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| To enact sections 3959.18, 3964.01 to 3964.09, and | 1 |
| 5111.0216 of the Revised Code to establish | 2 |
| standards for physician designations by health | 3 |
| care insurers. | 4 |
| Section 1. That sections 3959.18, 3964.01, 3964.02, 3964.03, | 5 |
| 3964.04, 3964.05, 3964.06, 3964.07, 3964.08, 3964.09, and | 6 |
| 5111.0216 of the Revised Code be enacted to read as follows: | 7 |
| Sec. 3959.18. Chapter 3964. of the Revised Code applies to | 8 |
| an administrator in the same manner that the chapter applies to a | 9 |
| health care insurer, as defined in section 3964.01 of the Revised | 10 |
| Code. | 11 |
| Sec. 3964.01. As used in this chapter: | 12 |
| (A) "Health care insurer" means an entity that offers a | 13 |
| policy, contract, or plan for covering the cost of health care | 14 |
| services for individuals who are beneficiaries of or enrolled in | 15 |
| the policy, contract, or plan, to the extent that the entity and | 16 |
| the policy, contract, or plan are subject to the laws of this | 17 |
| state. "Health care insurer" includes all of the following: | 18 |
| (1) A sickness and accident insurance company authorized to | 19 |
| do the business of insurance in this state; | 20 |
| (2) A health insuring corporation that holds a certificate of | 21 |
| authority issued under Chapter 1751. of the Revised Code; | 22 |
| (3) An entity that offers a multiple employer welfare | 23 |
| arrangement, as defined in section 1739.01 of the Revised Code; | 24 |
| (4) The state, a political subdivision, or any other | 25 |
| government entity that offers a public employee health benefit | 26 |
| plan. | 27 |
| (B) "Medicaid managed care organization" means a managed care | 28 |
| organization under contract with the department of job and family | 29 |
| services under section 5111.17 of the Revised Code to provide, or | 30 |
| arrange for the provision of, health care services to medicaid | 31 |
| recipients who are required or permitted to obtain health care | 32 |
| services through managed care organizations as part of the care | 33 |
| management system established under section 5111.16 of the Revised | 34 |
| Code. | 35 |
| (C) "Patient charter" means either the patient charter for | 36 |
| physician performance measurement, reporting, and tiering | 37 |
| programs, which is developed by the consumer-purchaser disclosure | 38 |
| project, or a substantially similar document developed by a | 39 |
| successor organization. | 40 |
| (D) "Physician" means an individual authorized under Chapter | 41 |
| 4731. of the Revised Code to practice medicine and surgery, | 42 |
| osteopathic medicine and surgery, or podiatric medicine and | 43 |
| surgery. | 44 |
| (E) "Physician designation" means a grade, star, tier, or any | 45 |
| other rating used by a health care insurer to characterize or | 46 |
| represent the insurer's assessment or measurement of a physician's | 47 |
| cost efficiency, quality of care, or clinical performance. | 48 |
| "Physician designation" does not include either of the following: | 49 |
| (1) Information derived solely from satisfaction surveys or | 50 |
| other comments provided by individuals who are beneficiaries of or | 51 |
| enrolled in a policy, contract, or plan offered by a health care | 52 |
| insurer; | 53 |
| (2) Information for a program established by a health care | 54 |
| insurer to assist individuals with estimating a physician's | 55 |
| routine fees for providing services. | 56 |
| Sec. 3964.02. A health care insurer that operates a system | 57 |
| for making physician designations shall operate the system in | 58 |
| accordance with either of the following: | 59 |
| (A) The criteria identified in the version of the patient | 60 |
| charter that is most current at the time the system is being | 61 |
| operated; | 62 |
| (B) The criteria identified in another version of the patient | 63 |
| charter that was in effect at any time during the twelve-month | 64 |
| period immediately preceding the time at which the system is being | 65 |
| operated. | 66 |
| Sec. 3964.03. Annually, in accordance with a schedule | 67 |
| established by the superintendent of insurance, a health care | 68 |
| insurer that operates a system for making physician designations | 69 |
| shall submit to the superintendent a certificate from an | 70 |
| independent ratings examiner attesting to the examiner's | 71 |
| determination that the insurer has been in compliance with section | 72 |
| 3964.02 of the Revised Code during the twelve-month period | 73 |
| immediately preceding the certificate's submission. The | 74 |
| independent ratings examiner that issues the certificate shall be | 75 |
| one approved by the superintendent of insurance pursuant to the | 76 |
| process established under section 3964.04 of the Revised Code. | 77 |
| The health care insurer shall pay all charges assessed by the | 78 |
| independent ratings examiners for the issuance of the certificate. | 79 |
| Sec. 3964.04. The superintendent of insurance shall | 80 |
| establish a process for approving independent ratings examiners | 81 |
| that may issue the certificates described in section 3964.03 of | 82 |
| the Revised Code. In establishing the approval process, the | 83 |
| superintendent is subject to both of the following: | 84 |
| (A) The superintendent may approve only independent rating | 85 |
| examiners that are members of at least one nationally recognized, | 86 |
| independent, health care quality standard-setting organization. | 87 |
| (B) The superintendent shall approve all entities determined | 88 |
| to be eligible by the consumer-purchaser disclosure project or its | 89 |
| successor to monitor compliance with the patient charter. | 90 |
| Sec. 3964.05. (A)(1) Subject to division (A)(2) of this | 91 |
| section, no health care insurer shall fail to comply with section | 92 |
| 3964.02 or 3964.03 of the Revised Code. | 93 |
| (2) Division (A)(1) of this section does not apply to a | 94 |
| medicaid managed care organization if the department of job and | 95 |
| family services, pursuant to section 5111.0216 of the Revised | 96 |
| Code, has extended to the organization the department's operation | 97 |
| of a system for making physician designations. | 98 |
| (B) In the case of a health care insurer that is regulated by | 99 |
| the department of insurance, a series of violations of this | 100 |
| section that, taken together, constitutes a pattern or practice of | 101 |
| violating this section shall be considered an unfair and deceptive | 102 |
| act or practice in the business of insurance under sections | 103 |
| 3901.19 to 3901.26 of the Revised Code. | 104 |
| Sec. 3964.06. Nothing in this chapter shall be construed to | 105 |
| deprive any person of any private right of action otherwise | 106 |
| available under the law. | 107 |
| Sec. 3964.07. If a provision of a contractual arrangement | 108 |
| between a physician and a health care insurer that operates a | 109 |
| system for making physician designations does either of the | 110 |
| following, the provision is unenforceable: | 111 |
| (A) Limits a right the physician has pursuant to this chapter | 112 |
| or the patient charter under which the health care insurer is | 113 |
| operating its system pursuant to section 3964.02 of the Revised | 114 |
| Code; | 115 |
| (B) Requires the physician or health care insurer to act in a | 116 |
| manner that is otherwise contrary to the provisions of this | 117 |
| chapter or the applicable patient charter. | 118 |
| Sec. 3964.08. Neither sections 1333.61 to 1333.69 of the | 119 |
| Revised Code nor any other provision of the Revised Code | 120 |
| pertaining to trade secrets excuses a health care insurer that is | 121 |
| operating a system for making physician designations from | 122 |
| complying with any disclosures of information that are required by | 123 |
| the patient charter under which the health care insurer is | 124 |
| operating its system pursuant to section 3964.02 of the Revised | 125 |
| Code. | 126 |
| Sec. 3964.09. The superintendent of insurance may adopt | 127 |
| rules as the superintendent considers necessary to carry out the | 128 |
| purposes of this chapter. The rules shall be adopted in accordance | 129 |
| with Chapter 119. of the Revised Code. | 130 |
| Sec. 5111.0216. (A) As used in this section: | 131 |
| (1) "Patient charter" and "physician" have the same meanings | 132 |
| as in section 3964.01 of the Revised Code. | 133 |
| (2) "Physician designation" means a grade, star, tier, or any | 134 |
| other rating to characterize or represent an assessment or | 135 |
| measurement of a physician's cost efficiency, quality of care, or | 136 |
| clinical performance. "Physician designation" does not include | 137 |
| either of the following: | 138 |
| (a) Information derived solely from satisfaction surveys or | 139 |
| other comments provided by medicaid recipients; | 140 |
| (b) Information established for the medicaid program to | 141 |
| assist medicaid recipients with estimating a physician's routine | 142 |
| fees for providing services. | 143 |
| (B) The department of job and family services may operate a | 144 |
| system for making physician designations for purposes of the | 145 |
| medicaid program. If such a system is operated, the department | 146 |
| shall extend the system to managed care organizations when | 147 |
| contracting with the organizations pursuant to section 5111.17 of | 148 |
| the Revised Code. | 149 |
| (C) In operating a system for making physician designations, | 150 |
| the department shall operate the system in accordance with either | 151 |
| of the following: | 152 |
| (1) The criteria identified in the version of the patient | 153 |
| charter that is most current at the time the system is being | 154 |
| operated; | 155 |
| (2) The criteria identified in another version of the patient | 156 |
| charter that was in effect at any time during the twelve-month | 157 |
| period immediately preceding the time at which the system is being | 158 |
| operated. | 159 |
| (D) Compliance with division (C) of this section shall be | 160 |
| determined by a nationally recognized, independent, health care | 161 |
| quality standard-setting organization that is selected by the | 162 |
| department. | 163 |
| (E) The department of insurance has no authority over the | 164 |
| department of job and family services in the operation of a system | 165 |
| for making physician designations. | 166 |
| Section 2. (A) As used in this section, "health care insurer" | 167 |
| and "physician designation" have the same meanings as in section | 168 |
| 3964.01 of the Revised Code, as enacted by this act. | 169 |
| (B) If, on the effective date of this section, a health care | 170 |
| insurer is operating a system for making physician designations | 171 |
| and the system has been in operation for at least three months, | 172 |
| the first certificate that is required to be submitted under | 173 |
| section 3964.03 of the Revised Code, as enacted by this act, is | 174 |
| due not later than six months after the effective date of this | 175 |
| section. Thereafter, the health care insurer shall annually submit | 176 |
| certificates in accordance with the schedule established by the | 177 |
| Superintendent of Insurance. | 178 |