As Passed by the House

126th General Assembly Regular Session 2005-2006

Am. Sub. S. B. No. 116

Senators Spada, Gardner, Schuring, Hottinger, Fedor, Fingerhut, Miller, R., Hagan, Dann, Zurz, Jacobson, Roberts, Prentiss, Austria, Harris, Armbruster, Goodman, Kearney, Miller, D. 

Representatives Redfern, Schneider, Smith, S., Peterson, Mason, Brown, Otterman, Barrett, Blessing, Boccieri, Book, Calvert, Carano, Cassell, Chandler, Collier, DeBose, DeGeeter, Distel, Domenick, Driehaus, Evans, C., Fende, Flowers, Foley, Garrison, Hartnett, Key, Kilbane, Koziura, Mitchell, Oelslager, Patton, S., Patton, T., Perry, Sayre, Schlichter, Seitz, Skindell, Stewart, D., Strahorn, Sykes, Ujvagi, Wagoner, Williams, Yates, Yuko, Hoops, Stewart, J. 

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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, and to

8

prohibit for ninety days, the establishment of

9

special hospitals in counties with a population of

10

more than one hundred forty thousand but less than

11

one hundred fifty thousand individuals.

12

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

Section 1.  That sections 1739.05, 1751.01, 1751.02, 3923.28,	13
3923.30, and 3923.51 be amended and sections 3923.281 and 3923.282	14
of the Revised Code be enacted to read as follows:	15

Sec. 1739.05.  (A) A multiple employer welfare arrangement	16
that is created pursuant to sections 1739.01 to 1739.22 of the	17
Revised Code and that operates a group self-insurance program may	18
be established only if any of the following applies:	19

(1) The arrangement has and maintains a minimum enrollment of	20
three hundred employees of two or more employers.	21

(2) The arrangement has and maintains a minimum enrollment of	22
three hundred self-employed individuals.	23

(3) The arrangement has and maintains a minimum enrollment of	24
three hundred employees or self-employed individuals in any	25
combination of divisions (A)(1) and (2) of this section.	26

(B) A multiple employer welfare arrangement that is created	27
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	28
that operates a group self-insurance program shall comply with all	29
laws applicable to self-funded programs in this state, including	30
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	31
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	32
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3924.031,	33
3924.032, and 3924.27 of the Revised Code.	34

(C) A multiple employer welfare arrangement created pursuant	35
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	36
enrollments only through agents or solicitors licensed pursuant to	37
Chapter 3905. of the Revised Code to sell or solicit sickness and	38
accident insurance.	39

(D) A multiple employer welfare arrangement created pursuant	40
to sections 1739.01 to 1739.22 of the Revised Code shall provide	41
benefits only to individuals who are members, employees of	42
members, or the dependents of members or employees, or are	43
eligible for continuation of coverage under section 1751.53 or	44
3923.38 of the Revised Code or under Title X of the "Consolidated	45
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	46
U.S.C.A. 1161, as amended.	47

Sec. 1751.01.  As used in this chapter:

48

(A)(1) "Basic health care services" means the following	49
services when medically necessary:	50

(1)(a) Physician's services, except when such services are	51
supplemental under division (B) of this section;	52

(2)(b) Inpatient hospital services;

53

(3)(c) Outpatient medical services;

54

(4)(d) Emergency health services;

55

(5)(e) Urgent care services;

56

(6)(f) Diagnostic laboratory services and diagnostic and	57
therapeutic radiologic services;	58

(7)(g) Diagnostic and treatment services, other than	59
prescription drug services, for biologically based mental	60
illnesses;	61

(h) Preventive health care services, including, but not	62
limited to, voluntary family planning services, infertility	63
services, periodic physical examinations, prenatal obstetrical	64
care, and well-child care.	65

"Basic health care services" does not include experimental	66
procedures.	67

AExcept as provided by divisions (A)(2) and (3) of this	68
section in connection with the offering of coverage for diagnostic	69
and treatment services for biologically based mental illnesses, a	70
health insuring corporation shall not offer coverage for a health	71
care service, defined as a basic health care service by this	72
division, unless it offers coverage for all listed basic health	73
care services. However, this requirement does not apply to the	74
coverage of beneficiaries enrolled in Title XVIII of the "Social	75
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended,	76
pursuant to a medicare contract, or to the coverage of	77
beneficiaries enrolled in the federal employee health benefits	78
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	79
beneficiaries enrolled in Title XIX of the "Social Security Act,"	80
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	81
medical assistance program or medicaid, provided by the department	82
of job and family services under Chapter 5111. of the Revised	83
Code, or to the coverage of beneficiaries under any federal health	84
care program regulated by a federal regulatory body, or to the	85
coverage of beneficiaries under any contract covering officers or	86
employees of the state that has been entered into by the	87
department of administrative services.	88

(2) A health insuring corporation may offer coverage for	89
diagnostic and treatment services for biologically based mental	90
illnesses without offering coverage for all other basic health	91
care services. A health insuring corporation may offer coverage	92
for diagnostic and treatment services for biologically based	93
mental illnesses alone or in combination with one or more	94
supplemental health care services. However, a health insuring	95
corporation that offers coverage for any other basic health care	96
service shall offer coverage for diagnostic and treatment services	97
for biologically based mental illnesses in combination with the	98
offer of coverage for all other listed basic health care services.	99

(3) A health insuring corporation that offers coverage for	100
basic health care services is not required to offer coverage for	101
diagnostic and treatment services for biologically based mental	102
illnesses in combination with the offer of coverage for all other	103
listed basic health care services if all of the following apply:	104

(a) The health insuring corporation submits documentation	105
certified by an independent member of the American academy of	106
actuaries to the superintendent of insurance showing that incurred	107
claims for diagnostic and treatment services for biologically	108
based mental illnesses for a period of at least sixmonths	109
independently caused the health insuring corporation's costs for	110
claims and administrative expenses for the coverage of basic	111
health care services to increase by more than one per cent per	112
year.	113

(b) The health insuring corporation submits a signed letter	114
from an independent member of the American academy of actuaries to	115
the superintendent of insurance opining that the increase in costs	116
described in division (A)(3)(a) of this section could reasonably	117
justify an increase of more than one per cent in the annual	118
premiums or rates charged by the health insuring corporation for	119
the coverage of basic health care services.	120

(c) The superintendent of insurance makes the following	121
determinations from the documentation and opinion submitted	122
pursuant to divisions (A)(3)(a) and (b) of this section:	123

(i) Incurred claims for diagnostic and treatment services for	124
biologically based mental illnesses for a period of at least six	125
months independently caused the health insuring corporation's	126
costs for claims and administrative expenses for the coverage of	127
basic health care services to increase by more than one per cent	128
per year.	129

(ii) The increase in costs reasonably justifies an increase	130
of more than one per cent in the annual premiums or rates charged	131
by the health insuring corporation for the coverage of basic	132
health care services.	133

Any determination made by the superintendent under this	134
division is subject to Chapter 119. of the Revised Code.	135

(B)(1) "Supplemental health care services" means any health	136
care services other than basic health care services that a health	137
insuring corporation may offer, alone or in combination with	138
either basic health care services or other supplemental health	139
care services, and includes:	140

(1)(a) Services of facilities for intermediate or long-term	141
care, or both;	142

(2)(b) Dental care services;

143

(3)(c) Vision care and optometric services including lenses	144
and frames;	145

(4)(d) Podiatric care or foot care services;

146

(5)(e) Mental health services including psychological	147
services, excluding diagnostic and treatment services for	148
biologically based mental illnesses;	149

(6)(f) Short-term outpatient evaluative and	150
crisis-intervention mental health services;	151

(7)(g) Medical or psychological treatment and referral	152
services for alcohol and drug abuse or addiction;	153

(8)(h) Home health services;

154

(9)(i) Prescription drug services;

155

(10)(j) Nursing services;

156

(11)(k) Services of a dietitian licensed under Chapter 4759.	157
of the Revised Code;	158

(12)(l) Physical therapy services;

159

(13)(m) Chiropractic services;

160

(14)(n) Any other category of services approved by the	161
superintendent of insurance.	162

(2) If a health insuring corporation offers prescription drug	163
services under this division, the coverage shall include	164
prescription drug services for the treatment of biologically based	165
mental illnesses on the same terms and conditions as other	166
physical diseases and disorders.	167

(C) "Specialty health care services" means one of the	168
supplemental health care services listed in division (B)(1) to	169
(13) of this section, when provided by a health insuring	170
corporation on an outpatient-only basis and not in combination	171
with other supplemental health care services.	172

(D) "Biologically based mental illnesses" means	173
schizophrenia, schizoaffective disorder, major depressive	174
disorder, bipolar disorder, paranoia and other psychotic	175
disorders, obsessive-compulsive disorder, and panic disorder, as	176
these terms are defined in the most recent edition of the	177
diagnostic and statistical manual of mental disorders published by	178
the American psychiatric association.	179

(E) "Closed panel plan" means a health care plan that	180
requires enrollees to use participating providers.	181

(E)(F) "Compensation" means remuneration for the provision of	182
health care services, determined on other than a fee-for-service	183
or discounted-fee-for-service basis.	184

(F)(G) "Contractual periodic prepayment" means the formula	185
for determining the premium rate for all subscribers of a health	186
insuring corporation.	187

(G)(H) "Corporation" means a corporation formed under Chapter	188
1701. or 1702. of the Revised Code or the similar laws of another	189
state.	190

(H)(I) "Emergency health services" means those health care	191
services that must be available on a seven-days-per-week,	192
twenty-four-hours-per-day basis in order to prevent jeopardy to an	193
enrollee's health status that would occur if such services were	194
not received as soon as possible, and includes, where appropriate,	195
provisions for transportation and indemnity payments or service	196
agreements for out-of-area coverage.	197

(I)(J) "Enrollee" means any natural person who is entitled to	198
receive health care benefits provided by a health insuring	199
corporation.	200

(J)(K) "Evidence of coverage" means any certificate,	201
agreement, policy, or contract issued to a subscriber that sets	202
out the coverage and other rights to which such person is entitled	203
under a health care plan.	204

(K)(L) "Health care facility" means any facility, except a	205
health care practitioner's office, that provides preventive,	206
diagnostic, therapeutic, acute convalescent, rehabilitation,	207
mental health, mental retardation, intermediate care, or skilled	208
nursing services.	209

(L)(M) "Health care services" means basic, supplemental, and	210
specialty health care services.	211

(M)(N) "Health delivery network" means any group of providers	212
or health care facilities, or both, or any representative thereof,	213
that have entered into an agreement to offer health care services	214
in a panel rather than on an individual basis.	215

(N)(O) "Health insuring corporation" means a corporation, as	216
defined in division (G)(H) of this section, that, pursuant to a	217
policy, contract, certificate, or agreement, pays for, reimburses,	218
or provides, delivers, arranges for, or otherwise makes available,	219
basic health care services, supplemental health care services, or	220
specialty health care services, or a combination of basic health	221
care services and either supplemental health care services or	222
specialty health care services, through either an open panel plan	223
or a closed panel plan.	224

"Health insuring corporation" does not include a limited	225
liability company formed pursuant to Chapter 1705. of the Revised	226
Code, an insurer licensed under Title XXXIX of the Revised Code if	227
that insurer offers only open panel plans under which all	228
providers and health care facilities participating receive their	229
compensation directly from the insurer, a corporation formed by or	230
on behalf of a political subdivision or a department, office, or	231
institution of the state, or a public entity formed by or on	232
behalf of a board of county commissioners, a county board of	233
mental retardation and developmental disabilities, an alcohol and	234
drug addiction services board, a board of alcohol, drug addiction,	235
and mental health services, or a community mental health board, as	236
those terms are used in Chapters 340. and 5126. of the Revised	237
Code. Except as provided by division (D) of section 1751.02 of	238
the Revised Code, or as otherwise provided by law, no board,	239
commission, agency, or other entity under the control of a	240
political subdivision may accept insurance risk in providing for	241
health care services. However, nothing in this division shall be	242
construed as prohibiting such entities from purchasing the	243
services of a health insuring corporation or a third-party	244
administrator licensed under Chapter 3959. of the Revised Code.	245

(O)(P) "Intermediary organization" means a health delivery	246
network or other entity that contracts with licensed health	247
insuring corporations or self-insured employers, or both, to	248
provide health care services, and that enters into contractual	249
arrangements with other entities for the provision of health care	250
services for the purpose of fulfilling the terms of its contracts	251
with the health insuring corporations and self-insured employers.	252

(P)(Q) "Intermediate care" means residential care above the	253
level of room and board for patients who require personal	254
assistance and health-related services, but who do not require	255
skilled nursing care.	256

(Q)(R) "Medical record" means the personal information that	257
relates to an individual's physical or mental condition, medical	258
history, or medical treatment.	259

(R)(S)(1) "Open panel plan" means a health care plan that	260
provides incentives for enrollees to use participating providers	261
and that also allows enrollees to use providers that are not	262
participating providers.	263

(2) No health insuring corporation may offer an open panel	264
plan, unless the health insuring corporation is also licensed as	265
an insurer under Title XXXIX of the Revised Code, the health	266
insuring corporation, on June 4, 1997, holds a certificate of	267
authority or license to operate under Chapter 1736. or 1740. of	268
the Revised Code, or an insurer licensed under Title XXXIX of the	269
Revised Code is responsible for the out-of-network risk as	270
evidenced by both an evidence of coverage filing under section	271
1751.11 of the Revised Code and a policy and certificate filing	272
under section 3923.02 of the Revised Code.	273

(S)(T) "Panel" means a group of providers or health care	274
facilities that have joined together to deliver health care	275
services through a contractual arrangement with a health insuring	276
corporation, employer group, or other payor.	277

(T)(U) "Person" has the same meaning as in section 1.59 of	278
the Revised Code, and, unless the context otherwise requires,	279
includes any insurance company holding a certificate of authority	280
under Title XXXIX of the Revised Code, any subsidiary and	281
affiliate of an insurance company, and any government agency.	282

(U)(V) "Premium rate" means any set fee regularly paid by a	283
subscriber to a health insuring corporation. A "premium rate" does	284
not include a one-time membership fee, an annual administrative	285
fee, or a nominal access fee, paid to a managed health care system	286
under which the recipient of health care services remains solely	287
responsible for any charges accessed for those services by the	288
provider or health care facility.	289

(V)(W) "Primary care provider" means a provider that is	290
designated by a health insuring corporation to supervise,	291
coordinate, or provide initial care or continuing care to an	292
enrollee, and that may be required by the health insuring	293
corporation to initiate a referral for specialty care and to	294
maintain supervision of the health care services rendered to the	295
enrollee.	296

(W)(X) "Provider" means any natural person or partnership of	297
natural persons who are licensed, certified, accredited, or	298
otherwise authorized in this state to furnish health care	299
services, or any professional association organized under Chapter	300
1785. of the Revised Code, provided that nothing in this chapter	301
or other provisions of law shall be construed to preclude a health	302
insuring corporation, health care practitioner, or organized	303
health care group associated with a health insuring corporation	304
from employing certified nurse practitioners, certified nurse	305
anesthetists, clinical nurse specialists, certified nurse	306
midwives, dietitians, physician assistants, dental assistants,	307
dental hygienists, optometric technicians, or other allied health	308
personnel who are licensed, certified, accredited, or otherwise	309
authorized in this state to furnish health care services.	310

(X)(Y) "Provider sponsored organization" means a corporation,	311
as defined in division (G)(H) of this section, that is at least	312
eighty per cent owned or controlled by one or more hospitals, as	313
defined in section 3727.01 of the Revised Code, or one or more	314
physicians licensed to practice medicine or surgery or osteopathic	315
medicine and surgery under Chapter 4731. of the Revised Code, or	316
any combination of such physicians and hospitals. Such control is	317
presumed to exist if at least eighty per cent of the voting rights	318
or governance rights of a provider sponsored organization are	319
directly or indirectly owned, controlled, or otherwise held by any	320
combination of the physicians and hospitals described in this	321
division.	322

(Y)(Z) "Solicitation document" means the written materials	323
provided to prospective subscribers or enrollees, or both, and	324
used for advertising and marketing to induce enrollment in the	325
health care plans of a health insuring corporation.	326

(Z)(AA) "Subscriber" means a person who is responsible for	327
making payments to a health insuring corporation for participation	328
in a health care plan, or an enrollee whose employment or other	329
status is the basis of eligibility for enrollment in a health	330
insuring corporation.	331

(AA)(BB) "Urgent care services" means those health care	332
services that are appropriately provided for an unforeseen	333
condition of a kind that usually requires medical attention	334
without delay but that does not pose a threat to the life, limb,	335
or permanent health of the injured or ill person, and may include	336
such health care services provided out of the health insuring	337
corporation's approved service area pursuant to indemnity payments	338
or service agreements.	339

Sec. 1751.02.  (A) Notwithstanding any law in this state to	340
the contrary, any corporation, as defined in section 1751.01 of	341
the Revised Code, may apply to the superintendent of insurance for	342
a certificate of authority to establish and operate a health	343
insuring corporation. If the corporation applying for a	344
certificate of authority is a foreign corporation domiciled in a	345
state without laws similar to those of this chapter, the	346
corporation must form a domestic corporation to apply for, obtain,	347
and maintain a certificate of authority under this chapter.	348

(B) No person shall establish, operate, or perform the	349
services of a health insuring corporation in this state without	350
obtaining a certificate of authority under this chapter.	351

(C) Except as provided by division (D) of this section, no	352
political subdivision or department, office, or institution of	353
this state, or corporation formed by or on behalf of any political	354
subdivision or department, office, or institution of this state,	355
shall establish, operate, or perform the services of a health	356
insuring corporation. Nothing in this section shall be construed	357
to preclude a board of county commissioners, a county board of	358
mental retardation and developmental disabilities, an alcohol and	359
drug addiction services board, a board of alcohol, drug addiction,	360
and mental health services, or a community mental health board, or	361
a public entity formed by or on behalf of any of these boards,	362
from using managed care techniques in carrying out the board's or	363
public entity's duties pursuant to the requirements of Chapters	364
307., 329., 340., and 5126. of the Revised Code. However, no such	365
board or public entity may operate so as to compete in the private	366
sector with health insuring corporations holding certificates of	367
authority under this chapter.	368

(D) A corporation formed by or on behalf of a publicly owned,	369
operated, or funded hospital or health care facility may apply to	370
the superintendent for a certificate of authority under division	371
(A) of this section to establish and operate a health insuring	372
corporation.	373

(E) A health insuring corporation shall operate in this state	374
in compliance with this chapter and Chapter 1753. of the Revised	375
Code, and with sections 3702.51 to 3702.62 of the Revised Code,	376
and shall operate in conformity with its filings with the	377
superintendent under this chapter, including filings made pursuant	378
to sections 1751.03, 1751.11, 1751.12, and 1751.31 of the Revised	379
Code.	380

(F) An insurer licensed under Title XXXIX of the Revised Code	381
need not obtain a certificate of authority as a health insuring	382
corporation to offer an open panel plan as long as the providers	383
and health care facilities participating in the open panel plan	384
receive their compensation directly from the insurer. If the	385
providers and health care facilities participating in the open	386
panel plan receive their compensation from any person other than	387
the insurer, or if the insurer offers a closed panel plan, the	388
insurer must obtain a certificate of authority as a health	389
insuring corporation.	390

(G) An intermediary organization need not obtain a	391
certificate of authority as a health insuring corporation,	392
regardless of the method of reimbursement to the intermediary	393
organization, as long as a health insuring corporation or a	394
self-insured employer maintains the ultimate responsibility to	395
assure delivery of all health care services required by the	396
contract between the health insuring corporation and the	397
subscriber and the laws of this state or between the self-insured	398
employer and its employees.	399

Nothing in this section shall be construed to require any	400
health care facility, provider, health delivery network, or	401
intermediary organization that contracts with a health insuring	402
corporation or self-insured employer, regardless of the method of	403
reimbursement to the health care facility, provider, health	404
delivery network, or intermediary organization, to obtain a	405
certificate of authority as a health insuring corporation under	406
this chapter, unless otherwise provided, in the case of contracts	407
with a self-insured employer, by operation of the "Employee	408
Retirement Income Security Act of 1974," 88 Stat. 829, 29 U.S.C.A.	409
1001, as amended.	410

(H) Any health delivery network doing business in this state,	411
including any health delivery network that is functioning as an	412
intermediary organization doing business in this state, that is	413
not required to obtain a certificate of authority under this	414
chapter shall certify to the superintendent annually, not later	415
than the first day of July, and shall provide a statement signed	416
by the highest ranking official which includes the following	417
information:	418

(1) The health delivery network's full name and the address	419
of its principal place of business;	420

(2) A statement that the health delivery network is not	421
required to obtain a certificate of authority under this chapter	422
to conduct its business.	423

(I) The superintendent shall not issue a certificate of	424
authority to a health insuring corporation that is a provider	425
sponsored organization unless all health care plans to be offered	426
by the health insuring corporation provide basic health care	427
services. Substantially all of the physicians and hospitals with	428
ownership or control of the provider sponsored organization, as	429
defined in division (X) of section 1751.01 of the Revised Code,	430
shall also be participating providers for the provision of basic	431
health care services for health care plans offered by the provider	432
sponsored organization. If a health insuring corporation that is a	433
provider sponsored organization offers health care plans that do	434
not provide basic health care services, the health insuring	435
corporation shall be deemed, for purposes of section 1751.35 of	436
the Revised Code, to have failed to substantially comply with this	437
chapter.	438

Except as specifically provided in this division and in	439
division (A) of section 1751.28 of the Revised Code, the	440
provisions of this chapter shall apply to all health insuring	441
corporations that are provider sponsored organizations in the same	442
manner that these provisions apply to all health insuring	443
corporations that are not provider sponsored organizations.	444

(J) Nothing in this section shall be construed to apply to	445
any multiple employer welfare arrangement operating pursuant to	446
Chapter 1739. of the Revised Code.	447

(K) Any person who violates division (B) of this section, and	448
any health delivery network that fails to comply with division (H)	449
of this section, is subject to the penalties set forth in section	450
1751.45 of the Revised Code.	451

Sec. 3923.28.  (A) Every policy of group sickness and	452
accident insurance providing hospital, surgical, or medical	453
expense coverage for other than specific diseases or accidents	454
only, and delivered, issued for delivery, or renewed in this state	455
on or after January 1, 1979, and that provides coverage for mental	456
or emotional disorders, shall provide benefits for services on an	457
outpatient basis for each eligible person under the policy who	458
resides in this state for mental or emotional disorders, or for	459
evaluations, that are at least equal to five hundred fifty dollars	460
in any calendar year or twelve-month period. The services shall be	461
legally performed by or under the clinical supervision of a	462
licensed physician or licensedauthorized under Chapter 4731. of	463
the Revised Code to practice medicine and surgery or osteopathic	464
medicine and surgery; a psychologist licensed under Chapter 4732.	465
of the Revised Code; a professional clinical counselor,	466
professional counselor, or independent social worker licensed	467
under Chapter 4757. of the Revised Code; or a clinical nurse	468
specialist licensed under Chapter 4723. of the Revised Code whose	469
nursing specialty is mental health, whether performed in an	470
office, in a hospital, or in a community mental health facility so	471
long as the hospital or community mental health facility is	472
approved by the joint commission on accreditation of healthcare	473
organizations, the council on accreditation for children and	474
family services, the rehabilitation accreditation commission, or,	475
until two years after the effective date of this amendmentJune 6,	476
2001, certified by the department of mental health as being in	477
compliance with standards established under division (H) of	478
section 5119.01 of the Revised Code.	479

(B) Outpatient benefits offered under division (A) of this	480
section shall be subject to reasonable contract limitations and	481
may be subject to reasonable deductibles and co-insurance costs.	482
Persons entitled to such benefit under more than one service or	483
insurance contract may be limited to a single	484
five-hundred-fifty-dollar outpatient benefit for services under	485
all contracts.	486

(C) In order to qualify for participation under division (A)	487
of this section, every facility specified in such division shall	488
have in effect a plan for utilization review and a plan for peer	489
review and every person specified in such division shall have in	490
effect a plan for peer review. Such plans shall have the purpose	491
of ensuring high quality patient care and effective and efficient	492
utilization of available health facilities and services.	493

(D) Nothing in this section shall be construed to require an	494
insurer to pay benefits which are greater than usual, customary,	495
and reasonable.	496

(E)(1) Services performed under the clinical supervision of a	497
licensed physician or licensed psychologisthealth care	498
professional identified in division (A) of this section, in order	499
to be reimbursable under the coverage required in division (A) of	500
this section, shall meet both of the following requirements:	501

(a) The services shall be performed in accordance with a	502
treatment plan that describes the expected duration, frequency,	503
and type of services to be performed;	504

(b) The plan shall be reviewed and approved by a licensed	505
physician or licensed psychologistthe health care professional	506
every three months.	507

(2) Payment of benefits for services reimbursable under	508
division (E)(1) of this section shall not be restricted to	509
services described in the treatment plan or conditioned upon	510
standards of clinical supervision that are more restrictive than	511
standards of a licensed physician or licensed psychologisthealth	512
care professional described in division (A) of this section, which	513
at least equal the requirements of division (E)(1) of this	514
section.	515

(F) The benefits provided by this section for mental and	516
emotional disorders shall not be reduced by the cost of benefits	517
provided pursuant to section 3923.281 of the Revised Code for	518
diagnostic and treatment services for biologically based mental	519
illnesses. This section does not apply to benefits for diagnostic	520
and treatment services for biologically based mental illnesses.	521

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

522

(1) "Biologically based mental illness" means schizophrenia,	523
schizoaffective disorder, major depressive disorder, bipolar	524
disorder, paranoia and other psychotic disorders,	525
obsessive-compulsive disorder, and panic disorder, as these terms	526
are defined in the most recent edition of the diagnostic and	527
statistical manual of mental disorders published by the American	528
psychiatric association.	529

(2) "Policy of sickness and accident insurance" has the same	530
meaning as in section 3923.01 of the Revised Code, but excludes	531
any hospital indemnity, medicare supplement, long-term care,	532
disability income, one-time-limited-duration policy of not longer	533
than six months, supplemental benefit, or other policy that	534
provides coverage for specific diseases or accidents only; any	535
policy that provides coverage for workers' compensation claims	536
compensable pursuant to Chapters 4121. and 4123. of the Revised	537
Code; and any policy that provides coverage to beneficiaries	538
enrolled in Title XIX of the "Social Security Act," 49 Stat. 620	539
(1935), 42 U.S.C.A. 301, as amended, known as the medical	540
assistance program or medicaid, as provided by the Ohio department	541
of job and family services under Chapter 5111. of the Revised	542
Code.	543

(B) Notwithstanding section 3901.71 of the Revised Code, and	544
subject to division (E) of this section, every group policy of	545
sickness and accident insurance shall provide benefits for the	546
diagnosis and treatment of biologically based mental illnesses on	547
the same terms and conditions as, and shall provide benefits no	548
less extensive than, those provided under the policy of sickness	549
and accident insurance for the treatment and diagnosis of all	550
other physical diseases and disorders, if both of the following	551
apply:	552

(1) The biologically based mental illness is clinically	553
diagnosed by a physician authorized under Chapter 4731. of the	554
Revised Code to practice medicine and surgery or osteopathic	555
medicine and surgery; a psychologist licensed under Chapter 4732.	556
of the Revised Code; a professional clinical counselor,	557
professional counselor, or independent social worker licensed	558
under Chapter 4757. of the Revised Code; or a clinical nurse	559
specialist licensed under Chapter 4723. of the Revised Code whose	560
nursing specialty is mental health.	561

(2) The prescribed treatment is not experimental or	562
investigational, having proven its clinical effectiveness in	563
accordance with generally accepted medical standards.	564

(C) Division (B) of this section applies to all coverages and	565
terms and conditions of the policy of sickness and accident	566
insurance, including, but not limited to, coverage of inpatient	567
hospital services, outpatient services, and medication; maximum	568
lifetime benefits; copayments; and individual and family	569
deductibles.	570

(D) Nothing in this section shall be construed as prohibiting	571
a sickness and accident insurance company from taking any of the	572
following actions:	573

(1) Negotiating separately with mental health care providers	574
with regard to reimbursement rates and the delivery of health care	575
services;	576

(2) Offering policies that provide benefits solely for the	577
diagnosis and treatment of biologically based mental illnesses;	578

(3) Managing the provision of benefits for the diagnosis or	579
treatment of biologically based mental illnesses through the use	580
of pre-admission screening, by requiring beneficiaries to obtain	581
authorization prior to treatment, or through the use of any other	582
mechanism designed to limit coverage to that treatment determined	583
to be necessary;	584

(4) Enforcing the terms and conditions of a policy of	585
sickness and accident insurance.	586

(E) An insurer that offers a group policy of sickness and	587
accident insurance is not required to provide benefits for the	588
diagnosis and treatment of biologically based mental illnesses	589
pursuant to division (B) of this section if all of the following	590
apply:	591

(1) The insurer submits documentation certified by an	592
independent member of the American academy of actuaries to the	593
superintendent of insurance showing that incurred claims for	594
diagnostic and treatment services for biologically based mental	595
illnesses for a period of at least six months independently caused	596
the insurer's costs for claims and administrative expenses for the	597
coverage of all other physical diseases and disorders to increase	598
by more than one per cent per year.	599

(2) The insurer submits a signed letter from an independent	600
member of the American academy of actuaries to the superintendent	601
of insurance opining that the increase described in division	602
(E)(1) of this section could reasonably justify an increase of	603
more than one per cent in the annual premiums or rates charged by	604
the insurer for the coverage of all other physical diseases and	605
disorders.	606

(3) The superintendent of insurance makes the following	607
determinations from the documentation and opinion submitted	608
pursuant to divisions (E)(1) and (2) of this section:	609

(a) Incurred claims for diagnostic and treatment services for	610
biologically based mental illnesses for a period of at least six	611
months independently caused the insurer's costs for claims and	612
administrative expenses for the coverage of all other physical	613
diseases and disorders to increase by more than one per cent per	614
year.	615

(b) The increase in costs reasonably justifies an increase of	616
more than one per cent in the annual premiums or rates charged by	617
the insurer for the coverage of all other physical diseases and	618
disorders.	619

Any determination made by the superintendent under this	620
division is subject to Chapter 119. of the Revised Code.	621

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

622

(1) "Biologically based mental illness" means schizophrenia,	623
schizoaffective disorder, major depressive disorder, bipolar	624
disorder, paranoia and other psychotic disorders,	625
obsessive-compulsive disorder, and panic disorder, as these terms	626
are defined in the most recent edition of the diagnostic and	627
statistical manual of mental disorders published by the American	628
psychiatric association.	629

(2) "Plan of health coverage" includes any private or public	630
employer group self-insurance plan that provides payment for	631
health care benefits for other than specific diseases or accidents	632
only, which benefits are not provided by contract with a sickness	633
and accident insurer or health insuring corporation.	634

(B) Notwithstanding section 3901.71 of the Revised Code, and	635
subject to division (F) of this section, each plan of health	636
coverage shall provide benefits for the diagnosis and treatment of	637
biologically based mental illnesses on the same terms and	638
conditions as, and shall provide benefits no less extensive than,	639
those provided under the plan of health coverage for the treatment	640
and diagnosis of all other physical diseases and disorders, if	641
both of the following apply:	642

(1) The biologically based mental illness is clinically	643
diagnosed by a physician authorized under Chapter 4731. of the	644
Revised Code to practice medicine and surgery or osteopathic	645
medicine and surgery; a psychologist licensed under Chapter 4732.	646
of the Revised Code; a professional clinical counselor,	647
professional counselor, or independent social worker licensed	648
under Chapter 4757. of the Revised Code; or a clinical nurse	649
specialist licensed under Chapter 4723. of the Revised Code whose	650
nursing specialty is mental health.	651

(2) The prescribed treatment is not experimental or	652
investigational, having proven its clinical effectiveness in	653
accordance with generally accepted medical standards.	654

(C) Division (B) of this section applies to all coverages and	655
terms and conditions of the plan of health coverage, including,	656
but not limited to, coverage of inpatient hospital services,	657
outpatient services, and medication; maximum lifetime benefits;	658
copayments; and individual and family deductibles.	659

(D) This section does not apply to a plan of health coverage	660
if federal law supersedes, preempts, prohibits, or otherwise	661
precludes its application to such plans. This section does not	662
apply to long-term care, hospital indemnity, disability income, or	663
medicare supplement plans of health coverage, or to any other	664
supplemental benefit plans of health coverage.	665

(E) Nothing in this section shall be construed as prohibiting	666
an employer from taking any of the following actions in connection	667
with a plan of health coverage:	668

(1) Negotiating separately with mental health care providers	669
with regard to reimbursement rates and the delivery of health care	670
services;	671

(2) Managing the provision of benefits for the diagnosis or	672
treatment of biologically based mental illnesses through the use	673
of pre-admission screening, by requiring beneficiaries to obtain	674
authorization prior to treatment, or through the use of any other	675
mechanism designed to limit coverage to that treatment determined	676
to be necessary;	677

(3) Enforcing the terms and conditions of a plan of health	678
coverage.	679

(F) An employer that offers a plan of health coverage is not	680
required to provide benefits for the diagnosis and treatment of	681
biologically based mental illnesses in combination with benefits	682
for the treatment and diagnosis of all other physical diseases and	683
disorders as described in division (B) of this section if both of	684
the following apply:	685

(1) The employer submits documentation certified by an	686
independent member of the American academy of actuaries to the	687
superintendent of insurance showing that incurred claims for	688
diagnostic and treatment services for biologically based mental	689
illnesses for a period of at least six months independently caused	690
the employer's costs for claims and administrative expenses for	691
the coverage of all other physical diseases and disorders to	692
increase by more than one per cent per year.	693

(2) The superintendent of insurance determines from the	694
documentation and opinion submitted pursuant to division (F) of	695
this section, that incurred claims for diagnostic and treatment	696
services for biologically based mental illnesses for a period of	697
at least six months independently caused the employer's costs for	698
claims and administrative expenses for the coverage of all other	699
physical diseases and disorders to increase by more than one per	700
cent per year.	701

Any determination made by the superintendent under this	702
division is subject to Chapter 119. of the Revised Code.	703

Sec. 3923.30.  Every person, the state and any of its	704
instrumentalities, any county, township, school district, or other	705
political subdivisions and any of its instrumentalities, and any	706
municipal corporation and any of its instrumentalities, which	707
provides payment for health care benefits for any of its employees	708
resident in this state, which benefits are not provided by	709
contract with an insurer qualified to provide sickness and	710
accident insurance, or a health insuring corporation, shall	711
include the following benefits in its plan of health care benefits	712
commencing on or after January 1, 1979:	713

(A) If such plan of health care benefits provides payment for	714
the treatment of mental or nervous disorders, then such plan shall	715
provide benefits for services on an outpatient basis for each	716
eligible employee and dependent for mental or emotional disorders,	717
or for evaluations, that are at least equal to the following:	718

(1) Payments not less than five hundred fifty dollars in a	719
twelve-month period, for services legally performed by or under	720
the clinical supervision of a licensed physician or a licensed	721
authorized under Chapter 4731. of the Revised Code to practice	722
medicine and surgery or osteopathic medicine and surgery; a	723
psychologist licensed under Chapter 4732. of the Revised Code; a	724
professional clinical counselor, professional counselor, or	725
independent social worker licensed under Chapter 4757. of the	726
Revised Code; or a clinical nurse specialist licensed under	727
Chapter 4723. of the Revised Code whose nursing specialty is	728
mental health, whether performed in an office, in a hospital, or	729
in a community mental health facility so long as the hospital or	730
community mental health facility is approved by the joint	731
commission on accreditation of healthcare organizations, the	732
council on accreditation for children and family services, the	733
rehabilitation accreditation commission, or, until two years after	734
the effective date of this amendmentJune 6, 2001, certified by	735
the department of mental health as being in compliance with	736
standards established under division (H) of section 5119.01 of the	737
Revised Code;	738

(2) Such benefit shall be subject to reasonable limitations,	739
and may be subject to reasonable deductibles and co-insurance	740
costs.	741

(3) In order to qualify for participation under this	742
division, every facility specified in this division shall have in	743
effect a plan for utilization review and a plan for peer review	744
and every person specified in this division shall have in effect a	745
plan for peer review. Such plans shall have the purpose of	746
ensuring high quality patient care and effective and efficient	747
utilization of available health facilities and services.	748

(4) Such payment for benefits shall not be greater than	749
usual, customary, and reasonable.	750

(5)(a) Services performed by or under the clinical	751
supervision of a licensed physician or licensed psychologist	752
health care professional identified in division (A)(1) of this	753
section, in order to be reimbursable under the coverage required	754
in division (A) of this section, shall meet both of the following	755
requirements:	756

(i) The services shall be performed in accordance with a	757
treatment plan that describes the expected duration, frequency,	758
and type of services to be performed;	759

(ii) The plan shall be reviewed and approved by a licensed	760
physician or licensed psychologistthe health care professional	761
every three months.	762

(b) Payment of benefits for services reimbursable under	763
division (A)(5)(a) of the section shall not be restricted to	764
services described in the treatment plan or conditioned upon	765
standards of a licensed physician or licensed psychologist, which	766
at least equal the requirements of division (A)(5)(a) of this	767
section.	768

(B) Payment for benefits for alcoholism treatment for	769
outpatient, inpatient, and intermediate primary care for each	770
eligible employee and dependent that are at least equal to the	771
following:	772

(1) Payments not less than five hundred fifty dollars in a	773
twelve-month period for services legally performed by or under the	774
clinical supervision of a licensed physician or licensed	775
psychologisthealth care professional identified in division	776
(A)(1) of this section, whether performed in an office, or in a	777
hospital or a community mental health facility or alcoholism	778
treatment facility so long as the hospital, community mental	779
health facility, or alcoholism treatment facility is approved by	780
the joint commission on accreditation of hospitals or certified by	781
the department of health;	782

(2) The benefits provided under this division shall be	783
subject to reasonable limitations and may be subject to reasonable	784
deductibles and co-insurance costs.	785

(3) A licensed physician or licensed psychologisthealth care	786
professional shall every three months certify a patient's need for	787
continued services performed by such facilities.	788

(4) In order to qualify for participation under this	789
division, every facility specified in this division shall have in	790
effect a plan for utilization review and a plan for peer review	791
and every person specified in this division shall have in effect a	792
plan for peer review. Such plans shall have the purpose of	793
ensuring high quality patient care and efficient utilization of	794
available health facilities and services. Such person or	795
facilities shall also have in effect a program of rehabilitation	796
or a program of rehabilitation and detoxification.	797

(5) Nothing in this section shall be construed to require	798
reimbursement for benefits which is greater than usual, customary,	799
and reasonable.	800

(C) The benefits provided by division (A) of this section for	801
mental and emotional disorders shall not be reduced by the cost of	802
benefits provided pursuant to section 3923.282 of the Revised Code	803
for diagnostic and treatment services for biologically based	804
mental illness. This section does not apply to benefits for	805
diagnostic and treatment services for biologically based mental	806
illnesses.	807

Sec. 3923.51.  (A) As used in this section, "official poverty	808
line" means the poverty line as defined by the United States	809
office of management and budget and revised by the secretary of	810
health and human services under 95 Stat. 511, 42 U.S.C.A. 9902, as	811
amended.	812

(B) Every insurer that is authorized to write sickness and	813
accident insurance in this state may offer group contracts of	814
sickness and accident insurance to any charitable foundation that	815
is certified as exempt from taxation under section 501(c)(3) of	816
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A.	817
1, as amended, and that has the sole purpose of issuing	818
certificates of coverage under these contracts to persons under	819
the age of nineteen who are members of families that have incomes	820
that are no greater than three hundred per cent of the official	821
poverty line.	822

(C) Contracts offered pursuant to division (B) of this	823
section are not subject to any of the following:	824

(1) Sections 3923.122, 3923.24, 3923.28, 3923.281, and	825
3923.29 of the Revised Code;	826

(2) Any other sickness and accident insurance coverage	827
required under this chapter on August 3, 1989. Any requirement of	828
sickness and accident insurance coverage enacted after that date	829
applies to this section only if the subsequent enactment	830
specifically refers to this section.	831

(3) Chapter 1751. of the Revised Code.

832

Section 2.  That existing sections 1739.05, 1751.01, 1751.02,	833
3923.28, 3923.30, and 3923.51 of the Revised Code are hereby	834
repealed.	835

Section 3.  Section 1751.01 of the Revised Code, as amended	836
by this act, shall apply only to policies, contracts, and	837
agreements that are delivered, issued for delivery, or renewed in	838
this state six months after the effective date of this act;	839
section 3923.28 of the Revised Code, as amended by this act, shall	840
apply only to policies of sickness and accident insurance six	841
months after the effective date of this act in accordance with	842
section 3923.01 of the Revised Code; sections 3923.281 and	843
3923.282 of the Revised Code, as enacted by this act, shall apply	844
only to policies of sickness and accident insurance and plans of	845
health coverage that are established or modified in this state six	846
months after the effective date of this act; and section 3923.30	847
of the Revised Code, as amended by this act, shall apply only to	848
public employee health plans established or modified in this state	849
six months after the effective date of this act.	850

Section 4.  (A) As used in this section, "special hospital"	851
means a hospital that is primarily or exclusively engaged in the	852
care and treatment of one or more of the following:	853

(1) Patients with a cardiac condition.

854

(2) Patients with an orthopedic condition.

855

(3) Patients receiving a surgical procedure.

856

(4) Patients receiving any other specialized category of	857
services specified by the Director of Health.	858

(B) Except as provided in division (C) of this section,	859
during the ninety-day period beginning on the effective date of	860
this act, no person, political subdivision, or agency or	861
instrumentality of this state shall establish, develop, or	862
construct a special hospital in a county with a population of more	863
than one hundred forty thousand but less than one hundred fifty	864
thousand individuals.	865

(C) The moratorium in division (B) of this section does not	866
affect a project for which all local permits necessary to begin	867
construction were obtained on or prior to the effective date of	868
this act.	869

(D) The director of health may petition the court of common	870
pleas of the county in which a special hospital is located for an	871
order enjoining any person, political subdivision, or agency or	872
instrumentality of this state from violating division (B) of this	873
section. Irrespective of any other remedy the director may have in	874
law or equity, the court may grant the order on a showing that the	875
respondent named in the petition is violating division (B) of this	876
section.	877