(B) A multiple employer welfare arrangement that is created | 21 |
pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 22 |
that operates a group self-insurance program shall comply with all | 23 |
laws applicable to self-funded programs in this state, including | 24 |
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 25 |
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 26 |
3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, | 27 |
3923.80, 3924.031, 3924.032, and 3924.27 of the Revised Code. | 28 |
(D) A multiple employer welfare arrangement created pursuant | 34 |
to sections 1739.01 to 1739.22 of the Revised Code shall provide | 35 |
benefits only to individuals who are members, employees of | 36 |
members, or the dependents of members or employees, or are | 37 |
eligible for continuation of coverage under section 1751.53 or | 38 |
3923.38 of the Revised Code or under Title X of the "Consolidated | 39 |
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 40 |
U.S.C.A. 1161, as amended. | 41 |
Sec. 1751.14. (A) Notwithstanding section 3901.71 of the | 42 |
Revised Code, any policy, contract, or agreement for health care | 43 |
services authorized by this chapter that is issued, delivered, or | 44 |
renewed in this state and that provides that coverage of an | 45 |
unmarried dependent child will terminate upon attainment of the | 46 |
limiting age for dependent children specified in the policy, | 47 |
contract, or agreement, shall also provide in substance both of | 48 |
the following: | 49 |
(4) "Qualified unemployed person" means one who became | 113 |
unemployed while a resident of this state from employment or | 114 |
self-employment and has since been continuously unemployed or is | 115 |
employed only so that the person does not have, or have a right to | 116 |
purchase, group health coverage. An individual who is, or who | 117 |
becomes, covered by medicare is not a qualified unemployed person. | 118 |
A person eligible for coverage under this section, who is also | 119 |
eligible for continuation of coverage under section 1751.53 or | 120 |
3923.38 of the Revised Code, may elect either coverage, but not | 121 |
both. A person who elects continuation of coverage under either of | 122 |
such sections may, upon the termination of the continuation of | 123 |
coverage, elect any coverage available under this section. | 124 |
(B) Any insurer may join with one or more other insurers, in | 125 |
an association, to offer, sell, and issue to a policyholder or | 126 |
subscriber selected by the association a policy or contract of | 127 |
group health coverage, covering residents of this state who are | 128 |
qualified unemployed persons and the spouses or dependents of such | 129 |
residents. The coverage shall be offered, issued, and administered | 130 |
in the name of the association. Membership in the association | 131 |
shall be open to any insurer and each insurer which participates | 132 |
shall be liable for a specified percentage of the risks. The | 133 |
policy or contract may be executed on behalf of the association by | 134 |
a duly authorized person. | 135 |
(C) The persons eligible for coverage under the policy or | 136 |
contract shall be all residents of this state who are qualified | 137 |
unemployed persons and their spouses and dependents, subject to | 138 |
reasonable underwriting restrictions to be set forth in the plan | 139 |
of the association. The policy or contract may provide basic | 140 |
hospital and surgical coverage, basic medical coverage, major | 141 |
medical coverage, and any combination of these; provided that it | 142 |
shall not be required as a condition for obtaining major medical | 143 |
coverage that any basic coverage be taken. | 144 |
(D) The association shall file with the superintendent of | 145 |
insurance any policy, contract, certificate, or other evidence of | 146 |
coverage, application, or other forms pertaining to such insurance | 147 |
together with the premium rates to be charged therefor. The | 148 |
superintendent may approve, disapprove, and withdraw approval of | 149 |
the forms in accordance with section 3923.02 of the Revised Code, | 150 |
or the premium rates if by reasonable assumptions such rates are | 151 |
excessive in relation to the benefits provided. In determining | 152 |
whether such rates by reasonable assumptions are excessive in | 153 |
relation to the benefits provided, the superintendent shall give | 154 |
due consideration to past and prospective claim experience, within | 155 |
and outside this state, and to fluctuations in such claim | 156 |
experience, to a reasonable risk charge, to contribution to | 157 |
surplus and contingency funds, to past and prospective expenses, | 158 |
both within and outside this state, and to all other relevant | 159 |
factors within and outside this state, including any differing | 160 |
operating methods of the insurers joining in the issuance of the | 161 |
policy or contract. In reviewing the forms the superintendent | 162 |
shall not be bound by the requirements of sections 3923.04 to | 163 |
3923.07 of the Revised Code with respect to standard provisions to | 164 |
be included in sickness and accident policies or forms. | 165 |
(H) Under any policy issued as provided in this section, the | 181 |
policyholder, or such person as the policyholder shall designate, | 182 |
shall alone be a member of each domestic mutual insurance company | 183 |
joining in the issue of the policy and shall be entitled to one | 184 |
vote by virtue of such policy at the meetings of each such mutual | 185 |
insurance company. Notice of the annual meetings of each such | 186 |
mutual insurance company may be given by written notice to the | 187 |
policyholder or as otherwise prescribed in said policy. | 188 |
Sec. 3923.24. (A) Notwithstanding section 3901.71 of the | 189 |
Revised Code, every certificate furnished by an insurer in | 190 |
connection with, or pursuant to any provision of, any group | 191 |
sickness and accident insurance policy delivered, issued for | 192 |
delivery, renewed, or used in this state on or after January 1, | 193 |
1972, every policy of sickness and accident insurance delivered, | 194 |
issued for delivery, renewed, or used in this state on or after | 195 |
January 1, 1972, and every multiple employer welfare arrangement | 196 |
offering an insurance program, which provides that coverage of an | 197 |
unmarried dependent child of a parent or legal guardian will | 198 |
terminate upon attainment of the limiting age for dependent | 199 |
children specified in the contract shall also provide in substance | 200 |
both of the following: | 201 |
(B) Proof of such incapacity and dependence for purposes of | 225 |
division (A)(2) of this section shall be furnished by the | 226 |
policyholder or by the certificate holder to the insurer within | 227 |
thirty-one days of the child's attainment of the limiting age. | 228 |
Upon request, but not more frequently than annually after the | 229 |
two-year period following the child's attainment of the limiting | 230 |
age, the insurer may require proof satisfactory to it of the | 231 |
continuance of such incapacity and dependency. | 232 |
(C) Nothing in this section shall require an insurer to cover | 233 |
a dependent child who is mentally retarded or physically | 234 |
handicapped if the contract is underwritten on evidence of | 235 |
insurability based on health factors set forth in the application, | 236 |
or if such dependent child does not satisfy the conditions of the | 237 |
contract as to any requirement for evidence of insurability or | 238 |
other provision of the contract, satisfaction of which is required | 239 |
for coverage thereunder to take effect. In any such case, the | 240 |
terms of the contract shall apply with regard to the coverage or | 241 |
exclusion of the dependent from such coverage. Nothing in this | 242 |
section shall apply to accidental death or dismemberment benefits | 243 |
provided by any such policy of sickness and accident insurance. | 244 |
(E) This section does not apply to any policies or | 254 |
certificates covering only accident, credit, dental, disability | 255 |
income, long-term care, hospital indemnity, medicare supplement, | 256 |
specified disease, or vision care; coverage under a | 257 |
one-time-limited-duration policy of not longer than six months; | 258 |
coverage issued as a supplement to liability insurance; insurance | 259 |
arising out of a workers' compensation or similar law; automobile | 260 |
medical-payment insurance; or insurance under which benefits are | 261 |
payable with or without regard to fault and that is statutorily | 262 |
required to be contained in any liability insurance policy or | 263 |
equivalent self-insurance. | 264 |
(D) This section does not apply to any public employee | 316 |
benefit plan covering only accident, credit, dental, disability | 317 |
income, long-term care, hospital indemnity, medicare supplement, | 318 |
specified disease, or vision care; coverage under a | 319 |
one-time-limited-duration policy of not longer than six months; | 320 |
coverage issued as a supplement to liability insurance; insurance | 321 |
arising out of a workers' compensation or similar law; automobile | 322 |
medical-payment insurance; or insurance under which benefits are | 323 |
payable with or without regard to fault and which is statutorily | 324 |
required to be contained in any liability insurance policy or | 325 |
equivalent self-insurance. | 326 |
(A) "Actuarial certification" means a written statement | 335 |
prepared by a member of the American academy of actuaries, or by | 336 |
any other person acceptable to the superintendent of insurance, | 337 |
that states that, based upon the person's examination, a carrier | 338 |
offering health benefit plans to small employers is in compliance | 339 |
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial | 340 |
certification" shall include a review of the appropriate records | 341 |
of, and the actuarial assumptions and methods used by, the carrier | 342 |
relative to establishing premium rates for the health benefit | 343 |
plans. | 344 |
(D) "Carrier" means any sickness and accident insurance | 358 |
company or health insuring corporation authorized to issue health | 359 |
benefit plans in this state or a MEWA. A sickness and accident | 360 |
insurance company that owns or operates a health insuring | 361 |
corporation, either as a separate corporation or as a line of | 362 |
business, shall be considered as a separate carrier from that | 363 |
health insuring corporation for purposes of sections 3924.01 to | 364 |
3924.14 of the Revised Code. | 365 |
(E) "Case characteristics" means, with respect to a small | 366 |
employer, the geographic area in which the employees work; the age | 367 |
and sex of the individual employees and their dependents; the | 368 |
appropriate industry classification as determined by the carrier; | 369 |
the number of employees and dependents; and such other objective | 370 |
criteria as may be established by the carrier. "Case | 371 |
characteristics" does not include claims experience, health | 372 |
status, or duration of coverage from the date of issue. | 373 |
(H) "Health benefit plan" means any hospital or medical | 382 |
expense policy or certificate or any health plan provided by a | 383 |
carrier, that is delivered, issued for delivery, renewed, or used | 384 |
in this state on or after the date occurring six months after | 385 |
November 24, 1995. "Health benefit plan" does not include policies | 386 |
covering only accident, credit, dental, disability income, | 387 |
long-term care, hospital indemnity, medicare supplement, specified | 388 |
disease, or vision care; coverage under a | 389 |
one-time-limited-duration policy of no longer than six months; | 390 |
coverage issued as a supplement to liability insurance; insurance | 391 |
arising out of a workers' compensation or similar law; automobile | 392 |
medical-payment insurance; or insurance under which benefits are | 393 |
payable with or without regard to fault and which is statutorily | 394 |
required to be contained in any liability insurance policy or | 395 |
equivalent self-insurance. | 396 |
(I) "Late enrollee" means an eligible employee or dependent | 397 |
who enrolls in a small employer's health benefit plan other than | 398 |
during the first period in which the employee or dependent is | 399 |
eligible to enroll under the plan or during a special enrollment | 400 |
period described in section 2701(f) of the "Health Insurance | 401 |
Portability and Accountability Act of 1996," Pub. L. No. 104-191, | 402 |
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended. | 403 |
(L) "Pre-existing conditions provision" means a policy | 414 |
provision that excludes or limits coverage for charges or expenses | 415 |
incurred during a specified period following the insured's | 416 |
enrollment date as to a condition for which medical advice, | 417 |
diagnosis, care, or treatment was recommended or received during a | 418 |
specified period immediately preceding the enrollment date. | 419 |
Genetic information shall not be treated as such a condition in | 420 |
the absence of a diagnosis of the condition related to such | 421 |
information. | 422 |
(2) For purposes of division (N)(1) of this section, all | 437 |
persons treated as a single employer under subsection (b), (c), | 438 |
(m), or (o) of section 414 of the "Internal Revenue Code of 1986," | 439 |
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one | 440 |
employer. In the case of an employer that was not in existence | 441 |
throughout the preceding calendar year, the determination of | 442 |
whether the employer is a small or large employer shall be based | 443 |
on the average number of eligible employees that it is reasonably | 444 |
expected the employer will employ on business days in the current | 445 |
calendar year. Any reference in division (N) of this section to an | 446 |
"employer" includes any predecessor of the employer. Except as | 447 |
otherwise specifically provided, provisions of sections 3924.01 to | 448 |
3924.14 of the Revised Code that apply to a small employer that | 449 |
has a health benefit plan shall continue to apply until the plan | 450 |
anniversary following the date the employer no longer meets the | 451 |
requirements of this division. | 452 |
Section 3. Sections 1739.05, 1751.14, and 3924.01 as amended | 460 |
by this act, apply only to policies, contracts, and agreements | 461 |
that are delivered, issued for delivery, or renewed in this state | 462 |
on or after January 1, 2015. Sections 3923.123, 3923.24, and | 463 |
3923.241 as amended by this act, apply only to policies of | 464 |
sickness and accident insurance delivered, issued for delivery, or | 465 |
renewed in this state and public or private employee benefit plans | 466 |
that are established or modified in this state on or after January | 467 |
1, 2015. | 468 |
Section 4. (A) During the period beginning on January 1, | 469 |
2015, and ending January 1, 2018, the operation of sections | 470 |
1751.53 and
3923.38 of the Revised Code are suspended. | 471 |
Accordingly, group insurance contracts issued on or after January | 472 |
1, 2015, and before January 1, 2018, shall not be required to | 473 |
provide that any eligible employee, or the employee's dependents, | 474 |
may continue coverage under the contract. | 475 |
(B) If any portion of 42 U.S.C. 300gg-1 to 300gg-6 is amended | 476 |
or repealed in such a way as to nullify insurance requirements | 477 |
related to guaranteed availability of coverage or guaranteed | 478 |
renewal of health insurance, prior to January 1, 2018, then | 479 |
sections 1751.53 and 3923.38 of the Revised Code, in either their | 480 |
present form or as they are later amended, shall again become | 481 |
operational. | 482 |