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| 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 |
| 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 |