As Reported by the House Insurance Committee

127th General Assembly Regular Session 2007-2008

Sub. S. B. No. 186

Senator Stivers 

Cosponsors: Senators Miller, D., Miller, R., Gardner, Cafaro, Carey, Cates, Fedor, Goodman, Harris, Kearney, Mason, Morano, Mumper, Niehaus, Padgett, Roberts, Sawyer, Schuring, Seitz, Smith, Spada, Wagoner, Wilson 

Representatives Adams, Barrett, DeBose, Batchelder 

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A BILL

To amend sections 1739.05 and 1751.01 and to enact

1

section 3923.80 of the Revised Code to prohibit

2

insurers, public employee benefit plans, and

3

multiple employer welfare arrangements from

4

excluding coverage for routine patient care

5

administered as part of a cancer clinical trial.

6

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

Section 1.  That sections 1739.05 and 1751.01 be amended and	7
section 3923.80 of the Revised Code be enacted to read as follows:	8

Sec. 1739.05.  (A) A multiple employer welfare arrangement	9
that is created pursuant to sections 1739.01 to 1739.22 of the	10
Revised Code and that operates a group self-insurance program may	11
be established only if any of the following applies:	12

(1) The arrangement has and maintains a minimum enrollment of	13
three hundred employees of two or more employers.	14

(2) The arrangement has and maintains a minimum enrollment of	15
three hundred self-employed individuals.	16

(3) The arrangement has and maintains a minimum enrollment of	17
three hundred employees or self-employed individuals in any	18
combination of divisions (A)(1) and (2) of this section.	19

(B) A multiple employer welfare arrangement that is created	20
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	21
that operates a group self-insurance program shall comply with all	22
laws applicable to self-funded programs in this state, including	23
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	24
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	25
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.80,	26
3924.031, 3924.032, and 3924.27 of the Revised Code.	27

(C) A multiple employer welfare arrangement created pursuant	28
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	29
enrollments only through agents or solicitors licensed pursuant to	30
Chapter 3905. of the Revised Code to sell or solicit sickness and	31
accident insurance.	32

(D) A multiple employer welfare arrangement created pursuant	33
to sections 1739.01 to 1739.22 of the Revised Code shall provide	34
benefits only to individuals who are members, employees of	35
members, or the dependents of members or employees, or are	36
eligible for continuation of coverage under section 1751.53 or	37
3923.38 of the Revised Code or under Title X of the "Consolidated	38
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	39
U.S.C.A. 1161, as amended.	40

Sec. 1751.01.  As used in this chapter:

41

(A)(1) "Basic health care services" means the following	42
services when medically necessary:	43

(a) Physician's services, except when such services are	44
supplemental under division (B) of this section;	45

(b) Inpatient hospital services;

46

(c) Outpatient medical services;

47

(d) Emergency health services;

48

(e) Urgent care services;

49

(f) Diagnostic laboratory services and diagnostic and	50
therapeutic radiologic services;	51

(g) Diagnostic and treatment services, other than	52
prescription drug services, for biologically based mental	53
illnesses;	54

(h) Preventive health care services, including, but not	55
limited to, voluntary family planning services, infertility	56
services, periodic physical examinations, prenatal obstetrical	57
care, and well-child care;	58

(i) Routine patient care for patients enrolled in an eligible	59
cancer clinical trial pursuant to section 3923.80 of the Revised	60
Code.	61

"Basic health care services" does not include experimental	62
procedures.	63

Except as provided by divisions (A)(2) and (3) of this	64
section in connection with the offering of coverage for diagnostic	65
and treatment services for biologically based mental illnesses, a	66
health insuring corporation shall not offer coverage for a health	67
care service, defined as a basic health care service by this	68
division, unless it offers coverage for all listed basic health	69
care services. However, this requirement does not apply to the	70
coverage of beneficiaries enrolled in Title XVIII of the "Social	71
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended,	72
pursuant to a medicare contract, or to the coverage of	73
beneficiaries enrolled in the federal employee health benefits	74
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	75
beneficiaries enrolled in Title XIX of the "Social Security Act,"	76
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	77
medical assistance program or medicaid, provided by the department	78
of job and family services under Chapter 5111. of the Revised	79
Code, or to the coverage of beneficiaries under any federal health	80
care program regulated by a federal regulatory body, or to the	81
coverage of beneficiaries under any contract covering officers or	82
employees of the state that has been entered into by the	83
department of administrative services.	84

(2) A health insuring corporation may offer coverage for	85
diagnostic and treatment services for biologically based mental	86
illnesses without offering coverage for all other basic health	87
care services. A health insuring corporation may offer coverage	88
for diagnostic and treatment services for biologically based	89
mental illnesses alone or in combination with one or more	90
supplemental health care services. However, a health insuring	91
corporation that offers coverage for any other basic health care	92
service shall offer coverage for diagnostic and treatment services	93
for biologically based mental illnesses in combination with the	94
offer of coverage for all other listed basic health care services.	95

(3) A health insuring corporation that offers coverage for	96
basic health care services is not required to offer coverage for	97
diagnostic and treatment services for biologically based mental	98
illnesses in combination with the offer of coverage for all other	99
listed basic health care services if all of the following apply:	100

(a) The health insuring corporation submits documentation	101
certified by an independent member of the American academy of	102
actuaries to the superintendent of insurance showing that incurred	103
claims for diagnostic and treatment services for biologically	104
based mental illnesses for a period of at least six months	105
independently caused the health insuring corporation's costs for	106
claims and administrative expenses for the coverage of basic	107
health care services to increase by more than one per cent per	108
year.	109

(b) The health insuring corporation submits a signed letter	110
from an independent member of the American academy of actuaries to	111
the superintendent of insurance opining that the increase in costs	112
described in division (A)(3)(a) of this section could reasonably	113
justify an increase of more than one per cent in the annual	114
premiums or rates charged by the health insuring corporation for	115
the coverage of basic health care services.	116

(c) The superintendent of insurance makes the following	117
determinations from the documentation and opinion submitted	118
pursuant to divisions (A)(3)(a) and (b) of this section:	119

(i) Incurred claims for diagnostic and treatment services for	120
biologically based mental illnesses for a period of at least six	121
months independently caused the health insuring corporation's	122
costs for claims and administrative expenses for the coverage of	123
basic health care services to increase by more than one per cent	124
per year.	125

(ii) The increase in costs reasonably justifies an increase	126
of more than one per cent in the annual premiums or rates charged	127
by the health insuring corporation for the coverage of basic	128
health care services.	129

Any determination made by the superintendent under this	130
division is subject to Chapter 119. of the Revised Code.	131

(B)(1) "Supplemental health care services" means any health	132
care services other than basic health care services that a health	133
insuring corporation may offer, alone or in combination with	134
either basic health care services or other supplemental health	135
care services, and includes:	136

(a) Services of facilities for intermediate or long-term	137
care, or both;	138

(b) Dental care services;

139

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

(d) Podiatric care or foot care services;

142

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

(f) Short-term outpatient evaluative and crisis-intervention	145
mental health services;	146

(g) Medical or psychological treatment and referral services	147
for alcohol and drug abuse or addiction;	148

(h) Home health services;

149

(i) Prescription drug services;

150

(j) Nursing services;

151

(k) Services of a dietitian licensed under Chapter 4759. of	152
the Revised Code;	153

(l) Physical therapy services;

154

(m) Chiropractic services;

155

(n) Any other category of services approved by the	156
superintendent of insurance.	157

(2) If a health insuring corporation offers prescription drug	158
services under this division, the coverage shall include	159
prescription drug services for the treatment of biologically based	160
mental illnesses on the same terms and conditions as other	161
physical diseases and disorders.	162

(C) "Specialty health care services" means one of the	163
supplemental health care services listed in division (B) of this	164
section, when provided by a health insuring corporation on an	165
outpatient-only basis and not in combination with other	166
supplemental health care services.	167

(D) "Biologically based mental illnesses" means	168
schizophrenia, schizoaffective disorder, major depressive	169
disorder, bipolar disorder, paranoia and other psychotic	170
disorders, obsessive-compulsive disorder, and panic disorder, as	171
these terms are defined in the most recent edition of the	172
diagnostic and statistical manual of mental disorders published by	173
the American psychiatric association.	174

(E) "Closed panel plan" means a health care plan that	175
requires enrollees to use participating providers.	176

(F) "Compensation" means remuneration for the provision of	177
health care services, determined on other than a fee-for-service	178
or discounted-fee-for-service basis.	179

(G) "Contractual periodic prepayment" means the formula for	180
determining the premium rate for all subscribers of a health	181
insuring corporation.	182

(H) "Corporation" means a corporation formed under Chapter	183
1701. or 1702. of the Revised Code or the similar laws of another	184
state.	185

(I) "Emergency health services" means those health care	186
services that must be available on a seven-days-per-week,	187
twenty-four-hours-per-day basis in order to prevent jeopardy to an	188
enrollee's health status that would occur if such services were	189
not received as soon as possible, and includes, where appropriate,	190
provisions for transportation and indemnity payments or service	191
agreements for out-of-area coverage.	192

(J) "Enrollee" means any natural person who is entitled to	193
receive health care benefits provided by a health insuring	194
corporation.	195

(K) "Evidence of coverage" means any certificate, agreement,	196
policy, or contract issued to a subscriber that sets out the	197
coverage and other rights to which such person is entitled under a	198
health care plan.	199

(L) "Health care facility" means any facility, except a	200
health care practitioner's office, that provides preventive,	201
diagnostic, therapeutic, acute convalescent, rehabilitation,	202
mental health, mental retardation, intermediate care, or skilled	203
nursing services.	204

(M) "Health care services" means basic, supplemental, and	205
specialty health care services.	206

(N) "Health delivery network" means any group of providers or	207
health care facilities, or both, or any representative thereof,	208
that have entered into an agreement to offer health care services	209
in a panel rather than on an individual basis.	210

(O) "Health insuring corporation" means a corporation, as	211
defined in division (H) of this section, that, pursuant to a	212
policy, contract, certificate, or agreement, pays for, reimburses,	213
or provides, delivers, arranges for, or otherwise makes available,	214
basic health care services, supplemental health care services, or	215
specialty health care services, or a combination of basic health	216
care services and either supplemental health care services or	217
specialty health care services, through either an open panel plan	218
or a closed panel plan.	219

"Health insuring corporation" does not include a limited	220
liability company formed pursuant to Chapter 1705. of the Revised	221
Code, an insurer licensed under Title XXXIX of the Revised Code if	222
that insurer offers only open panel plans under which all	223
providers and health care facilities participating receive their	224
compensation directly from the insurer, a corporation formed by or	225
on behalf of a political subdivision or a department, office, or	226
institution of the state, or a public entity formed by or on	227
behalf of a board of county commissioners, a county board of	228
mental retardation and developmental disabilities, an alcohol and	229
drug addiction services board, a board of alcohol, drug addiction,	230
and mental health services, or a community mental health board, as	231
those terms are used in Chapters 340. and 5126. of the Revised	232
Code. Except as provided by division (D) of section 1751.02 of	233
the Revised Code, or as otherwise provided by law, no board,	234
commission, agency, or other entity under the control of a	235
political subdivision may accept insurance risk in providing for	236
health care services. However, nothing in this division shall be	237
construed as prohibiting such entities from purchasing the	238
services of a health insuring corporation or a third-party	239
administrator licensed under Chapter 3959. of the Revised Code.	240

(P) "Intermediary organization" means a health delivery	241
network or other entity that contracts with licensed health	242
insuring corporations or self-insured employers, or both, to	243
provide health care services, and that enters into contractual	244
arrangements with other entities for the provision of health care	245
services for the purpose of fulfilling the terms of its contracts	246
with the health insuring corporations and self-insured employers.	247

(Q) "Intermediate care" means residential care above the	248
level of room and board for patients who require personal	249
assistance and health-related services, but who do not require	250
skilled nursing care.	251

(R) "Medical record" means the personal information that	252
relates to an individual's physical or mental condition, medical	253
history, or medical treatment.	254

(S)(1) "Open panel plan" means a health care plan that	255
provides incentives for enrollees to use participating providers	256
and that also allows enrollees to use providers that are not	257
participating providers.	258

(2) No health insuring corporation may offer an open panel	259
plan, unless the health insuring corporation is also licensed as	260
an insurer under Title XXXIX of the Revised Code, the health	261
insuring corporation, on June 4, 1997, holds a certificate of	262
authority or license to operate under Chapter 1736. or 1740. of	263
the Revised Code, or an insurer licensed under Title XXXIX of the	264
Revised Code is responsible for the out-of-network risk as	265
evidenced by both an evidence of coverage filing under section	266
1751.11 of the Revised Code and a policy and certificate filing	267
under section 3923.02 of the Revised Code.	268

(T) "Panel" means a group of providers or health care	269
facilities that have joined together to deliver health care	270
services through a contractual arrangement with a health insuring	271
corporation, employer group, or other payor.	272

(U) "Person" has the same meaning as in section 1.59 of the	273
Revised Code, and, unless the context otherwise requires, includes	274
any insurance company holding a certificate of authority under	275
Title XXXIX of the Revised Code, any subsidiary and affiliate of	276
an insurance company, and any government agency.	277

(V) "Premium rate" means any set fee regularly paid by a	278
subscriber to a health insuring corporation. A "premium rate" does	279
not include a one-time membership fee, an annual administrative	280
fee, or a nominal access fee, paid to a managed health care system	281
under which the recipient of health care services remains solely	282
responsible for any charges accessed for those services by the	283
provider or health care facility.	284

(W) "Primary care provider" means a provider that is	285
designated by a health insuring corporation to supervise,	286
coordinate, or provide initial care or continuing care to an	287
enrollee, and that may be required by the health insuring	288
corporation to initiate a referral for specialty care and to	289
maintain supervision of the health care services rendered to the	290
enrollee.	291

(X) "Provider" means any natural person or partnership of	292
natural persons who are licensed, certified, accredited, or	293
otherwise authorized in this state to furnish health care	294
services, or any professional association organized under Chapter	295
1785. of the Revised Code, provided that nothing in this chapter	296
or other provisions of law shall be construed to preclude a health	297
insuring corporation, health care practitioner, or organized	298
health care group associated with a health insuring corporation	299
from employing certified nurse practitioners, certified nurse	300
anesthetists, clinical nurse specialists, certified nurse	301
midwives, dietitians, physician assistants, dental assistants,	302
dental hygienists, optometric technicians, or other allied health	303
personnel who are licensed, certified, accredited, or otherwise	304
authorized in this state to furnish health care services.	305

(Y) "Provider sponsored organization" means a corporation, as	306
defined in division (H) of this section, that is at least eighty	307
per cent owned or controlled by one or more hospitals, as defined	308
in section 3727.01 of the Revised Code, or one or more physicians	309
licensed to practice medicine or surgery or osteopathic medicine	310
and surgery under Chapter 4731. of the Revised Code, or any	311
combination of such physicians and hospitals. Such control is	312
presumed to exist if at least eighty per cent of the voting rights	313
or governance rights of a provider sponsored organization are	314
directly or indirectly owned, controlled, or otherwise held by any	315
combination of the physicians and hospitals described in this	316
division.	317

(Z) "Solicitation document" means the written materials	318
provided to prospective subscribers or enrollees, or both, and	319
used for advertising and marketing to induce enrollment in the	320
health care plans of a health insuring corporation.	321

(AA) "Subscriber" means a person who is responsible for	322
making payments to a health insuring corporation for participation	323
in a health care plan, or an enrollee whose employment or other	324
status is the basis of eligibility for enrollment in a health	325
insuring corporation.	326

(BB) "Urgent care services" means those health care services	327
that are appropriately provided for an unforeseen condition of a	328
kind that usually requires medical attention without delay but	329
that does not pose a threat to the life, limb, or permanent health	330
of the injured or ill person, and may include such health care	331
services provided out of the health insuring corporation's	332
approved service area pursuant to indemnity payments or service	333
agreements.	334

Sec. 3923.80. (A) No health benefit plan or public employee	335
benefit plan shall deny coverage for the costs of any routine	336
patient care administered to an insured participating in any	337
stage of an eligible cancer clinical trial, if that care would be	338
covered under the plan if the insured was not participating in a	339
clinical trial.	340

(B) The coverage that may not be excluded under division (A)	341
of this section is subject to all terms, conditions, restrictions,	342
exclusions, and limitations that apply to any other coverage under	343
the plan, policy, or arrangement for services performed by	344
participating and nonparticipating providers. Nothing in this	345
section shall be construed as requiring reimbursement to a	346
provider or facility providing the routine care that does not have	347
a health care contract with the entity issuing the health benefit	348
plan or public employee benefit plan, or as prohibiting the entity	349
issuing a health benefit plan or public employee benefit plan that	350
does not have a health care contract with the provider or	351
facility providing the routine care from negotiating a single case	352
or other agreement for coverage.	353

(C) As used in this section:

354

(1) "Eligible cancer clinical trial" means a cancer clinical	355
trial that meets all of the following criteria:	356

(a) A purpose of the trial is to test whether the	357
intervention potentially improves the trial participant's health	358
outcomes.	359

(b) The treatment provided as part of the trial is given with	360
the intention of improving the trial participant's health	361
outcomes.	362

(c) The trial has a therapeutic intent and is not designed	363
exclusively to test toxicity or disease pathophysiology.	364

(d) The trial does one of the following:

365

(i) Tests how to administer a health care service, item, or	366
drug for the treatment of cancer;	367

(ii) Tests responses to a health care service, item, or drug	368
for the treatment of cancer;	369

(iii) Compares the effectiveness of a health care service,	370
item, or drug for the treatment of cancer with that of other	371
health care services, items, or drugs for the treatment of cancer;	372

(iv) Studies new uses of a health care service, item, or drug	373
for the treatment of cancer.	374

(e) The trial is approved by one of the following entities:

375

(i) The national institutes of health or one of its	376
cooperative groups or centers under the United States department	377
of health and human services;	378

(ii) The United States food and drug administration;

379

(iii) The United States department of defense;

380

(iv) The United States department of veterans' affairs.

381

(2) "Subject of a cancer clinical trial" means the health	382
care service, item, or drug that is being evaluated in the	383
clinical trial and that is not routine patient care.	384

(3) "Health benefit plan" has the same meaning as in section	385
3924.01 of the Revised Code.	386

(4) "Routine patient care" means all health care services	387
consistent with the coverage provided in the health benefit plan	388
or public employee benefit plan for the treatment of cancer,	389
including the type and frequency of any diagnostic modality,	390
that is typically covered for a cancer patient who is not	391
enrolled in a cancer clinical trial, and that was not	392
necessitated solely because of the trial.	393

(5) For purposes of this section, a health benefit plan or	394
public employee benefit plan may exclude coverage for any of the	395
following:	396

(a) A health care service, item, or drug that is the subject	397
of the cancer clinical trial;	398

(b) A health care service, item, or drug provided solely to	399
satisfy data collection and analysis needs for the cancer clinical	400
trial that is not used in the direct clinical management of the	401
patient;	402

(c) An investigational or experimental drug or device that	403
has not been approved for market by the United States food and	404
drug administration;	405

(d) Transportation, lodging, food, or other expenses for the	406
patient, or a family member or companion of the patient, that are	407
associated with the travel to or from a facility providing the	408
cancer clinical trial;	409

(e) An item or drug provided by the cancer clinical trial	410
sponsors free of charge for any patient;	411

(f) A service, item, or drug that is eligible for	412
reimbursement by a person other than the insurer, including the	413
sponsor of the cancer clinical trial.	414

Section 2. That existing sections 1739.05 and 1751.01 of the	415
Revised Code are hereby repealed.	416

Section 3. Section 3923.80 of the Revised Code, as enacted by	417
this act, shall take effect sixty days after the effective date of	418
this act and shall apply only to plans of health coverage that	419
are delivered, issued for delivery, or renewed in this state on	420
or after that delayed effective date.	421