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| To amend section 1739.05 and to enact sections | 1 |
| 1751.69 and 3923.85 of the Revised Code to | 2 |
| require health insurers to provide coverage for | 3 |
| prostheses. | 4 |
| Section 1. That section 1739.05 be amended and sections | 5 |
| 1751.69 and 3923.85 of the Revised Code be enacted to read as | 6 |
| follows: | 7 |
| Sec. 1739.05. (A) A multiple employer welfare arrangement | 8 |
| that is created pursuant to sections 1739.01 to 1739.22 of the | 9 |
| Revised Code and that operates a group self-insurance program may | 10 |
| be established only if any of the following applies: | 11 |
| (1) The arrangement has and maintains a minimum enrollment of | 12 |
| three hundred employees of two or more employers. | 13 |
| (2) The arrangement has and maintains a minimum enrollment of | 14 |
| three hundred self-employed individuals. | 15 |
| (3) The arrangement has and maintains a minimum enrollment of | 16 |
| three hundred employees or self-employed individuals in any | 17 |
| combination of divisions (A)(1) and (2) of this section. | 18 |
| (B) A multiple employer welfare arrangement that is created | 19 |
| pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 20 |
| that operates a group self-insurance program shall comply with all | 21 |
| laws applicable to self-funded programs in this state, including | 22 |
| sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 23 |
| to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 24 |
| 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.80, | 25 |
| 3923.85, 3924.031, 3924.032, and 3924.27 of the Revised Code. | 26 |
| (C) A multiple employer welfare arrangement created pursuant | 27 |
| to sections 1739.01 to 1739.22 of the Revised Code shall solicit | 28 |
| enrollments only through agents or solicitors licensed pursuant to | 29 |
| Chapter 3905. of the Revised Code to sell or solicit sickness and | 30 |
| accident insurance. | 31 |
| (D) A multiple employer welfare arrangement created pursuant | 32 |
| to sections 1739.01 to 1739.22 of the Revised Code shall provide | 33 |
| benefits only to individuals who are members, employees of | 34 |
| members, or the dependents of members or employees, or are | 35 |
| eligible for continuation of coverage under section 1751.53 or | 36 |
| 3923.38 of the Revised Code or under Title X of the "Consolidated | 37 |
| Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 38 |
| U.S.C.A. 1161, as amended. | 39 |
| Sec. 1751.69. As used in this section, "prosthesis" means an | 40 |
| artificial leg, arm, or eye, including a replacement if required | 41 |
| because of a change in the patient's physical condition. | 42 |
| (B) Notwithstanding section 3901.71 of the Revised Code, each | 43 |
| individual or group health insuring corporation policy, contract, | 44 |
| or agreement providing basic health care services that is | 45 |
| delivered, issued for delivery, or renewed in this state shall | 46 |
| provide coverage for benefits for a prosthesis that at least | 47 |
| equals the coverage provided under the federal medicare program | 48 |
| pursuant to Title XVIII of the "Social Security Act," 79 Stat. | 49 |
| 286 (1965), 42 U.S.C. 1395, as amended. | 50 |
| (C) The policy, contract, or agreement may require prior | 51 |
| authorization for a prosthesis in the same manner that prior | 52 |
| authorization is required for any other covered benefit. | 53 |
| (D) The policy, contract, or agreement may impose a | 54 |
| copayment, coinsurance, or both, on a prosthesis, not to exceed | 55 |
| the copayment or coinsurance amounts imposed under part B of the | 56 |
| medicare fee for service program. The policy, contract, or | 57 |
| agreement shall reimburse for a prosthesis at an amount not less | 58 |
| than the fee schedule amount for the prosthesis under federal | 59 |
| medicare reimbursement schedule. | 60 |
| (E) Covered benefits are limited to the most appropriate | 61 |
| model that adequately meets the medical needs of the patient as | 62 |
| determined by the enrollee's treating physician. | 63 |
| (F) The policy, contract, or agreement also shall provide | 64 |
| coverage for benefits for the repair or replacement of a | 65 |
| prosthesis under this section if the insured's treating physician | 66 |
| determines the repair or replacement is appropriate. | 67 |
| (G) The policy, contract, or agreement shall not impose any | 68 |
| annual or lifetime dollar maximum on coverage for prostheses | 69 |
| other than an annual or lifetime dollar maximum that applies in | 70 |
| the aggregate to all terms and services covered under the policy, | 71 |
| contract, or agreement. | 72 |
| Sec. 3923.85. As used in this section, "prosthesis" means an | 73 |
| artificial leg, arm, or eye, including a replacement if required | 74 |
| because of a change in the patient's physical condition. | 75 |
| (B) Notwithstanding section 3901.71 of the Revised Code, each | 76 |
| individual or group policy of sickness and accident insurance that | 77 |
| is delivered, issued for delivery, or renewed in this state and | 78 |
| each public employee benefit plan that is established or modified | 79 |
| in this state shall provide coverage for benefits for a | 80 |
| prosthesis that at least equals the coverage provided under the | 81 |
| federal medicare program pursuant to Title XVIII of the "Social | 82 |
| Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1395, as amended. | 83 |
| (C) The policy or plan may require prior authorization for a | 84 |
| prosthesis in the same manner that prior authorization is | 85 |
| required for any other covered benefit. | 86 |
| (D) The policy or plan may impose a copayment, coinsurance, | 87 |
| or both, on a prosthesis, not to exceed the copayment or | 88 |
| coinsurance amounts imposed under part B of the medicare fee for | 89 |
| service program. The policy or plan shall reimburse for a | 90 |
| prosthesis at an amount not less than the fee schedule amount for | 91 |
| the prosthesis under federal medicare reimbursement schedule. | 92 |
| (E) Covered benefits are limited to the most appropriate | 93 |
| model that adequately meets the medical needs of the patient as | 94 |
| determined by the insured's or plan member's treating physician. | 95 |
| (F) The policy or plan also shall provide coverage for | 96 |
| benefits for the repair or replacement of a prosthesis under this | 97 |
| section if the insured's treating physician determines the repair | 98 |
| or replacement is appropriate. | 99 |
| (G) The policy or plan shall not impose any annual or | 100 |
| lifetime dollar maximum on coverage for prostheses other than an | 101 |
| annual or lifetime dollar maximum that applies in the aggregate to | 102 |
| all terms and services covered under the policy or plan. | 103 |
| (H) This section does not apply to the offer or renewal of | 104 |
| any individual or group policy of sickness and accident insurance | 105 |
| that provides coverage for specific diseases or accidents only, or | 106 |
| to any hospital indemnity, medicare supplement, medicare, tricare, | 107 |
| long-term care, disability income, one-time limited duration | 108 |
| policy of not longer than six months, or other policy that offers | 109 |
| only supplemental benefits. | 110 |
| Section 2. That existing section 1739.05 of the Revised Code | 111 |
| is hereby repealed. | 112 |