As Reported by the House Health Committee

126th General Assembly Regular Session 2005-2006

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 

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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 incurred	103
claims for diagnostic and treatment services for biologically	104
based mental illnesses for a period of at least sixmonths	105
independently caused the health insuring corporation's costs for	106
claims and administrative expenses for the coverage of basic	107
health care services to increase by more than one per cent per	108
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) Incurred claims for diagnostic and treatment services for	120
biologically based mental illnesses for a period of at least six	121
months independently caused the health insuring corporation's	122
costs for claims and administrative expenses for the coverage of	123
basic health care services to increase by more than one per cent	124
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 subject to Chapter 119. of the Revised Code.	131

(B)(1) "Supplemental health care services" means any health	132
care 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)(a) Services of facilities for intermediate or long-term	137
care, or both;	138

(2)(b) Dental care services;

139

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

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

142

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

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

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

(8)(h) Home health services;

150

(9)(i) Prescription drug services;

151

(10)(j) Nursing services;

152

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

(12)(l) Physical therapy services;

155

(13)(m) Chiropractic services;

156

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

(2) If a health insuring corporation offers prescription drug	159
services under this division, the coverage shall include	160
prescription drug services for the treatment of biologically based	161
mental illnesses on the same terms and conditions as other	162
physical diseases and disorders.	163

(C) "Specialty health care services" means one of the	164
supplemental health care services listed in division (B)(1) to	165
(13) of this section, when provided by a health insuring	166
corporation on an outpatient-only basis and not in combination	167
with other supplemental health care services.	168

(D) "Biologically based mental illnesses" means	169
schizophrenia, schizoaffective disorder, major depressive	170
disorder, bipolar disorder, paranoia and other psychotic	171
disorders, obsessive-compulsive disorder, and panic disorder, as	172
these terms are defined in the most recent edition of the	173
diagnostic and statistical manual of mental disorders published by	174
the American psychiatric association.	175

(E) "Closed panel plan" means a health care plan that	176
requires enrollees to use participating providers.	177

(E)(F) "Compensation" means remuneration for the provision of	178
health care services, determined on other than a fee-for-service	179
or discounted-fee-for-service basis.	180

(F)(G) "Contractual periodic prepayment" means the formula	181
for determining the premium rate for all subscribers of a health	182
insuring corporation.	183

(G)(H) "Corporation" means a corporation formed under Chapter	184
1701. or 1702. of the Revised Code or the similar laws of another	185
state.	186

(H)(I) "Emergency health services" means those health care	187
services that must be available on a seven-days-per-week,	188
twenty-four-hours-per-day basis in order to prevent jeopardy to an	189
enrollee's health status that would occur if such services were	190
not received as soon as possible, and includes, where appropriate,	191
provisions for transportation and indemnity payments or service	192
agreements for out-of-area coverage.	193

(I)(J) "Enrollee" means any natural person who is entitled to	194
receive health care benefits provided by a health insuring	195
corporation.	196

(J)(K) "Evidence of coverage" means any certificate,	197
agreement, policy, or contract issued to a subscriber that sets	198
out the coverage and other rights to which such person is entitled	199
under a health care plan.	200

(K)(L) "Health care facility" means any facility, except a	201
health care practitioner's office, that provides preventive,	202
diagnostic, therapeutic, acute convalescent, rehabilitation,	203
mental health, mental retardation, intermediate care, or skilled	204
nursing services.	205

(L)(M) "Health care services" means basic, supplemental, and	206
specialty health care services.	207

(M)(N) "Health delivery network" means any group of providers	208
or health care facilities, or both, or any representative thereof,	209
that have entered into an agreement to offer health care services	210
in a panel rather than on an individual basis.	211

(N)(O) "Health insuring corporation" means a corporation, as	212
defined in division (G)(H) of this section, that, pursuant to a	213
policy, contract, certificate, or agreement, pays for, reimburses,	214
or provides, delivers, arranges for, or otherwise makes available,	215
basic health care services, supplemental health care services, or	216
specialty health care services, or a combination of basic health	217
care services and either supplemental health care services or	218
specialty health care services, through either an open panel plan	219
or a closed panel plan.	220

"Health insuring corporation" does not include a limited	221
liability company formed pursuant to Chapter 1705. of the Revised	222
Code, an insurer licensed under Title XXXIX of the Revised Code if	223
that insurer offers only open panel plans under which all	224
providers and health care facilities participating receive their	225
compensation directly from the insurer, a corporation formed by or	226
on behalf of a political subdivision or a department, office, or	227
institution of the state, or a public entity formed by or on	228
behalf of a board of county commissioners, a county board of	229
mental retardation and developmental disabilities, an alcohol and	230
drug addiction services board, a board of alcohol, drug addiction,	231
and mental health services, or a community mental health board, as	232
those terms are used in Chapters 340. and 5126. of the Revised	233
Code. Except as provided by division (D) of section 1751.02 of	234
the Revised Code, or as otherwise provided by law, no board,	235
commission, agency, or other entity under the control of a	236
political subdivision may accept insurance risk in providing for	237
health care services. However, nothing in this division shall be	238
construed as prohibiting such entities from purchasing the	239
services of a health insuring corporation or a third-party	240
administrator licensed under Chapter 3959. of the Revised Code.	241

(O)(P) "Intermediary organization" means a health delivery	242
network or other entity that contracts with licensed health	243
insuring corporations or self-insured employers, or both, to	244
provide health care services, and that enters into contractual	245
arrangements with other entities for the provision of health care	246
services for the purpose of fulfilling the terms of its contracts	247
with the health insuring corporations and self-insured employers.	248

(P)(Q) "Intermediate care" means residential care above the	249
level of room and board for patients who require personal	250
assistance and health-related services, but who do not require	251
skilled nursing care.	252

(Q)(R) "Medical record" means the personal information that	253
relates to an individual's physical or mental condition, medical	254
history, or medical treatment.	255

(R)(S)(1) "Open panel plan" means a health care plan that	256
provides incentives for enrollees to use participating providers	257
and that also allows enrollees to use providers that are not	258
participating providers.	259

(2) No health insuring corporation may offer an open panel	260
plan, unless the health insuring corporation is also licensed as	261
an insurer under Title XXXIX of the Revised Code, the health	262
insuring corporation, on June 4, 1997, holds a certificate of	263
authority or license to operate under Chapter 1736. or 1740. of	264
the Revised Code, or an insurer licensed under Title XXXIX of the	265
Revised Code is responsible for the out-of-network risk as	266
evidenced by both an evidence of coverage filing under section	267
1751.11 of the Revised Code and a policy and certificate filing	268
under section 3923.02 of the Revised Code.	269

(S)(T) "Panel" means a group of providers or health care	270
facilities that have joined together to deliver health care	271
services through a contractual arrangement with a health insuring	272
corporation, employer group, or other payor.	273

(T)(U) "Person" has the same meaning as in section 1.59 of	274
the Revised Code, and, unless the context otherwise requires,	275
includes any insurance company holding a certificate of authority	276
under Title XXXIX of the Revised Code, any subsidiary and	277
affiliate of an insurance company, and any government agency.	278

(U)(V) "Premium rate" means any set fee regularly paid by a	279
subscriber to a health insuring corporation. A "premium rate" does	280
not include a one-time membership fee, an annual administrative	281
fee, or a nominal access fee, paid to a managed health care system	282
under which the recipient of health care services remains solely	283
responsible for any charges accessed for those services by the	284
provider or health care facility.	285

(V)(W) "Primary care provider" means a provider that is	286
designated by a health insuring corporation to supervise,	287
coordinate, or provide initial care or continuing care to an	288
enrollee, and that may be required by the health insuring	289
corporation to initiate a referral for specialty care and to	290
maintain supervision of the health care services rendered to the	291
enrollee.	292

(W)(X) "Provider" means any natural person or partnership of	293
natural persons who are licensed, certified, accredited, or	294
otherwise authorized in this state to furnish health care	295
services, or any professional association organized under Chapter	296
1785. of the Revised Code, provided that nothing in this chapter	297
or other provisions of law shall be construed to preclude a health	298
insuring corporation, health care practitioner, or organized	299
health care group associated with a health insuring corporation	300
from employing certified nurse practitioners, certified nurse	301
anesthetists, clinical nurse specialists, certified nurse	302
midwives, dietitians, physician assistants, dental assistants,	303
dental hygienists, optometric technicians, or other allied health	304
personnel who are licensed, certified, accredited, or otherwise	305
authorized in this state to furnish health care services.	306

(X)(Y) "Provider sponsored organization" means a corporation,	307
as defined in division (G)(H) of this section, that is at least	308
eighty per cent owned or controlled by one or more hospitals, as	309
defined in section 3727.01 of the Revised Code, or one or more	310
physicians licensed to practice medicine or surgery or osteopathic	311
medicine and surgery under Chapter 4731. of the Revised Code, or	312
any combination of such physicians and hospitals. Such control is	313
presumed to exist if at least eighty per cent of the voting rights	314
or governance rights of a provider sponsored organization are	315
directly or indirectly owned, controlled, or otherwise held by any	316
combination of the physicians and hospitals described in this	317
division.	318

(Y)(Z) "Solicitation document" means the written materials	319
provided to prospective subscribers or enrollees, or both, and	320
used for advertising and marketing to induce enrollment in the	321
health care plans of a health insuring corporation.	322

(Z)(AA) "Subscriber" means a person who is responsible for	323
making payments to a health insuring corporation for participation	324
in a health care plan, or an enrollee whose employment or other	325
status is the basis of eligibility for enrollment in a health	326
insuring corporation.	327

(AA)(BB) "Urgent care services" means those health care	328
services that are appropriately provided for an unforeseen	329
condition of a kind that usually requires medical attention	330
without delay but that does not pose a threat to the life, limb,	331
or permanent health of the injured or ill person, and may include	332
such health care services provided out of the health insuring	333
corporation's approved service area pursuant to indemnity payments	334
or service agreements.	335

Sec. 1751.02.  (A) Notwithstanding any law in this state to	336
the contrary, any corporation, as defined in section 1751.01 of	337
the Revised Code, may apply to the superintendent of insurance for	338
a certificate of authority to establish and operate a health	339
insuring corporation. If the corporation applying for a	340
certificate of authority is a foreign corporation domiciled in a	341
state without laws similar to those of this chapter, the	342
corporation must form a domestic corporation to apply for, obtain,	343
and maintain a certificate of authority under this chapter.	344

(B) No person shall establish, operate, or perform the	345
services of a health insuring corporation in this state without	346
obtaining a certificate of authority under this chapter.	347

(C) Except as provided by division (D) of this section, no	348
political subdivision or department, office, or institution of	349
this state, or corporation formed by or on behalf of any political	350
subdivision or department, office, or institution of this state,	351
shall establish, operate, or perform the services of a health	352
insuring corporation. Nothing in this section shall be construed	353
to preclude a board of county commissioners, a county board of	354
mental retardation and developmental disabilities, an alcohol and	355
drug addiction services board, a board of alcohol, drug addiction,	356
and mental health services, or a community mental health board, or	357
a public entity formed by or on behalf of any of these boards,	358
from using managed care techniques in carrying out the board's or	359
public entity's duties pursuant to the requirements of Chapters	360
307., 329., 340., and 5126. of the Revised Code. However, no such	361
board or public entity may operate so as to compete in the private	362
sector with health insuring corporations holding certificates of	363
authority under this chapter.	364

(D) A corporation formed by or on behalf of a publicly owned,	365
operated, or funded hospital or health care facility may apply to	366
the superintendent for a certificate of authority under division	367
(A) of this section to establish and operate a health insuring	368
corporation.	369

(E) A health insuring corporation shall operate in this state	370
in compliance with this chapter and Chapter 1753. of the Revised	371
Code, and with sections 3702.51 to 3702.62 of the Revised Code,	372
and shall operate in conformity with its filings with the	373
superintendent under this chapter, including filings made pursuant	374
to sections 1751.03, 1751.11, 1751.12, and 1751.31 of the Revised	375
Code.	376

(F) An insurer licensed under Title XXXIX of the Revised Code	377
need not obtain a certificate of authority as a health insuring	378
corporation to offer an open panel plan as long as the providers	379
and health care facilities participating in the open panel plan	380
receive their compensation directly from the insurer. If the	381
providers and health care facilities participating in the open	382
panel plan receive their compensation from any person other than	383
the insurer, or if the insurer offers a closed panel plan, the	384
insurer must obtain a certificate of authority as a health	385
insuring corporation.	386

(G) An intermediary organization need not obtain a	387
certificate of authority as a health insuring corporation,	388
regardless of the method of reimbursement to the intermediary	389
organization, as long as a health insuring corporation or a	390
self-insured employer maintains the ultimate responsibility to	391
assure delivery of all health care services required by the	392
contract between the health insuring corporation and the	393
subscriber and the laws of this state or between the self-insured	394
employer and its employees.	395

Nothing in this section shall be construed to require any	396
health care facility, provider, health delivery network, or	397
intermediary organization that contracts with a health insuring	398
corporation or self-insured employer, regardless of the method of	399
reimbursement to the health care facility, provider, health	400
delivery network, or intermediary organization, to obtain a	401
certificate of authority as a health insuring corporation under	402
this chapter, unless otherwise provided, in the case of contracts	403
with a self-insured employer, by operation of the "Employee	404
Retirement Income Security Act of 1974," 88 Stat. 829, 29 U.S.C.A.	405
1001, as amended.	406

(H) Any health delivery network doing business in this state,	407
including any health delivery network that is functioning as an	408
intermediary organization doing business in this state, that is	409
not required to obtain a certificate of authority under this	410
chapter shall certify to the superintendent annually, not later	411
than the first day of July, and shall provide a statement signed	412
by the highest ranking official which includes the following	413
information:	414

(1) The health delivery network's full name and the address	415
of its principal place of business;	416

(2) A statement that the health delivery network is not	417
required to obtain a certificate of authority under this chapter	418
to conduct its business.	419

(I) The superintendent shall not issue a certificate of	420
authority to a health insuring corporation that is a provider	421
sponsored organization unless all health care plans to be offered	422
by the health insuring corporation provide basic health care	423
services. Substantially all of the physicians and hospitals with	424
ownership or control of the provider sponsored organization, as	425
defined in division (X) of section 1751.01 of the Revised Code,	426
shall also be participating providers for the provision of basic	427
health care services for health care plans offered by the provider	428
sponsored organization. If a health insuring corporation that is a	429
provider sponsored organization offers health care plans that do	430
not provide basic health care services, the health insuring	431
corporation shall be deemed, for purposes of section 1751.35 of	432
the Revised Code, to have failed to substantially comply with this	433
chapter.	434

Except as specifically provided in this division and in	435
division (A) of section 1751.28 of the Revised Code, the	436
provisions of this chapter shall apply to all health insuring	437
corporations that are provider sponsored organizations in the same	438
manner that these provisions apply to all health insuring	439
corporations that are not provider sponsored organizations.	440

(J) Nothing in this section shall be construed to apply to	441
any multiple employer welfare arrangement operating pursuant to	442
Chapter 1739. of the Revised Code.	443

(K) Any person who violates division (B) of this section, and	444
any health delivery network that fails to comply with division (H)	445
of this section, is subject to the penalties set forth in section	446
1751.45 of the Revised Code.	447

Sec. 3923.28.  (A) Every policy of group sickness and	448
accident insurance providing hospital, surgical, or medical	449
expense coverage for other than specific diseases or accidents	450
only, and delivered, issued for delivery, or renewed in this state	451
on or after January 1, 1979, and that provides coverage for mental	452
or emotional disorders, shall provide benefits for services on an	453
outpatient basis for each eligible person under the policy who	454
resides in this state for mental or emotional disorders, or for	455
evaluations, that are at least equal to five hundred fifty dollars	456
in any calendar year or twelve-month period. The services shall be	457
legally performed by or under the clinical supervision of a	458
licensed physician or licensedauthorized under Chapter 4731. of	459
the Revised Code to practice medicine and surgery or osteopathic	460
medicine and surgery; a psychologist licensed under Chapter 4732.	461
of the Revised Code; a professional clinical counselor,	462
professional counselor, or independent social worker licensed	463
under Chapter 4757. of the Revised Code; or a clinical nurse	464
specialist licensed under Chapter 4723. of the Revised Code whose	465
nursing specialty is mental health, whether performed in an	466
office, in a hospital, or in a community mental health facility so	467
long as the hospital or community mental health facility is	468
approved by the joint commission on accreditation of healthcare	469
organizations, the council on accreditation for children and	470
family services, the rehabilitation accreditation commission, or,	471
until two years after the effective date of this amendmentJune 6,	472
2001, certified by the department of mental health as being in	473
compliance with standards established under division (H) of	474
section 5119.01 of the Revised Code.	475

(B) Outpatient benefits offered under division (A) of this	476
section shall be subject to reasonable contract limitations and	477
may be subject to reasonable deductibles and co-insurance costs.	478
Persons entitled to such benefit under more than one service or	479
insurance contract may be limited to a single	480
five-hundred-fifty-dollar outpatient benefit for services under	481
all contracts.	482

(C) In order to qualify for participation under division (A)	483
of this section, every facility specified in such division shall	484
have in effect a plan for utilization review and a plan for peer	485
review and every person specified in such division shall have in	486
effect a plan for peer review. Such plans shall have the purpose	487
of ensuring high quality patient care and effective and efficient	488
utilization of available health facilities and services.	489

(D) Nothing in this section shall be construed to require an	490
insurer to pay benefits which are greater than usual, customary,	491
and reasonable.	492

(E)(1) Services performed under the clinical supervision of a	493
licensed physician or licensed psychologisthealth care	494
professional identified in division (A) of this section, in order	495
to be reimbursable under the coverage required in division (A) of	496
this section, shall meet both of the following requirements:	497

(a) The services shall be performed in accordance with a	498
treatment plan that describes the expected duration, frequency,	499
and type of services to be performed;	500

(b) The plan shall be reviewed and approved by a licensed	501
physician or licensed psychologistthe health care professional	502
every three months.	503

(2) Payment of benefits for services reimbursable under	504
division (E)(1) of this section shall not be restricted to	505
services described in the treatment plan or conditioned upon	506
standards of clinical supervision that are more restrictive than	507
standards of a licensed physician or licensed psychologisthealth	508
care professional described in division (A) of this section, which	509
at least equal the requirements of division (E)(1) of this	510
section.	511

(F) The benefits provided by this section for mental and	512
emotional disorders shall not be reduced by the cost of benefits	513
provided pursuant to section 3923.281 of the Revised Code for	514
diagnostic and treatment services for biologically based mental	515
illnesses. This section does not apply to benefits for diagnostic	516
and treatment services for biologically based mental illnesses.	517

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

518

(1) "Biologically based mental illness" means schizophrenia,	519
schizoaffective disorder, major depressive disorder, bipolar	520
disorder, paranoia and other psychotic disorders,	521
obsessive-compulsive disorder, and panic disorder, as these terms	522
are defined in the most recent edition of the diagnostic and	523
statistical manual of mental disorders published by the American	524
psychiatric association.	525

(2) "Policy of sickness and accident insurance" has the same	526
meaning as in section 3923.01 of the Revised Code, but excludes	527
any hospital indemnity, medicare supplement, long-term care,	528
disability income, one-time-limited-duration policy of not longer	529
than six months, supplemental benefit, or other policy that	530
provides coverage for specific diseases or accidents only; any	531
policy that provides coverage for workers' compensation claims	532
compensable pursuant to Chapters 4121. and 4123. of the Revised	533
Code; and any policy that provides coverage to beneficiaries	534
enrolled in Title XIX of the "Social Security Act," 49 Stat. 620	535
(1935), 42 U.S.C.A. 301, as amended, known as the medical	536
assistance program or medicaid, as provided by the Ohio department	537
of job and family services under Chapter 5111. of the Revised	538
Code.	539

(B) Notwithstanding section 3901.71 of the Revised Code, and	540
subject to division (E) of this section, every group policy of	541
sickness and accident insurance shall provide benefits for the	542
diagnosis and treatment of biologically based mental illnesses on	543
the same terms and conditions as, and shall provide benefits no	544
less extensive than, those provided under the policy of sickness	545
and accident insurance for the treatment and diagnosis of all	546
other physical diseases and disorders, if both of the following	547
apply:	548

(1) The biologically based mental illness is clinically	549
diagnosed by a physician authorized under Chapter 4731. of the	550
Revised Code to practice medicine and surgery or osteopathic	551
medicine and surgery; a psychologist licensed under Chapter 4732.	552
of the Revised Code; a professional clinical counselor,	553
professional counselor, or independent social worker licensed	554
under Chapter 4757. of the Revised Code; or a clinical nurse	555
specialist licensed under Chapter 4723. of the Revised Code whose	556
nursing specialty is mental health.	557

(2) The prescribed treatment is not experimental or	558
investigational, having proven its clinical effectiveness in	559
accordance with generally accepted medical standards.	560

(C) Division (B) of this section applies to all coverages and	561
terms and conditions of the policy of sickness and accident	562
insurance, including, but not limited to, coverage of inpatient	563
hospital services, outpatient services, and medication; maximum	564
lifetime benefits; copayments; and individual and family	565
deductibles.	566

(D) Nothing in this section shall be construed as prohibiting	567
a sickness and accident insurance company from taking any of the	568
following actions:	569

(1) Negotiating separately with mental health care providers	570
with regard to reimbursement rates and the delivery of health care	571
services;	572

(2) Offering policies that provide benefits solely for the	573
diagnosis and treatment of biologically based mental illnesses;	574

(3) Managing the provision of benefits for the diagnosis or	575
treatment of biologically based mental illnesses through the use	576
of pre-admission screening, by requiring beneficiaries to obtain	577
authorization prior to treatment, or through the use of any other	578
mechanism designed to limit coverage to that treatment determined	579
to be necessary;	580

(4) Enforcing the terms and conditions of a policy of	581
sickness and accident insurance.	582

(E) An insurer that offers a group policy of sickness and	583
accident insurance is not required to provide benefits for the	584
diagnosis and treatment of biologically based mental illnesses	585
pursuant to division (B) of this section if all of the following	586
apply:	587

(1) The insurer submits documentation certified by an	588
independent member of the American academy of actuaries to the	589
superintendent of insurance showing that incurred claims for	590
diagnostic and treatment services for biologically based mental	591
illnesses for a period of at least six months independently caused	592
the insurer's costs for claims and administrative expenses for the	593
coverage of all other physical diseases and disorders to increase	594
by more than one per cent per year.	595

(2) The insurer submits a signed letter from an independent	596
member of the American academy of actuaries to the superintendent	597
of insurance opining that the increase described in division	598
(E)(1) of this section could reasonably justify an increase of	599
more than one per cent in the annual premiums or rates charged by	600
the insurer for the coverage of all other physical diseases and	601
disorders.	602

(3) The superintendent of insurance makes the following	603
determinations from the documentation and opinion submitted	604
pursuant to divisions (E)(1) and (2) of this section:	605

(a) Incurred claims for diagnostic and treatment services for	606
biologically based mental illnesses for a period of at least six	607
months independently caused the insurer's costs for claims and	608
administrative expenses for the coverage of all other physical	609
diseases and disorders to increase by more than one per cent per	610
year.	611

(b) The increase in costs reasonably justifies an increase of	612
more than one per cent in the annual premiums or rates charged by	613
the insurer for the coverage of all other physical diseases and	614
disorders.	615

Any determination made by the superintendent under this	616
division is subject to Chapter 119. of the Revised Code.	617

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

618

(1) "Biologically based mental illness" means schizophrenia,	619
schizoaffective disorder, major depressive disorder, bipolar	620
disorder, paranoia and other psychotic disorders,	621
obsessive-compulsive disorder, and panic disorder, as these terms	622
are defined in the most recent edition of the diagnostic and	623
statistical manual of mental disorders published by the American	624
psychiatric association.	625

(2) "Plan of health coverage" includes any private or public	626
employer group self-insurance plan that provides payment for	627
health care benefits for other than specific diseases or accidents	628
only, which benefits are not provided by contract with a sickness	629
and accident insurer or health insuring corporation.	630

(B) Notwithstanding section 3901.71 of the Revised Code, and	631
subject to division (F) of this section, each plan of health	632
coverage shall provide benefits for the diagnosis and treatment of	633
biologically based mental illnesses on the same terms and	634
conditions as, and shall provide benefits no less extensive than,	635
those provided under the plan of health coverage for the treatment	636
and diagnosis of all other physical diseases and disorders, if	637
both of the following apply:	638

(1) The biologically based mental illness is clinically	639
diagnosed by a physician authorized under Chapter 4731. of the	640
Revised Code to practice medicine and surgery or osteopathic	641
medicine and surgery; a psychologist licensed under Chapter 4732.	642
of the Revised Code; a professional clinical counselor,	643
professional counselor, or independent social worker licensed	644
under Chapter 4757. of the Revised Code; or a clinical nurse	645
specialist licensed under Chapter 4723. of the Revised Code whose	646
nursing specialty is mental health.	647

(2) The prescribed treatment is not experimental or	648
investigational, having proven its clinical effectiveness in	649
accordance with generally accepted medical standards.	650

(C) Division (B) of this section applies to all coverages and	651
terms and conditions of the plan of health coverage, including,	652
but not limited to, coverage of inpatient hospital services,	653
outpatient services, and medication; maximum lifetime benefits;	654
copayments; and individual and family deductibles.	655

(D) This section does not apply to a plan of health coverage	656
if federal law supersedes, preempts, prohibits, or otherwise	657
precludes its application to such plans. This section does not	658
apply to long-term care, hospital indemnity, disability income, or	659
medicare supplement plans of health coverage, or to any other	660
supplemental benefit plans of health coverage.	661

(E) Nothing in this section shall be construed as prohibiting	662
an employer from taking any of the following actions in connection	663
with a plan of health coverage:	664

(1) Negotiating separately with mental health care providers	665
with regard to reimbursement rates and the delivery of health care	666
services;	667

(2) Managing the provision of benefits for the diagnosis or	668
treatment of biologically based mental illnesses through the use	669
of pre-admission screening, by requiring beneficiaries to obtain	670
authorization prior to treatment, or through the use of any other	671
mechanism designed to limit coverage to that treatment determined	672
to be necessary;	673

(3) Enforcing the terms and conditions of a plan of health	674
coverage.	675

(F) An employer that offers a plan of health coverage is not	676
required to provide benefits for the diagnosis and treatment of	677
biologically based mental illnesses in combination with benefits	678
for the treatment and diagnosis of all other physical diseases and	679
disorders as described in division (B) of this section if both of	680
the following apply:	681

(1) The employer submits documentation certified by an	682
independent member of the American academy of actuaries to the	683
superintendent of insurance showing that incurred claims for	684
diagnostic and treatment services for biologically based mental	685
illnesses for a period of at least six months independently caused	686
the employer's costs for claims and administrative expenses for	687
the coverage of all other physical diseases and disorders to	688
increase by more than one per cent per year.	689

(2) The superintendent of insurance determines from the	690
documentation and opinion submitted pursuant to division (F) of	691
this section, that incurred claims for diagnostic and treatment	692
services for biologically based mental illnesses for a period of	693
at least six months independently caused the employer's costs for	694
claims and administrative expenses for the coverage of all other	695
physical diseases and disorders to increase by more than one per	696
cent per year.	697

Any determination made by the superintendent under this	698
division is subject to Chapter 119. of the Revised Code.	699

Sec. 3923.30.  Every person, the state and any of its	700
instrumentalities, any county, township, school district, or other	701
political subdivisions and any of its instrumentalities, and any	702
municipal corporation and any of its instrumentalities, which	703
provides payment for health care benefits for any of its employees	704
resident in this state, which benefits are not provided by	705
contract with an insurer qualified to provide sickness and	706
accident insurance, or a health insuring corporation, shall	707
include the following benefits in its plan of health care benefits	708
commencing on or after January 1, 1979:	709

(A) If such plan of health care benefits provides payment for	710
the treatment of mental or nervous disorders, then such plan shall	711
provide benefits for services on an outpatient basis for each	712
eligible employee and dependent for mental or emotional disorders,	713
or for evaluations, that are at least equal to the following:	714

(1) Payments not less than five hundred fifty dollars in a	715
twelve-month period, for services legally performed by or under	716
the clinical supervision of a licensed physician or a licensed	717
authorized under Chapter 4731. of the Revised Code to practice	718
medicine and surgery or osteopathic medicine and surgery; a	719
psychologist licensed under Chapter 4732. of the Revised Code; a	720
professional clinical counselor, professional counselor, or	721
independent social worker licensed under Chapter 4757. of the	722
Revised Code; or a clinical nurse specialist licensed under	723
Chapter 4723. of the Revised Code whose nursing specialty is	724
mental health, whether performed in an office, in a hospital, or	725
in a community mental health facility so long as the hospital or	726
community mental health facility is approved by the joint	727
commission on accreditation of healthcare organizations, the	728
council on accreditation for children and family services, the	729
rehabilitation accreditation commission, or, until two years after	730
the effective date of this amendmentJune 6, 2001, certified by	731
the department of mental health as being in compliance with	732
standards established under division (H) of section 5119.01 of the	733
Revised Code;	734

(2) Such benefit shall be subject to reasonable limitations,	735
and may be subject to reasonable deductibles and co-insurance	736
costs.	737

(3) In order to qualify for participation under this	738
division, every facility specified in this division shall have in	739
effect a plan for utilization review and a plan for peer review	740
and every person specified in this division shall have in effect a	741
plan for peer review. Such plans shall have the purpose of	742
ensuring high quality patient care and effective and efficient	743
utilization of available health facilities and services.	744

(4) Such payment for benefits shall not be greater than	745
usual, customary, and reasonable.	746

(5)(a) Services performed by or under the clinical	747
supervision of a licensed physician or licensed psychologist	748
health care professional identified in division (A)(1) of this	749
section, in order to be reimbursable under the coverage required	750
in division (A) of this section, shall meet both of the following	751
requirements:	752

(i) The services shall be performed in accordance with a	753
treatment plan that describes the expected duration, frequency,	754
and type of services to be performed;	755

(ii) The plan shall be reviewed and approved by a licensed	756
physician or licensed psychologistthe health care professional	757
every three months.	758

(b) Payment of benefits for services reimbursable under	759
division (A)(5)(a) of the section shall not be restricted to	760
services described in the treatment plan or conditioned upon	761
standards of a licensed physician or licensed psychologist, which	762
at least equal the requirements of division (A)(5)(a) of this	763
section.	764

(B) Payment for benefits for alcoholism treatment for	765
outpatient, inpatient, and intermediate primary care for each	766
eligible employee and dependent that are at least equal to the	767
following:	768

(1) Payments not less than five hundred fifty dollars in a	769
twelve-month period for services legally performed by or under the	770
clinical supervision of a licensed physician or licensed	771
psychologisthealth care professional identified in division	772
(A)(1) of this section, whether performed in an office, or in a	773
hospital or a community mental health facility or alcoholism	774
treatment facility so long as the hospital, community mental	775
health facility, or alcoholism treatment facility is approved by	776
the joint commission on accreditation of hospitals or certified by	777
the department of health;	778

(2) The benefits provided under this division shall be	779
subject to reasonable limitations and may be subject to reasonable	780
deductibles and co-insurance costs.	781

(3) A licensed physician or licensed psychologisthealth care	782
professional shall every three months certify a patient's need for	783
continued services performed by such facilities.	784

(4) In order to qualify for participation under this	785
division, every facility specified in this division shall have in	786
effect a plan for utilization review and a plan for peer review	787
and every person specified in this division shall have in effect a	788
plan for peer review. Such plans shall have the purpose of	789
ensuring high quality patient care and efficient utilization of	790
available health facilities and services. Such person or	791
facilities shall also have in effect a program of rehabilitation	792
or a program of rehabilitation and detoxification.	793

(5) Nothing in this section shall be construed to require	794
reimbursement for benefits which is greater than usual, customary,	795
and reasonable.	796

(C) The benefits provided by division (A) of this section for	797
mental and emotional disorders shall not be reduced by the cost of	798
benefits provided pursuant to section 3923.282 of the Revised Code	799
for diagnostic and treatment services for biologically based	800
mental illness. This section does not apply to benefits for	801
diagnostic and treatment services for biologically based mental	802
illnesses.	803

Sec. 3923.51.  (A) As used in this section, "official poverty	804
line" means the poverty line as defined by the United States	805
office of management and budget and revised by the secretary of	806
health and human services under 95 Stat. 511, 42 U.S.C.A. 9902, as	807
amended.	808

(B) Every insurer that is authorized to write sickness and	809
accident insurance in this state may offer group contracts of	810
sickness and accident insurance to any charitable foundation that	811
is certified as exempt from taxation under section 501(c)(3) of	812
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A.	813
1, as amended, and that has the sole purpose of issuing	814
certificates of coverage under these contracts to persons under	815
the age of nineteen who are members of families that have incomes	816
that are no greater than three hundred per cent of the official	817
poverty line.	818

(C) Contracts offered pursuant to division (B) of this	819
section are not subject to any of the following:	820

(1) Sections 3923.122, 3923.24, 3923.28, 3923.281, and	821
3923.29 of the Revised Code;	822

(2) Any other sickness and accident insurance coverage	823
required under this chapter on August 3, 1989. Any requirement of	824
sickness and accident insurance coverage enacted after that date	825
applies to this section only if the subsequent enactment	826
specifically refers to this section.	827

(3) Chapter 1751. of the Revised Code.

828

Section 2.  That existing sections 1739.05, 1751.01, 1751.02,	829
3923.28, 3923.30, and 3923.51 of the Revised Code are hereby	830
repealed.	831

Section 3.  Section 1751.01 of the Revised Code, as amended	832
by this act, shall apply only to policies, contracts, and	833
agreements that are delivered, issued for delivery, or renewed in	834
this state six months after the effective date of this act;	835
section 3923.28 of the Revised Code, as amended by this act, shall	836
apply only to policies of sickness and accident insurance six	837
months after the effective date of this act in accordance with	838
section 3923.01 of the Revised Code; sections 3923.281 and	839
3923.282 of the Revised Code, as enacted by this act, shall apply	840
only to policies of sickness and accident insurance and plans of	841
health coverage that are established or modified in this state six	842
months after the effective date of this act; and section 3923.30	843
of the Revised Code, as amended by this act, shall apply only to	844
public employee health plans established or modified in this state	845
six months after the effective date of this act.	846