As Introduced

129th General Assembly Regular Session 2011-2012

S. B. No. 324

Senator Seitz 

Cosponsors: Senators LaRose, Beagle, Patton 

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A BILL

To amend sections 1753.07, 1753.09, 3901.21, 3963.01,

1

3963.02, and 3963.03 of the Revised Code to

2

prohibit a health insurer from reimbursing dental

3

providers based upon a fee schedule if the dental

4

services provided are not covered by any contract

5

or participating provider agreement between the

6

health insurer and the dental provider.

7

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

Section 1. That sections 1753.07, 1753.09, 3901.21, 3963.01,	8
3963.02, and 3963.03 of the Revised Code be amended to read as	9
follows:	10

Sec. 1753.07.  (A)(1) Prior to entering into a participation	11
contract with a provider under section 1751.13 of the Revised	12
Code, a health insuring corporation shall disclose basic	13
information regarding its programs and procedures to the provider.	14
The information shall include all of the following:	15

(a) How a participating provider is reimbursed for the	16
participating provider's services, including the range and	17
structure of any financial risk sharing arrangements, a	18
description of any incentive plans, and, if reimbursed according	19
to a type of fee-for-service arrangement, the level of	20
reimbursement for the participating provider's services;	21

(b) Insofar as division (A)(1) of section 3963.03 of the	22
Revised Code is applicable, all of the information that is	23
described in that division and is not included in division	24
(A)(1)(a) of this section.	25

(2) Prior to entering into a participation contract with a	26
provider under section 1751.13 of the Revised Code, a health	27
insuring corporation shall disclose the following information upon	28
the provider's request:	29

(a) How referrals to other participating providers or to	30
nonparticipating providers are made;	31

(b) The availability of dispute resolution procedures and the	32
potential for cost to be incurred;	33

(c) How a participating provider's name and address will be	34
used in marketing materials.	35

(B) A health insuring corporation shall provide all of the	36
following to a participating provider:	37

(1) Any material incorporated by reference into the	38
participation contract, that is not otherwise available as a	39
public record, if such material affects the participating	40
provider;	41

(2) Administrative manuals related to provider participation,	42
if any;	43

(3) Insofar as division (B) of section 3963.03 of the Revised	44
Code is applicable, the summary disclosure form with the	45
disclosures required under that division;	46

(4) A signed and dated copy of the final participation	47
contract.	48

(C) NothingExcept as otherwise provided in division (E) of	49
section 3963.02 of the Revised Code, nothing in this section	50
requires a health insuring corporation providing specialty health	51
care services or supplemental health care services to disclose the	52
health insuring corporation's aggregate maximum allowable fee	53
table used to determine providers' fees or fee schedules.	54

Sec. 1753.09.  (A) Except as provided in division (D) of this	55
section, prior to terminating the participation of a provider on	56
the basis of the participating provider's failure to meet the	57
health insuring corporation's standards for quality or utilization	58
in the delivery of health care services, a health insuring	59
corporation shall give the participating provider notice of the	60
reason or reasons for its decision to terminate the provider's	61
participation and an opportunity to take corrective action. The	62
health insuring corporation shall develop a performance	63
improvement plan in conjunction with the participating provider.	64
If after being afforded the opportunity to comply with the	65
performance improvement plan, the participating provider fails to	66
do so, the health insuring corporation may terminate the	67
participation of the provider.	68

(B)(1) A participating provider whose participation has been	69
terminated under division (A) of this section may appeal the	70
termination to the appropriate medical director of the health	71
insuring corporation. The medical director shall give the	72
participating provider an opportunity to discuss with the medical	73
director the reason or reasons for the termination.	74

(2) If a satisfactory resolution of a participating	75
provider's appeal cannot be reached under division (B)(1) of this	76
section, the participating provider may appeal the termination to	77
a panel composed of participating providers who have comparable or	78
higher levels of education and training than the participating	79
provider making the appeal. A representative of the participating	80
provider's specialty shall be a member of the panel, if possible.	81
This panel shall hold a hearing, and shall render its	82
recommendation in the appeal within thirty days after holding the	83
hearing. The recommendation shall be presented to the medical	84
director and to the participating provider.	85

(3) The medical director shall review and consider the	86
panel's recommendation before making a decision. The decision	87
rendered by the medical director shall be final.	88

(C) A provider's status as a participating provider shall	89
remain in effect during the appeal process set forth in division	90
(B) of this section unless the termination was based on any of the	91
reasons listed in division (D) of this section.	92

(D) Notwithstanding division (A) of this section, a	93
provider's participation may be immediately terminated if the	94
participating provider's conduct presents an imminent risk of harm	95
to an enrollee or enrollees; or if there has occurred unacceptable	96
quality of care, fraud, patient abuse, loss of clinical	97
privileges, loss of professional liability coverage, incompetence,	98
or loss of authority to practice in the participating provider's	99
field; or if a governmental action has impaired the participating	100
provider's ability to practice.	101

(E) Divisions (A) to (D) of this section apply only to	102
providers who are natural persons.	103

(F)(1) Nothing in this section prohibits a health insuring	104
corporation from rejecting a provider's application for	105
participation, or from terminating a participating provider's	106
contract, if the health insuring corporation determines that the	107
health care needs of its enrollees are being met and no need	108
exists for the provider's or participating provider's services.	109

(2) Nothing in this section shall be construed as prohibiting	110
a health insuring corporation from terminating a participating	111
provider who does not meet the terms and conditions of the	112
participating provider's contract.	113

(3) Nothing in this section shall be construed as prohibiting	114
a health insuring corporation from terminating a participating	115
provider's contract pursuant to any provision of the contract	116
described in division (E)(F)(2) of section 3963.02 of the Revised	117
Code, except that, notwithstanding any provision of a contract	118
described in that division, this section applies to the	119
termination of a participating provider's contract for any of the	120
causes described in divisions (A), (D), and (F)(1) and (2) of this	121
section.	122

(G) The superintendent of insurance may adopt rules as	123
necessary to implement and enforce sections 1753.06, 1753.07, and	124
1753.09 of the Revised Code. Such rules shall be adopted in	125
accordance with Chapter 119. of the Revised Code.	126

Sec. 3901.21.  The following are hereby defined as unfair and	127
deceptive acts or practices in the business of insurance:	128

(A) Making, issuing, circulating, or causing or permitting to	129
be made, issued, or circulated, or preparing with intent to so	130
use, any estimate, illustration, circular, or statement	131
misrepresenting the terms of any policy issued or to be issued or	132
the benefits or advantages promised thereby or the dividends or	133
share of the surplus to be received thereon, or making any false	134
or misleading statements as to the dividends or share of surplus	135
previously paid on similar policies, or making any misleading	136
representation or any misrepresentation as to the financial	137
condition of any insurer as shown by the last preceding verified	138
statement made by it to the insurance department of this state, or	139
as to the legal reserve system upon which any life insurer	140
operates, or using any name or title of any policy or class of	141
policies misrepresenting the true nature thereof, or making any	142
misrepresentation or incomplete comparison to any person for the	143
purpose of inducing or tending to induce such person to purchase,	144
amend, lapse, forfeit, change, or surrender insurance.	145

Any written statement concerning the premiums for a policy	146
which refers to the net cost after credit for an assumed dividend,	147
without an accurate written statement of the gross premiums, cash	148
values, and dividends based on the insurer's current dividend	149
scale, which are used to compute the net cost for such policy, and	150
a prominent warning that the rate of dividend is not guaranteed,	151
is a misrepresentation for the purposes of this division.	152

(B) Making, publishing, disseminating, circulating, or	153
placing before the public or causing, directly or indirectly, to	154
be made, published, disseminated, circulated, or placed before the	155
public, in a newspaper, magazine, or other publication, or in the	156
form of a notice, circular, pamphlet, letter, or poster, or over	157
any radio station, or in any other way, or preparing with intent	158
to so use, an advertisement, announcement, or statement containing	159
any assertion, representation, or statement, with respect to the	160
business of insurance or with respect to any person in the conduct	161
of the person's insurance business, which is untrue, deceptive, or	162
misleading.	163

(C) Making, publishing, disseminating, or circulating,	164
directly or indirectly, or aiding, abetting, or encouraging the	165
making, publishing, disseminating, or circulating, or preparing	166
with intent to so use, any statement, pamphlet, circular, article,	167
or literature, which is false as to the financial condition of an	168
insurer and which is calculated to injure any person engaged in	169
the business of insurance.	170

(D) Filing with any supervisory or other public official, or	171
making, publishing, disseminating, circulating, or delivering to	172
any person, or placing before the public, or causing directly or	173
indirectly to be made, published, disseminated, circulated,	174
delivered to any person, or placed before the public, any false	175
statement of financial condition of an insurer.	176

Making any false entry in any book, report, or statement of	177
any insurer with intent to deceive any agent or examiner lawfully	178
appointed to examine into its condition or into any of its	179
affairs, or any public official to whom such insurer is required	180
by law to report, or who has authority by law to examine into its	181
condition or into any of its affairs, or, with like intent,	182
willfully omitting to make a true entry of any material fact	183
pertaining to the business of such insurer in any book, report, or	184
statement of such insurer, or mutilating, destroying, suppressing,	185
withholding, or concealing any of its records.	186

(E) Issuing or delivering or permitting agents, officers, or	187
employees to issue or deliver agency company stock or other	188
capital stock or benefit certificates or shares in any common-law	189
corporation or securities or any special or advisory board	190
contracts or other contracts of any kind promising returns and	191
profits as an inducement to insurance.	192

(F) Making or permitting any unfair discrimination among	193
individuals of the same class and equal expectation of life in the	194
rates charged for any contract of life insurance or of life	195
annuity or in the dividends or other benefits payable thereon, or	196
in any other of the terms and conditions of such contract.	197

(G)(1) Except as otherwise expressly provided by law,	198
knowingly permitting or offering to make or making any contract of	199
life insurance, life annuity or accident and health insurance, or	200
agreement as to such contract other than as plainly expressed in	201
the contract issued thereon, or paying or allowing, or giving or	202
offering to pay, allow, or give, directly or indirectly, as	203
inducement to such insurance, or annuity, any rebate of premiums	204
payable on the contract, or any special favor or advantage in the	205
dividends or other benefits thereon, or any valuable consideration	206
or inducement whatever not specified in the contract; or giving,	207
or selling, or purchasing, or offering to give, sell, or purchase,	208
as inducement to such insurance or annuity or in connection	209
therewith, any stocks, bonds, or other securities, or other	210
obligations of any insurance company or other corporation,	211
association, or partnership, or any dividends or profits accrued	212
thereon, or anything of value whatsoever not specified in the	213
contract.	214

(2) Nothing in division (F) or division (G)(1) of this	215
section shall be construed as prohibiting any of the following	216
practices: (a) in the case of any contract of life insurance or	217
life annuity, paying bonuses to policyholders or otherwise abating	218
their premiums in whole or in part out of surplus accumulated from	219
nonparticipating insurance, provided that any such bonuses or	220
abatement of premiums shall be fair and equitable to policyholders	221
and for the best interests of the company and its policyholders;	222
(b) in the case of life insurance policies issued on the	223
industrial debit plan, making allowance to policyholders who have	224
continuously for a specified period made premium payments directly	225
to an office of the insurer in an amount which fairly represents	226
the saving in collection expenses; (c) readjustment of the rate of	227
premium for a group insurance policy based on the loss or expense	228
experience thereunder, at the end of the first or any subsequent	229
policy year of insurance thereunder, which may be made retroactive	230
only for such policy year.	231

(H) Making, issuing, circulating, or causing or permitting to	232
be made, issued, or circulated, or preparing with intent to so	233
use, any statement to the effect that a policy of life insurance	234
is, is the equivalent of, or represents shares of capital stock or	235
any rights or options to subscribe for or otherwise acquire any	236
such shares in the life insurance company issuing that policy or	237
any other company.	238

(I) Making, issuing, circulating, or causing or permitting to	239
be made, issued or circulated, or preparing with intent to so	240
issue, any statement to the effect that payments to a policyholder	241
of the principal amounts of a pure endowment are other than	242
payments of a specific benefit for which specific premiums have	243
been paid.	244

(J) Making, issuing, circulating, or causing or permitting to	245
be made, issued, or circulated, or preparing with intent to so	246
use, any statement to the effect that any insurance company was	247
required to change a policy form or related material to comply	248
with Title XXXIX of the Revised Code or any regulation of the	249
superintendent of insurance, for the purpose of inducing or	250
intending to induce any policyholder or prospective policyholder	251
to purchase, amend, lapse, forfeit, change, or surrender	252
insurance.	253

(K) Aiding or abetting another to violate this section.

254

(L) Refusing to issue any policy of insurance, or canceling	255
or declining to renew such policy because of the sex or marital	256
status of the applicant, prospective insured, insured, or	257
policyholder.	258

(M) Making or permitting any unfair discrimination between	259
individuals of the same class and of essentially the same hazard	260
in the amount of premium, policy fees, or rates charged for any	261
policy or contract of insurance, other than life insurance, or in	262
the benefits payable thereunder, or in underwriting standards and	263
practices or eligibility requirements, or in any of the terms or	264
conditions of such contract, or in any other manner whatever.	265

(N) Refusing to make available disability income insurance	266
solely because the applicant's principal occupation is that of	267
managing a household.	268

(O) Refusing, when offering maternity benefits under any	269
individual or group sickness and accident insurance policy, to	270
make maternity benefits available to the policyholder for the	271
individual or individuals to be covered under any comparable	272
policy to be issued for delivery in this state, including family	273
members if the policy otherwise provides coverage for family	274
members. Nothing in this division shall be construed to prohibit	275
an insurer from imposing a reasonable waiting period for such	276
benefits under an individual sickness and accident insurance	277
policy issued to an individual who is not a federally eligible	278
individual or a nonemployer-related group sickness and accident	279
insurance policy, but in no event shall such waiting period exceed	280
two hundred seventy days.	281

For purposes of division (O) of this section, "federally	282
eligible individual" means an eligible individual as defined in 45	283
C.F.R. 148.103.	284

(P) Using, or permitting to be used, a pattern settlement as	285
the basis of any offer of settlement. As used in this division,	286
"pattern settlement" means a method by which liability is	287
routinely imputed to a claimant without an investigation of the	288
particular occurrence upon which the claim is based and by using a	289
predetermined formula for the assignment of liability arising out	290
of occurrences of a similar nature. Nothing in this division shall	291
be construed to prohibit an insurer from determining a claimant's	292
liability by applying formulas or guidelines to the facts and	293
circumstances disclosed by the insurer's investigation of the	294
particular occurrence upon which a claim is based.	295

(Q) Refusing to insure, or refusing to continue to insure, or	296
limiting the amount, extent, or kind of life or sickness and	297
accident insurance or annuity coverage available to an individual,	298
or charging an individual a different rate for the same coverage	299
solely because of blindness or partial blindness. With respect to	300
all other conditions, including the underlying cause of blindness	301
or partial blindness, persons who are blind or partially blind	302
shall be subject to the same standards of sound actuarial	303
principles or actual or reasonably anticipated actuarial	304
experience as are sighted persons. Refusal to insure includes, but	305
is not limited to, denial by an insurer of disability insurance	306
coverage on the grounds that the policy defines "disability" as	307
being presumed in the event that the eyesight of the insured is	308
lost. However, an insurer may exclude from coverage disabilities	309
consisting solely of blindness or partial blindness when such	310
conditions existed at the time the policy was issued. To the	311
extent that the provisions of this division may appear to conflict	312
with any provision of section 3999.16 of the Revised Code, this	313
division applies.	314

(R)(1) Directly or indirectly offering to sell, selling, or	315
delivering, issuing for delivery, renewing, or using or otherwise	316
marketing any policy of insurance or insurance product in	317
connection with or in any way related to the grant of a student	318
loan guaranteed in whole or in part by an agency or commission of	319
this state or the United States, except insurance that is required	320
under federal or state law as a condition for obtaining such a	321
loan and the premium for which is included in the fees and charges	322
applicable to the loan; or, in the case of an insurer or insurance	323
agent, knowingly permitting any lender making such loans to engage	324
in such acts or practices in connection with the insurer's or	325
agent's insurance business.	326

(2) Except in the case of a violation of division (G) of this	327
section, division (R)(1) of this section does not apply to either	328
of the following:	329

(a) Acts or practices of an insurer, its agents,	330
representatives, or employees in connection with the grant of a	331
guaranteed student loan to its insured or the insured's spouse or	332
dependent children where such acts or practices take place more	333
than ninety days after the effective date of the insurance;	334

(b) Acts or practices of an insurer, its agents,	335
representatives, or employees in connection with the solicitation,	336
processing, or issuance of an insurance policy or product covering	337
the student loan borrower or the borrower's spouse or dependent	338
children, where such acts or practices take place more than one	339
hundred eighty days after the date on which the borrower is	340
notified that the student loan was approved.	341

(S) Denying coverage, under any health insurance or health	342
care policy, contract, or plan providing family coverage, to any	343
natural or adopted child of the named insured or subscriber solely	344
on the basis that the child does not reside in the household of	345
the named insured or subscriber.	346

(T)(1) Using any underwriting standard or engaging in any	347
other act or practice that, directly or indirectly, due solely to	348
any health status-related factor in relation to one or more	349
individuals, does either of the following:	350

(a) Terminates or fails to renew an existing individual	351
policy, contract, or plan of health benefits, or a health benefit	352
plan issued to an employer, for which an individual would	353
otherwise be eligible;	354

(b) With respect to a health benefit plan issued to an	355
employer, excludes or causes the exclusion of an individual from	356
coverage under an existing employer-provided policy, contract, or	357
plan of health benefits.	358

(2) The superintendent of insurance may adopt rules in	359
accordance with Chapter 119. of the Revised Code for purposes of	360
implementing division (T)(1) of this section.	361

(3) For purposes of division (T)(1) of this section, "health	362
status-related factor" means any of the following:	363

(a) Health status;

364

(b) Medical condition, including both physical and mental	365
illnesses;	366

(c) Claims experience;

367

(d) Receipt of health care;

368

(e) Medical history;

369

(f) Genetic information;

370

(g) Evidence of insurability, including conditions arising	371
out of acts of domestic violence;	372

(h) Disability.

373

(U) With respect to a health benefit plan issued to a small	374
employer, as those terms are defined in section 3924.01 of the	375
Revised Code, negligently or willfully placing coverage for	376
adverse risks with a certain carrier, as defined in section	377
3924.01 of the Revised Code.	378

(V) Using any program, scheme, device, or other unfair act or	379
practice that, directly or indirectly, causes or results in the	380
placing of coverage for adverse risks with another carrier, as	381
defined in section 3924.01 of the Revised Code.	382

(W) Failing to comply with section 3923.23, 3923.231,	383
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging in	384
any unfair, discriminatory reimbursement practice.	385

(X) Intentionally establishing an unfair premium for, or	386
misrepresenting the cost of, any insurance policy financed under a	387
premium finance agreement of an insurance premium finance company.	388

(Y)(1)(a) Limiting coverage under, refusing to issue,	389
canceling, or refusing to renew, any individual policy or contract	390
of life insurance, or limiting coverage under or refusing to issue	391
any individual policy or contract of health insurance, for the	392
reason that the insured or applicant for insurance is or has been	393
a victim of domestic violence;	394

(b) Adding a surcharge or rating factor to a premium of any	395
individual policy or contract of life or health insurance for the	396
reason that the insured or applicant for insurance is or has been	397
a victim of domestic violence;	398

(c) Denying coverage under, or limiting coverage under, any	399
policy or contract of life or health insurance, for the reason	400
that a claim under the policy or contract arises from an incident	401
of domestic violence;	402

(d) Inquiring, directly or indirectly, of an insured under,	403
or of an applicant for, a policy or contract of life or health	404
insurance, as to whether the insured or applicant is or has been a	405
victim of domestic violence, or inquiring as to whether the	406
insured or applicant has sought shelter or protection from	407
domestic violence or has sought medical or psychological treatment	408
as a victim of domestic violence.	409

(2) Nothing in division (Y)(1) of this section shall be	410
construed to prohibit an insurer from inquiring as to, or from	411
underwriting or rating a risk on the basis of, a person's physical	412
or mental condition, even if the condition has been caused by	413
domestic violence, provided that all of the following apply:	414

(a) The insurer routinely considers the condition in	415
underwriting or in rating risks, and does so in the same manner	416
for a victim of domestic violence as for an insured or applicant	417
who is not a victim of domestic violence;	418

(b) The insurer does not refuse to issue any policy or	419
contract of life or health insurance or cancel or refuse to renew	420
any policy or contract of life insurance, solely on the basis of	421
the condition, except where such refusal to issue, cancellation,	422
or refusal to renew is based on sound actuarial principles or is	423
related to actual or reasonably anticipated experience;	424

(c) The insurer does not consider a person's status as being	425
or as having been a victim of domestic violence, in itself, to be	426
a physical or mental condition;	427

(d) The underwriting or rating of a risk on the basis of the	428
condition is not used to evade the intent of division (Y)(1) of	429
this section, or of any other provision of the Revised Code.	430

(3)(a) Nothing in division (Y)(1) of this section shall be	431
construed to prohibit an insurer from refusing to issue a policy	432
or contract of life insurance insuring the life of a person who is	433
or has been a victim of domestic violence if the person who	434
committed the act of domestic violence is the applicant for the	435
insurance or would be the owner of the insurance policy or	436
contract.	437

(b) Nothing in division (Y)(2) of this section shall be	438
construed to permit an insurer to cancel or refuse to renew any	439
policy or contract of health insurance in violation of the "Health	440
Insurance Portability and Accountability Act of 1996," 110 Stat.	441
1955, 42 U.S.C.A. 300gg-41(b), as amended, or in a manner that	442
violates or is inconsistent with any provision of the Revised Code	443
that implements the "Health Insurance Portability and	444
Accountability Act of 1996."	445

(4) An insurer is immune from any civil or criminal liability	446
that otherwise might be incurred or imposed as a result of any	447
action taken by the insurer to comply with division (Y) of this	448
section.	449

(5) As used in division (Y) of this section, "domestic	450
violence" means any of the following acts:	451

(a) Knowingly causing or attempting to cause physical harm to	452
a family or household member;	453

(b) Recklessly causing serious physical harm to a family or	454
household member;	455

(c) Knowingly causing, by threat of force, a family or	456
household member to believe that the person will cause imminent	457
physical harm to the family or household member.	458

For the purpose of division (Y)(5) of this section, "family	459
or household member" has the same meaning as in section 2919.25 of	460
the Revised Code.	461

Nothing in division (Y)(5) of this section shall be construed	462
to require, as a condition to the application of division (Y) of	463
this section, that the act described in division (Y)(5) of this	464
section be the basis of a criminal prosecution.	465

(Z) Disclosing a coroner's records by an insurer in violation	466
of section 313.10 of the Revised Code.	467

(AA) Making, issuing, circulating, or causing or permitting	468
to be made, issued, or circulated any statement or representation	469
that a life insurance policy or annuity is a contract for the	470
purchase of funeral goods or services.	471

(BB)(1) Setting or requiring the insurer's approval of fees	472
for dental services that are not covered dental services, as	473
defined in section 3963.01 of the Revised Code, or making	474
available any health benefit plan that sets fees for dental	475
services that are not covered dental care services.	476

(2) Nothing in division (BB)(1) of this section shall be	477
construed to apply to any health benefit plan subject to	478
regulation by the "Employee Retirement Income Security Act of	479
1974," 88 Stat. 832, 29 U.S.C. 1001, et seq., as amended.	480

With respect to private passenger automobile insurance, no	481
insurer shall charge different premium rates to persons residing	482
within the limits of any municipal corporation based solely on the	483
location of the residence of the insured within those limits.	484

The enumeration in sections 3901.19 to 3901.26 of the Revised	485
Code of specific unfair or deceptive acts or practices in the	486
business of insurance is not exclusive or restrictive or intended	487
to limit the powers of the superintendent of insurance to adopt	488
rules to implement this section, or to take action under other	489
sections of the Revised Code.	490

This section does not prohibit the sale of shares of any	491
investment company registered under the "Investment Company Act of	492
1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any	493
policies, annuities, or other contracts described in section	494
3907.15 of the Revised Code.	495

As used in this section, "estimate," "statement,"	496
"representation," "misrepresentation," "advertisement," or	497
"announcement" includes oral or written occurrences.	498

Sec. 3963.01. As used in this chapter:

499

(A) "Affiliate" means any person or entity that has ownership	500
or control of a contracting entity, is owned or controlled by a	501
contracting entity, or is under common ownership or control with a	502
contracting entity.	503

(B) "Basic health care services" has the same meaning as in	504
division (A) of section 1751.01 of the Revised Code, except that	505
it does not include any services listed in that division that are	506
provided by a pharmacist or nursing home.	507

(C) "Contracting entity" means any person that has a primary	508
business purpose of contracting with participating providers for	509
the delivery of health care services.	510

(D) "Covered dental services" means dental services that meet	511
both of the following criteria:	512

(1) Dental services for which a reimbursement is available	513
under an enrollee's health benefit plan contract, or for which a	514
reimbursement would be available but for the application of	515
contractual limitations such as a deductible, copayment,	516
coinsurance, waiting period, annual or lifetime maximum, frequency	517
limitation, alternative benefit payment, or any other limitation;	518

(2) Dental services for which the available reimbursement	519
under an enrollee's health benefit plan contract is more than	520
fifty per cent of the provider's prevailing fee for those	521
services.	522

(E) "Credentialing" means the process of assessing and	523
validating the qualifications of a provider applying to be	524
approved by a contracting entity to provide basic health care	525
services, specialty health care services, or supplemental health	526
care services to enrollees.	527

(E)(F) "Edit" means adjusting one or more procedure codes	528
billed by a participating provider on a claim for payment or a	529
practice that results in any of the following:	530

(1) Payment for some, but not all of the procedure codes	531
originally billed by a participating provider;	532

(2) Payment for a different procedure code than the procedure	533
code originally billed by a participating provider;	534

(3) A reduced payment as a result of services provided to an	535
enrollee that are claimed under more than one procedure code on	536
the same service date.	537

(F)(G) "Electronic claims transport" means to accept and	538
digitize claims or to accept claims already digitized, to place	539
those claims into a format that complies with the electronic	540
transaction standards issued by the United States department of	541
health and human services pursuant to the "Health Insurance	542
Portability and Accountability Act of 1996," 110 Stat. 1955, 42	543
U.S.C. 1320d, et seq., as those electronic standards are	544
applicable to the parties and as those electronic standards are	545
updated from time to time, and to electronically transmit those	546
claims to the appropriate contracting entity, payer, or	547
third-party administrator.	548

(G)(H) "Enrollee" means any person eligible for health care	549
benefits under a health benefit plan, including an eligible	550
recipient of medicaid under Chapter 5111. of the Revised Code, and	551
includes all of the following terms:	552

(1) "Enrollee" and "subscriber" as defined by section 1751.01	553
of the Revised Code;	554

(2) "Member" as defined by section 1739.01 of the Revised	555
Code;	556

(3) "Insured" and "plan member" pursuant to Chapter 3923. of	557
the Revised Code;	558

(4) "Beneficiary" as defined by section 3901.38 of the	559
Revised Code.	560

(H)(I) "Health care contract" means a contract entered into,	561
materially amended, or renewed between a contracting entity and a	562
participating provider for the delivery of basic health care	563
services, specialty health care services, or supplemental health	564
care services to enrollees.	565

(I)(J) "Health care services" means basic health care	566
services, specialty health care services, and supplemental health	567
care services.	568

(J)(K) "Material amendment" means an amendment to a health	569
care contract that decreases the participating provider's payment	570
or compensation, changes the administrative procedures in a way	571
that may reasonably be expected to significantly increase the	572
provider's administrative expenses, or adds a new product. A	573
material amendment does not include any of the following:	574

(1) A decrease in payment or compensation resulting solely	575
from a change in a published fee schedule upon which the payment	576
or compensation is based and the date of applicability is clearly	577
identified in the contract;	578

(2) A decrease in payment or compensation that was	579
anticipated under the terms of the contract, if the amount and	580
date of applicability of the decrease is clearly identified in the	581
contract;	582

(3) An administrative change that may significantly increase	583
the provider's administrative expense, the specific applicability	584
of which is clearly identified in the contract;	585

(4) Changes to an existing prior authorization,	586
precertification, notification, or referral program that do not	587
substantially increase the provider's administrative expense;	588

(5) Changes to an edit program or to specific edits if the	589
participating provider is provided notice of the changes pursuant	590
to division (A)(1) of section 3963.04 of the Revised Code and the	591
notice includes information sufficient for the provider to	592
determine the effect of the change;	593

(6) Changes to a health care contract described in division	594
(B) of section 3963.04 of the Revised Code.	595

(K)(L) "Participating provider" means a provider that has a	596
health care contract with a contracting entity and is entitled to	597
reimbursement for health care services rendered to an enrollee	598
under the health care contract.	599

(L)(M) "Payer" means any person that assumes the financial	600
risk for the payment of claims under a health care contract or the	601
reimbursement for health care services provided to enrollees by	602
participating providers pursuant to a health care contract.	603

(M)(N) "Primary enrollee" means a person who is responsible	604
for making payments for participation in a health care plan or an	605
enrollee whose employment or other status is the basis of	606
eligibility for enrollment in a health care plan.	607

(N)(O) "Procedure codes" includes the American medical	608
association's current procedural terminology code, the American	609
dental association's current dental terminology, and the centers	610
for medicare and medicaid services health care common procedure	611
coding system.	612

(O)(P) "Product" means one of the following types of	613
categories of coverage for which a participating provider may be	614
obligated to provide health care services pursuant to a health	615
care contract:	616

(1) A health maintenance organization or other product	617
provided by a health insuring corporation;	618

(2) A preferred provider organization;

619

(3) Medicare;

620

(4) Medicaid;

621

(5) Workers' compensation.

622

(P)(Q) "Provider" means a physician, podiatrist, dentist,	623
chiropractor, optometrist, psychologist, physician assistant,	624
advanced practice nurse, occupational therapist, massage	625
therapist, physical therapist, professional counselor,	626
professional clinical counselor, hearing aid dealer, orthotist,	627
prosthetist, home health agency, hospice care program, or	628
hospital, or a provider organization or physician-hospital	629
organization that is acting exclusively as an administrator on	630
behalf of a provider to facilitate the provider's participation in	631
health care contracts. "Provider" does not mean a pharmacist,	632
pharmacy, nursing home, or a provider organization or	633
physician-hospital organization that leases the provider	634
organization's or physician-hospital organization's network to a	635
third party or contracts directly with employers or health and	636
welfare funds.	637

(Q)(R) "Specialty health care services" has the same meaning	638
as in section 1751.01 of the Revised Code, except that it does not	639
include any services listed in division (B) of section 1751.01 of	640
the Revised Code that are provided by a pharmacist or a nursing	641
home.	642

(R)(S) "Supplemental health care services" has the same	643
meaning as in division (B) of section 1751.01 of the Revised Code,	644
except that it does not include any services listed in that	645
division that are provided by a pharmacist or nursing home.	646

Sec. 3963.02. (A)(1) No contracting entity shall sell, rent,	647
or give a third party the contracting entity's rights to a	648
participating provider's services pursuant to the contracting	649
entity's health care contract with the participating provider	650
unless one of the following applies:	651

(a) The third party accessing the participating provider's	652
services under the health care contract is an employer or other	653
entity providing coverage for health care services to its	654
employees or members, and that employer or entity has a contract	655
with the contracting entity or its affiliate for the	656
administration or processing of claims for payment for services	657
provided pursuant to the health care contract with the	658
participating provider.	659

(b) The third party accessing the participating provider's	660
services under the health care contract either is an affiliate or	661
subsidiary of the contracting entity or is providing	662
administrative services to, or receiving administrative services	663
from, the contracting entity or an affiliate or subsidiary of the	664
contracting entity.	665

(c) The health care contract specifically provides that it	666
applies to network rental arrangements and states that one purpose	667
of the contract is selling, renting, or giving the contracting	668
entity's rights to the services of the participating provider,	669
including other preferred provider organizations, and the third	670
party accessing the participating provider's services is any of	671
the following:	672

(i) A payer or a third-party administrator or other entity	673
responsible for administering claims on behalf of the payer;	674

(ii) A preferred provider organization or preferred provider	675
network that receives access to the participating provider's	676
services pursuant to an arrangement with the preferred provider	677
organization or preferred provider network in a contract with the	678
participating provider that is in compliance with division	679
(A)(1)(c) of this section, and is required to comply with all of	680
the terms, conditions, and affirmative obligations to which the	681
originally contracted primary participating provider network is	682
bound under its contract with the participating provider,	683
including, but not limited to, obligations concerning patient	684
steerage and the timeliness and manner of reimbursement.	685

(iii) An entity that is engaged in the business of providing	686
electronic claims transport between the contracting entity and the	687
payer or third-party administrator and complies with all of the	688
applicable terms, conditions, and affirmative obligations of the	689
contracting entity's contract with the participating provider	690
including, but not limited to, obligations concerning patient	691
steerage and the timeliness and manner of reimbursement.	692

(2) The contracting entity that sells, rents, or gives the	693
contracting entity's rights to the participating provider's	694
services pursuant to the contracting entity's health care contract	695
with the participating provider as provided in division (A)(1) of	696
this section shall do both of the following:	697

(a) Maintain a web page that contains a listing of third	698
parties described in divisions (A)(1)(b) and (c) of this section	699
with whom a contracting entity contracts for the purpose of	700
selling, renting, or giving the contracting entity's rights to the	701
services of participating providers that is updated at least every	702
six months and is accessible to all participating providers, or	703
maintain a toll-free telephone number accessible to all	704
participating providers by means of which participating providers	705
may access the same listing of third parties;	706

(b) Require that the third party accessing the participating	707
provider's services through the participating provider's health	708
care contract is obligated to comply with all of the applicable	709
terms and conditions of the contract, including, but not limited	710
to, the products for which the participating provider has agreed	711
to provide services, except that a payer receiving administrative	712
services from the contracting entity or its affiliate shall be	713
solely responsible for payment to the participating provider.	714

(3) Any information disclosed to a participating provider	715
under this section shall be considered proprietary and shall not	716
be distributed by the participating provider.	717

(4) Except as provided in division (A)(1) of this section, no	718
entity shall sell, rent, or give a contracting entity's rights to	719
the participating provider's services pursuant to a health care	720
contract.	721

(B)(1) No contracting entity shall require, as a condition of	722
contracting with the contracting entity, that a participating	723
provider provide services for all of the products offered by the	724
contracting entity.	725

(2) Division (B)(1) of this section shall not be construed to	726
do any of the following:	727

(a) Prohibit any participating provider from voluntarily	728
accepting an offer by a contracting entity to provide health care	729
services under all of the contracting entity's products;	730

(b) Prohibit any contracting entity from offering any	731
financial incentive or other form of consideration specified in	732
the health care contract for a participating provider to provide	733
health care services under all of the contracting entity's	734
products;	735

(c) Require any contracting entity to contract with a	736
participating provider to provide health care services for less	737
than all of the contracting entity's products if the contracting	738
entity does not wish to do so.	739

(3)(a) Notwithstanding division (B)(2) of this section, no	740
contracting entity shall require, as a condition of contracting	741
with the contracting entity, that the participating provider	742
accept any future product offering that the contracting entity	743
makes.	744

(b) If a participating provider refuses to accept any future	745
product offering that the contracting entity makes, the	746
contracting entity may terminate the health care contract based on	747
the participating provider's refusal upon written notice to the	748
participating provider no sooner than one hundred eighty days	749
after the refusal.	750

(4) Once the contracting entity and the participating	751
provider have signed the health care contract, it is presumed that	752
the financial incentive or other form of consideration that is	753
specified in the health care contract pursuant to division	754
(B)(2)(b) of this section is the financial incentive or other form	755
of consideration that was offered by the contracting entity to	756
induce the participating provider to enter into the contract.	757

(C) No contracting entity shall require, as a condition of	758
contracting with the contracting entity, that a participating	759
provider waive or forego any right or benefit expressly conferred	760
upon a participating provider by state or federal law. However,	761
this division does not prohibit a contracting entity from	762
restricting a participating provider's scope of practice for the	763
services to be provided under the contract.	764

(D) No health care contract shall do any of the following:

765

(1) Prohibit any participating provider from entering into a	766
health care contract with any other contracting entity;	767

(2) Prohibit any contracting entity from entering into a	768
health care contract with any other provider;	769

(3) Preclude its use or disclosure for the purpose of	770
enforcing this chapter or other state or federal law, except that	771
a health care contract may require that appropriate measures be	772
taken to preserve the confidentiality of any proprietary or	773
trade-secret information.	774

(E)(1) No contracting entity shall require in any health care	775
contract that covers any dental services, either directly or	776
indirectly, that a participating provider who is a dentist provide	777
services to an enrollee at a fee set by, or a fee subject to the	778
approval of, the contracting entity unless the dental services are	779
covered dental services.	780

(2) To the extent that the provisions in division (E)(1) of	781
this section conflict with the provisions of the federal "Employee	782
Retirement Income Security Act of 1974," 88 Stat. 832, 29 U.S.C.	783
1001, et seq., as amended, the federal law shall control.	784

(F)(1) In addition to any other lawful reasons for	785
terminating a health care contract, a health care contract may	786
only be terminated under the circumstances described in division	787
(A)(3) of section 3963.04 of the Revised Code.	788

(2) If the health care contract provides for termination for	789
cause by either party, the health care contract shall state the	790
reasons that may be used for termination for cause, which terms	791
shall be reasonable. Once the contracting entity and the	792
participating provider have signed the health care contract, it is	793
presumed that the reasons stated in the health care contract for	794
termination for cause by either party are reasonable. Subject to	795
division (E)(F)(3) of this section, the health care contract shall	796
state the time by which the parties must provide notice of	797
termination for cause and to whom the parties shall give the	798
notice.	799

(3) Nothing in divisions (E)(F)(1) and (2) of this section	800
shall be construed as prohibiting any health insuring corporation	801
from terminating a participating provider's contract for any of	802
the causes described in divisions (A), (D), and (F)(1) and (2) of	803
section 1753.09 of the Revised Code. Notwithstanding any provision	804
in a health care contract pursuant to division (E)(F)(2) of this	805
section, section 1753.09 of the Revised Code applies to the	806
termination of a participating provider's contract for any of the	807
causes described in divisions (A), (D), and (F)(1) and (2) of	808
section 1753.09 of the Revised Code.	809

(4) Subject to sections 3963.01 to 3963.11 of the Revised	810
Code, nothing in this section prohibits the termination of a	811
health care contract without cause if the health care contract	812
otherwise provides for termination without cause.	813

(F)(G)(1) Disputes among parties to a health care contract	814
that only concern the enforcement of the contract rights conferred	815
by section 3963.02, divisions (A) and (D) of section 3963.03, and	816
section 3963.04 of the Revised Code are subject to a mutually	817
agreed upon arbitration mechanism that is binding on all parties.	818
The arbitrator may award reasonable attorney's fees and costs for	819
arbitration relating to the enforcement of this section to the	820
prevailing party.	821

(2) The arbitrator shall make the arbitrator's decision in an	822
arbitration proceeding having due regard for any applicable rules,	823
bulletins, rulings, or decisions issued by the department of	824
insurance or any court concerning the enforcement of the contract	825
rights conferred by section 3963.02, divisions (A) and (D) of	826
section 3963.03, and section 3963.04 of the Revised Code.	827

(3) A party shall not simultaneously maintain an arbitration	828
proceeding as described in division (F)(G)(1) of this section and	829
pursue a complaint with the superintendent of insurance to	830
investigate the subject matter of the arbitration proceeding.	831
However, if a complaint is filed with the department of insurance,	832
the superintendent may choose to investigate the complaint or,	833
after reviewing the complaint, advise the complainant to proceed	834
with arbitration to resolve the complaint. The superintendent may	835
request to receive a copy of the results of the arbitration. If	836
the superintendent of insurance notifies an insurer or a health	837
insuring corporation in writing that the superintendent has	838
initiated a market conduct examination into the specific subject	839
matter of the arbitration proceeding pending against that insurer	840
or health insuring corporation, the arbitration proceeding shall	841
be stayed at the request of the insurer or health insuring	842
corporation pending the outcome of the market conduct	843
investigation by the superintendent.	844

Sec. 3963.03. (A) Each health care contract shall include all	845
of the following information:	846

(1)(a) Information sufficient for the participating provider	847
to determine the compensation or payment terms for health care	848
services, including all of the following, subject to division	849
(A)(1)(b) of this section:	850

(i) The manner of payment, such as fee-for-service,	851
capitation, or risk;	852

(ii) The fee schedule of procedure codes reasonably expected	853
to be billed by a participating provider's specialty for services	854
provided pursuant to the health care contract and the associated	855
payment or compensation for each procedure code. A fee schedule	856
may be provided electronically. Upon request, a contracting entity	857
shall provide a participating provider with the fee schedule for	858
any other procedure codes requested and a written fee schedule,	859
that shall not be required more frequently than twice per year	860
excluding when it is provided in connection with any change to the	861
schedule. This requirement may be satisfied by providing a clearly	862
understandable, readily available mechanism, such as a specific	863
web site address, that allows a participating provider to	864
determine the effect of procedure codes on payment or compensation	865
before a service is provided or a claim is submitted.	866

(iii) The effect, if any, on payment or compensation if more	867
than one procedure code applies to the service also shall be	868
stated. This requirement may be satisfied by providing a clearly	869
understandable, readily available mechanism, such as a specific	870
web site address, that allows a participating provider to	871
determine the effect of procedure codes on payment or compensation	872
before a service is provided or a claim is submitted.	873

(b) If the contracting entity is unable to include the	874
information described in divisiondivisions (A)(1)(a)(ii) and	875
(iii) of this section, the contracting entity shall include both	876
of the following types of information instead:	877

(i) The methodology used to calculate any fee schedule, such	878
as relative value unit system and conversion factor or percentage	879
of billed charges. If applicable, the methodology disclosure shall	880
include the name of any relative value unit system, its version,	881
edition, or publication date, any applicable conversion or	882
geographic factor, and any date by which compensation or fee	883
schedules may be changed by the methodology as anticipated at the	884
time of contract.	885

(ii) The identity of any internal processing edits, including	886
the publisher, product name, version, and version update of any	887
editing software.	888

(c) If the contracting entity is not the payer and is unable	889
to include the information described in division (A)(1)(a) or (b)	890
of this section, then the contracting entity shall provide by	891
telephone a readily available mechanism, such as a specific web	892
site address, that allows the participating provider to obtain	893
that information from the payer.	894

(2) Any product or network for which the participating	895
provider is to provide services;	896

(3) The term of the health care contract;

897

(4) A specific web site address that contains the identity of	898
the contracting entity or payer responsible for the processing of	899
the participating provider's compensation or payment;	900

(5) Any internal mechanism provided by the contracting entity	901
to resolve disputes concerning the interpretation or application	902
of the terms and conditions of the contract. A contracting entity	903
may satisfy this requirement by providing a clearly	904
understandable, readily available mechanism, such as a specific	905
web site address or an appendix, that allows a participating	906
provider to determine the procedures for the internal mechanism to	907
resolve those disputes.	908

(6) A list of addenda, if any, to the contract.

909

(B)(1) Each contracting entity shall include a summary	910
disclosure form with a health care contract that includes all of	911
the information specified in division (A) of this section. The	912
information in the summary disclosure form shall refer to the	913
location in the health care contract, whether a page number,	914
section of the contract, appendix, or other identifiable location,	915
that specifies the provisions in the contract to which the	916
information in the form refers.	917

(2) The summary disclosure form shall include all of the	918
following statements:	919

(a) That the form is a guide to the health care contract and	920
that the terms and conditions of the health care contract	921
constitute the contract rights of the parties;	922

(b) That reading the form is not a substitute for reading the	923
entire health care contract;	924

(c) That by signing the health care contract, the	925
participating provider will be bound by the contract's terms and	926
conditions;	927

(d) That the terms and conditions of the health care contract	928
may be amended pursuant to section 3963.04 of the Revised Code and	929
the participating provider is encouraged to carefully read any	930
proposed amendments sent after execution of the contract;	931

(e) That nothing in the summary disclosure form creates any	932
additional rights or causes of action in favor of either party.	933

(3) No contracting entity that includes any information in	934
the summary disclosure form with the reasonable belief that the	935
information is truthful or accurate shall be subject to a civil	936
action for damages or to binding arbitration based on the summary	937
disclosure form. Division (B)(3) of this section does not impair	938
or affect any power of the department of insurance to enforce any	939
applicable law.	940

(4) The summary disclosure form described in divisions (B)(1)	941
and (2) of this section shall be in substantially the following	942
form:	943

"SUMMARY DISCLOSURE FORM	944

(1) Compensation terms

945

(a) Manner of payment

946

[ ] Fee for service

947

[ ] Capitation

948

[ ] Risk

949

[ ] Other ............... See ...............

950

(b) Fee schedule available at ...............

951

(c) Fee calculation schedule available at ...............

952

(d) Identity of internal processing edits available at	953
...............	954

(e) Information in (c) and (d) is not required if information	955
in (b) is provided.	956

(2) List of products or networks covered by this contract

957

[ ] ...............

958

[ ] ...............

959

[ ] ...............

960

[ ] ...............

961

[ ] ...............

962

(3) Term of this contract ...............

963

(4) Contracting entity or payer responsible for processing	964
payment available at ...............	965

(5) Internal mechanism for resolving disputes regarding	966
contract terms available at ...............	967

(6) Addenda to contract

968

Title           Subject

969

(a)

970

(b)

971

(c)

972

(d)

973

(7) Telephone number to access a readily available mechanism,	974
such as a specific web site address, to allow a participating	975
provider to receive the information in (1) through (6) from the	976
payer.	977

IMPORTANT INFORMATION - PLEASE READ CAREFULLY	978

The information provided in this Summary Disclosure Form is a	979
guide to the attached Health Care Contract as defined in section	980
3963.01(G)3963.01(I) of the Ohio Revised Code. The terms and	981
conditions of the attached Health Care Contract constitute the	982
contract rights of the parties.	983

Reading this Summary Disclosure Form is not a substitute for	984
reading the entire Health Care Contract. When you sign the Health	985
Care Contract, you will be bound by its terms and conditions.	986
These terms and conditions may be amended over time pursuant to	987
section 3963.04 of the Ohio Revised Code. You are encouraged to	988
read any proposed amendments that are sent to you after execution	989
of the Health Care Contract.	990

Nothing in this Summary Disclosure Form creates any	991
additional rights or causes of action in favor of either party."	992

(C) When a contracting entity presents a proposed health care	993
contract for consideration by a provider, the contracting entity	994
shall provide in writing or make reasonably available the	995
information required in division (A)(1) of this section.	996

(D) The contracting entity shall identify any utilization	997
management, quality improvement, or a similar program that the	998
contracting entity uses to review, monitor, evaluate, or assess	999
the services provided pursuant to a health care contract. The	1000
contracting entity shall disclose the policies, procedures, or	1001
guidelines of such a program applicable to a participating	1002
provider upon request by the participating provider within	1003
fourteen days after the date of the request.	1004

(E) Nothing in this section shall be construed as preventing	1005
or affecting the application of section 1753.07 of the Revised	1006
Code that would otherwise apply to a contract with a participating	1007
provider.	1008

(F) The requirements of division (C) of this section do not	1009
prohibit a contracting entity from requiring a reasonable	1010
confidentiality agreement between the provider and the contracting	1011
entity regarding the terms of the proposed health care contract.	1012
If either party violates the confidentiality agreement, a party to	1013
the confidentiality agreement may bring a civil action to enjoin	1014
the other party from continuing any act that is in violation of	1015
the confidentiality agreement, to recover damages, to terminate	1016
the contract, or to obtain any combination of relief.	1017

Section 2. That existing sections 1753.07, 1753.09, 3901.21,	1018
3963.01, 3963.02, and 3963.03 of the Revised Code are hereby	1019
repealed.	1020