H. B. No. 125 As Introduced

As Introduced

127th General Assembly

Regular Session

2007-2008

H. B. No. 125

Representative Huffman

Cosponsors: Representatives DeGeeter, Seitz, McGregor, J., Schneider, Latta, Adams, Gibbs, Setzer, Oelslager, Uecker, McGregor, R., Stewart, J., Stebelton, Fessler, Barrett, Wagoner, Celeste, Reinhard, Widener, Blessing, Book, Carmichael, Lundy

A BILL

To amend sections 1751.13 and 1753.09, to enact 1
sections 3963.01 to 3963.09, and to repeal 2
sections 1753.03, 1753.04, 1753.05, and 1753.08 of 3
the Revised Code to establish certain uniform 4
contract provisions between health care providers 5
and third-party payers, to establish standardized 6
credentialing, and to require third-party payers 7
to provide to health care providers specified 8
information concerning enrollees. 9

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

       Section 1. That sections 1751.13 and 1753.09 be amended and 10
sections 3963.01, 3963.02, 3963.03, 3963.04, 3963.05, 3963.06, 11
3963.07, 3963.08, and 3963.09 of the Revised Code be enacted to 12
read as follows: 13

       Sec. 1751.13. (A)(1)(a) A health insuring corporation shall, 14
either directly or indirectly, enter into contracts for the 15
provision of health care services with a sufficient number and 16
types of providers and health care facilities to ensure that all 17
covered health care services will be accessible to enrollees from 18
a contracted provider or health care facility. 19

       (b) A health insuring corporation shall not refuse to 20
contract with a physician for the provision of health care 21
services or refuse to recognize a physician as a specialist on the 22
basis that the physician attended an educational program or a 23
residency program approved or certified by the American 24
osteopathic association. A health insuring corporation shall not 25
refuse to contract with a health care facility for the provision 26
of health care services on the basis that the health care facility 27
is certified or accredited by the American osteopathic association 28
or that the health care facility is an osteopathic hospital as 29
defined in section 3702.51 of the Revised Code. 30

       (c) Nothing in division (A)(1)(b) of this section shall be 31
construed to require a health insuring corporation to make a 32
benefit payment under a closed panel plan to a physician or health 33
care facility with which the health insuring corporation does not 34
have a contract, provided that none of the bases set forth in that 35
division are used as a reason for failing to make a benefit 36
payment. 37

       (2) When a health insuring corporation is unable to provide a 38
covered health care service from a contracted provider or health 39
care facility, the health insuring corporation must provide that 40
health care service from a noncontracted provider or health care 41
facility consistent with the terms of the enrollee's policy, 42
contract, certificate, or agreement. The health insuring 43
corporation shall either ensure that the health care service be 44
provided at no greater cost to the enrollee than if the enrollee 45
had obtained the health care service from a contracted provider or 46
health care facility, or make other arrangements acceptable to the 47
superintendent of insurance. 48

       (3) Nothing in this section shall prohibit a health insuring 49
corporation from entering into contracts with out-of-state 50
providers or health care facilities that are licensed, certified, 51
accredited, or otherwise authorized in that state. 52

       (B)(1) A health insuring corporation shall, either directly 53
or indirectly, enter into contracts with all providers and health 54
care facilities through which health care services are provided to 55
its enrollees. 56

       (2) A health insuring corporation, upon written request, 57
shall assist its contracted providers in finding stop-loss or 58
reinsurance carriers. 59

       (C) A health insuring corporation shall file an annual 60
certificate with the superintendent certifying that all provider 61
contracts and contracts with health care facilities through which 62
health care services are being provided contain the following: 63

       (1) A description of the method by which the provider or 64
health care facility will be notified of the specific health care 65
services for which the provider or health care facility will be 66
responsible, including any limitations or conditions on such 67
services; 68

       (2) The specific hold harmless provision specifying 69
protection of enrollees set forth as follows: 70

       "[Provider/Health Care Facility] agrees that in no event, 71
including but not limited to nonpayment by the health insuring 72
corporation, insolvency of the health insuring corporation, or 73
breach of this agreement, shall [Provider/Health Care Facility] 74
bill, charge, collect a deposit from, seek remuneration or 75
reimbursement from, or have any recourse against, a subscriber, 76
enrollee, person to whom health care services have been provided, 77
or person acting on behalf of the covered enrollee, for health 78
care services provided pursuant to this agreement. This does not 79
prohibit [Provider/Health Care Facility] from collecting 80
co-insurance, deductibles, or copayments as specifically provided 81
in the evidence of coverage, or fees for uncovered health care 82
services delivered on a fee-for-service basis to persons 83
referenced above, nor from any recourse against the health 84
insuring corporation or its successor." 85

       (3) Provisions requiring the provider or health care facility 86
to continue to provide covered health care services to enrollees 87
in the event of the health insuring corporation's insolvency or 88
discontinuance of operations. The provisions shall require the 89
provider or health care facility to continue to provide covered 90
health care services to enrollees as needed to complete any 91
medically necessary procedures commenced but unfinished at the 92
time of the health insuring corporation's insolvency or 93
discontinuance of operations. The completion of a medically 94
necessary procedure shall include the rendering of all covered 95
health care services that constitute medically necessary follow-up 96
care for that procedure. If an enrollee is receiving necessary 97
inpatient care at a hospital, the provisions may limit the 98
required provision of covered health care services relating to 99
that inpatient care in accordance with division (D)(3) of section 100
1751.11 of the Revised Code, and may also limit such required 101
provision of covered health care services to the period ending 102
thirty days after the health insuring corporation's insolvency or 103
discontinuance of operations. 104

       The provisions required by division (C)(3) of this section 105
shall not require any provider or health care facility to continue 106
to provide any covered health care service after the occurrence of 107
any of the following: 108

       (a) The end of the thirty-day period following the entry of a 109
liquidation order under Chapter 3903. of the Revised Code; 110

       (b) The end of the enrollee's period of coverage for a 111
contractual prepayment or premium; 112

       (c) The enrollee obtains equivalent coverage with another 113
health insuring corporation or insurer, or the enrollee's employer 114
obtains such coverage for the enrollee; 115

       (d) The enrollee or the enrollee's employer terminates 116
coverage under the contract; 117

       (e) A liquidator effects a transfer of the health insuring 118
corporation's obligations under the contract under division (A)(8) 119
of section 3903.21 of the Revised Code. 120

       (4) A provision clearly stating the rights and 121
responsibilities of the health insuring corporation, and of the 122
contracted providers and health care facilities, with respect to 123
administrative policies and programs, including, but not limited 124
to, payments systems, utilization review, quality assurance, 125
assessment, and improvement programs, credentialing, 126
confidentiality requirements, and any applicable federal or state 127
programs; 128

       (5) A provision regarding the availability and 129
confidentiality of those health records maintained by providers 130
and health care facilities to monitor and evaluate the quality of 131
care, to conduct evaluations and audits, and to determine on a 132
concurrent or retrospective basis the necessity of and 133
appropriateness of health care services provided to enrollees. 134
The provision shall include terms requiring the provider or health 135
care facility to make these health records available to 136
appropriate state and federal authorities involved in assessing 137
the quality of care or in investigating the grievances or 138
complaints of enrollees, and requiring the provider or health care 139
facility to comply with applicable state and federal laws related 140
to the confidentiality of medical or health records. 141

       (6) A provision that states that contractual rights and 142
responsibilities may not be assigned or delegated by the provider 143
or health care facility without the prior written consent of the 144
health insuring corporation; 145

       (7) A provision requiring the provider or health care 146
facility to maintain adequate professional liability and 147
malpractice insurance. The provision shall also require the 148
provider or health care facility to notify the health insuring 149
corporation not more than ten days after the provider's or health 150
care facility's receipt of notice of any reduction or cancellation 151
of such coverage. 152

       (8) A provision requiring the provider or health care 153
facility to observe, protect, and promote the rights of enrollees 154
as patients; 155

       (9) A provision requiring the provider or health care 156
facility to provide health care services without discrimination on 157
the basis of a patient's participation in the health care plan, 158
age, sex, ethnicity, religion, sexual preference, health status, 159
or disability, and without regard to the source of payments made 160
for health care services rendered to a patient. This requirement 161
shall not apply to circumstances when the provider or health care 162
facility appropriately does not render services due to limitations 163
arising from the provider's or health care facility's lack of 164
training, experience, or skill, or due to licensing restrictions. 165

       (10) A provision containing the specifics of any obligation 166
on the primary care provider to provide, or to arrange for the 167
provision of, covered health care services twenty-four hours per 168
day, seven days per week; 169

       (11) A provision setting forth procedures for the resolution 170
of disputes arising out of the contract; 171

       (12) A provision stating that the hold harmless provision 172
required by division (C)(2) of this section shall survive the 173
termination of the contract with respect to services covered and 174
provided under the contract during the time the contract was in 175
effect, regardless of the reason for the termination, including 176
the insolvency of the health insuring corporation; 177

       (13) A provision requiring those terms that are used in the 178
contract and that are defined by this chapter, be used in the 179
contract in a manner consistent with those definitions. 180

       This division does not apply to the coverage of beneficiaries 181
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 620 182
(1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare risk 183
contract or medicare cost contract, or to the coverage of 184
beneficiaries enrolled in the federal employee health benefits 185
program pursuant to 5 U.S.C.A. 8905, or to the coverage of 186
beneficiaries enrolled in Title XIX of the "Social Security Act," 187
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the 188
medical assistance program or medicaid, provided by the department 189
of job and family services under Chapter 5111. of the Revised 190
Code, or to the coverage of beneficiaries under any federal health 191
care program regulated by a federal regulatory body, or to the 192
coverage of beneficiaries under any contract covering officers or 193
employees of the state that has been entered into by the 194
department of administrative services. 195

       (D)(1) No health insuring corporation contract with a 196
provider or health care facility shall contain any of the 197
following: 198

       (a) A provision that directly or indirectly offers an 199
inducement to the provider or health care facility to reduce or 200
limit medically necessary health care services to a covered 201
enrollee; 202

       (b) A provision that penalizes a provider or health care 203
facility that assists an enrollee to seek a reconsideration of the 204
health insuring corporation's decision to deny or limit benefits 205
to the enrollee; 206

       (c) A provision that limits or otherwise restricts the 207
provider's or health care facility's ethical and legal 208
responsibility to fully advise enrollees about their medical 209
condition and about medically appropriate treatment options; 210

       (d) A provision that penalizes a provider or health care 211
facility for principally advocating for medically necessary health 212
care services; 213

       (e) A provision that penalizes a provider or health care 214
facility for providing information or testimony to a legislative 215
or regulatory body or agency. This shall not be construed to 216
prohibit a health insuring corporation from penalizing a provider 217
or health care facility that provides information or testimony 218
that is libelous or slanderous or that discloses trade secrets 219
which the provider or health care facility has no privilege or 220
permission to disclose. 221

       (f) A provision that violates Chapter 3963. of the Revised 222
Code. 223

       (2) Nothing in this division shall be construed to prohibit a 224
health insuring corporation from doing either of the following: 225

       (a) Making a determination not to reimburse or pay for a 226
particular medical treatment or other health care service; 227

       (b) Enforcing reasonable peer review or utilization review 228
protocols, or determining whether a particular provider or health 229
care facility has complied with these protocols. 230

       (E) Any contract between a health insuring corporation and an 231
intermediary organization shall clearly specify that the health 232
insuring corporation must approve or disapprove the participation 233
of any provider or health care facility with which the 234
intermediary organization contracts. 235

       (F) If an intermediary organization that is not a health 236
delivery network contracting solely with self-insured employers 237
subcontracts with a provider or health care facility, the 238
subcontract with the provider or health care facility shall do all 239
of the following: 240

       (1) Contain the provisions required by divisions (C) and (G) 241
of this section, as made applicable to an intermediary 242
organization, without the inclusion of inducements or penalties 243
described in division (D) of this section; 244

       (2) Acknowledge that the health insuring corporation is a 245
third-party beneficiary to the agreement; 246

       (3) Acknowledge the health insuring corporation's role in 247
approving the participation of the provider or health care 248
facility, pursuant to division (E) of this section. 249

       (G) Any provider contract or contract with a health care 250
facility shall clearly specify the health insuring corporation's 251
statutory responsibility to monitor and oversee the offering of 252
covered health care services to its enrollees. 253

       (H)(1) A health insuring corporation shall maintain its 254
provider contracts and its contracts with health care facilities 255
at one or more of its places of business in this state, and shall 256
provide copies of these contracts to facilitate regulatory review 257
upon written notice by the superintendent of insurance. 258

       (2) Any contract with an intermediary organization that 259
accepts compensation shall include provisions requiring the 260
intermediary organization to provide the superintendent with 261
regulatory access to all books, records, financial information, 262
and documents related to the provision of health care services to 263
subscribers and enrollees under the contract. The contract shall 264
require the intermediary organization to maintain such books, 265
records, financial information, and documents at its principal 266
place of business in this state and to preserve them for at least 267
three years in a manner that facilitates regulatory review. 268

       (I)(1) A health insuring corporation shall notify its 269
affected enrollees of the termination of a contract for the 270
provision of health care services between the health insuring 271
corporation and a primary care physician or hospital, by mail, 272
within thirty days after the termination of the contract. 273

       (a) Notice shall be given to subscribers of the termination 274
of a contract with a primary care physician if the subscriber, or 275
a dependent covered under the subscriber's health care coverage, 276
has received health care services from the primary care physician 277
within the previous twelve months or if the subscriber or 278
dependent has selected the physician as the subscriber's or 279
dependent's primary care physician within the previous twelve 280
months. 281

       (b) Notice shall be given to subscribers of the termination 282
of a contract with a hospital if the subscriber, or a dependent 283
covered under the subscriber's health care coverage, has received 284
health care services from that hospital within the previous twelve 285
months. 286

       (2) The health insuring corporation shall pay, in accordance 287
with the terms of the contract, for all covered health care 288
services rendered to an enrollee by a primary care physician or 289
hospital between the date of the termination of the contract and 290
five days after the notification of the contract termination is 291
mailed to a subscriber at the subscriber's last known address. 292

       (J) Divisions (A) and (B) of this section do not apply to any 293
health insuring corporation that, on June 4, 1997, holds a 294
certificate of authority or license to operate under Chapter 1740. 295
of the Revised Code. 296

       (K) Nothing in this section shall restrict the governing body 297
of a hospital from exercising the authority granted it pursuant to 298
section 3701.351 of the Revised Code. 299

       Sec. 1753.09. (A) Except as provided in division (D) of this 300
section, prior to terminating the participation of a provider on 301
the basis of the participating provider's failure to meet the 302
health insuring corporation's standards for quality or utilization 303
in the delivery of health care services, a health insuring 304
corporation shall give the participating provider notice of the 305
reason or reasons for its decision to terminate the provider's 306
participation and an opportunity to take corrective action. The 307
health insuring corporation shall develop a performance 308
improvement plan in conjunction with the participating provider. 309
If after being afforded the opportunity to comply with the 310
performance improvement plan, the participating provider fails to 311
do so, the health insuring corporation may terminate the 312
participation of the provider. 313

       (B)(1) A participating provider whose participation has been 314
terminated under division (A) of this section may appeal the 315
termination to the appropriate medical director of the health 316
insuring corporation. The medical director shall give the 317
participating provider an opportunity to discuss with the medical 318
director the reason or reasons for the termination. 319

       (2) If a satisfactory resolution of a participating 320
provider's appeal cannot be reached under division (B)(1) of this 321
section, the participating provider may appeal the termination to 322
a panel composed of participating providers who have comparable or 323
higher levels of education and training than the participating 324
provider making the appeal. A representative of the participating 325
provider's specialty shall be a member of the panel, if possible. 326
This panel shall hold a hearing, and shall render its 327
recommendation in the appeal within thirty days after holding the 328
hearing. The recommendation shall be presented to the medical 329
director and to the participating provider. 330

       (3) The medical director shall review and consider the 331
panel's recommendation before making a decision. The decision 332
rendered by the medical director shall be final. 333

       (C) A provider's status as a participating provider shall 334
remain in effect during the appeal process set forth in division 335
(B) of this section unless the termination was based on any of the 336
reasons listed in division (D) of this section. 337

       (D) Notwithstanding division (A) of this section, a 338
provider's participation may be immediately terminated if the 339
participating provider's conduct presents an imminent risk of harm 340
to an enrollee or enrollees; or if there has occurred unacceptable 341
quality of care, fraud, patient abuse, loss of clinical 342
privileges, loss of professional liability coverage, incompetence, 343
or loss of authority to practice in the participating provider's 344
field; or if a governmental action has impaired the participating 345
provider's ability to practice. 346

       (E) Divisions (A) to (D) of this section apply only to 347
providers who are natural persons. 348

       (F)(1) Nothing in this section prohibits a health insuring 349
corporation from rejecting a provider's application for 350
participation, or from terminating a participating provider's 351
contract, if the health insuring corporation determines that the 352
health care needs of its enrollees are being met and no need 353
exists for the provider's or participating provider's services. 354

       (2) Nothing in this section shall be construed as prohibiting 355
a health insuring corporation from terminating a participating 356
provider who does not meet the terms and conditions of the 357
participating provider's contract. 358

       (G) The superintendent of insurance may adopt rules as 359
necessary to implement and enforce sections ~~1753.04 to~~1753.06, 360
1753.07, and 1753.09 of the Revised Code. Such rules shall be 361
adopted in accordance with Chapter 119. of the Revised Code. The 362
director of health may make recommendations to the superintendent 363
for rules necessary to implement and enforce sections ~~1753.04 to~~ 364
1753.06, 1753.07, and 1753.09 of the Revised Code. In adopting any 365
rules pursuant to this division, the Superintendent shall consider 366
the recommendations of the Director. 367

       Sec. 3963.01. As used in this chapter: 368

       (A) "Edit" means adjusting one or more procedure codes billed 369
by a provider on a claim for payment or a third-party payer's 370
practice that results in: 371

       (1) Payment for some, but not all of the procedure codes 372
originally billed by a provider; 373

       (2) Payment for a different procedure code than the procedure 374
code originally billed by a provider; 375

       (3) A reduced payment as a result of services provided to an 376
enrollee that are claimed under more than one procedure code on 377
the same service date. 378

       (B) "Health care contract" means a contract entered into or 379
renewed between a third-party payer and a provider for the 380
delivery of basic or supplemental health care services to 381
enrollees. 382

       (C) "Procedure codes" includes the American medical 383
association's current procedural terminology code, and the centers 384
for medicare and medicaid services health care common procedure 385
coding system. 386

       (D) "Product" means a product line for health services, 387
including, but not limited to a health insuring corporation 388
product or a medicare or medicaid product as established by a 389
third-party payer and for which the provider may be obligated to 390
provide services pursuant to a contract. 391

       (E) "Provider" means a physician, podiatrist, dentist, 392
pharmacist, chiropractor, optometrist, psychologist, or other 393
health care provider entitled to reimbursement by a third-party 394
payer for services rendered to an enrollee under a heath care 395
contract. "Provider" does not mean a hospital or nursing home. 396

       (F) "Third-party payer" means any person that has a primary 397
business purpose of contracting with health care providers for the 398
delivery of basic health care services. 399

       (G) "Credentialing" means the process of assessing and 400
validating the qualifications of a provider applying to be 401
approved by a third-party payer to provide basic health care 402
services to the third-party payer's enrollees. 403

       (H) "Enrollee" means any person eligible for health care 404
benefits under a health benefit plan and includes all of the 405
following terms: 406

       (1) Enrollee and subscriber as defined by section 1751.01 of 407
the Revised Code; 408

       (2) Member as defined by section 1739.01 of the Revised Code; 409

       (3) Insured and plan member pursuant to Chapter 3923. of the 410
Revised Code; 411

       (4) Beneficiary as defined by section 3901.38 of the Revised 412
Code; 413

       (5) Claimant pursuant to Chapter 4121., 4123., 4127., or 414
4131. of the Revised Code. 415

       (I) "Participating provider" means a provider that has a 416
health care contract with the third-party payer. 417

       Sec. 3963.02. (A) No third-party payer shall do either of the 418
following: 419

       (1) Sell, rent, or give its provider network information to 420
any other person, except for the purpose of providing claims 421
processing for the third-party payer; 422

       (2) Require, as a condition of contracting with the 423
third-party payer, that a provider: 424

       (a) Provide services under more than one product offered by 425
the third-party payer; 426

       (b) Waive or forego any right or benefit to which the 427
provider may be entitled under state or federal law. 428

       (B) No third-party payer, other than the third-party payer 429
that executes a health care contract, shall enforce against the 430
provider the payment or compensation terms of the health care 431
contract unless the other third-party payer is contractually bound 432
to all terms and conditions of the health care contract executed 433
by the provider, and; 434

       (1) The other third-party payer is clearly identified in the 435
health care contract executed by the provider, or 436

       (2) Before health care services are provided, the health care 437
contract is amended by a writing in which the provider agrees to 438
provide health care services for the payment or compensation 439
described in the health care contract to be paid by the other 440
third-party payer. 441

       (C) No health care contract shall: 442

       (1) Interfere with a provider's right to set the provider's 443
payer-mix ratio in the provider's practice; 444

       (2) Preclude its use or disclosure for the purpose of 445
enforcing this chapter or other state or federal law, except that 446
a health care contract may require that appropriate measures be 447
taken to preserve the confidentiality of any proprietary or 448
trade-secret information. 449

       (3)(a) Include a most favored nation clause if a third-party 450
payer controls more than twenty per cent of a health insurance 451
market share in a particular county. "Most favored nation clause" 452
means a contract provision that: 453

       (i) Prohibits, or grants a third-party payer an option to 454
prohibit, the provider from contracting with another third-party 455
payer to provide services at a lower price than the payment 456
specified in the contract; 457

       (ii) Requires, or grants a third-party payer an option to 458
require, the provider to accept a lower payment in the event the 459
provider agrees to provide services to any other third-party payer 460
at a lower price; 461

       (iii) Requires, or grants the third-party payer an option to 462
require, termination or renegotiation of the existing health care 463
contract in the event the provider agrees to provide services to 464
any other third-party payer at a lower price; 465

       (iv) Requires the provider to disclose the provider's 466
contractual reimbursement rates with other third-party payers. 467

       (b) Any health care contract provision violating division 468
(C)(3) of this section is null and void. 469

       (D) No term for compensation or payment in a health care 470
contract shall survive the termination of the contract, except 471
with the agreement of the provider or for a continuation of 472
coverage arrangement otherwise required by law. 473

       (E) Each health care contract shall provide that the 474
third-party payer or the provider may terminate the health care 475
contract without cause by giving not less than ninety days written 476
notice to the other party. 477

       (F) If the health care contract provides for termination for 478
cause by either party, the health care contract shall state the 479
reasons that may be used for termination for cause, which terms 480
shall be reasonable. The health care contract shall state the time 481
by which the parties must provide notice of termination for cause 482
and to whom the parties shall give the notice. 483

       (G) Disputes among parties concerning the enforcement of 484
sections 3963.01 to 3963.04 of the Revised Code are subject to a 485
mutually agreed upon arbitration mechanism, which is binding on 486
all parties. The arbitrator may award reasonable attorney's fees 487
and costs for arbitration relating to the enforcement of this 488
section to the prevailing party. The limitation to reasonable 489
attorney's fees and costs shall not apply to disputes regarding 490
breach of contract. 491

       Sec. 3963.03. (A) Each third-party payer shall include a 492
summary disclosure form with a health care contract that discloses 493
in plain language the following information: 494

       (1) Information sufficient for the provider to determine the 495
compensation or payment terms for health care services, including 496
all of the following: 497

       (a) The manner of payment, such as fee-for-service, 498
capitation, or risk; 499

       (b) The fee schedule of codes reasonably expected to be 500
billed by a provider's specialty for services provided pursuant to 501
the health care contract, including, if applicable, current 502
procedural terminology codes and the centers for medicare and 503
medicaid services health care common procedure coding system and 504
the associated payment or compensation for each procedure code. A 505
fee schedule may be provided electronically. Upon request, a 506
third-party payer shall provide a provider with the fee schedule 507
for any other codes requested and a written fee schedule, which 508
shall not be required more frequently than twice per year 509
excluding when it is provided in connection with any change to the 510
schedule. The third-party payer also shall state the effect, if 511
any, on payment or compensation if more than one procedure code 512
applies to the service. A third-party payer may satisfy this 513
requirement by providing a clearly understandable, readily 514
available mechanism, such as a web site, that allows a provider to 515
determine the effect of service codes on payment or compensation 516
before a service is provided or a claim is submitted. 517

       (c) The methodology used to calculate any fee schedule, such 518
as relative value unit system and conversion factor, percentage of 519
medicare payment system, or percentage of billed charges. If 520
applicable, the methodology disclosure shall include the name of 521
any relative value system, its version, edition, or publication 522
date, any applicable conversion or geographic factor, and any date 523
by which compensation or fee schedules may be changed by the 524
methodology as anticipated at the time of contract. 525

       (d) The identity of any internal processing edits used by the 526
third-party payer, including the publisher, product name, version, 527
and version update of any editing software used by the third-party 528
payer. 529

       (2) Any product for which the provider is to provide 530
services; 531

       (3) The term of the health care contract and how it may be 532
terminated; 533

       (4) The identity of the third-party payer responsible for the 534
processing of the provider's compensation or payment; 535

       (5) Any internal mechanism provided by the third-party payer 536
to resolve disputes concerning the interpretation or application 537
of the terms or conditions of the contract; 538

       (6) Any provisions for the amendment of the contract; 539

       (7) A list of addenda, if any, to the contract. 540

       (B) When a third-party payer presents a proposed health care 541
contract for consideration by a provider, the third-party payer 542
shall provide in writing or make reasonably available the 543
information required in division (A)(1) of this section. If the 544
information is not disclosed in writing, it shall be disclosed in 545
a manner that allows the provider to evaluate the provider's 546
payment or compensation for services under the health care 547
contract. After the health care contract is executed, a 548
third-party payer shall disclose the information required by 549
division (A)(1) of this section upon request by the provider. The 550
third-party payer need not provide such information in written 551
format more than twice a year. 552

       (C) The third-party payer shall identify any utilization 553
management, quality improvement, or a similar program the 554
third-party payer uses to review, monitor, evaluate, or assess the 555
services provided pursuant to a health care contract. The 556
third-party payer shall disclose the policies, procedures, or 557
guidelines of such a program applicable to a provider upon request 558
by the provider within fourteen days after the date of the 559
request. 560

       Sec. 3963.04. (A) A third-party payer shall notify a provider 561
one hundred twenty days prior to the effective date of an 562
amendment to the provider's contract with the third-party payer, 563
and one hundred twenty days prior to the effective date of an 564
amendment to any document incorporated by reference into the 565
contract if the amendment of the document directly and materially 566
affects the provider. Such amendments shall not be effective with 567
regard to a provider until the provider has agreed in writing to 568
the change. 569

       (B)(1) Division (A) of this section does not apply if the 570
delay caused by compliance with that division could result in 571
imminent harm to an enrollee or if the amendment is required by 572
state or federal law, rule, or regulation. 573

       (2) This section does not apply if the provider's payment or 574
compensation is based on the current medicare physician fee 575
schedule final rule as published by the centers for medicaid and 576
medicare services annually in the federal register and the change 577
in payment or compensation results solely from a change in the 578
physician fee schedule. 579

       (C) Notwithstanding divisions (A) and (B) of this section, a 580
health care contract may be modified, without the need for 581
amendment, by operation of law as required by any applicable state 582
or federal law or rule or regulation. Nothing in this section 583
shall be construed to require the renegotiation of a contract in 584
existence before the effective date of this section, until such 585
time as the contract is renewed or modified. 586

       Sec. 3963.05. (A) The credentialing form used by the council 587
for affordable quality healthcare (CAQH), in electronic or paper 588
format, shall be the standard credentialing form. 589

       (B) No third-party payer shall fail to use the standard 590
credentialing form described in division (A) of this section when 591
initially credentialing or recredentialing providers in connection 592
with policies, health care contracts, and agreements providing 593
basic or supplemental health care services. 594

       (C) No third-party payer shall require a provider to provide 595
any information in addition to the information required by the 596
standard credentialing form described in division (A) of this 597
section in connection with policies, health care contracts, and 598
agreements providing basic or supplemental health care services. 599

       Sec. 3963.06. (A) If a provider submits to a third-party 600
payer a credentialing form that is not complete the third-party 601
payer that receives the form shall notify the provider of the 602
deficiency not later than fourteen days after the third-party 603
payer receives the form. 604

       (B) A third-party payer shall reimburse a provider who has 605
submitted a complete credentialing form for entrance into a health 606
care contract with the third-party payer when the period of review 607
of the provider's credentialing form exceeds forty-five days and 608
until the third-party payer rejects or approves the provider for a 609
health care contract. 610

       (C)(1) If the third-party payer and the provider enter into a 611
health care contract, the third-party payer shall retroactively 612
reimburse the provider according to the terms of the contract for 613
any basic or supplemental health care services the provider 614
provided to enrollees after the provider submitted to the 615
third-party payer a complete credentialing form and until the 616
third-party payer and the provider enter into a health care 617
contract. 618

       (2) A provider may keep record of in-network claims incurred 619
while the provider's credentialing is pending and submit the 620
claims to be paid by the third-party payer once the third-party 621
payer and the provider enter into a health care contract. 622

       Sec. 3963.07. (A) Each third-party payer shall, upon a 623
participating provider's submission of an enrollee's name, the 624
enrollee's relationship to the primary enrollee, and the 625
enrollee's birth date, make available information maintained in 626
the ordinary course of business that is sufficient for the 627
provider to determine at the time of the enrollee's visit all of 628
the following: 629

       (1) The enrollee's identification number assigned by the 630
third-party payer; 631

       (2) The birth date and gender of the primary enrollee; 632

       (3) The names, birth dates and gender of all covered 633
dependents; 634

       (4) The current enrollment and eligibility status of the 635
enrollee; 636

       (5) Whether a specific type or category of service is a 637
covered benefit for the enrollee; 638

       (6) The enrollee's excluded benefits or limitations, whether 639
group or individual; 640

       (7) The enrollee's copayment requirements; 641

       (8) The unmet amount of the enrollee's deductible or the 642
enrollee's financial responsibility. 643

       (B) A third-party payer shall make available the information 644
required by this section electronically or by an internet portal. 645

       (C) Notwithstanding division (A) of this section, no 646
third-party payer shall make the information required by this 647
section available to any person except to a participating provider 648
who is authorized under state and federal law to receive 649
personally identifiable information concerning an enrollee or an 650
enrollee's dependent. 651

       (D) No third-party payer directly or indirectly shall charge 652
a provider any fee for the information the third-party payer makes 653
available pursuant to this section. 654

       Sec. 3963.08. The superintendent of insurance shall adopt 655
any rules necessary for the implementation of this chapter. 656

       Sec. 3963.09. Unless otherwise stated, a violation of this 657
chapter is an unfair and deceptive act or practice in the business 658
of insurance under sections 3901.19 to 3901.26 of the Revised 659
Code. 660

       Section 2. That existing sections 1751.13 and 1753.09 and 661
sections 1753.03, 1753.04, 1753.05, and 1753.08 of the Revised 662
Code are hereby repealed. 663

       Section 3. Sections 3963.01 to 3963.09 of the Revised Code, 664
as enacted by this act, shall apply only to contracts that are 665
delivered, issued for delivery, or renewed or modified in this 666
state on or after the effective date of this act. A health 667
insuring corporation having fewer than fifteen thousand enrollees 668
shall comply with the provisions of this section within twelve 669
months after the effective date of this act. 670

Section 1. That sections 1751.13 and 1753.09 be amended and	10
sections 3963.01, 3963.02, 3963.03, 3963.04, 3963.05, 3963.06,	11
3963.07, 3963.08, and 3963.09 of the Revised Code be enacted to	12
read as follows:	13

Sec. 1751.13. (A)(1)(a) A health insuring corporation shall,	14
either directly or indirectly, enter into contracts for the	15
provision of health care services with a sufficient number and	16
types of providers and health care facilities to ensure that all	17
covered health care services will be accessible to enrollees from	18
a contracted provider or health care facility.	19

(b) A health insuring corporation shall not refuse to	20
contract with a physician for the provision of health care	21
services or refuse to recognize a physician as a specialist on the	22
basis that the physician attended an educational program or a	23
residency program approved or certified by the American	24
osteopathic association. A health insuring corporation shall not	25
refuse to contract with a health care facility for the provision	26
of health care services on the basis that the health care facility	27
is certified or accredited by the American osteopathic association	28
or that the health care facility is an osteopathic hospital as	29
defined in section 3702.51 of the Revised Code.	30

(c) Nothing in division (A)(1)(b) of this section shall be	31
construed to require a health insuring corporation to make a	32
benefit payment under a closed panel plan to a physician or health	33
care facility with which the health insuring corporation does not	34
have a contract, provided that none of the bases set forth in that	35
division are used as a reason for failing to make a benefit	36
payment.	37

(2) When a health insuring corporation is unable to provide a	38
covered health care service from a contracted provider or health	39
care facility, the health insuring corporation must provide that	40
health care service from a noncontracted provider or health care	41
facility consistent with the terms of the enrollee's policy,	42
contract, certificate, or agreement. The health insuring	43
corporation shall either ensure that the health care service be	44
provided at no greater cost to the enrollee than if the enrollee	45
had obtained the health care service from a contracted provider or	46
health care facility, or make other arrangements acceptable to the	47
superintendent of insurance.	48

(3) Nothing in this section shall prohibit a health insuring	49
corporation from entering into contracts with out-of-state	50
providers or health care facilities that are licensed, certified,	51
accredited, or otherwise authorized in that state.	52

(B)(1) A health insuring corporation shall, either directly	53
or indirectly, enter into contracts with all providers and health	54
care facilities through which health care services are provided to	55
its enrollees.	56

(2) A health insuring corporation, upon written request,	57
shall assist its contracted providers in finding stop-loss or	58
reinsurance carriers.	59

(C) A health insuring corporation shall file an annual	60
certificate with the superintendent certifying that all provider	61
contracts and contracts with health care facilities through which	62
health care services are being provided contain the following:	63

(1) A description of the method by which the provider or	64
health care facility will be notified of the specific health care	65
services for which the provider or health care facility will be	66
responsible, including any limitations or conditions on such	67
services;	68

(2) The specific hold harmless provision specifying	69
protection of enrollees set forth as follows:	70

"[Provider/Health Care Facility] agrees that in no event,	71
including but not limited to nonpayment by the health insuring	72
corporation, insolvency of the health insuring corporation, or	73
breach of this agreement, shall [Provider/Health Care Facility]	74
bill, charge, collect a deposit from, seek remuneration or	75
reimbursement from, or have any recourse against, a subscriber,	76
enrollee, person to whom health care services have been provided,	77
or person acting on behalf of the covered enrollee, for health	78
care services provided pursuant to this agreement. This does not	79
prohibit [Provider/Health Care Facility] from collecting	80
co-insurance, deductibles, or copayments as specifically provided	81
in the evidence of coverage, or fees for uncovered health care	82
services delivered on a fee-for-service basis to persons	83
referenced above, nor from any recourse against the health	84
insuring corporation or its successor."	85

(3) Provisions requiring the provider or health care facility	86
to continue to provide covered health care services to enrollees	87
in the event of the health insuring corporation's insolvency or	88
discontinuance of operations. The provisions shall require the	89
provider or health care facility to continue to provide covered	90
health care services to enrollees as needed to complete any	91
medically necessary procedures commenced but unfinished at the	92
time of the health insuring corporation's insolvency or	93
discontinuance of operations. The completion of a medically	94
necessary procedure shall include the rendering of all covered	95
health care services that constitute medically necessary follow-up	96
care for that procedure. If an enrollee is receiving necessary	97
inpatient care at a hospital, the provisions may limit the	98
required provision of covered health care services relating to	99
that inpatient care in accordance with division (D)(3) of section	100
1751.11 of the Revised Code, and may also limit such required	101
provision of covered health care services to the period ending	102
thirty days after the health insuring corporation's insolvency or	103
discontinuance of operations.	104

The provisions required by division (C)(3) of this section	105
shall not require any provider or health care facility to continue	106
to provide any covered health care service after the occurrence of	107
any of the following:	108

(a) The end of the thirty-day period following the entry of a	109
liquidation order under Chapter 3903. of the Revised Code;	110

(b) The end of the enrollee's period of coverage for a	111
contractual prepayment or premium;	112

(c) The enrollee obtains equivalent coverage with another	113
health insuring corporation or insurer, or the enrollee's employer	114
obtains such coverage for the enrollee;	115

(d) The enrollee or the enrollee's employer terminates	116
coverage under the contract;	117

(e) A liquidator effects a transfer of the health insuring	118
corporation's obligations under the contract under division (A)(8)	119
of section 3903.21 of the Revised Code.	120

(4) A provision clearly stating the rights and	121
responsibilities of the health insuring corporation, and of the	122
contracted providers and health care facilities, with respect to	123
administrative policies and programs, including, but not limited	124
to, payments systems, utilization review, quality assurance,	125
assessment, and improvement programs, credentialing,	126
confidentiality requirements, and any applicable federal or state	127
programs;	128

(5) A provision regarding the availability and	129
confidentiality of those health records maintained by providers	130
and health care facilities to monitor and evaluate the quality of	131
care, to conduct evaluations and audits, and to determine on a	132
concurrent or retrospective basis the necessity of and	133
appropriateness of health care services provided to enrollees.	134
The provision shall include terms requiring the provider or health	135
care facility to make these health records available to	136
appropriate state and federal authorities involved in assessing	137
the quality of care or in investigating the grievances or	138
complaints of enrollees, and requiring the provider or health care	139
facility to comply with applicable state and federal laws related	140
to the confidentiality of medical or health records.	141

(6) A provision that states that contractual rights and	142
responsibilities may not be assigned or delegated by the provider	143
or health care facility without the prior written consent of the	144
health insuring corporation;	145

(7) A provision requiring the provider or health care	146
facility to maintain adequate professional liability and	147
malpractice insurance. The provision shall also require the	148
provider or health care facility to notify the health insuring	149
corporation not more than ten days after the provider's or health	150
care facility's receipt of notice of any reduction or cancellation	151
of such coverage.	152

(8) A provision requiring the provider or health care	153
facility to observe, protect, and promote the rights of enrollees	154
as patients;	155

(9) A provision requiring the provider or health care	156
facility to provide health care services without discrimination on	157
the basis of a patient's participation in the health care plan,	158
age, sex, ethnicity, religion, sexual preference, health status,	159
or disability, and without regard to the source of payments made	160
for health care services rendered to a patient. This requirement	161
shall not apply to circumstances when the provider or health care	162
facility appropriately does not render services due to limitations	163
arising from the provider's or health care facility's lack of	164
training, experience, or skill, or due to licensing restrictions.	165

(10) A provision containing the specifics of any obligation	166
on the primary care provider to provide, or to arrange for the	167
provision of, covered health care services twenty-four hours per	168
day, seven days per week;	169

(11) A provision setting forth procedures for the resolution	170
of disputes arising out of the contract;	171

(12) A provision stating that the hold harmless provision	172
required by division (C)(2) of this section shall survive the	173
termination of the contract with respect to services covered and	174
provided under the contract during the time the contract was in	175
effect, regardless of the reason for the termination, including	176
the insolvency of the health insuring corporation;	177

(13) A provision requiring those terms that are used in the	178
contract and that are defined by this chapter, be used in the	179
contract in a manner consistent with those definitions.	180

This division does not apply to the coverage of beneficiaries	181
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 620	182
(1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare risk	183
contract or medicare cost contract, or to the coverage of	184
beneficiaries enrolled in the federal employee health benefits	185
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	186
beneficiaries enrolled in Title XIX of the "Social Security Act,"	187
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	188
medical assistance program or medicaid, provided by the department	189
of job and family services under Chapter 5111. of the Revised	190
Code, or to the coverage of beneficiaries under any federal health	191
care program regulated by a federal regulatory body, or to the	192
coverage of beneficiaries under any contract covering officers or	193
employees of the state that has been entered into by the	194
department of administrative services.	195