As Passed by the House

127th General Assembly Regular Session 2007-2008

Am. Sub. 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, Hughes, Core, Dodd, Batchelder, Boyd, Budish, Chandler, Collier, Distel, Driehaus, Dyer, Evans, Flowers, Goyal, Hagan, J., Healy, Koziura, Letson, Luckie, Otterman, Patton, Yuko 

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A BILL

To amend sections 1751.13, 1753.01, 1753.07, 1753.09,

1

and 5111.17, to enact sections 3963.01 to 3963.10,

2

and to repeal sections 1753.03, 1753.04,

3

1753.05, and 1753.08 of the Revised Code to

4

establish certain uniform contract provisions

5

between health care providers and contracting

6

entities, to establish standardized

7

credentialing, to require contracting entities

8

to provide to health care providers specified

9

information concerning enrollees, to require

10

the Department of Job and Family Services to

11

allow managed care plans to use providers to

12

render care, and to create a Joint Legislative

13

Study Commission on Most Favored Nation Clauses

14

in Health Care Contracts.

15

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

Section 1. That sections 1751.13, 1753.01, 1753.07, 1753.09,	16
and 5111.17 be amended and sections 3963.01, 3963.02, 3963.03,	17
3963.04, 3963.05, 3963.06, 3963.07, 3963.08, 3963.09, and 3963.10	18
of the Revised Code be enacted to read as follows:	19

Sec. 1751.13.  (A)(1)(a) A health insuring corporation shall,	20
either directly or indirectly, enter into contracts for the	21
provision of health care services with a sufficient number and	22
types of providers and health care facilities to ensure that all	23
covered health care services will be accessible to enrollees from	24
a contracted provider or health care facility.	25

(b) A health insuring corporation shall not refuse to	26
contract with a physician for the provision of health care	27
services or refuse to recognize a physician as a specialist on the	28
basis that the physician attended an educational program or a	29
residency program approved or certified by the American	30
osteopathic association. A health insuring corporation shall not	31
refuse to contract with a health care facility for the provision	32
of health care services on the basis that the health care facility	33
is certified or accredited by the American osteopathic association	34
or that the health care facility is an osteopathic hospital as	35
defined in section 3702.51 of the Revised Code.	36

(c) Nothing in division (A)(1)(b) of this section shall be	37
construed to require a health insuring corporation to make a	38
benefit payment under a closed panel plan to a physician or health	39
care facility with which the health insuring corporation does not	40
have a contract, provided that none of the bases set forth in that	41
division are used as a reason for failing to make a benefit	42
payment.	43

(2) When a health insuring corporation is unable to provide a	44
covered health care service from a contracted provider or health	45
care facility, the health insuring corporation must provide that	46
health care service from a noncontracted provider or health care	47
facility consistent with the terms of the enrollee's policy,	48
contract, certificate, or agreement. The health insuring	49
corporation shall either ensure that the health care service be	50
provided at no greater cost to the enrollee than if the enrollee	51
had obtained the health care service from a contracted provider or	52
health care facility, or make other arrangements acceptable to the	53
superintendent of insurance.	54

(3) Nothing in this section shall prohibit a health insuring	55
corporation from entering into contracts with out-of-state	56
providers or health care facilities that are licensed, certified,	57
accredited, or otherwise authorized in that state.	58

(B)(1) A health insuring corporation shall, either directly	59
or indirectly, enter into contracts with all providers and health	60
care facilities through which health care services are provided to	61
its enrollees.	62

(2) A health insuring corporation, upon written request,	63
shall assist its contracted providers in finding stop-loss or	64
reinsurance carriers.	65

(C) A health insuring corporation shall file an annual	66
certificate with the superintendent certifying that all provider	67
contracts and contracts with health care facilities through which	68
health care services are being provided contain the following:	69

(1) A description of the method by which the provider or	70
health care facility will be notified of the specific health care	71
services for which the provider or health care facility will be	72
responsible, including any limitations or conditions on such	73
services;	74

(2) The specific hold harmless provision specifying	75
protection of enrollees set forth as follows:	76

"[Provider/Health Care Facility] agrees that in no event,	77
including but not limited to nonpayment by the health insuring	78
corporation, insolvency of the health insuring corporation, or	79
breach of this agreement, shall [Provider/Health Care Facility]	80
bill, charge, collect a deposit from, seek remuneration or	81
reimbursement from, or have any recourse against, a subscriber,	82
enrollee, person to whom health care services have been provided,	83
or person acting on behalf of the covered enrollee, for health	84
care services provided pursuant to this agreement. This does not	85
prohibit [Provider/Health Care Facility] from collecting	86
co-insurance, deductibles, or copayments as specifically provided	87
in the evidence of coverage, or fees for uncovered health care	88
services delivered on a fee-for-service basis to persons	89
referenced above, nor from any recourse against the health	90
insuring corporation or its successor."	91

(3) Provisions requiring the provider or health care facility	92
to continue to provide covered health care services to enrollees	93
in the event of the health insuring corporation's insolvency or	94
discontinuance of operations. The provisions shall require the	95
provider or health care facility to continue to provide covered	96
health care services to enrollees as needed to complete any	97
medically necessary procedures commenced but unfinished at the	98
time of the health insuring corporation's insolvency or	99
discontinuance of operations. The completion of a medically	100
necessary procedure shall include the rendering of all covered	101
health care services that constitute medically necessary follow-up	102
care for that procedure. If an enrollee is receiving necessary	103
inpatient care at a hospital, the provisions may limit the	104
required provision of covered health care services relating to	105
that inpatient care in accordance with division (D)(3) of section	106
1751.11 of the Revised Code, and may also limit such required	107
provision of covered health care services to the period ending	108
thirty days after the health insuring corporation's insolvency or	109
discontinuance of operations.	110

The provisions required by division (C)(3) of this section	111
shall not require any provider or health care facility to continue	112
to provide any covered health care service after the occurrence of	113
any of the following:	114

(a) The end of the thirty-day period following the entry of a	115
liquidation order under Chapter 3903. of the Revised Code;	116

(b) The end of the enrollee's period of coverage for a	117
contractual prepayment or premium;	118

(c) The enrollee obtains equivalent coverage with another	119
health insuring corporation or insurer, or the enrollee's employer	120
obtains such coverage for the enrollee;	121

(d) The enrollee or the enrollee's employer terminates	122
coverage under the contract;	123

(e) A liquidator effects a transfer of the health insuring	124
corporation's obligations under the contract under division (A)(8)	125
of section 3903.21 of the Revised Code.	126

(4) A provision clearly stating the rights and	127
responsibilities of the health insuring corporation, and of the	128
contracted providers and health care facilities, with respect to	129
administrative policies and programs, including, but not limited	130
to, payments systems, utilization review, quality assurance,	131
assessment, and improvement programs, credentialing,	132
confidentiality requirements, and any applicable federal or state	133
programs;	134

(5) A provision regarding the availability and	135
confidentiality of those health records maintained by providers	136
and health care facilities to monitor and evaluate the quality of	137
care, to conduct evaluations and audits, and to determine on a	138
concurrent or retrospective basis the necessity of and	139
appropriateness of health care services provided to enrollees.	140
The provision shall include terms requiring the provider or health	141
care facility to make these health records available to	142
appropriate state and federal authorities involved in assessing	143
the quality of care or in investigating the grievances or	144
complaints of enrollees, and requiring the provider or health care	145
facility to comply with applicable state and federal laws related	146
to the confidentiality of medical or health records.	147

(6) A provision that states that contractual rights and	148
responsibilities may not be assigned or delegated by the provider	149
or health care facility without the prior written consent of the	150
health insuring corporation;	151

(7) A provision requiring the provider or health care	152
facility to maintain adequate professional liability and	153
malpractice insurance. The provision shall also require the	154
provider or health care facility to notify the health insuring	155
corporation not more than ten days after the provider's or health	156
care facility's receipt of notice of any reduction or cancellation	157
of such coverage.	158

(8) A provision requiring the provider or health care	159
facility to observe, protect, and promote the rights of enrollees	160
as patients;	161

(9) A provision requiring the provider or health care	162
facility to provide health care services without discrimination on	163
the basis of a patient's participation in the health care plan,	164
age, sex, ethnicity, religion, sexual preference, health status,	165
or disability, and without regard to the source of payments made	166
for health care services rendered to a patient. This requirement	167
shall not apply to circumstances when the provider or health care	168
facility appropriately does not render services due to limitations	169
arising from the provider's or health care facility's lack of	170
training, experience, or skill, or due to licensing restrictions.	171

(10) A provision containing the specifics of any obligation	172
on the primary care provider to provide, or to arrange for the	173
provision of, covered health care services twenty-four hours per	174
day, seven days per week;	175

(11) A provision setting forth procedures for the resolution	176
of disputes arising out of the contract;	177

(12) A provision stating that the hold harmless provision	178
required by division (C)(2) of this section shall survive the	179
termination of the contract with respect to services covered and	180
provided under the contract during the time the contract was in	181
effect, regardless of the reason for the termination, including	182
the insolvency of the health insuring corporation;	183

(13) A provision requiring those terms that are used in the	184
contract and that are defined by this chapter, be used in the	185
contract in a manner consistent with those definitions.	186

This division does not apply to the coverage of beneficiaries	187
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 620	188
(1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare risk	189
contract or medicare cost contract, or to the coverage of	190
beneficiaries enrolled in the federal employee health benefits	191
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	192
beneficiaries enrolled in Title XIX of the "Social Security Act,"	193
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	194
medical assistance program or medicaid, provided by the department	195
of job and family services under Chapter 5111. of the Revised	196
Code, or to the coverage of beneficiaries under any federal health	197
care program regulated by a federal regulatory body, or to the	198
coverage of beneficiaries under any contract covering officers or	199
employees of the state that has been entered into by the	200
department of administrative services.	201

(D)(1) No health insuring corporation contract with a	202
provider or health care facility shall contain any of the	203
following:	204

(a) A provision that directly or indirectly offers an	205
inducement to the provider or health care facility to reduce or	206
limit medically necessary health care services to a covered	207
enrollee;	208

(b) A provision that penalizes a provider or health care	209
facility that assists an enrollee to seek a reconsideration of the	210
health insuring corporation's decision to deny or limit benefits	211
to the enrollee;	212

(c) A provision that limits or otherwise restricts the	213
provider's or health care facility's ethical and legal	214
responsibility to fully advise enrollees about their medical	215
condition and about medically appropriate treatment options;	216

(d) A provision that penalizes a provider or health care	217
facility for principally advocating for medically necessary health	218
care services;	219

(e) A provision that penalizes a provider or health care	220
facility for providing information or testimony to a legislative	221
or regulatory body or agency. This shall not be construed to	222
prohibit a health insuring corporation from penalizing a provider	223
or health care facility that provides information or testimony	224
that is libelous or slanderous or that discloses trade secrets	225
which the provider or health care facility has no privilege or	226
permission to disclose.	227

(f) A provision that violates Chapter 3963. of the Revised	228
Code.	229

(2) Nothing in this division shall be construed to prohibit a	230
health insuring corporation from doing either of the following:	231

(a) Making a determination not to reimburse or pay for a	232
particular medical treatment or other health care service;	233

(b) Enforcing reasonable peer review or utilization review	234
protocols, or determining whether a particular provider or health	235
care facility has complied with these protocols.	236

(E) Any contract between a health insuring corporation and an	237
intermediary organization shall clearly specify that the health	238
insuring corporation must approve or disapprove the participation	239
of any provider or health care facility with which the	240
intermediary organization contracts.	241

(F) If an intermediary organization that is not a health	242
delivery network contracting solely with self-insured employers	243
subcontracts with a provider or health care facility, the	244
subcontract with the provider or health care facility shall do all	245
of the following:	246

(1) Contain the provisions required by divisions (C) and (G)	247
of this section, as made applicable to an intermediary	248
organization, without the inclusion of inducements or penalties	249
described in division (D) of this section;	250

(2) Acknowledge that the health insuring corporation is a	251
third-party beneficiary to the agreement;	252

(3) Acknowledge the health insuring corporation's role in	253
approving the participation of the provider or health care	254
facility, pursuant to division (E) of this section.	255

(G) Any provider contract or contract with a health care	256
facility shall clearly specify the health insuring corporation's	257
statutory responsibility to monitor and oversee the offering of	258
covered health care services to its enrollees.	259

(H)(1) A health insuring corporation shall maintain its	260
provider contracts and its contracts with health care facilities	261
at one or more of its places of business in this state, and shall	262
provide copies of these contracts to facilitate regulatory review	263
upon written notice by the superintendent of insurance.	264

(2) Any contract with an intermediary organization that	265
accepts compensation shall include provisions requiring the	266
intermediary organization to provide the superintendent with	267
regulatory access to all books, records, financial information,	268
and documents related to the provision of health care services to	269
subscribers and enrollees under the contract. The contract shall	270
require the intermediary organization to maintain such books,	271
records, financial information, and documents at its principal	272
place of business in this state and to preserve them for at least	273
three years in a manner that facilitates regulatory review.	274

(I)(1) A health insuring corporation shall notify its	275
affected enrollees of the termination of a contract for the	276
provision of health care services between the health insuring	277
corporation and a primary care physician or hospital, by mail,	278
within thirty days after the termination of the contract.	279

(a) Notice shall be given to subscribers of the termination	280
of a contract with a primary care physician if the subscriber, or	281
a dependent covered under the subscriber's health care coverage,	282
has received health care services from the primary care physician	283
within the previous twelve months or if the subscriber or	284
dependent has selected the physician as the subscriber's or	285
dependent's primary care physician within the previous twelve	286
months.	287

(b) Notice shall be given to subscribers of the termination	288
of a contract with a hospital if the subscriber, or a dependent	289
covered under the subscriber's health care coverage, has received	290
health care services from that hospital within the previous twelve	291
months.	292

(2) The health insuring corporation shall pay, in accordance	293
with the terms of the contract, for all covered health care	294
services rendered to an enrollee by a primary care physician or	295
hospital between the date of the termination of the contract and	296
five days after the notification of the contract termination is	297
mailed to a subscriber at the subscriber's last known address.	298

(J) Divisions (A) and (B) of this section do not apply to any	299
health insuring corporation that, on June 4, 1997, holds a	300
certificate of authority or license to operate under Chapter 1740.	301
of the Revised Code.	302

(K) Nothing in this section shall restrict the governing body	303
of a hospital from exercising the authority granted it pursuant to	304
section 3701.351 of the Revised Code.	305

Sec. 1753.01.  As used in this chapter:

306

(A) "Economic profiling" means a health insuring	307
corporation's use of economic performance data and economic	308
information in determining whether to contract with a provider for	309
the provision of covered health care services to enrollees as a	310
participating provider.	311

(B) "Basic, "basic health care services," "enrollee," "health	312
care facility," "health care services," "health insuring	313
corporation," "medical record," "person," "primary care provider,"	314
"provider," "subscriber," and "supplemental health care services"	315
have the same meanings as in section 1751.01 of the Revised Code.	316

Sec. 1753.07.  (A)(1) Prior to entering into a participation	317
contract with a provider under section 1751.13 of the Revised	318
Code, a health insuring corporation shall disclose basic	319
information regarding its programs and procedures to the provider,	320
upon the provider's request. The information shall include all of	321
the following:	322

(1)(a) How a participating provider is reimbursed for the	323
participating provider's services, including the range and	324
structure of any financial risk sharing arrangements, a	325
description of any incentive plans, and, if reimbursed according	326
to a type of fee-for-service arrangement, the level of	327
reimbursement for the participating provider's services;	328

(2)(b) Insofar as division (A)(1) of section 3963.03 of the	329
Revised Code is applicable, all of the information that is	330
described in that division and is not included in division	331
(A)(1)(a) of this section.	332

(2) Prior to entering into a participation contract with a	333
provider under section 1751.13 of the Revised Code, a health	334
insuring corporation shall disclose the following information upon	335
the provider's request:	336

(a) How referrals to other participating providers or to	337
nonparticipating providers are made;	338

(3)(b) The availability of dispute resolution procedures and	339
the potential for cost to be incurred;	340

(4)(c) How a participating provider's name and address will	341
be used in marketing materials.	342

(B) A health insuring corporation shall provide all of the	343
following to a participating provider:	344

(1) Any material incorporated by reference into the	345
participation contract, that is not otherwise available as a	346
public record, if such material affects the participating	347
provider;	348

(2) Administrative manuals related to provider participation,	349
if any;	350

(3) Insofar as division (B) of section 3963.03 of the Revised	351
Code is applicable, the summary disclosure form with the	352
disclosures required under that division;	353

(4) A signed and dated copy of the final participation	354
contract.	355

Sec. 1753.09.  (A) Except as provided in division (D) of this	356
section, prior to terminating the participation of a provider on	357
the basis of the participating provider's failure to meet the	358
health insuring corporation's standards for quality or utilization	359
in the delivery of health care services, a health insuring	360
corporation shall give the participating provider notice of the	361
reason or reasons for its decision to terminate the provider's	362
participation and an opportunity to take corrective action. The	363
health insuring corporation shall develop a performance	364
improvement plan in conjunction with the participating provider.	365
If after being afforded the opportunity to comply with the	366
performance improvement plan, the participating provider fails to	367
do so, the health insuring corporation may terminate the	368
participation of the provider.	369

(B)(1) A participating provider whose participation has been	370
terminated under division (A) of this section may appeal the	371
termination to the appropriate medical director of the health	372
insuring corporation. The medical director shall give the	373
participating provider an opportunity to discuss with the medical	374
director the reason or reasons for the termination.	375

(2) If a satisfactory resolution of a participating	376
provider's appeal cannot be reached under division (B)(1) of this	377
section, the participating provider may appeal the termination to	378
a panel composed of participating providers who have comparable or	379
higher levels of education and training than the participating	380
provider making the appeal. A representative of the participating	381
provider's specialty shall be a member of the panel, if possible.	382
This panel shall hold a hearing, and shall render its	383
recommendation in the appeal within thirty days after holding the	384
hearing. The recommendation shall be presented to the medical	385
director and to the participating provider.	386

(3) The medical director shall review and consider the	387
panel's recommendation before making a decision. The decision	388
rendered by the medical director shall be final.	389

(C) A provider's status as a participating provider shall	390
remain in effect during the appeal process set forth in division	391
(B) of this section unless the termination was based on any of the	392
reasons listed in division (D) of this section.	393

(D) Notwithstanding division (A) of this section, a	394
provider's participation may be immediately terminated if the	395
participating provider's conduct presents an imminent risk of harm	396
to an enrollee or enrollees; or if there has occurred unacceptable	397
quality of care, fraud, patient abuse, loss of clinical	398
privileges, loss of professional liability coverage, incompetence,	399
or loss of authority to practice in the participating provider's	400
field; or if a governmental action has impaired the participating	401
provider's ability to practice.	402

(E) Divisions (A) to (D) of this section apply only to	403
providers who are natural persons.	404

(F)(1) Nothing in this section prohibits a health insuring	405
corporation from rejecting a provider's application for	406
participation, or from terminating a participating provider's	407
contract, if the health insuring corporation determines that the	408
health care needs of its enrollees are being met and no need	409
exists for the provider's or participating provider's services.	410

(2) Nothing in this section shall be construed as prohibiting	411
a health insuring corporation from terminating a participating	412
provider who does not meet the terms and conditions of the	413
participating provider's contract.	414

(3) Nothing in this section shall be construed as prohibiting	415
a health insuring corporation from terminating a participating	416
provider's contract pursuant to any provision of the contract	417
described in division (E)(2) of section 3963.02 of the Revised	418
Code, except that, notwithstanding any provision of a contract	419
described in that division, this section applies to the	420
termination of a participating provider's contract for any of the	421
causes described in divisions (A), (D), and (F)(1) and (2) of	422
this section.	423

(G) The superintendent of insurance may adopt rules as	424
necessary to implement and enforce sections 1753.04 to1753.06,	425
1753.07, and 1753.09 of the Revised Code. Such rules shall be	426
adopted in accordance with Chapter 119. of the Revised Code. The	427
director of health may make recommendations to the superintendent	428
for rules necessary to implement and enforce sections 1753.04 to	429
1753.06, 1753.07, and 1753.09 of the Revised Code. In adopting any	430
rules pursuant to this division, the superintendent shall consider	431
the recommendations of the director.	432

Sec. 3963.01. As used in this chapter:

433

(A) "Affiliate" means any person or entity that has ownership	434
or control of a contracting entity, is owned or controlled by a	435
contracting entity, or is under common ownership or control with a	436
contracting entity.	437

(B) "Basic health care services" has the same meaning as in	438
division (A) of section 1751.01 of the Revised Code, except that	439
it does not include any services listed in that division that are	440
provided by a pharmacist or nursing home.	441

(C) "Contracting entity" means any person that has a primary	442
business purpose of contracting with participating providers for	443
the delivery of health care services.	444

(D) "Credentialing" means the process of assessing and	445
validating the qualifications of a provider applying to be	446
approved by a contracting entity to provide basic or supplemental	447
health care services to enrollees.	448

(E) "Edit" means adjusting one or more procedure codes billed	449
by a participating provider on a claim for payment or a practice	450
that results in any of the following:	451

(1) Payment for some, but not all of the procedure codes	452
originally billed by a participating provider;	453

(2) Payment for a different procedure code than the procedure	454
code originally billed by a participating provider;	455

(3) A reduced payment as a result of services provided to an	456
enrollee that are claimed under more than one procedure code on	457
the same service date.	458

(F) "Enrollee" means any person eligible for health care	459
benefits under a health benefit plan and includes all of the	460
following terms:	461

(1) "Enrollee" and "subscriber" as defined by section 1751.01	462
of the Revised Code;	463

(2) "Member" as defined by section 1739.01 of the Revised	464
Code;	465

(3) "Insured" and "plan member" pursuant to Chapter 3923. of	466
the Revised Code;	467

(4) "Beneficiary" as defined by section 3901.38 of the	468
Revised Code.	469

(G) "Health care contract" means a contract entered into,	470
modified, or renewed between a contracting entity and a	471
participating provider for the delivery of basic or supplemental	472
health care services to enrollees.	473

(H) "Health care services" means basic health care services	474
and supplemental health care services.	475

(I) "Participating provider" means a provider that has a	476
health care contract with a contracting entity and is entitled to	477
reimbursement for health care services rendered to an enrollee	478
under the health care contract.	479

(J) "Payer" means any person that assumes the financial risk	480
for the payment of claims under a health care contract or the	481
reimbursement for health care services provided to enrollees by	482
participating providers pursuant to a health care contract.	483

(K) "Primary enrollee" means a person who is responsible for	484
making payments for participation in a health care plan or an	485
enrollee whose employment or other status is the basis of	486
eligibility for enrollment in a health care plan.	487

(L) "Procedure codes" includes the American medical	488
association's current procedural terminology code, the American	489
dental association's current dental terminology, and the centers	490
for medicare and medicaid services health care common procedure	491
coding system.	492

(M) "Product" means a product line for health care services,	493
including, but not limited to a health insuring corporation	494
product or a medicaid product for which the participating provider	495
may be obligated to provide health care services pursuant to a	496
health care contract.	497

(N) "Provider" means a physician, podiatrist, dentist,	498
chiropractor, optometrist, psychologist, advanced practice nurse,	499
occupational therapist, massage therapist, physical therapist,	500
professional counselor, professional clinical counselor, hearing	501
aid dealer, orthotist, prosthetist, home medical equipment	502
services provider, hospital, ambulatory surgery center, or	503
medical transportation company. "Provider" does not mean a	504
pharmacist or nursing home.	505

(O) "Supplemental health care services" has the same meaning	506
as in division (B) of section 1751.01 of the Revised Code, except	507
that it does not include any services listed in that division that	508
are provided by a pharmacist or nursing home.	509

Sec. 3963.02. (A)(1) No contracting entity shall sell, rent,	510
or give the contracting entity's rights to a participating	511
provider's services pursuant to the contracting entity's health	512
care contract with the participating provider unless one of the	513
following applies:	514

(a) The third party accessing the participating provider's	515
services under the health care contract is an employer or other	516
entity providing coverage for health care services to its	517
employees or members, and that employer or entity has a contract	518
with the contracting entity or its affiliate for the	519
administration or processing of claims for payment or service	520
provided pursuant to the health care contract with the	521
participating provider.	522

(b) The third party accessing the participating provider's	523
services under the health care contract is either of the	524
following:	525

(i) An affiliate or subsidiary of the contracting entity;

526

(ii) Providing administrative services to, or receiving	527
administrative services from, the contracting entity or an	528
affiliate or subsidiary of the contracting entity.	529

(c) The health care contract specifically provides that it	530
applies to network rental arrangements and states that one purpose	531
of the contract is selling, renting, or giving the contracting	532
entity's rights to the services of the participating provider,	533
including other preferred provider organizations, and the third	534
party accessing the participating provider's services is either of	535
the following:	536

(i) A payer or a third-party administrator or other entity	537
responsible for administering claims on behalf of the payer;	538

(ii) A preferred provider organization or preferred provider	539
network that receives access to the participating provider's	540
services pursuant to an arrangement with the preferred provider	541
organization or preferred provider network in a contract with the	542
participating provider that is in compliance with division	543
(A)(1)(c) of this section, and is required to comply with all of	544
the terms, conditions, and affirmative obligations to which the	545
originally contracted primary participating provider network is	546
bound under its contract with the participating provider,	547
including, but not limited to, obligations concerning patient	548
steerage and the timeliness and manner of reimbursement.	549

(2) The contracting entity that sells, rents, or gives the	550
contracting entity's rights to the participating provider's	551
services pursuant to the contracting entity's health care contract	552
with the participating provider as provided in division (A)(1) of	553
this section shall do both of the following:	554

(a) Maintain a web page that contains a listing of third	555
parties described in divisions (A)(1)(b)(i) and (c) of this	556
section with whom a contracting entity contracts for the purpose	557
of selling, renting, or giving the contracting entity's rights to	558
the services of participating providers that is updated at least	559
every six months and is accessible to all participating providers,	560
or maintain a toll-free telephone number accessible to all	561
participating providers by means of which participating providers	562
may access the same listing of third parties;	563

(b) Require that the third party accessing the participating	564
provider's services through the participating provider's health	565
care contract is obligated to comply with all of the applicable	566
terms and conditions of the contract, including, but not limited	567
to, the products for which the participating provider has agreed	568
to provide services, except that a payer receiving administrative	569
services from the contracting entity or its affiliate shall be	570
solely responsible for payment to the participating provider.	571

(3) Any information disclosed to a participating provider	572
under this section shall be considered proprietary and shall not	573
be distributed by the participating provider.	574

(4) Except as provided in division (A)(1) of this section, no	575
entity other than a contracting entity shall sell, rent, or give a	576
contracting entity's rights to the participating provider's	577
services pursuant to a health care contract.	578

(B)(1) No contracting entity shall require, as a condition of	579
contracting with the contracting entity, that a participating	580
provider provide services for more than one product offered by the	581
contracting entity.	582

(2) Division (B)(1) of this section shall not be construed to	583
do any of the following:	584

(a) Prohibit any participating provider from voluntarily	585
accepting an offer by a contracting entity to provide health care	586
services under more than one of the contracting entity's products;	587

(b) Prohibit any contracting entity from offering any	588
financial incentive or other form of consideration specified in	589
the health care contract for a participating provider to provide	590
health care services under more than one of the contracting	591
entity's products;	592

(c) Require any contracting entity to contract with a	593
participating provider to provide health care services under only	594
one of the contracting entity's products if the contracting	595
entity does not wish to do so.	596

(3) Notwithstanding division (B)(2) of this section, no	597
contracting entity shall require, as a condition of contracting	598
with the contracting entity, that the participating provider	599
accept any future product offering that the contracting entity	600
makes.	601

(C) No contracting entity shall require, as a condition of	602
contracting with the contracting entity, that a participating	603
provider waive or forego any right or benefit to which the	604
participating provider may be entitled under state or federal law.	605
However, a contracting entity may restrict a participating	606
provider's scope of practice for the services to be provided	607
under the contract.	608

(D) No health care contract shall do either of the following:

609

(1) Prohibit any participating provider from entering into a	610
health care contract with any other contracting entity;	611

(2) Preclude its use or disclosure for the purpose of	612
enforcing this chapter or other state or federal law, except that	613
a health care contract may require that appropriate measures be	614
taken to preserve the confidentiality of any proprietary or	615
trade-secret information.	616

(E)(1) In addition to any other lawful reasons for	617
terminating a health care contract, a health care contract may be	618
terminated under the circumstances described in division (A)(2)	619
of section 3963.04 of the Revised Code.	620

(2) If the health care contract provides for termination for	621
cause by either party, the health care contract shall state the	622
reasons that may be used for termination for cause, which terms	623
shall be reasonable. Subject to division (E)(3) of this section,	624
the health care contract shall state the time by which the parties	625
must provide notice of termination for cause and to whom the	626
parties shall give the notice.	627

(3) Nothing in divisions (E)(1) and (2) of this section shall	628
be construed as prohibiting any health insuring corporation from	629
terminating a participating provider's contract for any of the	630
causes described in divisions (A), (D), and (F)(1) and (2) of	631
section 1753.09 of the Revised Code. Notwithstanding any provision	632
in a health care contract pursuant to division (E)(2) of this	633
section, section 1753.09 of the Revised Code applies to the	634
termination of a participating provider's contract for any of the	635
causes described in divisions (A), (D), and (F)(1) and (2) of	636
section 1753.09 of the Revised Code.	637

(F)(1) Disputes among parties that only concern the	638
enforcement of the contract rights conferred by sections 3963.02	639
and 3963.04, utilizing the applicable definitions in section	640
3963.01, of the Revised Code are subject to a mutually agreed	641
upon arbitration mechanism that is binding on all parties. The	642
arbitrator may award reasonable attorney's fees and costs for	643
arbitration relating to the enforcement of this section to the	644
prevailing party.	645

(2) A party shall not simultaneously maintain an arbitration	646
proceeding as described in division (F)(1) of this section and	647
pursue a complaint with the superintendent of insurance to	648
investigate the subject matter of the arbitration proceeding. If	649
the superintendent of insurance initiates an investigation into	650
the subject matter of a pending arbitration proceeding, the	651
arbitration proceeding shall be stayed at the request of any	652
party pending the outcome of the investigation by the	653
superintendent. The arbitrator shall make the arbitrator's	654
decision in an arbitration proceeding having due regard for any	655
applicable rules, bulletins, rulings, or decisions theretofore	656
issued by the department of insurance or any court concerning the	657
enforcement of the contract rights conferred by sections 3963.02	658
and 3963.04, utilizing the applicable definitions in section	659
3963.01, of the Revised Code.	660

Sec. 3963.03. (A) Each health care contract shall include all	661
of the following information:	662

(1)(a) Information sufficient for the participating provider	663
to determine the compensation or payment terms for health care	664
services, including all of the following, subject to division	665
(A)(1)(b) of this section:	666

(i) The manner of payment, such as fee-for-service,	667
capitation, or risk;	668

(ii) The fee schedule of procedure codes reasonably expected	669
to be billed by a participating provider's specialty for services	670
provided pursuant to the health care contract and the associated	671
payment or compensation for each procedure code. A fee schedule	672
may be provided electronically. Upon request, a contracting	673
entity shall provide a participating provider with the fee	674
schedule for any other procedure codes requested and a written	675
fee schedule, that shall not be required more frequently than	676
twice per year excluding when it is provided in connection with	677
any change to the schedule. The effect, if any, on payment or	678
compensation if more than one procedure code applies to the	679
service also shall be stated. This requirement may be satisfied	680
by providing a clearly understandable, readily available	681
mechanism, such as a specific web site address, that allows a	682
participating provider to determine the effect of procedure	683
codes on payment or compensation before a service is provided or	684
a claim is submitted.	685

(b) If the contracting entity is unable to include the	686
information described in division (A)(1)(a)(ii) of this section,	687
the contracting entity shall include both of the following types	688
of information instead:	689

(i) The methodology used to calculate any fee schedule, such	690
as relative value unit system and conversion factor or percentage	691
of billed charges. If applicable, the methodology disclosure	692
shall include the name of any relative value unit system, its	693
version, edition, or publication date, any applicable conversion	694
or geographic factor, and any date by which compensation or fee	695
schedules may be changed by the methodology as anticipated at the	696
time of contract.	697

(ii) The identity of any internal processing edits ,	698
including the publisher, product name, version, and version	699
update of any editing software.	700

(2) Any product or network for which the participating	701
provider is to provide services;	702

(3) The term of the health care contract;

703

(4) A specific web site address that contains the identity of	704
the contracting entity or payer responsible for the processing of	705
the participating provider's compensation or payment;	706

(5) Any internal mechanism provided by the contracting entity	707
to resolve disputes concerning the interpretation or application	708
of the terms and conditions of the contract. A contracting entity	709
may satisfy this requirement by providing a clearly	710
understandable, readily available mechanism, such as a specific	711
web site address or an appendix, that allows a participating	712
provider to determine the procedures for the internal mechanism to	713
resolve those disputes.	714

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

715

(B)(1) Each contracting entity shall include a summary	716
disclosure form with a health care contract that includes all of	717
the information specified in division (A) of this section. The	718
information in the summary disclosure form shall refer to the	719
location in the health care contract, whether a page number,	720
section of the contract, appendix, or other identifiable location,	721
that specifies the provisions in the contract to which the	722
information in the form refers.	723

(2) The summary disclosure form shall include all of the	724
following statements:	725

(a) That the form is a guide to the health care contract and	726
that the terms and conditions of the health care contract	727
constitute the contract rights of the parties;	728

(b) That reading the form is not a substitute for reading the	729
entire health care contract;	730

(c) That by signing the health care contract, the	731
participating provider will be bound by the contract's terms and	732
conditions;	733

(d) That the terms and conditions of the health care contract	734
may be amended pursuant to section 3963.04 of the Revised Code and	735
the participating provider is encouraged to carefully read any	736
proposed amendments sent after execution of the contract;	737

(e) That nothing in the summary disclosure form creates any	738
additional rights or causes of action in favor of either party.	739

(3) No contracting entity that includes any information in	740
the summary disclosure form with the reasonable belief that the	741
information is truthful or accurate shall be subject to a civil	742
action for damages or to binding arbitration based on the summary	743
disclosure form. Division (B)(3) of this section does not impair	744
or affect any power of the department of insurance to enforce any	745
applicable law.	746

(4) The summary disclosure form described in divisions (B)(1)	747
and (2) of this section shall be in substantially the following	748
form:	749

"SUMMARY DISCLOSURE FORM	750

(1) Compensation terms

751

(a) Manner of payment

752

[ ] Fee for service

753

[ ] Capitation

754

[ ] Risk

755

[ ] Other ............... See ...............

756

(b) Fee schedule available at ...............

757

(c) Fee calculation schedule available at ...............

758

(d) Identity of internal processing edits available at	759
...............	760

(e) Information in (c) and (d) is not required if information	761
in (b) is provided.	762

(2) List of products or networks covered by this contract

763

[ ] ...............

764

[ ] ...............

765

[ ] ...............

766

[ ] ...............

767

[ ] ...............

768

(3) Term of this contract ...............

769

(4) Contracting entity or payer responsible for processing	770
payment available at ...............	771

(5) Internal mechanism for resolving disputes regarding	772
contract terms available at ...............	773

(6) Addenda to contract

774

Title           Subject

775

(a)

776

(b)

777

(c)

778

(d)

779

IMPORTANT INFORMATION - PLEASE READ CAREFULLY	780

The information provided in this Summary Disclosure Form is a	781
guide to the attached Health Care Contract as defined in section	782
3963.01(G) of the Ohio Revised Code. The terms and conditions of	783
the attached Health Care Contract constitute the contract rights	784
of the parties.	785

Reading this Summary Disclosure Form is not a substitute for	786
reading the entire Health Care Contract. When you sign the Health	787
Care Contract, you will be bound by its terms and conditions.	788
These terms and conditions may be amended over time pursuant to	789
section 3963.04 of the Ohio Revised Code. You are encouraged to	790
read any proposed amendments that are sent to you after execution	791
of the Health Care Contract.	792

Nothing in this Summary Disclosure Form creates any	793
additional rights or causes of action in favor of either party."	794

(C) When a contracting entity presents a proposed health care	795
contract for consideration by a participating provider, the	796
contracting entity shall provide in writing or make reasonably	797
available the information required in division (A)(1) of this	798
section. If the information is not disclosed in writing, it shall	799
be disclosed in a manner that allows the participating provider	800
to evaluate the participating provider's payment or compensation	801
for services under the health care contract. The contracting	802
entity need not provide such information to the participating	803
provider in written format more than twice a year.	804

(D) The contracting entity shall identify any utilization	805
management, quality improvement, or a similar program that the	806
contracting entity uses to review, monitor, evaluate, or assess	807
the services provided pursuant to a health care contract. The	808
contracting entity shall disclose the policies, procedures, or	809
guidelines of such a program applicable to a participating	810
provider upon request by the participating provider within	811
fourteen days after the date of the request.	812

(E) Nothing in this section shall be construed as preventing	813
or affecting the application of section 1753.07 of the Revised	814
Code that would otherwise apply to a contract with a participating	815
provider.	816

Sec. 3963.04. (A)(1) An amendment of a health care contract	817
shall occur only if the contracting entity provides to the	818
participating provider the proposed amendment in writing and	819
notice of the proposed amendment not later than sixty days prior	820
to the effective date of the amendment. The notice shall be	821
conspicuously entitled "Notice of Material Change to Contract" and	822
shall specify the effective date of the proposed amendment.	823

(2) Subject to division (A)(4) of this section, if within	824
thirty days after receiving the proposed amendment and notice	825
described in division (A)(1) of this section the participating	826
provider objects in writing to the proposed amendment, and there	827
is no resolution of the objection, either party may terminate	828
the health care contract upon written notice of termination	829
provided to the other party not later than thirty days prior to	830
the effective date of the proposed amendment.	831

(3) If the participating provider does not object to the	832
proposed amendment in the manner described in division (A)(2) of	833
this section, the amendment shall be effective as specified in	834
the notice described in division (A)(1) of this section.	835

(4) If a proposed amendment is the addition of a new category	836
of coverage under the health care contract, the participating	837
provider objects to that proposed amendment in the manner	838
described in division (A)(2) of this section, and there is no	839
resolution of the objection, the amendment shall not be effective	840
as to the participating provider, and the objection shall not be	841
a basis upon which the contracting entity may terminate the	842
contract under that division.	843

(B)(1) Division (A) of this section does not apply if the	844
delay caused by compliance with that division could result in	845
imminent harm to an enrollee or if the amendment of a health care	846
contract is required by state or federal law, rule, or regulation.	847

(2) This section does not apply under any of the following	848
circumstances:	849

(a) The participating provider's payment or compensation is	850
based on the current medicaid or medicare physician fee schedule,	851
and the change in payment or compensation results solely from a	852
change in that physician fee schedule.	853

(b) A routine change or update of the health care contract is	854
made in response to any addition, deletion, or revision of any	855
service code, procedure code, or reporting code, or a pricing	856
change is made by any third party source.	857

For purposes of division (B)(2)(b) of this section:

858

(i) "Service code, procedure code, or reporting code" means	859
the current procedural terminology (CPT), the healthcare common	860
procedure coding system (HCPCS), the international classification	861
of diseases (ICD), or the drug topics redbook average wholesale	862
price (AWP).	863

(ii) "Third party source" means the American medical	864
association, the centers for medicare and medicaid services, the	865
national center for health statistics, the department of health	866
and human services office of the inspector general, the Ohio	867
department of insurance, or the Ohio department of job and family	868
services.	869

(C) Notwithstanding divisions (A) and (B) of this section, a	870
health care contract may be modified, without the need for an	871
amendment pursuant to division (A) of this section, by operation	872
of law as required by any applicable state or federal law, rule,	873
or regulation. Nothing in this section shall be construed to	874
require the renegotiation of a health care contract that is in	875
existence before the effective date of this section, until the	876
time that the contract is renewed or modified.	877

Sec. 3963.05. (A) The department of insurance shall prepare	878
and adopt a form, in electronic or paper format, that is	879
substantially similar to the credentialing form used by the	880
council for affordable quality healthcare (CAQH), and that form	881
shall be the standard credentialing form for physicians. The	882
department of insurance also shall prepare the standard	883
credentialing form for all other providers.	884

(B) No contracting entity shall fail to use the applicable	885
standard credentialing form described in division (A) of this	886
section when initially credentialing or recredentialing providers	887
in connection with policies, health care contracts, and	888
agreements providing basic or supplemental health care services.	889

(C) No contracting entity shall require a provider to provide	890
any information in addition to the information required by the	891
applicable standard credentialing form described in division (A)	892
of this section in connection with policies, health care	893
contracts, and agreements providing basic or supplemental health	894
care services.	895

Sec. 3963.06. (A) If a provider, upon the oral or written	896
request of a contracting entity to submit a credentialing form,	897
submits a credentialing form that is not complete, the contracting	898
entity that receives the form shall notify the provider of the	899
deficiency electronically or by certified mail, return receipt	900
requested, not later than twenty-one days after the contracting	901
entity receives the form.	902

(B) If a contracting entity receives any information that is	903
inconsistent with the information given by the provider in the	904
credentialing form, the contracting entity may request the	905
provider to submit a written clarification of the inconsistency.	906
The contracting entity shall send the request described in this	907
division electronically or by certified mail, return receipt	908
requested.	909

(C)(1) The credentialing process under this section starts	910
when a provider initially submits a credentialing form upon the	911
oral or written request of a contracting entity. Subject to	912
division (C)(2) of this section, a contracting entity shall	913
complete the credentialing process not later than ninety days	914
after the contracting entity receives that credentialing form	915
from the provider. A contracting entity that does not complete the	916
credentialing process within the ninety-day period specified in	917
this division is liable for a civil penalty payable to the	918
provider in the amount of five hundred dollars per day, including	919
weekend days, starting at the expiration of that ninety-day period	920
until the provider's application for the health care contract is	921
granted or denied.	922

(2) The requirement that the credentialing process be	923
completed within the ninety-day period specified in division	924
(C)(1) of this section does not apply to a contracting entity if a	925
provider that submits a credentialing form to the contracting	926
entity under that division is a home medical equipment services	927
provider, hospital, ambulatory surgery center, or medical	928
transportation company.	929

Sec. 3963.07. (A)(1) Upon a participating provider's	930
submission of an enrollee's name, the enrollee's relationship to	931
the primary enrollee, the enrollee's birth date, or the	932
enrollee's social security number, each contracting entity shall	933
make available information maintained in the ordinary course of	934
business that is sufficient for the participating provider to	935
determine at the time of the enrollee's visit all of the	936
following:	937

(a) The enrollee's identification number assigned by the	938
contracting entity;	939

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

940

(c) The names, birth dates, and gender of all covered	941
dependents;	942

(d) The current enrollment and eligibility status of the	943
enrollee;	944

(e) Whether a specific type or category of service is a	945
covered benefit for the enrollee;	946

(f) The enrollee's excluded benefits or limitations, whether	947
group or individual;	948

(g) The enrollee's copayment requirements;

949

(h) The unmet amount of the enrollee's deductible or the	950
enrollee's financial responsibility.	951

(2) A contracting entity that maintains enrollee information	952
in the ordinary course of business shall make available the	953
information required by division (A)(1) of this section	954
electronically or by an internet portal and shall maintain the	955
flexibility to determine the manner described in division (A)(1)	956
of this section by which the participating provider shall accesses	957
the information specified in that division. The information	958
required by division (A)(1) of this section shall include a	959
statement to the effect that the information made available is not	960
necessarily the final indication of the eligibility status of the	961
enrollee due to changes that may have occurred prior to or after	962
that date of which the contracting entity is unaware, and that the	963
information was obtained from sources that the contracting entity	964
reasonably believes to be accurate. Any information specified in	965
division (A)(1) of this section that is provided in good faith by	966
the contracting entity shall not be used in any enforcement action	967
under this chapter.	968

(3) Notwithstanding division (A)(1) of this section, no	969
contracting entity shall make the information required by that	970
division available to any person except to a participating	971
provider or the participating provider's agent or to any person or	972
governmental entity that is authorized under state and federal	973
law to receive personally identifiable information concerning an	974
enrollee or an enrollee's dependent.	975

(4) No contracting entity directly or indirectly shall charge	976
a participating provider any fee for the information the	977
contracting entity makes available pursuant to division (A) of	978
this section.	979

(5) A contracting entity is considered as having complied	980
with division (A) of this section if the information specified in	981
division (A)(1) of this section is updated once a month and the	982
date on which the information is updated is included with the	983
information that is made available electronically or by internet	984
portal pursuant to division (A)(2) of this section.	985

(B) All remittance notices sent by a payer, whether written	986
or electronic, shall include both of the following:	987

(1) The name of the payer issuing the payment to the	988
participating provider;	989

(2) The name of the contracting entity through which the	990
payment rate and any discount are claimed, if the contracting	991
entity is different from the payer.	992

(C) Division (A) of this section takes effect January 1,	993
2009.	994

Sec. 3963.08.  The superintendent of insurance shall adopt	995
any rules necessary for the implementation of this chapter.	996

Sec. 3963.09. (A) A series of violations of this chapter by	997
any person regulated by the department of insurance under Title	998
XVII or Title XXXIX of the Revised Code that, taken together,	999
constitute a pattern or practice of violating this chapter may be	1000
defined as an unfair and deceptive insurance practice under	1001
sections 3901.19 to 3901.26 of the Revised Code.	1002

(B) The superintendent of insurance may conduct a market	1003
conduct examination of any person regulated by the department of	1004
insurance under Title XVII or Title XXXIX of the Revised Code to	1005
determine whether any violation of this chapter has occurred. When	1006
conducting that type of examination, the superintendent of	1007
insurance may assess the costs of the examination against the	1008
person examined. The superintendent may enter into a consent	1009
agreement to impose any administrative assessment or fine for	1010
conduct discovered that may be a violation of this chapter. All	1011
costs, assessments, and fines collected under this section shall	1012
be deposited to the credit of the department of insurance	1013
operating fund.	1014

Sec. 3963.10.  This chapter does not apply with respect to	1015
any of the following:	1016

(A) Payments made to providers for rendering health care	1017
services to medicaid recipients pursuant to the reimbursement	1018
system referred to by the department of job and family services	1019
as the fee-for-service system;	1020

(B) Payments made to providers for rendering health care	1021
services to claimants pursuant to claims made under Chapter 4121.,	1022
4123., 4127., or 4131. of the Revised Code;	1023

(C) Payments made to providers for rendering health care	1024
services to beneficiaries of the medicare program established	1025
under Title XVIII of the "Social Security Act," 79 Stat. 286	1026
(1965), 42 U.S.C. 1395, as amended;	1027

(D) An exclusive contract between a health insuring	1028
corporation and a single group of providers in a specific	1029
geographic area to provide or arrange for the provision of health	1030
care services.	1031

Sec. 5111.17.  (A) The department of job and family services	1032
may enter into contracts with managed care organizations,	1033
including health insuring corporations, under which the	1034
organizations are authorized to provide, or arrange for the	1035
provision of, health care services to medical assistance	1036
recipients who are required or permitted to obtain health care	1037
services through managed care organizations as part of the care	1038
management system established under section 5111.16 of the	1039
Revised Code.	1040

(B) The director of job and family services may adopt rules	1041
in accordance with Chapter 119. of the Revised Code to implement	1042
this section.	1043

(C) The department of job and family services shall allow	1044
managed care plans to use providers to render care upon	1045
completion of the managed care plan's credentialing process.	1046

Section 2. That existing sections 1751.13, 1753.01, 1753.07,	1047
1753.09, and 5111.17 and sections 1753.03, 1753.04, 1753.05, and	1048
1753.08 of the Revised Code are hereby repealed.	1049

Section 3. Sections 3963.01 to 3963.10 of the Revised Code,	1050
as enacted by this act, shall apply only to contracts that are	1051
delivered, issued for delivery, or renewed or modified in this	1052
state on or after the effective date of this act. A health	1053
insuring corporation having fewer than fifteen thousand enrollees	1054
shall comply with the provisions of this section within twelve	1055
months after the effective date of this act.	1056

Section 4. Division (A) of section 3963.07 of the Revised	1057
Code, as enacted by this act, takes effect January 1, 2009.	1058

Section 5. (A) As used in this section and Section 6 of this	1059
act:	1060

(1) "Most favored nation clause" means a provision in a	1061
health care contract that does any of the following:	1062

(a) Prohibits, or grants a contracting entity an option to	1063
prohibit, the participating provider from contracting with another	1064
contracting entity to provide health care services at a lower	1065
price than the payment specified in the contract;	1066

(b) Requires, or grants a contracting entity an option to	1067
require, the participating provider to accept a lower payment in	1068
the event the participating provider agrees to provide health care	1069
services to any other contracting entity at a lower price;	1070

(c) Requires, or grants a contracting entity an option to	1071
require, termination or renegotiation of the existing health care	1072
contract in the event the participating provider agrees to provide	1073
health care services to any other contracting entity at a lower	1074
price;	1075

(d) Requires the participating provider to disclose the	1076
participating provider's contractual reimbursement rates with	1077
other contracting entities.	1078

(2) "Contracting entity," "health care contract," "health	1079
care services," "participating provider," and "provider" have the	1080
same meanings as in section 3963.01 of the Revised Code, as	1081
enacted by this act.	1082

(B) No health care contract that includes a most favored	1083
nation clause shall be entered into, and no health care contract	1084
at the instance of a contracting entity shall be amended,	1085
modified, or renewed to include a most favored nation clause, for	1086
a period of two years after the effective date of this act,	1087
subject to extension as provided in Section 6 of this act.	1088

Section 6. (A) There is hereby created the Joint Legislative	1089
Study Commission on Most Favored Nation Clauses in Health Care	1090
Contracts consisting of fifteen members as follows:	1091

(1) The Superintendent of Insurance;

1092

(2) Two members of the House of Representatives, one	1093
representing the majority party and one representing the minority	1094
party;	1095

(3) Two members of the Senate, one representing the majority	1096
party and one representing the minority party;	1097

(4) Three providers who are individuals;

1098

(5) Two representatives of hospitals;

1099

(6) Two representatives of contracting entities regulated by	1100
the Department of Insurance under Title XVII of the Revised Code;	1101

(7) Two representatives of contracting entities regulated by	1102
the Department of Insurance under Title XXXIX of the Revised Code;	1103

(8) One representative of an employer that pays for the	1104
health insurance coverage of its employees.	1105

(B) The members of the Commission shall be appointed as	1106
follows:	1107

(1) The Speaker of the House of Representatives shall appoint	1108
the two members of the House specified in division (A)(2) of this	1109
section.	1110

(2) The President of the Senate shall appoint the two members	1111
of the Senate specified in division (A)(3) of this section.	1112

(3) The Speaker of the House of Representatives and the	1113
President of the Senate jointly shall appoint the remaining	1114
members specified in divisions (A)(4) to (8) of this section.	1115

(C) Initial appointments to the Commission shall be made	1116
within thirty days after the effective date of this act. The	1117
appointments shall be for the term of the Commission as provided	1118
in division (F)(2) of this section. Vacancies shall be filled in	1119
the same manner provided for original appointments.	1120

(D)(1) The Superintendent of Insurance shall be the	1121
Chairperson of the Commission. Meetings of the Commission shall be	1122
at the call of the Chairperson. All of the members of the	1123
Commission shall be voting members. Meetings of the Commission	1124
shall be held pursuant to section 121.22 of the Revised Code.	1125

(2) The Department of Insurance shall provide office space or	1126
other facilities, any administrative or other technical,	1127
professional, or clerical employees, and any necessary supplies	1128
for the work of the Commission.	1129

(3) The Chairperson of the Commission shall keep the records	1130
of the Commission. Upon submission of the Commission's final	1131
report to the General Assembly under division (F) of this section,	1132
the Chairperson shall deliver all of the Commission's records to	1133
the General Assembly.	1134

(E)(1) The Commission shall study the following areas	1135
pertaining to health care contracts:	1136

(a) The procompetitive and anticompetitive aspects of most	1137
favored nation clauses;	1138

(b) The impact of most favored nation clauses on health care	1139
costs and on the availability of and accessibility to quality	1140
health care;	1141

(c) The costs associated with the enforcement of most favored	1142
nation clauses;	1143

(d) Other state laws and rules pertaining to most favored	1144
nation clauses in their health care contracts;	1145

(e) Matters determined by the Department of Insurance as	1146
relevant to the study of most favored nation clauses;	1147

(f) Any other matters that the Commission considers	1148
appropriate to determine the effectiveness of most favored nation	1149
clauses.	1150

(2) The Commission may take testimony from experts or	1151
interested parties on the areas of its study as described in	1152
division (E)(1) of this section.	1153

(F)(1) Not less than ninety days prior to the expiration of	1154
the two-year period specified in Section 5 of this act, the	1155
Commission shall report its preliminary findings to the General	1156
Assembly and a recommendation of whether to extend that two-year	1157
period for one additional year. If the General Assembly does not	1158
grant the extension, the Commission shall submit its final report	1159
to the General Assembly not later than three months after the	1160
expiration of the two-year period specified in Section 5 of this	1161
act. If the General Assembly grants the extension, the extension	1162
shall be for not more than one year after the expiration of the	1163
two-year period specified in Section 5 of this act, and the	1164
Commission shall submit its final report to the General Assembly	1165
not later than six months prior to the expiration of the one-year	1166
extension.	1167

(2) The final report of the Commission shall include its	1168
findings and recommendations on whether state law should prohibit	1169
or restrict most favored nation clauses in health care contracts.	1170
The Commission shall cease to exist upon the submission of its	1171
final report to the General Assembly.	1172