(B) A multiple employer welfare arrangement that is
created | 23 |
pursuant to sections 1739.01 to 1739.22 of the Revised
Code and | 24 |
that operates a group self-insurance program shall
comply with all | 25 |
laws applicable to self-funded programs in this
state, including | 26 |
sections 3901.04, 3901.041, 3901.19 to 3901.26,
3901.38, 3901.381 | 27 |
to
3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to
3902.14, | 28 |
3923.282,
3923.30,
3923.301, 3923.38,
3923.581, 3923.63, 3923.80, | 29 |
3924.031,
3924.032,
and
3924.27
of the Revised Code. | 30 |
(D) A multiple employer welfare arrangement created
pursuant | 36 |
to sections 1739.01 to 1739.22 of the Revised Code shall
provide | 37 |
benefits only to individuals who are members, employees
of | 38 |
members, or the dependents of members or employees, or are | 39 |
eligible for continuation of coverage under section 1751.53 or | 40 |
3923.38 of the Revised Code or under Title X of the "Consolidated | 41 |
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 42 |
U.S.C.A. 1161, as amended. | 43 |
Except as provided by divisions (A)(2) and (3) of this | 67 |
section in
connection with the offering of coverage for diagnostic | 68 |
and treatment
services for biologically based mental illnesses and | 69 |
substance abuse
and addiction conditions, a
health insuring | 70 |
corporation shall not offer coverage for
a health
care service, | 71 |
defined as a basic health care service by
this
division, unless | 72 |
it offers coverage for all listed basic
health
care services. | 73 |
However,
this requirement does not apply to the
coverage of | 74 |
beneficiaries
enrolled in
medicare pursuant
to a
medicare | 75 |
contract, or to the
coverage of
beneficiaries enrolled
in the | 76 |
federal employee
health benefits
program pursuant to 5
U.S.C.A. | 77 |
8905, or to the coverage of
medicaid
recipients, or to
the | 78 |
coverage of participants of the children's
buy-in program, or
to | 79 |
the coverage of beneficiaries under any
federal health care | 80 |
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 and substance abuse and addiction conditions without | 87 |
offering coverage for all other basic health
care services. A | 88 |
health insuring corporation may offer coverage
for diagnostic and | 89 |
treatment services for biologically based
mental illnesses and | 90 |
substance abuse and addiction conditions alone or in combination | 91 |
with one or more
supplemental health care services. However, a | 92 |
health insuring
corporation that offers coverage for any other | 93 |
basic health care
service shall offer coverage for diagnostic and | 94 |
treatment services
for biologically based mental illnesses and | 95 |
substance abuse and addiction conditions in combination with the | 96 |
offer of coverage for all other listed basic health care services. | 97 |
(a) The health insuring corporation submits documentation | 104 |
certified by an independent member of the American academy of | 105 |
actuaries to the superintendent of insurance showing that incurred | 106 |
claims for diagnostic and treatment services for biologically | 107 |
based mental illnesses and substance abuse and addiction | 108 |
conditions for a period of at least six months
independently | 109 |
caused the health insuring corporation's costs for
claims and | 110 |
administrative expenses for the coverage of basic
health care | 111 |
services to increase by more than one per cent per
year. | 112 |
(D) "Biologically based mental illnesses" means | 173 |
schizophrenia, schizoaffective disorder, major depressive | 174 |
disorder, bipolar disorder, paranoia and other psychotic | 175 |
disorders, obsessive-compulsive disorder, and panic disorder, as | 176 |
these terms are defined in"Mental illness" means any condition or | 177 |
disorder involving mental illness as defined by the most recent | 178 |
edition of the
diagnostic and statistical manual of mental | 179 |
disorders published by
the American psychiatric association or as | 180 |
defined by any diagnostic category listed in the mental disorder | 181 |
section of the most recent edition of the international | 182 |
classification of diseases. | 183 |
(J)(K) "Emergency health
services" means those health care | 203 |
services that must be
available on a seven-days-per-week, | 204 |
twenty-four-hours-per-day
basis in order to prevent jeopardy to an | 205 |
enrollee's health
status that would occur if such services were | 206 |
not received as
soon as possible, and includes, where appropriate, | 207 |
provisions
for transportation and indemnity payments or service | 208 |
agreements
for out-of-area coverage. | 209 |
(M)(N) "Health care
facility" means any facility, except a | 217 |
health care
practitioner's office, that provides preventive, | 218 |
diagnostic,
therapeutic, acute convalescent, rehabilitation, | 219 |
mental health,
mental retardation, intermediate care, or skilled | 220 |
nursing
services. | 221 |
(P)(Q) "Health insuring
corporation" means a corporation, as | 228 |
defined in division (I)(J) of this
section, that, pursuant to a | 229 |
policy, contract,
certificate, or agreement, pays for, reimburses, | 230 |
or provides,
delivers, arranges for, or otherwise makes available, | 231 |
basic
health care services, supplemental health care services, or | 232 |
specialty health care services, or a combination of basic health | 233 |
care services and either supplemental health care services or | 234 |
specialty
health care services, through either an open panel plan | 235 |
or a closed panel
plan. | 236 |
"Health insuring
corporation" does not include a limited | 237 |
liability company formed
pursuant to Chapter 1705. of
the Revised | 238 |
Code,
an insurer licensed under
Title
XXXIX of the
Revised
Code if | 239 |
that insurer offers
only open panel plans under which all | 240 |
providers and health care
facilities participating receive their | 241 |
compensation directly
from the insurer, a corporation formed by
or | 242 |
on behalf of a political subdivision or a department, office,
or | 243 |
institution of the state, or a public entity formed by or on | 244 |
behalf of
a board of county commissioners, a county
board of | 245 |
mental retardation and developmental disabilities,
an
alcohol and | 246 |
drug
addiction services board, a board of alcohol, drug addiction, | 247 |
and mental health services, or a community mental health board,
as | 248 |
those terms are used in Chapters 340. and 5126. of the
Revised | 249 |
Code.
Except as provided by division (D)
of section 1751.02 of | 250 |
the
Revised
Code, or as
otherwise provided by law, no
board, | 251 |
commission,
agency, or other entity under the control of a | 252 |
political
subdivision may accept insurance risk in providing for | 253 |
health
care services. However, nothing in this division shall be | 254 |
construed as prohibiting such entities from purchasing the | 255 |
services of a health insuring corporation or a third-party | 256 |
administrator licensed under Chapter 3959. of the Revised
Code. | 257 |
(Q)(R) "Intermediary
organization" means a health delivery | 258 |
network or other entity
that contracts with licensed health | 259 |
insuring corporations or self-insured
employers, or both, to | 260 |
provide health care services, and that enters into
contractual | 261 |
arrangements with other entities for the provision
of health care | 262 |
services for the purpose of fulfilling the terms
of its contracts | 263 |
with the health insuring corporations and self-insured
employers. | 264 |
(2) No health insuring corporation may offer an open
panel | 281 |
plan, unless the health insuring corporation is also
licensed as | 282 |
an insurer under Title XXXIX of the
Revised Code, the health | 283 |
insuring corporation, on June 4,
1997,
holds a certificate of | 284 |
authority or license to
operate under Chapter 1736. or 1740. of | 285 |
the Revised Code, or an insurer licensed under
Title XXXIX of the | 286 |
Revised Code is
responsible for the out-of-network risk as | 287 |
evidenced by both an evidence of
coverage filing under section | 288 |
1751.11
of the Revised Code and a policy and
certificate filing | 289 |
under section 3923.02 of the
Revised Code. | 290 |
(Y)(Z) "Premium rate" means any set fee
regularly paid by a | 300 |
subscriber to a health insuring corporation. A "premium
rate" does | 301 |
not include a one-time membership fee, an annual
administrative | 302 |
fee, or a nominal access fee, paid to a managed
health care system | 303 |
under which the recipient of health care
services remains solely | 304 |
responsible for any charges accessed for
those services by the | 305 |
provider or health care facility. | 306 |
(AA)(BB) "Provider" means any
natural person or partnership | 314 |
of
natural persons who are
licensed, certified, accredited, or | 315 |
otherwise authorized in this
state to furnish health care | 316 |
services, or any professional
association organized under Chapter | 317 |
1785. of the Revised
Code, provided that nothing in
this chapter | 318 |
or other provisions of law shall be construed to
preclude a health | 319 |
insuring corporation, health care
practitioner, or organized | 320 |
health care group associated with a
health insuring corporation | 321 |
from employing certified nurse practitioners,
certified nurse | 322 |
anesthetists, clinical nurse specialists, certified nurse | 323 |
midwives, dietitians, physician assistants, dental assistants, | 324 |
dental
hygienists, optometric technicians, or other allied health | 325 |
personnel who are licensed, certified, accredited, or otherwise | 326 |
authorized in this state to furnish health care services. | 327 |
(BB)(CC) "Provider sponsored
organization" means a | 328 |
corporation,
as defined in division
(I)(J) of this section, that | 329 |
is at least
eighty per cent owned or
controlled
by one or more | 330 |
hospitals, as
defined in section 3727.01 of the
Revised Code, or | 331 |
one or more
physicians licensed
to practice medicine or surgery | 332 |
or
osteopathic medicine and
surgery under Chapter 4731. of the | 333 |
Revised
Code, or any combination of such physicians and
hospitals. | 334 |
Such control is presumed to exist if at least eighty per cent
of | 335 |
the voting rights or governance rights of a provider
sponsored | 336 |
organization are directly or indirectly owned,
controlled, or | 337 |
otherwise held by any combination of the
physicians and hospitals | 338 |
described in this division. | 339 |
(EE)(FF) "Urgent care
services" means those health care | 349 |
services
that are
appropriately provided for an unforeseen | 350 |
condition of a
kind
that usually requires medical attention | 351 |
without delay but
that
does not pose a threat to the life, limb, | 352 |
or permanent
health of
the injured or ill person,
and may include | 353 |
such health
care services provided
out of the health insuring | 354 |
corporation's
approved service area
pursuant to indemnity | 355 |
payments
or service
agreements. | 356 |
(1)
"Biologically based mental illness" means schizophrenia, | 358 |
schizoaffective disorder, major depressive disorder, bipolar | 359 |
disorder, paranoia and other psychotic disorders, | 360 |
obsessive-compulsive disorder, and panic disorder, as these terms | 361 |
are defined in"Mental illness" means any condition or disorder | 362 |
involving mental illness as defined by the most recent edition of | 363 |
the diagnostic and
statistical manual of mental disorders | 364 |
published by the American
psychiatric association or as defined | 365 |
by
any diagnostic category listed in the mental disorder section | 366 |
of
the most recent edition of the international classification of | 367 |
diseases. | 368 |
(2)
"Policy of sickness and accident insurance" has the same | 369 |
meaning as in section 3923.01 of the Revised Code, but excludes | 370 |
any hospital indemnity, medicare supplement, long-term care, | 371 |
disability income, one-time-limited-duration policy of not longer | 372 |
than six months, supplemental benefit, or other policy
that | 373 |
provides coverage for specific diseases or
accidents only; any | 374 |
policy that provides coverage for workers' compensation claims | 375 |
compensable pursuant to Chapters 4121. and 4123. of the Revised | 376 |
Code; any policy that provides coverage to beneficiaries
enrolled | 377 |
in Title XIX of the "Social Security Act," 49 Stat. 620
(1935), | 378 |
42 U.S.C.A. 301, as amended, known as the medical
assistance | 379 |
program or medicaid, as provided by the Ohio department
of job | 380 |
and family services under Chapter 5111. of the Revised
Code; and | 381 |
any policy that provides coverage to beneficiaries
enrolled in | 382 |
the children's buy-in program established under
sections | 383 |
5101.5211 to 5101.5216 of the Revised Code. | 384 |
(B)
Notwithstanding section 3901.71 of the
Revised
Code,
and | 391 |
subject to division (E) of this section, every
policy of | 392 |
sickness
and accident insurance shall provide
benefits
for the | 393 |
diagnosis
and treatment of biologically based mental illnesses and | 394 |
substance abuse or addiction conditions on
the same
terms and | 395 |
conditions as, and
shall provide benefits no
less
extensive than, | 396 |
those provided
under the policy of sickness
and
accident | 397 |
insurance
for the
treatment and diagnosis of all
other
physical | 398 |
diseases and
disorders, if both of the following
apply: | 399 |
(1)
The biologically based mental illness or substance abuse | 400 |
or addiction condition is clinically
diagnosed by a physician | 401 |
authorized under Chapter 4731.
of the
Revised
Code to practice | 402 |
medicine and
surgery or osteopathic
medicine and surgery; a | 403 |
psychologist
licensed under Chapter 4732.
of
the Revised
Code; a | 404 |
professional clinical
counselor,
professional counselor, or | 405 |
independent social worker
licensed
under Chapter 4757. of
the | 406 |
Revised
Code; or a clinical nurse
specialist licensed under | 407 |
Chapter 4723. of the
Revised
Code whose
nursing specialty is | 408 |
mental health. | 409 |
(1) The insurer submits documentation certified by an | 442 |
independent member of the American academy of actuaries to the | 443 |
superintendent of insurance showing that incurred claims for | 444 |
diagnostic and treatment services for biologically basedand | 445 |
substance abuse or addiction conditions mental
illnesses for a | 446 |
period of at least six months independently caused
the insurer's | 447 |
costs for claims and administrative expenses for the
coverage of | 448 |
all other physical diseases and disorders to increase
by more | 449 |
than one per cent per year. | 450 |
(1)
"Biologically based mental illness" means schizophrenia, | 475 |
schizoaffective disorder, major depressive disorder, bipolar | 476 |
disorder, paranoia and other psychotic disorders, | 477 |
obsessive-compulsive disorder, and panic disorder, as these terms | 478 |
are defined in"Mental illness" means any condition or disorder | 479 |
involving mental illness as defined by the most recent edition of | 480 |
the diagnostic and statistical manual of mental disorders | 481 |
published by the American psychiatric association or as defined by | 482 |
any diagnostic category listed in the mental disorder section of | 483 |
the most recent edition of the international classification of | 484 |
diseases. | 485 |
(B)
Notwithstanding section 3901.71 of the
Revised
Code, and | 497 |
subject to division (F) of this section,
each
plan of health | 498 |
coverage shall provide benefits for the
diagnosis
and treatment
of | 499 |
biologically based mental illnesses and substance abuse or | 500 |
addiction conditions on the same terms and conditions as,
and | 501 |
shall
provide benefits no less extensive than, those provided | 502 |
under
the plan of health coverage for the treatment and diagnosis | 503 |
of
all other physical diseases and disorders, if both of the | 504 |
following apply: | 505 |
(1)
The biologically based mental illness or substance abuse | 506 |
or addiction condition is clinically diagnosed by a physician | 507 |
authorized under Chapter 4731.
of the Revised
Code to practice | 508 |
medicine and
surgery or osteopathic medicine and surgery; a | 509 |
psychologist
licensed under Chapter 4732. of
the Revised
Code; a | 510 |
professional clinical
counselor, professional counselor, or | 511 |
independent social worker
licensed under Chapter 4757. of
the | 512 |
Revised
Code; or a clinical nurse
specialist licensed under | 513 |
Chapter 4723. of the
Revised
Code whose nursing specialty is | 514 |
mental health. | 515 |
(D)
This section does
not apply to a plan of health
coverage | 524 |
if federal
law supersedes, preempts, prohibits, or
otherwise | 525 |
precludes its
application to such plans. This section does not | 526 |
apply to long-term care, hospital indemnity, disability income, or | 527 |
medicare supplement plans of health coverage, or to any other | 528 |
supplemental benefit plans of health coverage. | 529 |
(1) The employer submits documentation certified by an | 552 |
independent member of the American academy of actuaries to the | 553 |
superintendent of insurance showing that incurred claims for | 554 |
diagnostic and treatment services for biologically based mental | 555 |
illnesses and substance abuse or addiction conditions for a period | 556 |
of at least six months independently caused the employer's costs | 557 |
for claims and administrative expenses for the coverage of all | 558 |
other physical diseases and disorders to increase by more than one | 559 |
per cent per year. | 560 |
(2) The superintendent of insurance determines from the | 561 |
documentation and opinion submitted pursuant to division (F) of | 562 |
this section, that incurred claims for diagnostic and treatment | 563 |
services for biologically based mental illnesses and substance | 564 |
abuse or addiction conditions for a period of at least six months | 565 |
independently caused the employer's costs for claims and | 566 |
administrative expenses for the coverage of all other physical | 567 |
diseases and disorders to increase by more than one per cent per | 568 |
year. | 569 |
(B) Every insurer that is authorized to write sickness and | 577 |
accident insurance in this state may offer group contracts of | 578 |
sickness and accident insurance to any charitable foundation that | 579 |
is certified as exempt from taxation under section 501(c)(3) of | 580 |
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. | 581 |
1, as amended, and that has the sole purpose of issuing | 582 |
certificates of coverage under these contracts to persons under | 583 |
the age of nineteen who are members of families that have incomes | 584 |
that are no greater than three hundred per cent of the official | 585 |
poverty line. | 586 |
Section 3. Section 1751.01 of the Revised Code is
presented | 600 |
in
this act as a composite of the section as amended by
both Am. | 601 |
Sub. H.B. 562 and Sub. S.B. 186 of
the 127th General
Assembly. | 602 |
The General Assembly, applying the
principle stated in
division | 603 |
(B) of section 1.52 of the Revised
Code that amendments
are to be | 604 |
harmonized if reasonably capable of
simultaneous
operation, finds | 605 |
that the composite is the resulting
version of
the section in | 606 |
effect prior to the effective date of
the section
as presented in | 607 |
this act. | 608 |