed	549
under Chapter 4757. of the Revised Code; or a clinical nurse	550
specialist licensed under Chapter 4723. of the Revised Code whose	551
nursing specialty is mental health.	552

(2) The prescribed treatment is not experimental or	553
investigational, having proven its clinical effectiveness in	554
accordance with generally accepted medical standards.	555

(C) Division (B) of this section applies to all coverages and	556
terms and conditions of the policy of sickness and accident	557
insurance, including, but not limited to, coverage of inpatient	558
hospital services, outpatient services, and medication; maximum	559
lifetime benefits; copayments; and individual and family	560
deductibles.	561

(D) Nothing in this section shall be construed as prohibiting	562
a sickness and accident insurance company from taking any of the	563
following actions:	564

(1) Negotiating separately with mental health care providers	565
with regard to reimbursement rates and the delivery of health care	566
services;	567

(2) Offering policies that provide benefits solely for the	568
diagnosis and treatment of biologically based mental illnesses;	569

(3) Managing the provision of benefits for the diagnosis or	570
treatment of biologically based mental illnesses through the use	571
of pre-admission screening, by requiring beneficiaries to obtain	572
authorization prior to treatment, or through the use of any other	573
mechanism designed to limit coverage to that treatment determined	574
to be necessary;	575

(4) Enforcing the terms and conditions of a policy of	576
sickness and accident insurance.	577

(E) An insurer that offers a group policy of sickness and	578
accident insurance is not required to provide benefits for the	579
diagnosis and treatment of biologically based mental illnesses	580
pursuant to division (B) of this section if all of the following	581
apply:	582

(1) The insurer submits documentation certified by an	583
independent member of the American academy of actuaries to the	584
superintendent of insurance showing that actual claims for	585
diagnostic and treatment services for biologically based mental	586
illnesses incurred for a period of at least six months	587
independently caused the insurer's costs for claims and	588
administrative expenses for the coverage of all other physical	589
diseases and disorders to increase by more than one per cent per	590
year.	591

(2) The insurer submits a signed letter from an independent	592
member of the American academy of actuaries to the superintendent	593
of insurance opining that the increase described in division	594
(E)(1) of this section could reasonably justify an increase of	595
more than one per cent in the annual premiums or rates charged by	596
the insurer for the coverage of all other physical diseases and	597
disorders.	598

(3) The superintendent of insurance makes the following	599
determinations from the documentation and opinion submitted	600
pursuant to divisions (E)(1) and (2) of this section:	601

(a) Actual claims for diagnostic and treatment services for	602
biologically based mental illnesses incurred for a period of at	603
least six months independently caused the insurer's costs for	604
claims and administrative expenses for the coverage of all other	605
physical diseases and disorders to increase by more than one per	606
cent per year.	607

(b) The increase in costs reasonably justifies an increase of	608
more than one per cent in the annual premiums or rates charged by	609
the insurer for the coverage of all other physical diseases and	610
disorders.	611

Any determination made by the superintendent under this	612
division is final.	613

Sec. 3923.282. (A) As used in this section:

614

(1) "Biologically based mental illness" means schizophrenia,	615
schizoaffective disorder, major depressive disorder, bipolar	616
disorder, paranoia and other psychotic disorders,	617
obsessive-compulsive disorder, and panic disorder, as these terms	618
are defined in the most recent edition of the diagnostic and	619
statistical manual of mental disorders published by the American	620
psychiatric association.	621

(2) "Plan of health insurance" includes any private or public	622
employer group self-insurance plan that provides payment for	623
health care benefits for other than specific diseases or accidents	624
only, which benefits are not provided by contract with a sickness	625
and accident insurer or health insuring corporation.	626

(B) Notwithstanding section 3901.71 of the Revised Code, and	627
subject to division (F) of this section, each plan of health	628
insurance shall provide benefits for the diagnosis and treatment	629
of biologically based mental illnesses on the same terms and	630
conditions as, and shall provide benefits no less extensive than,	631
those provided under the plan of health insurance for the	632
treatment and diagnosis of all other physical diseases and	633
disorders, if both of the following apply:	634

(1) The biologically based mental illness is clinically	635
diagnosed by a physician authorized under Chapter 4731. of the	636
Revised Code to practice medicine and surgery or osteopathic	637
medicine and surgery; a psychologist licensed under Chapter 4732.	638
of the Revised Code; a professional clinical counselor,	639
professional counselor, or independent social worker licensed	640
under Chapter 4757. of the Revised Code; or a clinical nurse	641
specialist licensed under Chapter 4723. of the Revised Code whose	642
nursing specialty is mental health.	643

(2) The prescribed treatment is not experimental or	644
investigational, having proven its clinical effectiveness in	645
accordance with generally accepted medical standards.	646

(C) Division (B) of this section applies to all coverages and	647
terms and conditions of the plan of health insurance, including,	648
but not limited to, coverage of inpatient hospital services,	649
outpatient services, and medication; maximum lifetime benefits;	650
copayments; and individual and family deductibles.	651

(D) This section does not apply to a plan of health insurance	652
if federal law supersedes, preempts, prohibits, or otherwise	653
precludes its application to such plans. This section does not	654
apply to long-term care, hospital indemnity, disability income, or	655
medicare supplement plans of health insurance, or to any other	656
supplemental benefit plans of health insurance.	657

(E) Nothing in this section shall be construed as prohibiting	658
an employer from taking any of the following actions in connection	659
with a plan of health insurance:	660

(1) Negotiating separately with mental health care providers	661
with regard to reimbursement rates and the delivery of health care	662
services;	663

(2) Managing the provision of benefits for the diagnosis or	664
treatment of biologically based mental illnesses through the use	665
of pre-admission screening, by requiring beneficiaries to obtain	666
authorization prior to treatment, or through the use of any other	667
mechanism designed to limit coverage to that treatment determined	668
to be necessary;	669

(3) Enforcing the terms and conditions of a plan of health	670
insurance.	671

(F) An insurer that offers a plan of health insurance is not	672
required to provide benefits for the diagnosis and treatment of	673
biologically based mental illnesses in combination with benefits	674
for the treatment and diagnosis of all other physical diseases and	675
disorders as described in division (B) of this section if all of	676
the following apply:	677

(1) The insurer submits documentation certified by an	678
independent member of the American academy of actuaries to the	679
superintendent of insurance showing that actual claims for	680
diagnostic and treatment services for biologically based mental	681
illnesses incurred for a period of at least six months	682
independently caused the insurer's costs for claims and	683
administrative expenses for the coverage of all other physical	684
diseases and disorders to increase by more than one per cent per	685
year.	686

(2) The insurer submits a signed letter from an independent	687
member of the American academy of actuaries to the superintendent	688
of insurance opining that the increase described in division	689
(F)(1) of this section could reasonably justify an increase of	690
more than one per cent in the annual premiums or rates charged by	691
the insurer for the coverage of all other physical diseases and	692
disorders.	693

(3) The superintendent of insurance makes the following	694
determinations from the documentation and opinion submitted	695
pursuant to divisions (F)(1) and (2) of this section:	696

(a) Actual claims for diagnostic and treatment services for	697
biologically based mental illnesses incurred for a period of at	698
least six months independently caused the insurer's costs for	699
claims and administrative expenses for the coverage of all other	700
physical diseases and disorders to increase by more than one per	701
cent per year.	702

(b) The increase in costs reasonably justifies an increase of	703
more than one per cent in the annual premiums or rates charged by	704
the insurer for the coverage of all other physical diseases and	705
disorders.	706

Any determination made by the superintendent under this	707
division is final.	708

Sec. 3923.30.  Every person, the state and any of its	709
instrumentalities, any county, township, school district, or other	710
political subdivisions and any of its instrumentalities, and any	711
municipal corporation and any of its instrumentalities, which	712
provides payment for health care benefits for any of its employees	713
resident in this state, which benefits are not provided by	714
contract with an insurer qualified to provide sickness and	715
accident insurance, or a health insuring corporation, shall	716
include the following benefits in its plan of health care benefits	717
commencing on or after January 1, 1979:	718

(A) If such plan of health care benefits provides payment for	719
the treatment of mental or nervous disorders, then such plan shall	720
provide benefits for services on an outpatient basis for each	721
eligible employee and dependent for mental or emotional disorders,	722
or for evaluations, that are at least equal to the following:	723

(1) Payments not less than five hundred fifty dollars in a	724
twelve-month period, for services legally performed by or under	725
the clinical supervision of a licensed physician or a licensed	726
authorized under Chapter 4731. of the Revised Code to practice	727
medicine and surgery or osteopathic medicine and surgery; a	728
psychologist licensed under Chapter 4732. of the Revised Code; a	729
professional clinical counselor, professional counselor, or	730
independent social worker licensed under Chapter 4757. of the	731
Revised Code; or a clinical nurse specialist licensed under	732
Chapter 4723. of the Revised Code whose nursing specialty is	733
mental health, whether performed in an office, in a hospital, or	734
in a community mental health facility so long as the hospital or	735
community mental health facility is approved by the joint	736
commission on accreditation of healthcare organizations, the	737
council on accreditation for children and family services, the	738
rehabilitation accreditation commission, or, until two years after	739
the effective date of this amendmentJune 6, 2001, certified by	740
the department of mental health as being in compliance with	741
standards established under division (H) of section 5119.01 of the	742
Revised Code;	743

(2) Such benefit shall be subject to reasonable limitations,	744
and may be subject to reasonable deductibles and co-insurance	745
costs.	746

(3) In order to qualify for participation under this	747
division, every facility specified in this division shall have in	748
effect a plan for utilization review and a plan for peer review	749
and every person specified in this division shall have in effect a	750
plan for peer review. Such plans shall have the purpose of	751
ensuring high quality patient care and effective and efficient	752
utilization of available health facilities and services.	753

(4) Such payment for benefits shall not be greater than	754
usual, customary, and reasonable.	755

(5)(a) Services performed by or under the clinical	756
supervision of a licensed physician or licensed psychologist	757
health care professional identified in division (A)(1) of this	758
section, in order to be reimbursable under the coverage required	759
in division (A) of this section, shall meet both of the following	760
requirements:	761

(i) The services shall be performed in accordance with a	762
treatment plan that describes the expected duration, frequency,	763
and type of services to be performed;	764

(ii) The plan shall be reviewed and approved by a licensed	765
physician or licensed psychologistthe health care professional	766
every three months.	767

(b) Payment of benefits for services reimbursable under	768
division (A)(5)(a) of the section shall not be restricted to	769
services described in the treatment plan or conditioned upon	770
standards of a licensed physician or licensed psychologist, which	771
at least equal the requirements of division (A)(5)(a) of this	772
section.	773

(B) Payment for benefits for alcoholism treatment for	774
outpatient, inpatient, and intermediate primary care for each	775
eligible employee and dependent that are at least equal to the	776
following:	777

(1) Payments not less than five hundred fifty dollars in a	778
twelve-month period for services legally performed by or under the	779
clinical supervision of a licensed physician or licensed	780
psychologisthealth care professional identified in division	781
(A)(1) of this section, whether performed in an office, or in a	782
hospital or a community mental health facility or alcoholism	783
treatment facility so long as the hospital, community mental	784
health facility, or alcoholism treatment facility is approved by	785
the joint commission on accreditation of hospitals or certified by	786
the department of health;	787

(2) The benefits provided under this division shall be	788
subject to reasonable limitations and may be subject to reasonable	789
deductibles and co-insurance costs.	790

(3) A licensed physician or licensed psychologisthealth care	791
professional shall every three months certify a patient's need for	792
continued services performed by such facilities.	793

(4) In order to qualify for participation under this	794
division, every facility specified in this division shall have in	795
effect a plan for utilization review and a plan for peer review	796
and every person specified in this division shall have in effect a	797
plan for peer review. Such plans shall have the purpose of	798
ensuring high quality patient care and efficient utilization of	799
available health facilities and services. Such person or	800
facilities shall also have in effect a program of rehabilitation	801
or a program of rehabilitation and detoxification.	802

(5) Nothing in this section shall be construed to require	803
reimbursement for benefits which is greater than usual, customary,	804
and reasonable.	805

(C) The benefits provided by division (A) of this section for	806
mental and emotional disorders shall not be reduced by the cost of	807
benefits provided pursuant to section 3923.282 of the Revised Code	808
for diagnostic and treatment services for biologically based	809
mental illness. This section does not provide benefits for	810
diagnostic and treatment services for biologically based mental	811
illnesses.	812

Sec. 3923.51.  (A) As used in this section, "official poverty	813
line" means the poverty line as defined by the United States	814
office of management and budget and revised by the secretary of	815
health and human services under 95 Stat. 511, 42 U.S.C.A. 9902, as	816
amended.	817

(B) Every insurer that is authorized to write sickness and	818
accident insurance in this state may offer group contracts of	819
sickness and accident insurance to any charitable foundation that	820
is certified as exempt from taxation under section 501(c)(3) of	821
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A.	822
1, as amended, and that has the sole purpose of issuing	823
certificates of coverage under these contracts to persons under	824
the age of nineteen who are members of families that have incomes	825
that are no greater than three hundred per cent of the official	826
poverty line.	827

(C) Contracts offered pursuant to division (B) of this	828
section are not subject to any of the following:	829

(1) Sections 3923.122, 3923.24, 3923.28, 3923.281, and	830
3923.29 of the Revised Code;	831

(2) Any other sickness and accident insurance coverage	832
required under this chapter on August 3, 1989. Any requirement of	833
sickness and accident insurance coverage enacted after that date	834
applies to this section only if the subsequent enactment	835
specifically refers to this section.	836

(3) Chapter 1751. of the Revised Code.

837

Section 2.  That existing sections 1739.05, 1751.01, 1751.02,	838
3923.28, 3923.30, and 3923.51 of the Revised Code are hereby	839
repealed.	840

Section 3.  Section 1751.01 of the Revised Code, as amended	841
by this act, shall apply only to policies, contracts, and	842
agreements that are delivered, issued for delivery, or renewed in	843
this state on or after the effective date of this act; section	844
3923.28 of the Revised Code, as amended by this act, shall apply	845
only to policies of sickness and accident insurance on or after	846
the effective date of this act in accordance with section 3923.01	847
of the Revised Code; sections 3923.281 and 3923.282 of the Revised	848
Code, as enacted by this act, shall apply only to policies of	849
sickness and accident insurance and plans of health insurance that	850
are established or modified in this state on or after the	851
effective date of this act; and section 3923.30 of the Revised	852
Code, as amended by this act, shall apply only to public employee	853
health plans established or modified in this state on or after the	854
effective date of this act.	855