As Passed by the House

130th General Assembly Regular Session 2013-2014

Am. H. B. No. 511

Representative Sears 

Cosponsors: Representatives Boose, Grossman, Henne, Romanchuk, Smith, Wachtmann, Young, Amstutz, Beck, Blessing, Burkley, Conditt, Green, Hackett, Hill, Scherer, Thompson Speaker Batchelder 

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A BILL

To amend sections 1739.061, 1751.14, 3923.022,

1

3923.24, 3923.241, 3923.281, 3923.57, 3923.58,

2

3923.601, 3923.65, 3923.83, and 3924.01, to enact

3

sections 505.377, 737.082, and 737.222 of the

4

Revised Code to clarify the status of volunteer

5

firefighters for purposes of the Patient

6

Protection and Affordable Care Act, to make

7

changes regarding coverage for a dependent child

8

under a parent's health insurance plan and the

9

hours of work needed to qualify for coverage under

10

a small employer health benefit plan, and to

11

increase the duration of the health insurance

12

considered to be short-term under certain

13

insurance laws.

14

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

Section 1. That sections 1739.061, 1751.14, 3923.022,	15
3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601, 3923.65,	16
3923.83, and 3924.01 be amended and sections 505.377, 737.082, and	17
737.222 of the Revised Code be enacted to read as follows:	18

Sec. 505.377.  A volunteer firefighter appointed pursuant to	19
this chapter is a bona fide volunteer and not an employee for	20
purposes of section 513 of the "Patient Protection and Affordable	21
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	22
providing those fire protection services, the volunteer receives	23
any of the benefits provided in Chapter 146., 4121., or 4123. or	24
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	25
Code.	26

Sec. 737.082.  A volunteer firefighter appointed pursuant to	27
this chapter is a bona fide volunteer and not an employee for	28
purposes of section 513 of the "Patient Protection and Affordable	29
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	30
providing those fire protection services, the volunteer receives	31
any of the benefits provided in Chapter 146., 4121., or 4123. or	32
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	33
Code.	34

Sec. 737.222.  A volunteer firefighter appointed pursuant to	35
this chapter is a bona fide volunteer and not an employee for	36
purposes of section 513 of the "Patient Protection and Affordable	37
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	38
providing those fire protection services, the volunteer receives	39
any of the benefits provided in Chapter 146., 4121., or 4123. or	40
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	41
Code.	42

Sec. 1739.061. (A)(1) This section applies to both of the	43
following:	44

(a) A multiple employer welfare arrangement that issues or	45
requires the use of a standardized identification card or an	46
electronic technology for submission and routing of prescription	47
drug claims;	48

(b) A person or entity that a multiple employer welfare	49
arrangement contracts with to issue a standardized identification	50
card or an electronic technology described in division (A)(1)(a)	51
of this section.	52

(2) Notwithstanding division (A)(1) of this section, this	53
section does not apply to the issuance or required use of a	54
standardized identification card or an electronic technology for	55
the submission and routing of prescription drug claims in	56
connection with any of the following:	57

(a) Any program or arrangement covering only accident,	58
credit, dental, disability income, long-term care, hospital	59
indemnity, medicare supplement, medicare, tricare, specified	60
disease, or vision care; coverage under a	61
one-time-limited-duration policy of not longerthat is less than	62
sixtwelve months; coverage issued as a supplement to liability	63
insurance; insurance arising out of workers' compensation or	64
similar law; automobile medical payment insurance; or insurance	65
under which benefits are payable with or without regard to fault	66
and which is statutorily required to be contained in any liability	67
insurance policy or equivalent self-insurance.	68

(b) Coverage provided under the medicaid program.

69

(c) Coverage provided under an employer's self-insurance plan	70
or by any of its administrators, as defined in section 3959.01 of	71
the Revised Code, to the extent that federal law supersedes,	72
preempts, prohibits, or otherwise precludes the application of	73
this section to the plan and its administrators.	74

(B) A standardized identification card or an electronic	75
technology issued or required to be used as provided in division	76
(A)(1) of this section shall contain uniform prescription drug	77
information in accordance with either division (B)(1) or (2) of	78
this section.	79

(1) The standardized identification card or the electronic	80
technology shall be in a format and contain information fields	81
approved by the national council for prescription drug programs or	82
a successor organization, as specified in the council's or	83
successor organization's pharmacy identification card	84
implementation guide in effect on the first day of October most	85
immediately preceding the issuance or required use of the	86
standardized identification card or the electronic technology.	87

(2) If the multiple employer welfare arrangement or person	88
under contract with it to issue a standardized identification card	89
or an electronic technology requires the information for the	90
submission and routing of a claim, the standardized identification	91
card or the electronic technology shall contain any of the	92
following information:	93

(a) The name of the multiple employer welfare arrangement;

94

(b) The individual's name, group number, and identification	95
number;	96

(c) A telephone number to inquire about pharmacy-related	97
issues;	98

(d) The issuer's international identification number, labeled	99
as "ANSI BIN" or "RxBIN";	100

(e) The processor's control number, labeled as "RxPCN";

101

(f) The individual's pharmacy benefits group number if	102
different from the insured's medical group number, labeled as	103
"RxGrp."	104

(C) If the standardized identification card or the electronic	105
technology issued or required to be used as provided in division	106
(A)(1) of this section is also used for submission and routing of	107
nonpharmacy claims, the designation "Rx" is required to be	108
included as part of the labels identified in divisions (B)(2)(d)	109
and (e) of this section if the issuer's international	110
identification number or the processor's control number is	111
different for medical and pharmacy claims.	112

(D) Each multiple employer welfare arrangement described in	113
division (A) of this section shall annually file a certificate	114
with the superintendent of insurance certifying that it or any	115
person it contracts with to issue a standardized identification	116
card or electronic technology for submission and routing of	117
prescription drug claims complies with this section.	118

(E)(1) Except as provided in division (E)(2) of this section,	119
if there is a change in the information contained in the	120
standardized identification card or the electronic technology	121
issued to an individual, the multiple employer welfare arrangement	122
or person under contract with it to issue a standardized	123
identification card or an electronic technology shall issue a new	124
card or electronic technology to the individual.	125

(2) A multiple employer welfare arrangement or person under	126
contract with it is not required under division (E)(1) of this	127
section to issue a new card or electronic technology to an	128
individual more than once during a twelve-month period.	129

(F) Nothing in this section shall be construed as requiring a	130
multiple employer welfare arrangement to produce more than one	131
standardized identification card or one electronic technology for	132
use by individuals accessing health care benefits provided under a	133
multiple employer welfare arrangement.	134

Sec. 1751.14.  (A) Notwithstanding section 3901.71 of the	135
Revised Code, any policy, contract, or agreement for health care	136
services authorized by this chapter that is issued, delivered, or	137
renewed in this state and that provides that coverage of an	138
unmarried dependent child will terminate upon attainment of the	139
limiting age for dependent children specified in the policy,	140
contract, or agreement, shall also provide in substance both of	141
the following:	142

(1) Once an unmarried child has attained the limiting age for	143
dependent children, as provided in the policy, contract, or	144
agreement, upon the request of the subscriber, the health insuring	145
corporation shall offer to cover the unmarried child until the	146
child attains twenty-eighttwenty-six years of age if all of the	147
following are true:	148

(a) The child is the natural child, stepchild, or adopted	149
child of the subscriber.	150

(b) The child is a resident of this state or a full-time	151
student at an accredited public or private institution of higher	152
education.	153

(c) The child is not employed by an employer that offers any	154
health benefit plan under which the child is eligible for	155
coverage.	156

(d) The child is not eligible for coverage under the medicaid	157
program or the medicare program.	158

(2) That attainment of the limiting age for dependent	159
children shall not operate to terminate the coverage of a	160
dependent child if the child is and continues to be both of the	161
following:	162

(a) Incapable of self-sustaining employment by reason of	163
mental retardation or physical handicap;	164

(b) Primarily dependent upon the subscriber for support and	165
maintenance.	166

(B) Proof of incapacity and dependence for purposes of	167
division (A)(2) of this section shall be furnished to the health	168
insuring corporation within thirty-one days of the child's	169
attainment of the limiting age. Upon request, but not more	170
frequently than annually, the health insuring corporation may	171
require proof satisfactory to it of the continuance of such	172
incapacity and dependency.	173

(C) Nothing in this section shall do any of the following:

174

(1) Require that any policy, contract, or agreement offer	175
coverage for dependent children or provide coverage for an	176
unmarried dependent child's children as dependents on the policy,	177
contract, or agreement;	178

(2) Require an employer to pay for any part of the premium	179
for an unmarried dependent child that has attained the limiting	180
age for dependents, as provided in the policy, contract, or	181
agreement;	182

(3) Require an employer to offer health insurance coverage to	183
the dependents of any employee.	184

(D) This section does not apply to any health insuring	185
corporation policy, contract, or agreement offering only	186
supplemental health care services or specialty health care	187
services.	188

(E) As used in this section, "health benefit plan" has the	189
same meaning as in section 3924.01 of the Revised Code and also	190
includes both of the following:	191

(1) A public employee benefit plan;

192

(2) A health benefit plan as regulated under the "Employee	193
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	194

Sec. 3923.022.  (A) As used in this section:

195

(1)(a) "Administrative expense" means the amount resulting	196
from the following: the amount of premiums earned by the insurer	197
for sickness and accident insurance business plus the amount of	198
losses recovered from reinsurance coverage minus the sum of the	199
amount of claims for losses paid; the amount of losses incurred	200
but not reported; the amount incurred for state fees, federal and	201
state taxes, and reinsurance; and the incurred costs and expenses	202
related, either directly or indirectly, to the payment of	203
commissions, measures to control fraud, and managed care.	204

(b) "Administrative expense" does not include any amounts	205
collected, or administrative expenses incurred, by an insurer for	206
the administration of an employee health benefit plan subject to	207
regulation by the federal "Employee Retirement Income Security Act	208
of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts	209
collected or administrative expenses incurred" means the total	210
amount paid to an administrator for the administration and payment	211
of claims minus the sum of the amount of claims for losses paid	212
and the amount of losses incurred but not reported.	213

(2) "Insurer" means any insurance company authorized under	214
Title XXXIX of the Revised Code to do the business of sickness and	215
accident insurance in this state.	216

(3) "Sickness and accident insurance business" does not	217
include coverage provided by an insurer for specific diseases or	218
accidents only; any hospital indemnity, medicare supplement,	219
long-term care, disability income, one-time-limited-duration	220
policy of no longerthat is less than sixtwelve months, or other	221
policy that offers only supplemental benefits; or coverage	222
provided to individuals who are not residents of this state.	223

(4) "Individual business" includes both individual sickness	224
and accident insurance and sickness and accident insurance made	225
available by insurers in the individual market to individuals,	226
with or without family members or dependents, through group	227
policies issued to one or more associations or entities.	228

(B) Notwithstanding section 3941.14 of the Revised Code, each	229
insurer shall have aggregate administrative expenses of no more	230
than twenty per cent of the premium income of the insurer, based	231
on the premiums earned in that year on the sickness and accident	232
insurance business of the insurer.	233

(C)(1) Each insurer, on the first day of January or within	234
sixty days thereafter, shall annually prepare, under oath, and	235
deposit in the office of the superintendent of insurance a	236
statement of the aggregate administrative expenses of the insurer,	237
based on the premiums earned in the immediately preceding calendar	238
year on the sickness and accident insurance business of the	239
insurer. The statement shall itemize and separately detail all of	240
the following information with respect to the insurer's sickness	241
and accident insurance business:	242

(a) The amount of premiums earned by the insurer both before	243
and after any costs related to the insurer's purchase of	244
reinsurance coverage;	245

(b) The total amount of claims for losses paid by the insurer	246
both before and after any reimbursement from reinsurance coverage;	247

(c) The amount of any losses incurred by the insurer but not	248
reported by the insurer in the current or prior year;	249

(d) The amount of costs incurred by the insurer for state	250
fees and federal and state taxes;	251

(e) The amount of costs incurred by the insurer for	252
reinsurance coverage;	253

(f) The amount of costs incurred by the insurer that are	254
related to the insurer's payment of commissions;	255

(g) The amount of costs incurred by the insurer that are	256
related to the insurer's fraud prevention measures;	257

(h) The amount of costs incurred by the insurer that are	258
related to managed care; and	259

(i) Any other administrative expenses incurred by the	260
insurer.	261

(2) The statement also shall include all of the information	262
required under division (C)(1) of this section separately detailed	263
for the insurer's individual business, small group business, and	264
large group business.	265

(D) No insurer shall fail to comply with this section.

266

(E) If the superintendent determines that an insurer has	267
violated this section, the superintendent, pursuant to an	268
adjudication conducted in accordance with Chapter 119. of the	269
Revised Code, may order the suspension of the insurer's license to	270
do the business of sickness and accident insurance in this state	271
until the superintendent is satisfied that the insurer is in	272
compliance with this section. If the insurer continues to do the	273
business of sickness and accident insurance in this state while	274
under the suspension order, the superintendent shall order the	275
insurer to pay one thousand dollars for each day of the violation.	276

(F) Any money collected by the superintendent under division	277
(E) of this section shall be deposited by the superintendent into	278
the state treasury to the credit of the department of insurance	279
operating fund.	280

(G) The statement of aggregate expenses filed pursuant to	281
this section separately detailing an insurer's individual, small	282
group, and large group business shall be considered work papers	283
resulting from the conduct of a market analysis of an entity	284
subject to examination by the superintendent under division (C) of	285
section 3901.48 of the Revised Code, except that the	286
superintendent may share aggregated market information that	287
identifies the premiums earned as reported under division	288
(C)(1)(a) of this section, the administrative expenses reported	289
under division (C)(1)(i) of this section, the amount of	290
commissions reported under division (C)(1)(f) of this section, the	291
amount of taxes paid as reported under division (C)(1)(d) of this	292
section, the total of the remaining benefit costs as reported	293
under divisions (C)(1)(b) and (c) of this section, and the amount	294
of fraud and managed care expenses reported under divisions	295
(C)(1)(g) and (h) of this section.	296

Sec. 3923.24.  (A) Notwithstanding section 3901.71 of the	297
Revised Code, every certificate furnished by an insurer in	298
connection with, or pursuant to any provision of, any group	299
sickness and accident insurance policy delivered, issued for	300
delivery, renewed, or used in this state on or after January 1,	301
1972, every policy of sickness and accident insurance delivered,	302
issued for delivery, renewed, or used in this state on or after	303
January 1, 1972, and every multiple employer welfare arrangement	304
offering an insurance program, which provides that coverage of an	305
unmarried dependent child of a parent or legal guardian will	306
terminate upon attainment of the limiting age for dependent	307
children specified in the contract shall also provide in substance	308
both of the following:	309

(1) Once an unmarried child has attained the limiting age for	310
dependent children, as provided in the policy, upon the request of	311
the insured, the insurer shall offer to cover the unmarried child	312
until the child attains twenty-eighttwenty-six years of age if	313
all of the following are true:	314

(a) The child is the natural child, stepchild, or adopted	315
child of the insured.	316

(b) The child is a resident of this state or a full-time	317
student at an accredited public or private institution of higher	318
education.	319

(c) The child is not employed by an employer that offers any	320
health benefit plan under which the child is eligible for	321
coverage.	322

(d) The child is not eligible for the medicaid program or the	323
medicare program.	324

(2) That attainment of the limiting age for dependent	325
children shall not operate to terminate the coverage of a	326
dependent child if the child is and continues to be both of the	327
following:	328

(a) Incapable of self-sustaining employment by reason of	329
mental retardation or physical handicap;	330

(b) Primarily dependent upon the policyholder or certificate	331
holder for support and maintenance.	332

(B) Proof of such incapacity and dependence for purposes of	333
division (A)(2) of this section shall be furnished by the	334
policyholder or by the certificate holder to the insurer within	335
thirty-one days of the child's attainment of the limiting age.	336
Upon request, but not more frequently than annually after the	337
two-year period following the child's attainment of the limiting	338
age, the insurer may require proof satisfactory to it of the	339
continuance of such incapacity and dependency.	340

(C) Nothing in this section shall require an insurer to cover	341
a dependent child who is mentally retarded or physically	342
handicapped if the contract is underwritten on evidence of	343
insurability based on health factors set forth in the application,	344
or if such dependent child does not satisfy the conditions of the	345
contract as to any requirement for evidence of insurability or	346
other provision of the contract, satisfaction of which is required	347
for coverage thereunder to take effect. In any such case, the	348
terms of the contract shall apply with regard to the coverage or	349
exclusion of the dependent from such coverage. Nothing in this	350
section shall apply to accidental death or dismemberment benefits	351
provided by any such policy of sickness and accident insurance.	352

(D) Nothing in this section shall do any of the following:

353

(1) Require that any policy offer coverage for dependent	354
children or provide coverage for an unmarried dependent child's	355
children as dependents on the policy;	356

(2) Require an employer to pay for any part of the premium	357
for an unmarried dependent child that has attained the limiting	358
age for dependents, as provided in the policy;	359

(3) Require an employer to offer health insurance coverage to	360
the dependents of any employee.	361

(E) This section does not apply to any policies or	362
certificates covering only accident, credit, dental, disability	363
income, long-term care, hospital indemnity, medicare supplement,	364
specified disease, or vision care; coverage under a	365
one-time-limited-duration policy of not longerthat is less than	366
sixtwelve months; coverage issued as a supplement to liability	367
insurance; insurance arising out of a workers' compensation or	368
similar law; automobile medical-payment insurance; or insurance	369
under which benefits are payable with or without regard to fault	370
and that is statutorily required to be contained in any liability	371
insurance policy or equivalent self-insurance.	372

(F) As used in this section, "health benefit plan" has the	373
same meaning as in section 3924.01 of the Revised Code and also	374
includes both of the following:	375

(1) A public employee benefit plan;

376

(2) A health benefit plan as regulated under the "Employee	377
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	378

Sec. 3923.241. (A) Notwithstanding section 3901.71 of the	379
Revised Code, any public employee benefit plan that provides that	380
coverage of an unmarried dependent child will terminate upon	381
attainment of the limiting age for dependent children specified in	382
the plan shall also provide in substance both of the following:	383

(1) Once an unmarried child has attained the limiting age for	384
dependent children, as provided in the plan, upon the request of	385
the employee, the public employee benefit plan shall offer to	386
cover the unmarried child until the child attains twenty-eight	387
twenty-six years of age if all of the following are true:	388

(a) The child is the natural child, stepchild, or adopted	389
child of the employee.	390

(b) The child is a resident of this state or a full-time	391
student at an accredited public or private institution of higher	392
education.	393

(c) The child is not employed by an employer that offers any	394
health benefit plan under which the child is eligible for	395
coverage.	396

(d) The child is not eligible for the medicaid program or the	397
medicare program.	398

(2) That attainment of the limiting age for dependent	399
children shall not operate to terminate the coverage of a	400
dependent child if the child is and continues to be both of the	401
following:	402

(a) Incapable of self-sustaining employment by reason of	403
mental retardation or physical handicap;	404

(b) Primarily dependent upon the plan member for support and	405
maintenance.	406

(B) Proof of incapacity and dependence for purposes of	407
division (A)(2) of this section shall be furnished to the public	408
employee benefit plan within thirty-one days of the child's	409
attainment of the limiting age. Upon request, but not more	410
frequently than annually, the public employee benefit plan may	411
require proof satisfactory to it of the continuance of such	412
incapacity and dependency.	413

(C) Nothing in this section shall do any of the following:

414

(1) Require that any public employee benefit plan offer	415
coverage for dependent children or provide coverage for an	416
unmarried dependent child's children as dependents on the public	417
employee benefit plan;	418

(2) Require an employer to pay for any part of the premium	419
for an unmarried dependent child that has attained the limiting	420
age for dependents, as provided in the plan;	421

(3) Require an employer to offer health insurance coverage to	422
the dependents of any employee.	423

(D) This section does not apply to any public employee	424
benefit plan covering only accident, credit, dental, disability	425
income, long-term care, hospital indemnity, medicare supplement,	426
specified disease, or vision care; coverage under a	427
one-time-limited-duration policy of not longerthat is less than	428
sixtwelve months; coverage issued as a supplement to liability	429
insurance; insurance arising out of a workers' compensation or	430
similar law; automobile medical-payment insurance; or insurance	431
under which benefits are payable with or without regard to fault	432
and which is statutorily required to be contained in any liability	433
insurance policy or equivalent self-insurance.	434

(E) As used in this section, "health benefit plan" has the	435
same meaning as in section 3924.01 of the Revised Code and also	436
includes both of the following:	437

(1) A public employee benefit plan;

438

(2) A health benefit plan as regulated under the "Employee	439
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	440

Sec. 3923.281.  (A) As used in this section:

441

(1) "Biologically based mental illness" means schizophrenia,	442
schizoaffective disorder, major depressive disorder, bipolar	443
disorder, paranoia and other psychotic disorders,	444
obsessive-compulsive disorder, and panic disorder, as these terms	445
are defined in the most recent edition of the diagnostic and	446
statistical manual of mental disorders published by the American	447
psychiatric association.	448

(2) "Policy of sickness and accident insurance" has the same	449
meaning as in section 3923.01 of the Revised Code, but excludes	450
any hospital indemnity, medicare supplement, long-term care,	451
disability income, one-time-limited-duration policy of not longer	452
that is less than sixtwelve months, supplemental benefit, or	453
other policy that provides coverage for specific diseases or	454
accidents only; any policy that provides coverage for workers'	455
compensation claims compensable pursuant to Chapters 4121. and	456
4123. of the Revised Code; and any policy that provides coverage	457
to medicaid recipients.	458

(B) Notwithstanding section 3901.71 of the Revised Code, and	459
subject to division (E) of this section, every policy of sickness	460
and accident insurance shall provide benefits for the diagnosis	461
and treatment of biologically based mental illnesses on the same	462
terms and conditions as, and shall provide benefits no less	463
extensive than, those provided under the policy of sickness and	464
accident insurance for the treatment and diagnosis of all other	465
physical diseases and disorders, if both of the following apply:	466

(1) The biologically based mental illness is clinically	467
diagnosed by a physician authorized under Chapter 4731. of the	468
Revised Code to practice medicine and surgery or osteopathic	469
medicine and surgery; a psychologist licensed under Chapter 4732.	470
of the Revised Code; a professional clinical counselor,	471
professional counselor, or independent social worker licensed	472
under Chapter 4757. of the Revised Code; or a clinical nurse	473
specialist licensed under Chapter 4723. of the Revised Code whose	474
nursing specialty is mental health.	475

(2) The prescribed treatment is not experimental or	476
investigational, having proven its clinical effectiveness in	477
accordance with generally accepted medical standards.	478

(C) Division (B) of this section applies to all coverages and	479
terms and conditions of the policy of sickness and accident	480
insurance, including, but not limited to, coverage of inpatient	481
hospital services, outpatient services, and medication; maximum	482
lifetime benefits; copayments; and individual and family	483
deductibles.	484

(D) Nothing in this section shall be construed as prohibiting	485
a sickness and accident insurance company from taking any of the	486
following actions:	487

(1) Negotiating separately with mental health care providers	488
with regard to reimbursement rates and the delivery of health care	489
services;	490

(2) Offering policies that provide benefits solely for the	491
diagnosis and treatment of biologically based mental illnesses;	492

(3) Managing the provision of benefits for the diagnosis or	493
treatment of biologically based mental illnesses through the use	494
of pre-admission screening, by requiring beneficiaries to obtain	495
authorization prior to treatment, or through the use of any other	496
mechanism designed to limit coverage to that treatment determined	497
to be necessary;	498

(4) Enforcing the terms and conditions of a policy of	499
sickness and accident insurance.	500

(E) An insurer that offers any policy of sickness and	501
accident insurance is not required to provide benefits for the	502
diagnosis and treatment of biologically based mental illnesses	503
pursuant to division (B) of this section if all of the following	504
apply:	505

(1) The insurer submits documentation certified by an	506
independent member of the American academy of actuaries to the	507
superintendent of insurance showing that incurred claims for	508
diagnostic and treatment services for biologically based mental	509
illnesses for a period of at least six months independently caused	510
the insurer's costs for claims and administrative expenses for the	511
coverage of all other physical diseases and disorders to increase	512
by more than one per cent per year.	513

(2) The insurer submits a signed letter from an independent	514
member of the American academy of actuaries to the superintendent	515
of insurance opining that the increase described in division	516
(E)(1) of this section could reasonably justify an increase of	517
more than one per cent in the annual premiums or rates charged by	518
the insurer for the coverage of all other physical diseases and	519
disorders.	520

(3) The superintendent of insurance makes the following	521
determinations from the documentation and opinion submitted	522
pursuant to divisions (E)(1) and (2) of this section:	523

(a) Incurred claims for diagnostic and treatment services for	524
biologically based mental illnesses for a period of at least six	525
months independently caused the insurer's costs for claims and	526
administrative expenses for the coverage of all other physical	527
diseases and disorders to increase by more than one per cent per	528
year.	529

(b) The increase in costs reasonably justifies an increase of	530
more than one per cent in the annual premiums or rates charged by	531
the insurer for the coverage of all other physical diseases and	532
disorders.	533

Any determination made by the superintendent under this	534
division is subject to Chapter 119. of the Revised Code.	535

Sec. 3923.57.  Notwithstanding any provision of this chapter,	536
every individual policy of sickness and accident insurance that is	537
delivered, issued for delivery, or renewed in this state is	538
subject to the following conditions, as applicable:	539

(A) Pre-existing conditions provisions shall not exclude or	540
limit coverage for a period beyond twelve months following the	541
policyholder's effective date of coverage and may only relate to	542
conditions during the six months immediately preceding the	543
effective date of coverage.	544

(B) In determining whether a pre-existing conditions	545
provision applies to a policyholder or dependent, each policy	546
shall credit the time the policyholder or dependent was covered	547
under a previous policy, contract, or plan if the previous	548
coverage was continuous to a date not more than thirty days prior	549
to the effective date of the new coverage, exclusive of any	550
applicable service waiting period under the policy.	551

(C)(1) Except as otherwise provided in division (C) of this	552
section, an insurer that provides an individual sickness and	553
accident insurance policy to an individual shall renew or continue	554
in force such coverage at the option of the individual.	555

(2) An insurer may nonrenew or discontinue coverage of an	556
individual in the individual market based only on one or more of	557
the following reasons:	558

(a) The individual failed to pay premiums or contributions in	559
accordance with the terms of the policy or the insurer has not	560
received timely premium payments.	561

(b) The individual performed an act or practice that	562
constitutes fraud or made an intentional misrepresentation of	563
material fact under the terms of the policy.	564

(c) The insurer is ceasing to offer coverage in the	565
individual market in accordance with division (D) of this section	566
and the applicable laws of this state.	567

(d) If the insurer offers coverage in the market through a	568
network plan, the individual no longer resides, lives, or works in	569
the service area, or in an area for which the insurer is	570
authorized to do business; provided, however, that such coverage	571
is terminated uniformly without regard to any health	572
status-related factor of covered individuals.	573

(e) If the coverage is made available in the individual	574
market only through one or more bona fide associations, the	575
membership of the individual in the association, on the basis of	576
which the coverage is provided, ceases; provided, however, that	577
such coverage is terminated under division (C)(2)(e) of this	578
section uniformly without regard to any health status-related	579
factor of covered individuals.	580

An insurer offering coverage to individuals solely through	581
membership in a bona fide association shall not be deemed, by	582
virtue of that offering, to be in the individual market for	583
purposes of sections 3923.58 and 3923.581 of the Revised Code.	584
Such an insurer shall not be required to accept applicants for	585
coverage in the individual market pursuant to sections 3923.58 and	586
3923.581 of the Revised Code unless the insurer also offers	587
coverage to individuals other than through bona fide associations.	588

(3) An insurer may cancel or decide not to renew the coverage	589
of a dependent of an individual if the dependent has performed an	590
act or practice that constitutes fraud or made an intentional	591
misrepresentation of material fact under the terms of the coverage	592
and if the cancellation or nonrenewal is not based, either	593
directly or indirectly, on any health status-related factor in	594
relation to the dependent.	595

(D)(1) If an insurer decides to discontinue offering a	596
particular type of health insurance coverage offered in the	597
individual market, coverage of such type may be discontinued by	598
the insurer if the insurer does all of the following:	599

(a) Provides notice to each individual provided coverage of	600
this type in such market of the discontinuation at least ninety	601
days prior to the date of the discontinuation of the coverage;	602

(b) Offers to each individual provided coverage of this type	603
in such market, the option to purchase any other individual health	604
insurance coverage currently being offered by the insurer for	605
individuals in that market;	606

(c) In exercising the option to discontinue coverage of this	607
type and in offering the option of coverage under division	608
(D)(1)(b) of this section, acts uniformly without regard to any	609
health status-related factor of covered individuals or of	610
individuals who may become eligible for such coverage.	611

(2) If an insurer elects to discontinue offering all health	612
insurance coverage in the individual market in this state, health	613
insurance coverage may be discontinued by the insurer only if both	614
of the following apply:	615

(a) The insurer provides notice to the department of	616
insurance and to each individual of the discontinuation at least	617
one hundred eighty days prior to the date of the expiration of the	618
coverage.	619

(b) All health insurance delivered or issued for delivery in	620
this state in such market is discontinued and coverage under that	621
health insurance in that market is not renewed.	622

(3) In the event of a discontinuation under division (D)(2)	623
of this section in the individual market, the insurer shall not	624
provide for the issuance of any health insurance coverage in the	625
market and this state during the five-year period beginning on the	626
date of the discontinuation of the last health insurance coverage	627
not so renewed.	628

(E) Notwithstanding divisions (C) and (D) of this section, an	629
insurer may, at the time of coverage renewal, modify the health	630
insurance coverage for a policy form offered to individuals in the	631
individual market if the modification is consistent with the law	632
of this state and effective on a uniform basis among all	633
individuals with that policy form.	634

(F) Such policies are subject to sections 2743 and 2747 of	635
the "Health Insurance Portability and Accountability Act of 1996,"	636
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and	637
300gg-47, as amended.	638

(G) Sections 3924.031 and 3924.032 of the Revised Code shall	639
apply to sickness and accident insurance policies offered in the	640
individual market in the same manner as they apply to health	641
benefit plans offered in the small employer market.	642

In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of	643
this section also apply to all group sickness and accident	644
insurance policies that are not sold in connection with an	645
employment-related group health plan and that provide more than	646
short-term, limited duration coverage.	647

In applying divisions (C) to (G) of this section with respect	648
to health insurance coverage that is made available by an insurer	649
in the individual market to individuals only through one or more	650
associations, the term "individual" includes the association of	651
which the individual is a member.	652

For purposes of this section, any policy issued pursuant to	653
division (C) of section 3923.13 of the Revised Code in connection	654
with a public or private college or university student health	655
insurance program is considered to be issued to a bona fide	656
association.	657

As used in this section, "bona fide association" has the same	658
meaning as in section 3924.03 of the Revised Code, and "health	659
status-related factor" and "network plan" have the same meanings	660
as in section 3924.031 of the Revised Code.	661

This section does not apply to any policy that provides	662
coverage for specific diseases or accidents only, or to any	663
hospital indemnity, medicare supplement, long-term care,	664
disability income, one-time-limited-duration policy of no longer	665
that is less than sixtwelve months, or other policy that offers	666
only supplemental benefits.	667

Sec. 3923.58.  (A) As used in sections 3923.58 and 3923.59 of	668
the Revised Code:	669

(1) "Base rate" means, as to any health benefit plan that is	670
issued by a carrier in the individual market, the lowest premium	671
rate for new or existing business prescribed by the carrier for	672
the same or similar coverage under a plan or arrangement covering	673
any individual with similar case characteristics.	674

(2) "Carrier," "health benefit plan," and "MEWA" have the	675
same meanings as in section 3924.01 of the Revised Code.	676

(3) "Network plan" means a health benefit plan of a carrier	677
under which the financing and delivery of medical care, including	678
items and services paid for as medical care, are provided, in	679
whole or in part, through a defined set of providers under	680
contract with the carrier.	681

(4) "Ohio health care basic and standard plans" means those	682
plans established under section 3924.10 of the Revised Code.	683

(5) "Pre-existing conditions provision" means a policy	684
provision that excludes or limits coverage for charges or expenses	685
incurred during a specified period following the insured's	686
effective date of coverage as to a condition which, during a	687
specified period immediately preceding the effective date of	688
coverage, had manifested itself in such a manner as would cause an	689
ordinarily prudent person to seek medical advice, diagnosis, care,	690
or treatment or for which medical advice, diagnosis, care, or	691
treatment was recommended or received, or a pregnancy existing on	692
the effective date of coverage.	693

(B) Beginning in January of each year, carriers in the	694
business of issuing health benefit plans to individuals and	695
nonemployer groups, except individual health benefit plans issued	696
pursuant to sections 1751.16 and 3923.122 of the Revised Code,	697
shall accept applicants for open enrollment coverage, as set forth	698
in this division, in the order in which they apply for coverage	699
and subject to the limitation set forth in division (G) of this	700
section. Carriers shall accept for coverage pursuant to this	701
section individuals to whom both of the following conditions	702
apply:	703

(1) The individual is not applying for coverage as an	704
employee of an employer, as a member of an association, or as a	705
member of any other group.	706

(2) The individual is not covered, and is not eligible for	707
coverage, under any other private or public health benefits	708
arrangement, including the medicare program established under	709
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42	710
U.S.C.A. 301, as amended, or any other act of congress or law of	711
this or any other state of the United States that provides	712
benefits comparable to the benefits provided under this section,	713
any medicare supplement policy, or any continuation of coverage	714
policy under state or federal law.	715

(C) A carrier shall offer to any individual accepted under	716
this section the Ohio health care basic and standard plans or	717
health benefit plans that are substantially similar to the Ohio	718
health care basic and standard plans in benefit plan design and	719
scope of covered services.	720

A carrier may offer other health benefit plans in addition	721
to, but not in lieu of, the plans required to be offered under	722
this division. A basic health benefit plan shall provide, at a	723
minimum, the coverage provided by the Ohio health care basic plan	724
or any health benefit plan that is substantially similar to the	725
Ohio health care basic plan in benefit plan design and scope of	726
covered services. A standard health benefit plan shall provide, at	727
a minimum, the coverage provided by the Ohio health care standard	728
plan or any health benefit plan that is substantially similar to	729
the Ohio health care standard plan in benefit plan design and	730
scope of covered services.	731

For purposes of this division, the superintendent of	732
insurance shall determine whether a health benefit plan is	733
substantially similar to the Ohio health care basic and standard	734
plans in benefit plan design and scope of covered services.	735

(D)(1) Health benefit plans issued under this section may	736
establish pre-existing conditions provisions that exclude or limit	737
coverage for a period of up to twelve months following the	738
individual's effective date of coverage and that may relate only	739
to conditions during the six months immediately preceding the	740
effective date of coverage. A health insuring corporation may	741
apply a pre-existing condition provision for any basic health care	742
service related to a transplant of a body organ if the transplant	743
occurs within one year after the effective date of an enrollee's	744
coverage under this section except with respect to a newly born	745
child who meets the requirements for coverage under section	746
1751.61 of the Revised Code.	747

(2) In determining whether a pre-existing conditions	748
provision applies to an insured or dependent, each policy shall	749
credit the time the insured or dependent was covered under a	750
previous policy, contract, or plan if the previous coverage was	751
continuous to a date not more than sixty-three days prior to the	752
effective date of the new coverage, exclusive of any applicable	753
service waiting period under the policy.	754

(E) Premiums charged to individuals under this section may	755
not exceed the amounts specified below:	756

(1) For calendar years 2010 and 2011, an amount that is two	757
times the base rate for coverage offered to any other individual	758
to which the carrier is currently accepting new business, and for	759
which similar copayments and deductibles are applied;	760

(2) For calendar year 2012 and every year thereafter, an	761
amount that is one and one-half times the base rate for coverage	762
offered to any other individual to which the carrier is currently	763
accepting new business and for which similar copayments and	764
deductibles are applied, unless the superintendent of insurance	765
determines that the amendments by this act to this section and	766
section 3923.581 of the Revised Code, have resulted in the	767
market-wide average medical loss ratio for coverage sold to	768
individual insureds and nonemployer group insureds in this state,	769
including open enrollment insureds, to increase by more than five	770
and one quarter percentage points during calendar year 2010. If	771
the superintendent makes that determination, the premium limit	772
established by division (E)(1) of this section shall remain in	773
effect. The superintendent's determination shall be supported by a	774
signed letter from a member of the American academy of actuaries.	775

(F) In offering health benefit plans under this section, a	776
carrier may require the purchase of health benefit plans that	777
condition the reimbursement of health services upon the use of a	778
specific network of providers.	779

(G)(1) A carrier shall not be required to accept new	780
applicants under this section if the total number of the carrier's	781
current insureds with open enrollment coverage issued under this	782
section calculated as of the immediately preceding thirty-first	783
day of December and excluding the carrier's medicare supplement	784
policies and conversion or continuation of coverage policies under	785
state or federal law and any policies described in division (L) of	786
this section meets the following limits:	787

(a) For calendar years 2010 and 2011, four per cent of the	788
carrier's total number of individual or nonemployer group insureds	789
in this state;	790

(b) For calendar year 2012 and every year thereafter, eight	791
per cent of the carrier's total number of insured individuals and	792
nonemployer group insureds in this state, unless the	793
superintendent of insurance determines that the amendments by this	794
act to this section and section 3923.581 of the Revised Code, have	795
resulted in the market-wide average medical loss ratio for	796
coverage sold to individual insureds and nonemployer group	797
insureds in this state, including open enrollment insureds, to	798
increase by more than five and one quarter percentage points	799
during calendar year 2010. If the superintendent makes that	800
determination, the enrollment limit established by division	801
(G)(1)(a) of this section shall remain in effect. The	802
superintendent's determination shall be supported by a signed	803
letter from a member of the American academy of actuaries.	804

(2) An officer of the carrier shall certify to the department	805
of insurance when it has met the enrollment limit set forth in	806
division (G)(1) of this section. Upon providing such	807
certification, the carrier shall be relieved of its open	808
enrollment requirement under this section as long as the carrier	809
continues to meet the open enrollment limit. If the total number	810
of the carrier's current insureds with open enrollment coverage	811
issued under this section falls below the enrollment limit, the	812
carrier shall accept new applicants. A carrier may establish a	813
waiting list if the carrier has met the open enrollment limit and	814
shall notify the superintendent if the carrier has a waiting list	815
in effect.	816

(H) A carrier shall not be required to accept under this	817
section applicants who, at the time of enrollment, are confined to	818
a health care facility because of chronic illness, permanent	819
injury, or other infirmity that would cause economic impairment to	820
the carrier if the applicants were accepted. A carrier shall not	821
be required to make the effective date of benefits for individuals	822
accepted under this section earlier than ninety days after the	823
date of acceptance, except that when the individual had prior	824
coverage with a health benefit plan that was terminated by a	825
carrier because the carrier exited the market and the individual	826
was accepted for open enrollment under this section within	827
sixty-three days of that termination, the effective date of	828
benefits shall be the date of enrollment.	829

(I) The requirements of this section do not apply to any	830
carrier that is currently in a state of supervision, insolvency,	831
or liquidation. If a carrier demonstrates to the satisfaction of	832
the superintendent that the requirements of this section would	833
place the carrier in a state of supervision, insolvency, or	834
liquidation, or would otherwise jeopardize the carrier's economic	835
viability overall or in the individual market, the superintendent	836
may waive or modify the requirements of division (B) or (G) of	837
this section. The actions of the superintendent under this	838
division shall be effective for a period of not more than one	839
year. At the expiration of such time, a new showing of need for a	840
waiver or modification by the carrier shall be made before a new	841
waiver or modification is issued or imposed.	842

(J) No hospital, health care facility, or health care	843
practitioner, and no person who employs any health care	844
practitioner, shall balance bill any individual or dependent of an	845
individual for any health care supplies or services provided to	846
the individual or dependent who is insured under a policy issued	847
under this section. The hospital, health care facility, or health	848
care practitioner, or any person that employs the health care	849
practitioner, shall accept payments made to it by the carrier	850
under the terms of the policy or contract insuring or covering	851
such individual as payment in full for such health care supplies	852
or services.	853

As used in this division, "hospital" has the same meaning as	854
in section 3727.01 of the Revised Code; "health care practitioner"	855
has the same meaning as in section 4769.01 of the Revised Code;	856
and "balance bill" means charging or collecting an amount in	857
excess of the amount reimbursable or payable under the policy or	858
health care service contract issued to an individual under this	859
section for such health care supply or service. "Balance bill"	860
does not include charging for or collecting copayments or	861
deductibles required by the policy or contract.	862

(K) A carrier may pay an agent a commission in the amount of	863
not more than five per cent of the premium charged for initial	864
placement or for otherwise securing the issuance of a policy or	865
contract issued to an individual under this section, and not more	866
than four per cent of the premium charged for the renewal of such	867
a policy or contract. The superintendent may adopt, in accordance	868
with Chapter 119. of the Revised Code, such rules as are necessary	869
to enforce this division.	870

(L) This section does not apply to any policy that provides	871
coverage for specific diseases or accidents only, or to any	872
hospital indemnity, medicare supplement, long-term care,	873
disability income, one-time-limited-duration policy of no longer	874
that is less than sixtwelve months, or other policy that offers	875
only supplemental benefits.	876

(M) If a carrier offers a health benefit plan in the	877
individual market through a network plan, the carrier may do both	878
of the following:	879

(1) Limit the individuals that may apply for such coverage to	880
those who live, work, or reside in the service area of the network	881
plan;	882

(2) Within the service area of the network plan, deny the	883
coverage to individuals if the carrier has demonstrated both of	884
the following to the superintendent:	885

(a) The carrier will not have the capacity to deliver	886
services adequately to any additional individuals because of the	887
carrier's obligations to existing group contract holders and	888
individuals.	889

(b) The carrier is applying division (M)(2) of this section	890
uniformly to all individuals without regard to any health	891
status-related factors of those individuals.	892

(N) A carrier that, pursuant to division (M)(2) of this	893
section, denies coverage to an individual in the service area of a	894
network plan, shall not offer coverage in the individual market	895
within that service area for at least one hundred eighty days	896
after the date the carrier denies the coverage.	897

Sec. 3923.601. (A)(1) This section applies to both of the	898
following:	899

(a) A sickness and accident insurer that issues or requires	900
the use of a standardized identification card or an electronic	901
technology for submission and routing of prescription drug claims	902
pursuant to a policy, contract, or agreement for health care	903
services;	904

(b) A person that a sickness and accident insurer contracts	905
with to issue a standardized identification card or an electronic	906
technology described in division (A)(1)(a) of this section.	907

(2) Notwithstanding division (A)(1) of this section, this	908
section does not apply to the issuance or required use of a	909
standardized identification card or an electronic technology for	910
the submission and routing of prescription drug claims in	911
connection with any of the following:	912

(a) Any individual or group policy of sickness and accident	913
insurance covering only accident, credit, dental, disability	914
income, long-term care, hospital indemnity, medicare supplement,	915
medicare, tricare, specified disease, or vision care; coverage	916
under a one-time-limited-duration policy of not longerthat is	917
less than sixtwelve months; coverage issued as a supplement to	918
liability insurance; insurance arising out of workers'	919
compensation or similar law; automobile medical payment insurance;	920
or insurance under which benefits are payable with or without	921
regard to fault and which is statutorily required to be contained	922
in any liability insurance policy or equivalent self-insurance.	923

(b) Coverage provided under the medicaid program.

924

(c) Coverage provided under an employer's self-insurance plan	925
or by any of its administrators, as defined in section 3959.01 of	926
the Revised Code, to the extent that federal law supersedes,	927
preempts, prohibits, or otherwise precludes the application of	928
this section to the plan and its administrators.	929

(B) A standardized identification card or an electronic	930
technology issued or required to be used as provided in division	931
(A)(1) of this section shall contain uniform prescription drug	932
information in accordance with either division (B)(1) or (2) of	933
this section.	934

(1) The standardized identification card or the electronic	935
technology shall be in a format and contain information fields	936
approved by the national council for prescription drug programs or	937
a successor organization, as specified in the council's or	938
successor organization's pharmacy identification card	939
implementation guide in effect on the first day of October most	940
immediately preceding the issuance or required use of the	941
standardized identification card or the electronic technology.	942

(2) If the insurer or person under contract with the insurer	943
to issue a standardized identification card or an electronic	944
technology requires the information for the submission and routing	945
of a claim, the standardized identification card or the electronic	946
technology shall contain any of the following information:	947

(a) The insurer's name;

948

(b) The insured's name, group number, and identification	949
number;	950

(c) A telephone number to inquire about pharmacy-related	951
issues;	952

(d) The issuer's international identification number, labeled	953
as "ANSI BIN" or "RxBIN";	954

(e) The processor's control number, labeled as "RxPCN";

955

(f) The insured's pharmacy benefits group number if different	956
from the insured's medical group number, labeled as "RxGrp."	957

(C) If the standardized identification card or the electronic	958
technology issued or required to be used as provided in division	959
(A)(1) of this section is also used for submission and routing of	960
nonpharmacy claims, the designation "Rx" is required to be	961
included as part of the labels identified in divisions (B)(2)(d)	962
and (e) of this section if the issuer's international	963
identification number or the processor's control number is	964
different for medical and pharmacy claims.	965

(D) Each sickness and accident insurer described in division	966
(A) of this section shall annually file a certificate with the	967
superintendent of insurance certifying that it or any person it	968
contracts with to issue a standardized identification card or	969
electronic technology for submission and routing of prescription	970
drug claims complies with this section.	971

(E)(1) Except as provided in division (E)(2) of this section,	972
if there is a change in the information contained in the	973
standardized identification card or the electronic technology	974
issued to an insured, the insurer or person under contract with	975
the insurer to issue a standardized identification card or an	976
electronic technology shall issue a new card or electronic	977
technology to the insured.	978

(2) An insurer or person under contract with the insurer is	979
not required under division (E)(1) of this section to issue a new	980
card or electronic technology to an insured more than once during	981
a twelve-month period.	982

(F) Nothing in this section shall be construed as requiring	983
an insurer to produce more than one standardized identification	984
card or one electronic technology for use by insureds accessing	985
health care benefits provided under a policy of sickness and	986
accident insurance.	987

Sec. 3923.65.  (A) As used in this section:

988

(1) "Emergency medical condition" means a medical condition	989
that manifests itself by such acute symptoms of sufficient	990
severity, including severe pain, that a prudent layperson with	991
average knowledge of health and medicine could reasonably expect	992
the absence of immediate medical attention to result in any of the	993
following:	994

(a) Placing the health of the individual or, with respect to	995
a pregnant woman, the health of the woman or her unborn child, in	996
serious jeopardy;	997

(b) Serious impairment to bodily functions;

998

(c) Serious dysfunction of any bodily organ or part.

999

(2) "Emergency services" means the following:

1000

(a) A medical screening examination, as required by federal	1001
law, that is within the capability of the emergency department of	1002
a hospital, including ancillary services routinely available to	1003
the emergency department, to evaluate an emergency medical	1004
condition;	1005

(b) Such further medical examination and treatment that are	1006
required by federal law to stabilize an emergency medical	1007
condition and are within the capabilities of the staff and	1008
facilities available at the hospital, including any trauma and	1009
burn center of the hospital.	1010

(B) Every individual or group policy of sickness and accident	1011
insurance that provides hospital, surgical, or medical expense	1012
coverage shall cover emergency services without regard to the day	1013
or time the emergency services are rendered or to whether the	1014
policyholder, the hospital's emergency department where the	1015
services are rendered, or an emergency physician treating the	1016
policyholder, obtained prior authorization for the emergency	1017
services.	1018

(C) Every individual policy or certificate furnished by an	1019
insurer in connection with any sickness and accident insurance	1020
policy shall provide information regarding the following:	1021

(1) The scope of coverage for emergency services;

1022

(2) The appropriate use of emergency services, including the	1023
use of the 9-1-1 system and any other telephone access systems	1024
utilized to access prehospital emergency services;	1025

(3) Any copayments for emergency services.

1026

(D) This section does not apply to any individual or group	1027
policy of sickness and accident insurance covering only accident,	1028
credit, dental, disability income, long-term care, hospital	1029
indemnity, medicare supplement, medicare, tricare, specified	1030
disease, or vision care; coverage under a one-time limited	1031
duration policy of no longerthat is less than sixtwelve months;	1032
coverage issued as a supplement to liability insurance; insurance	1033
arising out of workers' compensation or similar law; automobile	1034
medical payment insurance; or insurance under which benefits are	1035
payable with or without regard to fault and which is statutorily	1036
required to be contained in any liability insurance policy or	1037
equivalent self-insurance.	1038

Sec. 3923.83. (A)(1) This section applies to both of the	1039
following:	1040

(a) A public employee benefit plan that issues or requires	1041
the use of a standardized identification card or an electronic	1042
technology for submission and routing of prescription drug claims	1043
pursuant to a policy, contract, or agreement for health care	1044
services;	1045

(b) A person or entity that a public employee benefit plan	1046
contracts with to issue a standardized identification card or an	1047
electronic technology described in division (A)(1)(a) of this	1048
section.	1049

(2) Notwithstanding division (A)(1) of this section, this	1050
section does not apply to the issuance or required use of a	1051
standardized identification card or an electronic technology for	1052
the submission and routing of prescription drug claims in	1053
connection with either of the following:	1054

(a) Any individual or group policy of insurance covering only	1055
accident, credit, dental, disability income, long-term care,	1056
hospital indemnity, medicare supplement, medicare, tricare,	1057
specified disease, or vision care; coverage under a	1058
one-time-limited-duration policy of not longerthat is less than	1059
sixtwelve months; coverage issued as a supplement to liability	1060
insurance; insurance arising out of workers' compensation or	1061
similar law; automobile medical payment insurance; or insurance	1062
under which benefits are payable with or without regard to fault	1063
and which is statutorily required to be contained in any liability	1064
insurance policy or equivalent self-insurance.	1065

(b) Coverage provided under the medicaid program.

1066

(B) A standardized identification card or an electronic	1067
technology issued or required to be used as provided in division	1068
(A)(1) of this section shall contain uniform prescription drug	1069
information in accordance with either division (B)(1) or (2) of	1070
this section.	1071

(1) The standardized identification card or the electronic	1072
technology shall be in a format and contain information fields	1073
approved by the national council for prescription drug programs or	1074
a successor organization, as specified in the council's or	1075
successor organization's pharmacy identification card	1076
implementation guide in effect on the first day of October most	1077
immediately preceding the issuance or required use of the	1078
standardized identification card or the electronic technology.	1079

(2) If the public employee benefit plan or person under	1080
contract with the plan to issue a standardized identification card	1081
or an electronic technology requires the information for the	1082
submission and routing of a claim, the standardized identification	1083
card or the electronic technology shall contain any of the	1084
following information:	1085

(a) The plan's name;

1086

(b) The insured's name, group number, and identification	1087
number;	1088

(c) A telephone number to inquire about pharmacy-related	1089
issues;	1090

(d) The issuer's international identification number, labeled	1091
as "ANSI BIN" or "RxBIN";	1092

(e) The processor's control number, labeled as "RxPCN";

1093

(f) The insured's pharmacy benefits group number if different	1094
from the insured's medical group number, labeled as "RxGrp."	1095

(C) If the standardized identification card or the electronic	1096
technology issued or required to be used as provided in division	1097
(A)(1) of this section is also used for submission and routing of	1098
nonpharmacy claims, the designation "Rx" is required to be	1099
included as part of the labels identified in divisions (B)(2)(d)	1100
and (e) of this section if the issuer's international	1101
identification number or the processor's control number is	1102
different for medical and pharmacy claims.	1103

(D)(1) Except as provided in division (D)(2) of this section,	1104
if there is a change in the information contained in the	1105
standardized identification card or the electronic technology	1106
issued to an insured, the public employee benefit plan or person	1107
under contract with the plan to issue a standardized	1108
identification card or electronic technology shall issue a new	1109
card or electronic technology to the insured.	1110

(2) A public employee benefit plan or person under contract	1111
with the plan is not required under division (D)(1) of this	1112
section to issue a new card or electronic technology to an insured	1113
more than once during a twelve-month period.	1114

(E) Nothing in this section shall be construed as requiring a	1115
public employee benefit plan to produce more than one standardized	1116
identification card or one electronic technology for use by	1117
insureds accessing health care benefits provided under a health	1118
benefit plan.	1119

Sec. 3924.01.  As used in sections 3924.01 to 3924.14 of the	1120
Revised Code:	1121

(A) "Actuarial certification" means a written statement	1122
prepared by a member of the American academy of actuaries, or by	1123
any other person acceptable to the superintendent of insurance,	1124
that states that, based upon the person's examination, a carrier	1125
offering health benefit plans to small employers is in compliance	1126
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial	1127
certification" shall include a review of the appropriate records	1128
of, and the actuarial assumptions and methods used by, the carrier	1129
relative to establishing premium rates for the health benefit	1130
plans.	1131

(B) "Adjusted average market premium price" means the average	1132
market premium price as determined by the board of directors of	1133
the Ohio health reinsurance program either on the basis of the	1134
arithmetic mean of all carriers' premium rates for an OHC plan	1135
sold to groups with similar case characteristics by all carriers	1136
selling OHC plans in the state, or on any other equitable basis	1137
determined by the board.	1138

(C) "Base premium rate" means, as to any health benefit plan	1139
that is issued by a carrier and that covers at least two but no	1140
more than fifty employees of a small employer, the lowest premium	1141
rate for a new or existing business prescribed by the carrier for	1142
the same or similar coverage under a plan or arrangement covering	1143
any small employer with similar case characteristics.	1144

(D) "Carrier" means any sickness and accident insurance	1145
company or health insuring corporation authorized to issue health	1146
benefit plans in this state or a MEWA. A sickness and accident	1147
insurance company that owns or operates a health insuring	1148
corporation, either as a separate corporation or as a line of	1149
business, shall be considered as a separate carrier from that	1150
health insuring corporation for purposes of sections 3924.01 to	1151
3924.14 of the Revised Code.	1152

(E) "Case characteristics" means, with respect to a small	1153
employer, the geographic area in which the employees work; the age	1154
and sex of the individual employees and their dependents; the	1155
appropriate industry classification as determined by the carrier;	1156
the number of employees and dependents; and such other objective	1157
criteria as may be established by the carrier. "Case	1158
characteristics" does not include claims experience, health	1159
status, or duration of coverage from the date of issue.	1160

(F) "Dependent" means the spouse or child of an eligible	1161
employee, subject to applicable terms of the health benefits plan	1162
covering the employee.	1163

(G) "Eligible employee" means an employee who works a normal	1164
work week of twenty-fivethirty or more hours. "Eligible employee"	1165
does not include a temporary or substitute employee, or a seasonal	1166
employee who works only part of the calendar year on the basis of	1167
natural or suitable times or circumstances.	1168

(H) "Health benefit plan" means any hospital or medical	1169
expense policy or certificate or any health plan provided by a	1170
carrier, that is delivered, issued for delivery, renewed, or used	1171
in this state on or after the date occurring six months after	1172
November 24, 1995. "Health benefit plan" does not include policies	1173
covering only accident, credit, dental, disability income,	1174
long-term care, hospital indemnity, medicare supplement, specified	1175
disease, or vision care; coverage under a	1176
one-time-limited-duration policy of no longerthat is less than	1177
sixtwelve months; coverage issued as a supplement to liability	1178
insurance; insurance arising out of a workers' compensation or	1179
similar law; automobile medical-payment insurance; or insurance	1180
under which benefits are payable with or without regard to fault	1181
and which is statutorily required to be contained in any liability	1182
insurance policy or equivalent self-insurance.	1183

(I) "Late enrollee" means an eligible employee or dependent	1184
who enrolls in a small employer's health benefit plan other than	1185
during the first period in which the employee or dependent is	1186
eligible to enroll under the plan or during a special enrollment	1187
period described in section 2701(f) of the "Health Insurance	1188
Portability and Accountability Act of 1996," Pub. L. No. 104-191,	1189
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended.	1190

(J) "MEWA" means any "multiple employer welfare arrangement"	1191
as defined in section 3 of the "Federal Employee Retirement Income	1192
Security Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended,	1193
except for any arrangement which is fully insured as defined in	1194
division (b)(6)(D) of section 514 of that act.	1195

(K) "Midpoint rate" means, for small employers with similar	1196
case characteristics and plan designs and as determined by the	1197
applicable carrier for a rating period, the arithmetic average of	1198
the applicable base premium rate and the corresponding highest	1199
premium rate.	1200

(L) "Pre-existing conditions provision" means a policy	1201
provision that excludes or limits coverage for charges or expenses	1202
incurred during a specified period following the insured's	1203
enrollment date as to a condition for which medical advice,	1204
diagnosis, care, or treatment was recommended or received during a	1205
specified period immediately preceding the enrollment date.	1206
Genetic information shall not be treated as such a condition in	1207
the absence of a diagnosis of the condition related to such	1208
information.	1209

For purposes of this division, "enrollment date" means, with	1210
respect to an individual covered under a group health benefit	1211
plan, the date of enrollment of the individual in the plan or, if	1212
earlier, the first day of the waiting period for such enrollment.	1213

(M) "Service waiting period" means the period of time after	1214
employment begins before an employee is eligible to be covered for	1215
benefits under the terms of any applicable health benefit plan	1216
offered by the small employer.	1217

(N)(1) "Small employer" means, in connection with a group	1218
health benefit plan and with respect to a calendar year and a plan	1219
year, an employer who employed an average of at least two but no	1220
more than fifty eligible employees on business days during the	1221
preceding calendar year and who employs at least two employees on	1222
the first day of the plan year.	1223

(2) For purposes of division (N)(1) of this section, all	1224
persons treated as a single employer under subsection (b), (c),	1225
(m), or (o) of section 414 of the "Internal Revenue Code of 1986,"	1226
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one	1227
employer. In the case of an employer that was not in existence	1228
throughout the preceding calendar year, the determination of	1229
whether the employer is a small or large employer shall be based	1230
on the average number of eligible employees that it is reasonably	1231
expected the employer will employ on business days in the current	1232
calendar year. Any reference in division (N) of this section to an	1233
"employer" includes any predecessor of the employer. Except as	1234
otherwise specifically provided, provisions of sections 3924.01 to	1235
3924.14 of the Revised Code that apply to a small employer that	1236
has a health benefit plan shall continue to apply until the plan	1237
anniversary following the date the employer no longer meets the	1238
requirements of this division.	1239

(O) "OHC plan" means an Ohio health care plan, which is the	1240
basic, standard, or carrier reimbursement plan for small employers	1241
and individuals established in accordance with section 3924.10 of	1242
the Revised Code.	1243

Section 2. That existing sections 1739.061, 1751.14,	1244
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601,	1245
3923.65, 3923.83, and 3924.01 of the Revised Code are hereby	1246
repealed.	1247

Section 3. Sections 1751.14, and 3924.01 as amended by this	1248
act, apply only to policies, contracts, and agreements that are	1249
delivered, issued for delivery, or renewed in this state on or	1250
after January 1, 2015. Sections 3923.24 and 3923.241 as amended by	1251
this act, apply only to policies of sickness and accident	1252
insurance delivered, issued for delivery, or renewed in this state	1253
and public or private employee benefit plans that are established	1254
or modified in this state on or after January 1, 2015.	1255

Section 4. The General Assembly declares that the amendments	1256
made to section 3923.58 of the Revised Code by this act are not to	1257
supersede the suspension of the operation of this section enacted	1258
by Section 3 of Sub. S.B. 9 of the 130th General Assembly. Rather,	1259
it is the intent of the General Assembly to ensure consistency in	1260
Ohio Insurance Law should this suspension be nullified.	1261