H. B. No. 137 As Introduced

As Introduced

127th General Assembly

Regular Session

2007-2008

H. B. No. 137

Representatives Schneider, Beatty

Cosponsors: Representatives Combs, Dodd, Peterson, Flowers, Seitz, Webster, Schindel, Yuko, Bubp, Sykes, McGregor, J., Lundy, Blessing, Chandler, Carano, Oelslager, Skindell, Patton, Hughes, Stebelton, Wagoner

A BILL

To amend sections 1739.05 and 1751.01 and to enact 1
section 3923.71 of the Revised Code to require 2
certain health care policies, contracts, 3
agreements, and plans to provide benefits for 4
equipment, supplies, and medication for the 5
diagnosis, treatment, and management of diabetes 6
and for diabetes self-management education. 7

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

       Section 1. That sections 1739.05 and 1751.01 be amended and 8
section 3923.71 of the Revised Code be enacted to read as follows: 9

       Sec. 1739.05. (A) A multiple employer welfare arrangement 10
that is created pursuant to sections 1739.01 to 1739.22 of the 11
Revised Code and that operates a group self-insurance program may 12
be established only if any of the following applies: 13

       (1) The arrangement has and maintains a minimum enrollment of 14
three hundred employees of two or more employers. 15

       (2) The arrangement has and maintains a minimum enrollment of 16
three hundred self-employed individuals. 17

       (3) The arrangement has and maintains a minimum enrollment of 18
three hundred employees or self-employed individuals in any 19
combination of divisions (A)(1) and (2) of this section. 20

       (B) A multiple employer welfare arrangement that is created 21
pursuant to sections 1739.01 to 1739.22 of the Revised Code and 22
that operates a group self-insurance program shall comply with all 23
laws applicable to self-funded programs in this state, including 24
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 25
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 26
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.71, 27
3924.031, 3924.032, and 3924.27 of the Revised Code. 28

       (C) A multiple employer welfare arrangement created pursuant 29
to sections 1739.01 to 1739.22 of the Revised Code shall solicit 30
enrollments only through agents or solicitors licensed pursuant to 31
Chapter 3905. of the Revised Code to sell or solicit sickness and 32
accident insurance. 33

       (D) A multiple employer welfare arrangement created pursuant 34
to sections 1739.01 to 1739.22 of the Revised Code shall provide 35
benefits only to individuals who are members, employees of 36
members, or the dependents of members or employees, or are 37
eligible for continuation of coverage under section 1751.53 or 38
3923.38 of the Revised Code or under Title X of the "Consolidated 39
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 40
U.S.C.A. 1161, as amended. 41

       Sec. 1751.01. As used in this chapter: 42

       (A)(1) "Basic health care services" means the following 43
services when medically necessary: 44

       (a) Physician's services, except when such services are 45
supplemental under division (B) of this section; 46

       (b) Inpatient hospital services; 47

       (c) Outpatient medical services; 48

       (d) Emergency health services; 49

       (e) Urgent care services; 50

       (f) Diagnostic laboratory services and diagnostic and 51
therapeutic radiologic services; 52

       (g) Diagnostic and treatment services, other than 53
prescription drug services, for biologically based mental 54
illnesses; 55

       (h) Preventive health care services, including, but not 56
limited to, voluntary family planning services, infertility 57
services, periodic physical examinations, prenatal obstetrical 58
care, and well-child care; 59

       (i) Diabetes self-management education, medical nutrition 60
therapy, and equipment, supplies, and medication, as provided in 61
section 3923.71 of the Revised Code. 62

       "Basic health care services" does not include experimental 63
procedures. 64

        Except as provided by divisions (A)(2) and (3) of this 65
section in connection with the offering of coverage for diagnostic 66
and treatment services for biologically based mental illnesses, a 67
health insuring corporation shall not offer coverage for a health 68
care service, defined as a basic health care service by this 69
division, unless it offers coverage for all listed basic health 70
care services. However, this requirement does not apply to the 71
coverage of beneficiaries enrolled in Title XVIII of the "Social 72
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, 73
pursuant to a medicare contract, or to the coverage of 74
beneficiaries enrolled in the federal employee health benefits 75
program pursuant to 5 U.S.C.A. 8905, or to the coverage of 76
beneficiaries enrolled in Title XIX of the "Social Security Act," 77
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the 78
medical assistance program or medicaid, provided by the department 79
of job and family services under Chapter 5111. of the Revised 80
Code, or to the coverage of beneficiaries under any federal health 81
care program regulated by a federal regulatory body, or to the 82
coverage of beneficiaries under any contract covering officers or 83
employees of the state that has been entered into by the 84
department of administrative services. 85

       (2) A health insuring corporation may offer coverage for 86
diagnostic and treatment services for biologically based mental 87
illnesses without offering coverage for all other basic health 88
care services. A health insuring corporation may offer coverage 89
for diagnostic and treatment services for biologically based 90
mental illnesses alone or in combination with one or more 91
supplemental health care services. However, a health insuring 92
corporation that offers coverage for any other basic health care 93
service shall offer coverage for diagnostic and treatment services 94
for biologically based mental illnesses in combination with the 95
offer of coverage for all other listed basic health care services. 96

       (3) A health insuring corporation that offers coverage for 97
basic health care services is not required to offer coverage for 98
diagnostic and treatment services for biologically based mental 99
illnesses in combination with the offer of coverage for all other 100
listed basic health care services if all of the following apply: 101

       (a) The health insuring corporation submits documentation 102
certified by an independent member of the American academy of 103
actuaries to the superintendent of insurance showing that incurred 104
claims for diagnostic and treatment services for biologically 105
based mental illnesses for a period of at least six months 106
independently caused the health insuring corporation's costs for 107
claims and administrative expenses for the coverage of basic 108
health care services to increase by more than one per cent per 109
year. 110

       (b) The health insuring corporation submits a signed letter 111
from an independent member of the American academy of actuaries to 112
the superintendent of insurance opining that the increase in costs 113
described in division (A)(3)(a) of this section could reasonably 114
justify an increase of more than one per cent in the annual 115
premiums or rates charged by the health insuring corporation for 116
the coverage of basic health care services. 117

       (c) The superintendent of insurance makes the following 118
determinations from the documentation and opinion submitted 119
pursuant to divisions (A)(3)(a) and (b) of this section: 120

       (i) Incurred claims for diagnostic and treatment services for 121
biologically based mental illnesses for a period of at least six 122
months independently caused the health insuring corporation's 123
costs for claims and administrative expenses for the coverage of 124
basic health care services to increase by more than one per cent 125
per year. 126

       (ii) The increase in costs reasonably justifies an increase 127
of more than one per cent in the annual premiums or rates charged 128
by the health insuring corporation for the coverage of basic 129
health care services. 130

       Any determination made by the superintendent under this 131
division is subject to Chapter 119. of the Revised Code. 132

       (B)(1) "Supplemental health care services" means any health 133
care services other than basic health care services that a health 134
insuring corporation may offer, alone or in combination with 135
either basic health care services or other supplemental health 136
care services, and includes: 137

       (a) Services of facilities for intermediate or long-term 138
care, or both; 139

       (b) Dental care services; 140

       (c) Vision care and optometric services including lenses and 141
frames; 142

       (d) Podiatric care or foot care services; 143

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

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

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

       (h) Home health services; 150

       (i) Prescription drug services; 151

       (j) Nursing services; 152

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

       (l) Physical therapy services; 155

       (m) Chiropractic services; 156

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

       Sec. 3923.71. (A) As used in this section: 336

       (1) "Health benefit plan" means any of the following when the 337
contract, policy, or plan provides payment or reimbursement for 338
the costs of health care services other than for specific diseases 339
or accidents only: 340

       (a) An individual, group, or blanket policy of sickness and 341
accident insurance that provides coverage other than for specific 342
diseases or accidents only, for hospital indemnity only, for 343
supplemental medicare benefits only, or for any other supplemental 344
benefits only, and that is delivered, issued for delivery, or 345
renewed in this state; 346

       (b) An individual or group contract of a health insuring 347
corporation; 348

       (c) A public employee benefit plan; 349

       (d) A multiple employer welfare arrangement as defined in 350
section 1739.01 of the Revised Code. 351

       (2) "Equipment, supplies and medication" includes both of the 352
following, when determined to be medically necessary: 353

        (a) Nonexperimental equipment, single-use medical supplies, 354
and related devices approved by the United States food and drug 355
administration for the treatment and management of diabetes; 356

        (b) Nonexperimental medication, insulin, glucagons, and 357
insulin syringes for controlling blood sugar approved by the 358
United States food and drug administration for the treatment and 359
management of diabetes. 360

        (3) "Medical nutrition therapy" means nutritional diagnostic, 361
therapeutic, and counseling services for the purpose of diabetes 362
disease management provided by a dietitian licensed under Chapter 363
4759. of the Revised Code or a nutrition professional pursuant to 364
a physician's referral. 365

        (4) "Diabetes self-management education" means an interactive 366
and ongoing process prescribed by a physician involving a patient 367
with diabetes and the physician or other professional with 368
expertise in diabetes. "Diabetes self-management education" 369
includes assessment and identification of the patient's diabetes 370
needs and management goals, education and behavioral intervention 371
directed toward helping the patient attain self-management goals, 372
and evaluation of the patient's progress in attaining 373
self-management goals. 374

       (B) Notwithstanding section 3901.71 of the Revised Code, each 375
health benefit plan shall provide benefits for the expenses of the 376
following, when determined to be medically necessary: 377

       (1) Equipment, supplies, and medication; 378

       (2) Medical nutrition therapy; 379

       (3) Diabetes self-management education. 380

       (C) All of the following apply to the provision of benefits 381
for the expenses of diabetes self-management education and medical 382
nutrition therapy: 383

       (1) The benefits shall cover the expenses of diabetes 384
self-management education and medical nutrition therapy only if 385
the education is determined to be medically necessary and is 386
prescribed by a physician or other individual whose professional 387
practice established by licensure under the Revised Code includes 388
the authority to prescribe the education. 389

       (2) During the first twelve-month period immediately after a 390
patient begins to receive diabetes self-management education, the 391
benefits shall cover the expenses of ten hours of education, which 392
may include medical nutrition therapy in a program based on the 393
standards for diabetes self-management education as outlined in 394
the American diabetes association's standards of care. 395

       (3) In each year following the provision of coverage under 396
division (C)(2) of this section, the benefits shall cover the 397
expenses of two hours of diabetes self-management education, of 398
which one hour may be used for medical nutrition therapy, as an 399
annual maintenance program for the patient, if the education is 400
medically necessary and prescribed by a physician or other 401
individual whose professional practice established by licensure 402
under the Revised Code includes the authority to prescribe the 403
education. Any coverage provided for the expenses of a required 404
medical examination shall not reduce the coverage provided for the 405
expenses of the patient's annual education maintenance program 406
described in this section. 407

       (4) The benefits shall cover the expenses of any diabetes 408
self-management education determined to be medically necessary, 409
whether provided during home visits, in a group setting, or by 410
individual counseling. 411

       (5) The benefits shall cover the expenses of diabetes 412
self-management education only if the education is provided by an 413
individual with expertise in diabetes care, whose professional 414
practice established by licensure under the Revised Code includes 415
the authority to provide the education. The benefits shall cover 416
the expenses of medical nutrition therapy only if the therapy is 417
provided by a dietitian licensed under Chapter 4759. of the 418
Revised Code unless the patient's health plan does not include a 419
dietitian in its network of providers. 420

       (D) A health benefit plan is not required to provide benefits 421
for diabetes care pursuant to division (B) of this section if all 422
of the following apply: 423

       (1) The health benefit plan insurer submits documentation 424
certified by an independent member of the American academy of 425
actuaries to the superintendent of insurance showing that incurred 426
claims for diabetes care pursuant to division (B) of this section 427
for a period of at least six months independently caused the 428
insurer's costs for claims and administrative expenses for the 429
coverage of all other physical diseases and disorders to increase 430
by more than one per cent per year. 431

       (2) The insurer submits a signed letter from an independent 432
member of the American academy of actuaries to the superintendent 433
of insurance opining that the increase described in division 434
(D)(1) of this section could reasonably justify an increase of 435
more than one per cent in the annual premiums or rates charged by 436
the insurer for the coverage of all other physical diseases and 437
disorders. 438

       (3) The superintendent of insurance makes the following 439
determinations from the documentation and opinion submitted 440
pursuant to divisions (D)(1) and (2) of this section: 441

       (a) Incurred claims for diabetes care pursuant to division 442
(B) of this section for a period of at least six months 443
independently caused the insurer's costs for claims and 444
administrative expenses for the coverage of all other physical 445
diseases and disorders to increase by more than one per cent per 446
year. 447

       (b) The increase in costs reasonably justifies an increase of 448
more than one per cent in the annual premiums or rates charged by 449
the insurer for the coverage of all other physical diseases and 450
disorders. 451

       Any determination made by the superintendent under this 452
division is subject to Chapter 119. of the Revised Code. 453

       Section 2. That existing sections 1739.05 and 1751.01 of the 454
Revised Code are hereby repealed. 455

       Section 3. Section 3923.71 of the Revised Code shall apply 456
only to health benefit plans as defined in that section that are 457
established or modified, delivered, issued for delivery, or 458
renewed in this state on or after the effective date of this act. 459

Section 1. That sections 1739.05 and 1751.01 be amended and	8
section 3923.71 of the Revised Code be enacted to read as follows:	9

Sec. 1739.05. (A) A multiple employer welfare arrangement	10
that is created pursuant to sections 1739.01 to 1739.22 of the	11
Revised Code and that operates a group self-insurance program may	12
be established only if any of the following applies:	13

(1) The arrangement has and maintains a minimum enrollment of	14
three hundred employees of two or more employers.	15

(2) The arrangement has and maintains a minimum enrollment of	16
three hundred self-employed individuals.	17

(3) The arrangement has and maintains a minimum enrollment of	18
three hundred employees or self-employed individuals in any	19
combination of divisions (A)(1) and (2) of this section.	20

(B) A multiple employer welfare arrangement that is created	21
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	22
that operates a group self-insurance program shall comply with all	23
laws applicable to self-funded programs in this state, including	24
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	25
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	26
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.71,	27
3924.031, 3924.032, and 3924.27 of the Revised Code.	28

(C) A multiple employer welfare arrangement created pursuant	29
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	30
enrollments only through agents or solicitors licensed pursuant to	31
Chapter 3905. of the Revised Code to sell or solicit sickness and	32
accident insurance.	33

(D) A multiple employer welfare arrangement created pursuant	34
to sections 1739.01 to 1739.22 of the Revised Code shall provide	35
benefits only to individuals who are members, employees of	36
members, or the dependents of members or employees, or are	37
eligible for continuation of coverage under section 1751.53 or	38
3923.38 of the Revised Code or under Title X of the "Consolidated	39
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	40
U.S.C.A. 1161, as amended.	41

(A)(1) "Basic health care services" means the following	43
services when medically necessary:	44

(a) Physician's services, except when such services are	45
supplemental under division (B) of this section;	46

(f) Diagnostic laboratory services and diagnostic and	51
therapeutic radiologic services;	52

(g) Diagnostic and treatment services, other than	53
prescription drug services, for biologically based mental	54
illnesses;	55

(h) Preventive health care services, including, but not	56
limited to, voluntary family planning services, infertility	57
services, periodic physical examinations, prenatal obstetrical	58
care, and well-child care;	59

(i) Diabetes self-management education, medical nutrition	60
therapy, and equipment, supplies, and medication, as provided in	61
section 3923.71 of the Revised Code.	62

"Basic health care services" does not include experimental	63
procedures.	64

Except as provided by divisions (A)(2) and (3) of this	65
section in connection with the offering of coverage for diagnostic	66
and treatment services for biologically based mental illnesses, a	67
health insuring corporation shall not offer coverage for a health	68
care service, defined as a basic health care service by this	69
division, unless it offers coverage for all listed basic health	70
care services. However, this requirement does not apply to the	71
coverage of beneficiaries enrolled in Title XVIII of the "Social	72
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended,	73
pursuant to a medicare contract, or to the coverage of	74
beneficiaries enrolled in the federal employee health benefits	75
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	76
beneficiaries enrolled in Title XIX of the "Social Security Act,"	77
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	78
medical assistance program or medicaid, provided by the department	79
of job and family services under Chapter 5111. of the Revised	80
Code, or to the coverage of beneficiaries under any federal health	81
care program regulated by a federal regulatory body, or to the	82
coverage of beneficiaries under any contract covering officers or	83
employees of the state that has been entered into by the	84
department of administrative services.	85

(2) A health insuring corporation may offer coverage for	86
diagnostic and treatment services for biologically based mental	87
illnesses without offering coverage for all other basic health	88
care services. A health insuring corporation may offer coverage	89
for diagnostic and treatment services for biologically based	90
mental illnesses alone or in combination with one or more	91
supplemental health care services. However, a health insuring	92
corporation that offers coverage for any other basic health care	93
service shall offer coverage for diagnostic and treatment services	94
for biologically based mental illnesses in combination with the	95
offer of coverage for all other listed basic health care services.	96

(3) A health insuring corporation that offers coverage for	97
basic health care services is not required to offer coverage for	98
diagnostic and treatment services for biologically based mental	99
illnesses in combination with the offer of coverage for all other	100
listed basic health care services if all of the following apply:	101

(a) The health insuring corporation submits documentation	102
certified by an independent member of the American academy of	103
actuaries to the superintendent of insurance showing that incurred	104
claims for diagnostic and treatment services for biologically	105
based mental illnesses for a period of at least six months	106
independently caused the health insuring corporation's costs for	107
claims and administrative expenses for the coverage of basic	108
health care services to increase by more than one per cent per	109
year.	110

(b) The health insuring corporation submits a signed letter	111
from an independent member of the American academy of actuaries to	112
the superintendent of insurance opining that the increase in costs	113
described in division (A)(3)(a) of this section could reasonably	114
justify an increase of more than one per cent in the annual	115
premiums or rates charged by the health insuring corporation for	116
the coverage of basic health care services.	117

(c) The superintendent of insurance makes the following	118
determinations from the documentation and opinion submitted	119
pursuant to divisions (A)(3)(a) and (b) of this section:	120

(i) Incurred claims for diagnostic and treatment services for	121
biologically based mental illnesses for a period of at least six	122
months independently caused the health insuring corporation's	123
costs for claims and administrative expenses for the coverage of	124
basic health care services to increase by more than one per cent	125
per year.	126

(ii) The increase in costs reasonably justifies an increase	127
of more than one per cent in the annual premiums or rates charged	128
by the health insuring corporation for the coverage of basic	129
health care services.	130

Any determination made by the superintendent under this	131
division is subject to Chapter 119. of the Revised Code.	132

(B)(1) "Supplemental health care services" means any health	133
care services other than basic health care services that a health	134
insuring corporation may offer, alone or in combination with	135
either basic health care services or other supplemental health	136
care services, and includes:	137

(a) Services of facilities for intermediate or long-term	138
care, or both;	139

(c) Vision care and optometric services including lenses and	141
frames;	142

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

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

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