As Introduced

130th General Assembly
Regular Session
2013-2014
S. B. No. 330


Senator Cafaro 

Cosponsors: Senators Brown, Smith 



A BILL
To amend section 1739.05 and to enact sections 1
1751.72, 3901.90, 3923.251, and 5160.33 of the 2
Revised Code to amend the law related to the prior 3
authorization requirements of insurers and of the 4
medical assistance programs administered by the 5
Department of Medicaid.6


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

       Section 1. That section 1739.05 be amended and sections 7
1751.72, 3901.90, 3923.251, and 5160.33 of the Revised Code be 8
enacted to read as follows:9

       Sec. 1739.05.  (A) A multiple employer welfare arrangement 10
that is created pursuant to sections 1739.01 to 1739.22 of the 11
Revised Code and that operates a group self-insurance program may 12
be established only if any of the following applies:13

       (1) The arrangement has and maintains a minimum enrollment of 14
three hundred employees of two or more employers.15

       (2) The arrangement has and maintains a minimum enrollment of 16
three hundred self-employed individuals.17

       (3) The arrangement has and maintains a minimum enrollment of 18
three hundred employees or self-employed individuals in any 19
combination of divisions (A)(1) and (2) of this section.20

       (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, 3923.251, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 27
3923.63, 3923.80, 3924.031, 3924.032, and 3924.27 of the Revised 28
Code.29

       (C) A multiple employer welfare arrangement created pursuant 30
to sections 1739.01 to 1739.22 of the Revised Code shall solicit 31
enrollments only through agents or solicitors licensed pursuant to 32
Chapter 3905. of the Revised Code to sell or solicit sickness and 33
accident insurance.34

       (D) A multiple employer welfare arrangement created pursuant 35
to sections 1739.01 to 1739.22 of the Revised Code shall provide 36
benefits only to individuals who are members, employees of 37
members, or the dependents of members or employees, or are 38
eligible for continuation of coverage under section 1751.53 or 39
3923.38 of the Revised Code or under Title X of the "Consolidated 40
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 41
U.S.C.A. 1161, as amended.42

       Sec. 1751.72.  (A) As used in this section:43

       (1) "Covered person" has the same meaning as in section 44
3901.90 of the Revised Code.45

       (2) "Prior authorization requirement" means any practice 46
implemented by a health insuring corporation in which coverage of 47
a health care service is dependent upon a covered person, or a 48
health care provider, notifying the health insuring corporation 49
that the service is going to be provided or requesting and 50
receiving approval from the health insuring corporation. "Prior 51
authorization" includes any precertification, notification, or 52
referral program, or a prospective or utilization review conducted 53
prior to providing a health care service. 54

       (3) "Utilization review" has the same meaning as in section 55
1751.77 of the Revised Code. 56

       (B) If a policy, contract, or agreement issued by a health 57
insuring corporation contains a prior authorization requirement, 58
then the health insuring corporation shall comply with both of the 59
following:60

       (1) The health insuring corporation shall use the prior 61
authorization form adopted in rule by the superintendent of 62
insurance under section 3901.90 of the Revised Code for all prior 63
authorization requests or notifications made under a prior 64
authorization requirement.65

       (2) If the prior authorization requirement stipulates that 66
the health insuring corporation must either respond to a request 67
for coverage or approve or deny a request for coverage, then the 68
health insuring corporation shall either respond to the request or 69
deny or authorize the request, as appropriate, within forty-eight 70
hours after the health insuring corporation receives the form.71

       (C) Failure to comply with division (B) of this section shall 72
be considered an unfair and deceptive practice under sections 73
3901.19 to 3901.26 of the Revised Code. 74

       Sec. 3901.90.  (A) As used in this section:75

       (1) "Covered person" means a person receiving coverage for 76
health services under a policy, contract, agreement, or plan 77
issued by a health plan issuer. 78

       (2) "Health plan issuer" means a health insuring corporation, 79
a sickness and accident insurer, a public employee benefit plan, 80
or a multiple employer welfare arrangement. 81

       (3) "Prior authorization requirement" means any practice 82
implemented by a health plan issuer in which coverage of a health 83
care service is dependent upon a covered person, or a health care 84
provider, notifying the health plan issuer that the service is 85
going to be provided or requesting and receiving approval from the 86
health plan issuer. "Prior authorization" includes any 87
precertification, notification, or referral program, or a 88
prospective or utilization review conducted prior to providing a 89
health care service.90

       (4) "Utilization review" has the same meaning as in section 91
1751.77 of the Revised Code.92

       (B) The superintendent shall adopt in rule a standard form by 93
which a covered person may request prior authorization under a 94
prior authorization requirement. 95

       Sec. 3923.251.  (A) As used in this section:96

       (1) "Covered person" has the same meaning as in section 97
3901.90 of the Revised Code.98

       (2) "Prior authorization requirement" means any practice 99
implemented by either a sickness and accident insurer or a public 100
employee benefit plan in which coverage of a health care service 101
is dependent upon a covered person, or the health care provider, 102
notifying the insurer or plan that the service is going to be 103
provided or requesting and receiving approval from the insurer or 104
plan. "Prior authorization requirement" includes any 105
precertification, notification, or referral program, or a 106
prospective or utilization review conducted prior to providing a 107
health care service. 108

       (3) "Utilization review" has the same meaning as in section 109
1751.77 of the Revised Code. 110

       (B) If a policy issued by a sickness and accident insurer or 111
a public employee benefit plan contains a prior authorization 112
requirement, then the insurer or plan shall comply with both of 113
the following:114

       (1) The insurer or plan shall use the prior authorization 115
form adopted in rule by the superintendent of insurance under 116
section 3901.90 of the Revised Code for all prior authorization 117
notifications or requests made under a prior authorization 118
requirement.119

        (2) If the prior authorization requirement stipulates that 120
the insurer or plan must either respond to a request for coverage 121
or approve or deny a request for coverage, then the insurer or 122
plan shall either respond to the request or deny or authorize the 123
request, as appropriate, within forty-eight hours after the 124
insurer or plan receives the form.125

       (C) Failure to comply with division (B) of this section shall 126
be considered an unfair and deceptive practice under sections 127
3901.19 to 3901.26 of the Revised Code. 128

       Sec. 5160.33.  The department of medicaid shall establish a 129
standardized form to be used by medical assistance recipients and 130
individuals acting on the behalf of medical assistance recipients 131
to request prior authorization for services that are covered by a 132
medical assistance program and require prior authorization. The 133
department may provide for the form to be completed and submitted 134
to the department or its designee through an electronic submission 135
process. To the extent possible, the form shall be modeled on the 136
standardized prior authorization form adopted by the 137
superintendent of insurance under section 3901.90 of the Revised 138
Code.139

       The department or its designee shall approve or deny a prior 140
authorization request made on the form established under this 141
section not later than forty-eight hours after the department or 142
its designee receives the form.143

       Section 2.  That existing section 1739.05 of the Revised Code 144
is hereby repealed.145