S. B. No. 104 As Introduced

Senator Mumper

A BILL
To amend section 3901.386 of the Revised Code to 1
require insurers and other third-party payers to 2
accept and honor assignment-of-benefit agreements 3
entered into between plan beneficiaries and 4
treating health care providers. 5

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

       Section 1. That section 3901.386 of the Revised Code be 6
amended to read as follows: 7

       Sec. 3901.386. (A) Notwithstanding section 1751.13 or 8
division (I)(2) of section 3923.04 of the Revised Code, a 9
reimbursement contract entered into or renewed on or after June 10
29, 1988, between a third-party payer and a hospital shall provide 11
that reimbursement for any service provided by a hospital pursuant 12
to a reimbursement contract and covered under a benefits contract 13
shall be made directly to the hospital. 14

       (B) If ~~the~~a third-party payer and ~~the hospital~~a provider 15
have not entered into a contract regarding the provision and 16
reimbursement of covered services, the third-party payer shall 17
accept and honor a completed and validly executed assignment of 18
benefits with a ~~hospital~~provider by a beneficiary~~, except when~~ 19
~~the third-party payer has notified the hospital in writing of the~~ 20
~~conditions under which the third-party payer will not accept and~~ 21
~~honor an assignment of benefits. Such notice shall be made~~ 22
~~annually~~. 23

       (C) ~~A third-party payer may not refuse to accept and honor a~~ 24
~~validly executed assignment of benefits with a hospital pursuant~~ 25
~~to division (B) of this section for medically necessary hospital~~ 26
~~services provided on an emergency basis~~ 27

       A claim under a benefits contract is not settled until the 28
provider receives payment for those health care services rendered 29
to a beneficiary that are covered under a benefits contract. Both 30
a beneficiary executing an assignment of benefits with a provider 31
and a third-party payer accepting the assignment of benefits are 32
liable for the amount due to the provider. 33

       When a valid assignment-of-benefits agreement is executed, a 34
health care provider shall not bill the beneficiary more than the 35
difference between eighty per cent of the health care provider's 36
total billed charges and the amount paid to the provider directly 37
by the third party payer except when emergency services are 38
provided. 39

       (D) As used in this section: 40

       (1) "Emergency services" means health care services rendered 41
by any of the following: 42

       (a) A physician, physician group, physician partnership, or 43
physician professional corporation who provides health care 44
services in a hospital emergency department; 45

       (b) An ambulance or other vehicle that provides emergency 46
medical services, as defined in division (G) of section 4765.01 of 47
the Revised Code, in response to a call placed to a 9-1-1 system, 48
as defined in section 4931.40 of the Revised Code; 49

       (c) An air medical service organization providing air medical 50
transportation and is otherwise engaged in providing emergency 51
medical services to the public with a rotorcraft air ambulance or 52
fixed wing air ambulance. 53

       (2) "Patient" means any individual who as a result of illness 54
or injury needs medical attention, whose physical or mental 55
condition is such that there is imminent danger of loss of life or 56
significant health impairment, or who may be otherwise 57
incapacitated or helpless as a result of a physical or mental 58
condition. 59

       (3) "Provider" means a hospital, long-term care facility, 60
nursing home, physician, podiatrist, dentist, pharmacist, 61
chiropractor, or other licensed health care provider, provider 62
partnership, or provider professional corporation. "Provider" also 63
includes any person licensed or otherwise authorized to transport 64
patients, including but not limited to emergency victims, to, 65
from, or between providers. 66

       (4) "Third-party payer" means a sickness and accident 67
insurer, health insuring corporation, intermediary organization as 68
defined in section 1751.01 of the Revised Code, or any other 69
person obligated pursuant to a benefits contract to reimburse for 70
covered health care services rendered to beneficiaries, up to the 71
limits and exclusions contained in the benefits contract. 72

       Section 2. That existing section 3901.386 of the Revised Code 73
is hereby repealed. 74

Section 1. That section 3901.386 of the Revised Code be	6
amended to read as follows:	7

Sec. 3901.386. (A) Notwithstanding section 1751.13 or	8
division (I)(2) of section 3923.04 of the Revised Code, a	9
reimbursement contract entered into or renewed on or after June	10
29, 1988, between a third-party payer and a hospital shall provide	11
that reimbursement for any service provided by a hospital pursuant	12
to a reimbursement contract and covered under a benefits contract	13
shall be made directly to the hospital.	14

(B) If ~~the~~a third-party payer and ~~the hospital~~a provider	15
have not entered into a contract regarding the provision and	16
reimbursement of covered services, the third-party payer shall	17
accept and honor a completed and validly executed assignment of	18
benefits with a ~~hospital~~provider by a beneficiary~~, except when~~	19
~~the third-party payer has notified the hospital in writing of the~~	20
~~conditions under which the third-party payer will not accept and~~	21
~~honor an assignment of benefits. Such notice shall be made~~	22
~~annually~~.	23

(C) ~~A third-party payer may not refuse to accept and honor a~~	24
~~validly executed assignment of benefits with a hospital pursuant~~	25
~~to division (B) of this section for medically necessary hospital~~	26
~~services provided on an emergency basis~~	27

A claim under a benefits contract is not settled until the	28
provider receives payment for those health care services rendered	29
to a beneficiary that are covered under a benefits contract. Both	30
a beneficiary executing an assignment of benefits with a provider	31
and a third-party payer accepting the assignment of benefits are	32
liable for the amount due to the provider.	33

When a valid assignment-of-benefits agreement is executed, a	34
health care provider shall not bill the beneficiary more than the	35
difference between eighty per cent of the health care provider's	36
total billed charges and the amount paid to the provider directly	37
by the third party payer except when emergency services are	38
provided.	39

(1) "Emergency services" means health care services rendered	41
by any of the following:	42

(a) A physician, physician group, physician partnership, or	43
physician professional corporation who provides health care	44
services in a hospital emergency department;	45

(b) An ambulance or other vehicle that provides emergency	46
medical services, as defined in division (G) of section 4765.01 of	47
the Revised Code, in response to a call placed to a 9-1-1 system,	48
as defined in section 4931.40 of the Revised Code;	49

(c) An air medical service organization providing air medical	50
transportation and is otherwise engaged in providing emergency	51
medical services to the public with a rotorcraft air ambulance or	52
fixed wing air ambulance.	53

(2) "Patient" means any individual who as a result of illness	54
or injury needs medical attention, whose physical or mental	55
condition is such that there is imminent danger of loss of life or	56
significant health impairment, or who may be otherwise	57
incapacitated or helpless as a result of a physical or mental	58
condition.	59

(3) "Provider" means a hospital, long-term care facility,	60
nursing home, physician, podiatrist, dentist, pharmacist,	61
chiropractor, or other licensed health care provider, provider	62
partnership, or provider professional corporation. "Provider" also	63
includes any person licensed or otherwise authorized to transport	64
patients, including but not limited to emergency victims, to,	65
from, or between providers.	66

(4) "Third-party payer" means a sickness and accident	67
insurer, health insuring corporation, intermediary organization as	68
defined in section 1751.01 of the Revised Code, or any other	69
person obligated pursuant to a benefits contract to reimburse for	70
covered health care services rendered to beneficiaries, up to the	71
limits and exclusions contained in the benefits contract.	72

Section 2. That existing section 3901.386 of the Revised Code	73
is hereby repealed.	74