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To amend sections 1739.061, 1751.14, 1751.69, | 1 |
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, | 2 |
3923.58, 3923.601, 3923.65, 3923.83, 3923.85, | 3 |
3924.01, 4729.291, and 4729.541 and to enact | 4 |
sections 505.377, 737.082, 737.222, 3702.40, and | 5 |
4731.056 of the Revised Code to require a | 6 |
mammography facility to include certain | 7 |
information in the mammography report summary sent | 8 |
to a patient under federal law if the patient's | 9 |
mammogram demonstrates the presence of dense | 10 |
breast tissue; to establish requirements regarding | 11 |
controlled substances containing buprenorphine | 12 |
used for the purpose of treating drug dependence | 13 |
or addiction; to clarify the status of volunteer | 14 |
firefighters for purposes of the Patient | 15 |
Protection and Affordable Care Act; to make | 16 |
changes regarding coverage for a dependent child | 17 |
under a parent's health insurance plan and the | 18 |
hours of work needed to qualify for coverage under | 19 |
a small employer health benefit plan; to increase | 20 |
the duration of the health insurance considered to | 21 |
be short-term under certain insurance laws; and to | 22 |
make changes to the chemotherapy parity law. | 23 |
Section 1. That sections 1739.061, 1751.14, 1751.69, | 24 |
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601, | 25 |
3923.65, 3923.83, 3923.85, 3924.01, 4729.291, and 4729.541 be | 26 |
amended and sections 505.377, 737.082, 737.222, 3702.40, and | 27 |
4731.056 of the Revised Code be enacted to read as follows: | 28 |
Sec. 505.377. A volunteer firefighter appointed pursuant to | 29 |
this chapter is a bona fide volunteer and not an employee for | 30 |
purposes of section 513 of the "Patient Protection and Affordable | 31 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 32 |
providing those fire protection services, the volunteer receives | 33 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 34 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 35 |
Code. | 36 |
Sec. 737.082. A volunteer firefighter appointed pursuant to | 37 |
this chapter is a bona fide volunteer and not an employee for | 38 |
purposes of section 513 of the "Patient Protection and Affordable | 39 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 40 |
providing those fire protection services, the volunteer receives | 41 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 42 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 43 |
Code. | 44 |
Sec. 737.222. A volunteer firefighter appointed pursuant to | 45 |
this chapter is a bona fide volunteer and not an employee for | 46 |
purposes of section 513 of the "Patient Protection and Affordable | 47 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 48 |
providing those fire protection services, the volunteer receives | 49 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 50 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 51 |
Code. | 52 |
Sec. 1739.061. (A)(1) This section applies to both of the | 53 |
following: | 54 |
(a) A multiple employer welfare arrangement that issues or | 55 |
requires the use of a standardized identification card or an | 56 |
electronic technology for submission and routing of prescription | 57 |
drug claims; | 58 |
(b) A person or entity that a multiple employer welfare | 59 |
arrangement contracts with to issue a standardized identification | 60 |
card or an electronic technology described in division (A)(1)(a) | 61 |
of this section. | 62 |
(2) Notwithstanding division (A)(1) of this section, this | 63 |
section does not apply to the issuance or required use of a | 64 |
standardized identification card or an electronic technology for | 65 |
the submission and routing of prescription drug claims in | 66 |
connection with any of the following: | 67 |
(a) Any program or arrangement covering only accident, | 68 |
credit, dental, disability income, long-term care, hospital | 69 |
indemnity, medicare supplement, medicare, tricare, specified | 70 |
disease, or vision care; coverage under a | 71 |
one-time-limited-duration policy | 72 |
73 | |
insurance; insurance arising out of workers' compensation or | 74 |
similar law; automobile medical payment insurance; or insurance | 75 |
under which benefits are payable with or without regard to fault | 76 |
and which is statutorily required to be contained in any liability | 77 |
insurance policy or equivalent self-insurance. | 78 |
(b) Coverage provided under the medicaid program. | 79 |
(c) Coverage provided under an employer's self-insurance plan | 80 |
or by any of its administrators, as defined in section 3959.01 of | 81 |
the Revised Code, to the extent that federal law supersedes, | 82 |
preempts, prohibits, or otherwise precludes the application of | 83 |
this section to the plan and its administrators. | 84 |
(B) A standardized identification card or an electronic | 85 |
technology issued or required to be used as provided in division | 86 |
(A)(1) of this section shall contain uniform prescription drug | 87 |
information in accordance with either division (B)(1) or (2) of | 88 |
this section. | 89 |
(1) The standardized identification card or the electronic | 90 |
technology shall be in a format and contain information fields | 91 |
approved by the national council for prescription drug programs or | 92 |
a successor organization, as specified in the council's or | 93 |
successor organization's pharmacy identification card | 94 |
implementation guide in effect on the first day of October most | 95 |
immediately preceding the issuance or required use of the | 96 |
standardized identification card or the electronic technology. | 97 |
(2) If the multiple employer welfare arrangement or person | 98 |
under contract with it to issue a standardized identification card | 99 |
or an electronic technology requires the information for the | 100 |
submission and routing of a claim, the standardized identification | 101 |
card or the electronic technology shall contain any of the | 102 |
following information: | 103 |
(a) The name of the multiple employer welfare arrangement; | 104 |
(b) The individual's name, group number, and identification | 105 |
number; | 106 |
(c) A telephone number to inquire about pharmacy-related | 107 |
issues; | 108 |
(d) The issuer's international identification number, labeled | 109 |
as "ANSI BIN" or "RxBIN"; | 110 |
(e) The processor's control number, labeled as "RxPCN"; | 111 |
(f) The individual's pharmacy benefits group number if | 112 |
different from the insured's medical group number, labeled as | 113 |
"RxGrp." | 114 |
(C) If the standardized identification card or the electronic | 115 |
technology issued or required to be used as provided in division | 116 |
(A)(1) of this section is also used for submission and routing of | 117 |
nonpharmacy claims, the designation "Rx" is required to be | 118 |
included as part of the labels identified in divisions (B)(2)(d) | 119 |
and (e) of this section if the issuer's international | 120 |
identification number or the processor's control number is | 121 |
different for medical and pharmacy claims. | 122 |
(D) Each multiple employer welfare arrangement described in | 123 |
division (A) of this section shall annually file a certificate | 124 |
with the superintendent of insurance certifying that it or any | 125 |
person it contracts with to issue a standardized identification | 126 |
card or electronic technology for submission and routing of | 127 |
prescription drug claims complies with this section. | 128 |
(E)(1) Except as provided in division (E)(2) of this section, | 129 |
if there is a change in the information contained in the | 130 |
standardized identification card or the electronic technology | 131 |
issued to an individual, the multiple employer welfare arrangement | 132 |
or person under contract with it to issue a standardized | 133 |
identification card or an electronic technology shall issue a new | 134 |
card or electronic technology to the individual. | 135 |
(2) A multiple employer welfare arrangement or person under | 136 |
contract with it is not required under division (E)(1) of this | 137 |
section to issue a new card or electronic technology to an | 138 |
individual more than once during a twelve-month period. | 139 |
(F) Nothing in this section shall be construed as requiring a | 140 |
multiple employer welfare arrangement to produce more than one | 141 |
standardized identification card or one electronic technology for | 142 |
use by individuals accessing health care benefits provided under a | 143 |
multiple employer welfare arrangement. | 144 |
Sec. 1751.14. (A) Notwithstanding section 3901.71 of the | 145 |
Revised Code, any policy, contract, or agreement for health care | 146 |
services authorized by this chapter that is issued, delivered, or | 147 |
renewed in this state and that provides that coverage of an | 148 |
unmarried dependent child will terminate upon attainment of the | 149 |
limiting age for dependent children specified in the policy, | 150 |
contract, or agreement, shall also provide in substance both of | 151 |
the following: | 152 |
(1) Once an unmarried child has attained the limiting age for | 153 |
dependent children, as provided in the policy, contract, or | 154 |
agreement, upon the request of the subscriber, the health insuring | 155 |
corporation shall offer to cover the unmarried child until the | 156 |
child attains | 157 |
following are true: | 158 |
(a) The child is the natural child, stepchild, or adopted | 159 |
child of the subscriber. | 160 |
(b) The child is a resident of this state or a full-time | 161 |
student at an accredited public or private institution of higher | 162 |
education. | 163 |
(c) The child is not employed by an employer that offers any | 164 |
health benefit plan under which the child is eligible for | 165 |
coverage. | 166 |
(d) The child is not eligible for coverage under the medicaid | 167 |
program or the medicare program. | 168 |
(2) That attainment of the limiting age for dependent | 169 |
children shall not operate to terminate the coverage of a | 170 |
dependent child if the child is and continues to be both of the | 171 |
following: | 172 |
(a) Incapable of self-sustaining employment by reason of | 173 |
mental retardation or physical handicap; | 174 |
(b) Primarily dependent upon the subscriber for support and | 175 |
maintenance. | 176 |
(B) Proof of incapacity and dependence for purposes of | 177 |
division (A)(2) of this section shall be furnished to the health | 178 |
insuring corporation within thirty-one days of the child's | 179 |
attainment of the limiting age. Upon request, but not more | 180 |
frequently than annually, the health insuring corporation may | 181 |
require proof satisfactory to it of the continuance of such | 182 |
incapacity and dependency. | 183 |
(C) Nothing in this section shall do any of the following: | 184 |
(1) Require that any policy, contract, or agreement offer | 185 |
coverage for dependent children or provide coverage for an | 186 |
unmarried dependent child's children as dependents on the policy, | 187 |
contract, or agreement; | 188 |
(2) Require an employer to pay for any part of the premium | 189 |
for an unmarried dependent child that has attained the limiting | 190 |
age for dependents, as provided in the policy, contract, or | 191 |
agreement; | 192 |
(3) Require an employer to offer health insurance coverage to | 193 |
the dependents of any employee. | 194 |
(D) This section does not apply to any health insuring | 195 |
corporation policy, contract, or agreement offering only | 196 |
supplemental health care services or specialty health care | 197 |
services. | 198 |
(E) As used in this section, "health benefit plan" has the | 199 |
same meaning as in section 3924.01 of the Revised Code and also | 200 |
includes both of the following: | 201 |
(1) A public employee benefit plan; | 202 |
(2) A health benefit plan as regulated under the "Employee | 203 |
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq. | 204 |
Sec. 1751.69. (A) As used in this section, "cost sharing" | 205 |
means the cost to an individual insured under an individual or | 206 |
group health insuring corporation policy, contract, or agreement | 207 |
according to any coverage limit, copayment, coinsurance, | 208 |
deductible, or other out-of-pocket expense requirements imposed by | 209 |
the policy, contract, or agreement. | 210 |
(B) Notwithstanding section 3901.71 of the Revised Code and | 211 |
subject to division (D) of this section, no individual or group | 212 |
health insuring corporation policy, contract, or agreement | 213 |
providing basic health care services or prescription drug services | 214 |
that is delivered, issued for delivery, or renewed in this state, | 215 |
if the policy, contract, or agreement provides coverage for cancer | 216 |
chemotherapy treatment, shall fail to comply with either of the | 217 |
following: | 218 |
(1) The policy, contract, or agreement shall not provide | 219 |
coverage or impose cost sharing for a prescribed, orally | 220 |
administered cancer medication on a less favorable basis than the | 221 |
coverage it provides or cost sharing it imposes for intraveneously | 222 |
administered or injected cancer medications. | 223 |
(2) The policy, contract, or agreement shall not comply with | 224 |
division (B)(1) of this section by imposing an increase in cost | 225 |
sharing solely for orally administered, intravenously | 226 |
administered, or injected cancer medications. | 227 |
(C) Notwithstanding any provision of this section to the | 228 |
contrary, an individual or group health insuring corporation | 229 |
policy, contract, or agreement shall be deemed to be in compliance | 230 |
with this section if the cost sharing imposed under such a policy, | 231 |
contract, or agreement for orally administered cancer treatments | 232 |
does not exceed one hundred dollars per prescription fill. The | 233 |
cost sharing limit of one hundred dollars per prescription fill | 234 |
shall apply to a high deductible plan, as defined in 26 U.S.C. | 235 |
223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only | 236 |
after the deductible has been met. | 237 |
(D) The prohibitions in division (B) of this section do not | 238 |
preclude an individual or group health insuring corporation | 239 |
policy, contract, or agreement from requiring an enrollee to | 240 |
obtain prior authorization before orally administered cancer | 241 |
medication is dispensed to the enrollee. | 242 |
(E) A health insuring corporation that offers coverage for | 243 |
basic health care services is not required to comply with division | 244 |
(B) of this section if all of the following apply: | 245 |
(1) The health insuring corporation submits documentation | 246 |
certified by an independent member of the American academy of | 247 |
actuaries to the superintendent of insurance showing that | 248 |
compliance with division (B)(1) of this section for a period of at | 249 |
least six months independently caused the health insuring | 250 |
corporation's costs for claims and administrative expenses for the | 251 |
coverage of basic health care services to increase by more than | 252 |
one per cent per year. | 253 |
(2) The health insuring corporation submits a signed letter | 254 |
from an independent member of the American academy of actuaries to | 255 |
the superintendent of insurance opining that the increase in costs | 256 |
described in division (E)(1) of this section could reasonably | 257 |
justify an increase of more than one per cent in the annual | 258 |
premiums or rates charged by the health insuring corporation for | 259 |
the coverage of basic health care services. | 260 |
(3)(a) The superintendent of insurance makes the following | 261 |
determinations from the documentation and opinion submitted | 262 |
pursuant to divisions (E)(1) and (2) of this section: | 263 |
(i) Compliance with division (B)(1) of this section for a | 264 |
period of at least six months independently caused the health | 265 |
insuring corporation's costs for claims and administrative | 266 |
expenses for the coverage of basic health care services to | 267 |
increase more than one per cent per year. | 268 |
(ii) The increase in costs reasonably justifies an increase | 269 |
of more than one per cent in the annual premiums or rates charged | 270 |
by the health insuring corporation for the coverage of basic | 271 |
health care services. | 272 |
(b) Any determination made by the superintendent under | 273 |
division (E)(3) of this section is subject to Chapter 119. of the | 274 |
Revised Code. | 275 |
Sec. 3702.40. (A) As used in this section, "mammogram" and | 276 |
"facility" have the same meanings as in section 263b(a) of the | 277 |
"Mammography Quality Standards Act of 1992," 106 Stat. 3547 | 278 |
(1992), 42 U.S.C. 263b(a), as amended. | 279 |
(B) As required by 21 C.F.R. 900.12(c)(2), a facility shall | 280 |
send to each patient who has a mammogram at the facility a summary | 281 |
of the written report containing the results of the patient's | 282 |
mammogram. If, based on the breast imaging reporting and data | 283 |
system established by the American college of radiology, the | 284 |
patient's mammogram demonstrates that the patient has dense breast | 285 |
tissue, the summary shall include the following statement: | 286 |
"Your mammogram demonstrates that you have dense breast | 287 |
tissue, which could hide abnormalities. Dense breast tissue, in | 288 |
and of itself, is a relatively common condition. Therefore, this | 289 |
information is not provided to cause undue concern; rather, it is | 290 |
to raise your awareness and promote discussion with your health | 291 |
care provider regarding the presence of dense breast tissue in | 292 |
addition to other risk factors." | 293 |
As required by 21 C.F.R. 900.12(c)(3), the facility shall | 294 |
send to the patient's health care provider, if known, a copy of | 295 |
the written report containing the results of the patient's | 296 |
mammogram not later than thirty days after the mammogram was | 297 |
performed. | 298 |
(C) This section does not do either of the following: | 299 |
(1) Create a new cause of action or substantive legal right | 300 |
against a person, facility, or other entity. | 301 |
(2) Create a standard of care, obligation, or duty for a | 302 |
person, facility, or other entity that would provide the basis for | 303 |
a cause of action or substantive legal right, other than the duty | 304 |
to send the summary and written report described in division (B) | 305 |
of this section. | 306 |
Sec. 3923.022. (A) As used in this section: | 307 |
(1)(a) "Administrative expense" means the amount resulting | 308 |
from the following: the amount of premiums earned by the insurer | 309 |
for sickness and accident insurance business plus the amount of | 310 |
losses recovered from reinsurance coverage minus the sum of the | 311 |
amount of claims for losses paid; the amount of losses incurred | 312 |
but not reported; the amount incurred for state fees, federal and | 313 |
state taxes, and reinsurance; and the incurred costs and expenses | 314 |
related, either directly or indirectly, to the payment of | 315 |
commissions, measures to control fraud, and managed care. | 316 |
(b) "Administrative expense" does not include any amounts | 317 |
collected, or administrative expenses incurred, by an insurer for | 318 |
the administration of an employee health benefit plan subject to | 319 |
regulation by the federal "Employee Retirement Income Security Act | 320 |
of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts | 321 |
collected or administrative expenses incurred" means the total | 322 |
amount paid to an administrator for the administration and payment | 323 |
of claims minus the sum of the amount of claims for losses paid | 324 |
and the amount of losses incurred but not reported. | 325 |
(2) "Insurer" means any insurance company authorized under | 326 |
Title XXXIX of the Revised Code to do the business of sickness and | 327 |
accident insurance in this state. | 328 |
(3) "Sickness and accident insurance business" does not | 329 |
include coverage provided by an insurer for specific diseases or | 330 |
accidents only; any hospital indemnity, medicare supplement, | 331 |
long-term care, disability income, one-time-limited-duration | 332 |
policy | 333 |
policy that offers only supplemental benefits; or coverage | 334 |
provided to individuals who are not residents of this state. | 335 |
(4) "Individual business" includes both individual sickness | 336 |
and accident insurance and sickness and accident insurance made | 337 |
available by insurers in the individual market to individuals, | 338 |
with or without family members or dependents, through group | 339 |
policies issued to one or more associations or entities. | 340 |
(B) Notwithstanding section 3941.14 of the Revised Code, each | 341 |
insurer shall have aggregate administrative expenses of no more | 342 |
than twenty per cent of the premium income of the insurer, based | 343 |
on the premiums earned in that year on the sickness and accident | 344 |
insurance business of the insurer. | 345 |
(C)(1) Each insurer, on the first day of January or within | 346 |
sixty days thereafter, shall annually prepare, under oath, and | 347 |
deposit in the office of the superintendent of insurance a | 348 |
statement of the aggregate administrative expenses of the insurer, | 349 |
based on the premiums earned in the immediately preceding calendar | 350 |
year on the sickness and accident insurance business of the | 351 |
insurer. The statement shall itemize and separately detail all of | 352 |
the following information with respect to the insurer's sickness | 353 |
and accident insurance business: | 354 |
(a) The amount of premiums earned by the insurer both before | 355 |
and after any costs related to the insurer's purchase of | 356 |
reinsurance coverage; | 357 |
(b) The total amount of claims for losses paid by the insurer | 358 |
both before and after any reimbursement from reinsurance coverage; | 359 |
(c) The amount of any losses incurred by the insurer but not | 360 |
reported by the insurer in the current or prior year; | 361 |
(d) The amount of costs incurred by the insurer for state | 362 |
fees and federal and state taxes; | 363 |
(e) The amount of costs incurred by the insurer for | 364 |
reinsurance coverage; | 365 |
(f) The amount of costs incurred by the insurer that are | 366 |
related to the insurer's payment of commissions; | 367 |
(g) The amount of costs incurred by the insurer that are | 368 |
related to the insurer's fraud prevention measures; | 369 |
(h) The amount of costs incurred by the insurer that are | 370 |
related to managed care; and | 371 |
(i) Any other administrative expenses incurred by the | 372 |
insurer. | 373 |
(2) The statement also shall include all of the information | 374 |
required under division (C)(1) of this section separately detailed | 375 |
for the insurer's individual business, small group business, and | 376 |
large group business. | 377 |
(D) No insurer shall fail to comply with this section. | 378 |
(E) If the superintendent determines that an insurer has | 379 |
violated this section, the superintendent, pursuant to an | 380 |
adjudication conducted in accordance with Chapter 119. of the | 381 |
Revised Code, may order the suspension of the insurer's license to | 382 |
do the business of sickness and accident insurance in this state | 383 |
until the superintendent is satisfied that the insurer is in | 384 |
compliance with this section. If the insurer continues to do the | 385 |
business of sickness and accident insurance in this state while | 386 |
under the suspension order, the superintendent shall order the | 387 |
insurer to pay one thousand dollars for each day of the violation. | 388 |
(F) Any money collected by the superintendent under division | 389 |
(E) of this section shall be deposited by the superintendent into | 390 |
the state treasury to the credit of the department of insurance | 391 |
operating fund. | 392 |
(G) The statement of aggregate expenses filed pursuant to | 393 |
this section separately detailing an insurer's individual, small | 394 |
group, and large group business shall be considered work papers | 395 |
resulting from the conduct of a market analysis of an entity | 396 |
subject to examination by the superintendent under division (C) of | 397 |
section 3901.48 of the Revised Code, except that the | 398 |
superintendent may share aggregated market information that | 399 |
identifies the premiums earned as reported under division | 400 |
(C)(1)(a) of this section, the administrative expenses reported | 401 |
under division (C)(1)(i) of this section, the amount of | 402 |
commissions reported under division (C)(1)(f) of this section, the | 403 |
amount of taxes paid as reported under division (C)(1)(d) of this | 404 |
section, the total of the remaining benefit costs as reported | 405 |
under divisions (C)(1)(b) and (c) of this section, and the amount | 406 |
of fraud and managed care expenses reported under divisions | 407 |
(C)(1)(g) and (h) of this section. | 408 |
Sec. 3923.24. (A) Notwithstanding section 3901.71 of the | 409 |
Revised Code, every certificate furnished by an insurer in | 410 |
connection with, or pursuant to any provision of, any group | 411 |
sickness and accident insurance policy delivered, issued for | 412 |
delivery, renewed, or used in this state on or after January 1, | 413 |
1972, every policy of sickness and accident insurance delivered, | 414 |
issued for delivery, renewed, or used in this state on or after | 415 |
January 1, 1972, and every multiple employer welfare arrangement | 416 |
offering an insurance program, which provides that coverage of an | 417 |
unmarried dependent child of a parent or legal guardian will | 418 |
terminate upon attainment of the limiting age for dependent | 419 |
children specified in the contract shall also provide in substance | 420 |
both of the following: | 421 |
(1) Once an unmarried child has attained the limiting age for | 422 |
dependent children, as provided in the policy, upon the request of | 423 |
the insured, the insurer shall offer to cover the unmarried child | 424 |
until the child attains | 425 |
all of the following are true: | 426 |
(a) The child is the natural child, stepchild, or adopted | 427 |
child of the insured. | 428 |
(b) The child is a resident of this state or a full-time | 429 |
student at an accredited public or private institution of higher | 430 |
education. | 431 |
(c) The child is not employed by an employer that offers any | 432 |
health benefit plan under which the child is eligible for | 433 |
coverage. | 434 |
(d) The child is not eligible for the medicaid program or the | 435 |
medicare program. | 436 |
(2) That attainment of the limiting age for dependent | 437 |
children shall not operate to terminate the coverage of a | 438 |
dependent child if the child is and continues to be both of the | 439 |
following: | 440 |
(a) Incapable of self-sustaining employment by reason of | 441 |
mental retardation or physical handicap; | 442 |
(b) Primarily dependent upon the policyholder or certificate | 443 |
holder for support and maintenance. | 444 |
(B) Proof of such incapacity and dependence for purposes of | 445 |
division (A)(2) of this section shall be furnished by the | 446 |
policyholder or by the certificate holder to the insurer within | 447 |
thirty-one days of the child's attainment of the limiting age. | 448 |
Upon request, but not more frequently than annually after the | 449 |
two-year period following the child's attainment of the limiting | 450 |
age, the insurer may require proof satisfactory to it of the | 451 |
continuance of such incapacity and dependency. | 452 |
(C) Nothing in this section shall require an insurer to cover | 453 |
a dependent child who is mentally retarded or physically | 454 |
handicapped if the contract is underwritten on evidence of | 455 |
insurability based on health factors set forth in the application, | 456 |
or if such dependent child does not satisfy the conditions of the | 457 |
contract as to any requirement for evidence of insurability or | 458 |
other provision of the contract, satisfaction of which is required | 459 |
for coverage thereunder to take effect. In any such case, the | 460 |
terms of the contract shall apply with regard to the coverage or | 461 |
exclusion of the dependent from such coverage. Nothing in this | 462 |
section shall apply to accidental death or dismemberment benefits | 463 |
provided by any such policy of sickness and accident insurance. | 464 |
(D) Nothing in this section shall do any of the following: | 465 |
(1) Require that any policy offer coverage for dependent | 466 |
children or provide coverage for an unmarried dependent child's | 467 |
children as dependents on the policy; | 468 |
(2) Require an employer to pay for any part of the premium | 469 |
for an unmarried dependent child that has attained the limiting | 470 |
age for dependents, as provided in the policy; | 471 |
(3) Require an employer to offer health insurance coverage to | 472 |
the dependents of any employee. | 473 |
(E) This section does not apply to any policies or | 474 |
certificates covering only accident, credit, dental, disability | 475 |
income, long-term care, hospital indemnity, medicare supplement, | 476 |
specified disease, or vision care; coverage under a | 477 |
one-time-limited-duration policy | 478 |
479 | |
insurance; insurance arising out of a workers' compensation or | 480 |
similar law; automobile medical-payment insurance; or insurance | 481 |
under which benefits are payable with or without regard to fault | 482 |
and that is statutorily required to be contained in any liability | 483 |
insurance policy or equivalent self-insurance. | 484 |
(F) As used in this section, "health benefit plan" has the | 485 |
same meaning as in section 3924.01 of the Revised Code and also | 486 |
includes both of the following: | 487 |
(1) A public employee benefit plan; | 488 |
(2) A health benefit plan as regulated under the "Employee | 489 |
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq. | 490 |
Sec. 3923.241. (A) Notwithstanding section 3901.71 of the | 491 |
Revised Code, any public employee benefit plan that provides that | 492 |
coverage of an unmarried dependent child will terminate upon | 493 |
attainment of the limiting age for dependent children specified in | 494 |
the plan shall also provide in substance both of the following: | 495 |
(1) Once an unmarried child has attained the limiting age for | 496 |
dependent children, as provided in the plan, upon the request of | 497 |
the employee, the public employee benefit plan shall offer to | 498 |
cover the unmarried child until the child attains | 499 |
twenty-six years of age if all of the following are true: | 500 |
(a) The child is the natural child, stepchild, or adopted | 501 |
child of the employee. | 502 |
(b) The child is a resident of this state or a full-time | 503 |
student at an accredited public or private institution of higher | 504 |
education. | 505 |
(c) The child is not employed by an employer that offers any | 506 |
health benefit plan under which the child is eligible for | 507 |
coverage. | 508 |
(d) The child is not eligible for the medicaid program or the | 509 |
medicare program. | 510 |
(2) That attainment of the limiting age for dependent | 511 |
children shall not operate to terminate the coverage of a | 512 |
dependent child if the child is and continues to be both of the | 513 |
following: | 514 |
(a) Incapable of self-sustaining employment by reason of | 515 |
mental retardation or physical handicap; | 516 |
(b) Primarily dependent upon the plan member for support and | 517 |
maintenance. | 518 |
(B) Proof of incapacity and dependence for purposes of | 519 |
division (A)(2) of this section shall be furnished to the public | 520 |
employee benefit plan within thirty-one days of the child's | 521 |
attainment of the limiting age. Upon request, but not more | 522 |
frequently than annually, the public employee benefit plan may | 523 |
require proof satisfactory to it of the continuance of such | 524 |
incapacity and dependency. | 525 |
(C) Nothing in this section shall do any of the following: | 526 |
(1) Require that any public employee benefit plan offer | 527 |
coverage for dependent children or provide coverage for an | 528 |
unmarried dependent child's children as dependents on the public | 529 |
employee benefit plan; | 530 |
(2) Require an employer to pay for any part of the premium | 531 |
for an unmarried dependent child that has attained the limiting | 532 |
age for dependents, as provided in the plan; | 533 |
(3) Require an employer to offer health insurance coverage to | 534 |
the dependents of any employee. | 535 |
(D) This section does not apply to any public employee | 536 |
benefit plan covering only accident, credit, dental, disability | 537 |
income, long-term care, hospital indemnity, medicare supplement, | 538 |
specified disease, or vision care; coverage under a | 539 |
one-time-limited-duration policy | 540 |
541 | |
insurance; insurance arising out of a workers' compensation or | 542 |
similar law; automobile medical-payment insurance; or insurance | 543 |
under which benefits are payable with or without regard to fault | 544 |
and which is statutorily required to be contained in any liability | 545 |
insurance policy or equivalent self-insurance. | 546 |
(E) As used in this section, "health benefit plan" has the | 547 |
same meaning as in section 3924.01 of the Revised Code and also | 548 |
includes both of the following: | 549 |
(1) A public employee benefit plan; | 550 |
(2) A health benefit plan as regulated under the "Employee | 551 |
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq. | 552 |
Sec. 3923.281. (A) As used in this section: | 553 |
(1) "Biologically based mental illness" means schizophrenia, | 554 |
schizoaffective disorder, major depressive disorder, bipolar | 555 |
disorder, paranoia and other psychotic disorders, | 556 |
obsessive-compulsive disorder, and panic disorder, as these terms | 557 |
are defined in the most recent edition of the diagnostic and | 558 |
statistical manual of mental disorders published by the American | 559 |
psychiatric association. | 560 |
(2) "Policy of sickness and accident insurance" has the same | 561 |
meaning as in section 3923.01 of the Revised Code, but excludes | 562 |
any hospital indemnity, medicare supplement, long-term care, | 563 |
disability income, one-time-limited-duration policy | 564 |
that is less than | 565 |
other policy that provides coverage for specific diseases or | 566 |
accidents only; any policy that provides coverage for workers' | 567 |
compensation claims compensable pursuant to Chapters 4121. and | 568 |
4123. of the Revised Code; and any policy that provides coverage | 569 |
to medicaid recipients. | 570 |
(B) Notwithstanding section 3901.71 of the Revised Code, and | 571 |
subject to division (E) of this section, every policy of sickness | 572 |
and accident insurance shall provide benefits for the diagnosis | 573 |
and treatment of biologically based mental illnesses on the same | 574 |
terms and conditions as, and shall provide benefits no less | 575 |
extensive than, those provided under the policy of sickness and | 576 |
accident insurance for the treatment and diagnosis of all other | 577 |
physical diseases and disorders, if both of the following apply: | 578 |
(1) The biologically based mental illness is clinically | 579 |
diagnosed by a physician authorized under Chapter 4731. of the | 580 |
Revised Code to practice medicine and surgery or osteopathic | 581 |
medicine and surgery; a psychologist licensed under Chapter 4732. | 582 |
of the Revised Code; a licensed professional clinical counselor, | 583 |
licensed professional counselor, independent social worker, or | 584 |
independent marriage and family therapist licensed under Chapter | 585 |
4757. of the Revised Code; or a clinical nurse specialist or | 586 |
certified nurse practitioner licensed under Chapter 4723. of the | 587 |
Revised Code whose nursing specialty is mental health. | 588 |
(2) The prescribed treatment is not experimental or | 589 |
investigational, having proven its clinical effectiveness in | 590 |
accordance with generally accepted medical standards. | 591 |
(C) Division (B) of this section applies to all coverages and | 592 |
terms and conditions of the policy of sickness and accident | 593 |
insurance, including, but not limited to, coverage of inpatient | 594 |
hospital services, outpatient services, and medication; maximum | 595 |
lifetime benefits; copayments; and individual and family | 596 |
deductibles. | 597 |
(D) Nothing in this section shall be construed as prohibiting | 598 |
a sickness and accident insurance company from taking any of the | 599 |
following actions: | 600 |
(1) Negotiating separately with mental health care providers | 601 |
with regard to reimbursement rates and the delivery of health care | 602 |
services; | 603 |
(2) Offering policies that provide benefits solely for the | 604 |
diagnosis and treatment of biologically based mental illnesses; | 605 |
(3) Managing the provision of benefits for the diagnosis or | 606 |
treatment of biologically based mental illnesses through the use | 607 |
of pre-admission screening, by requiring beneficiaries to obtain | 608 |
authorization prior to treatment, or through the use of any other | 609 |
mechanism designed to limit coverage to that treatment determined | 610 |
to be necessary; | 611 |
(4) Enforcing the terms and conditions of a policy of | 612 |
sickness and accident insurance. | 613 |
(E) An insurer that offers any policy of sickness and | 614 |
accident insurance is not required to provide benefits for the | 615 |
diagnosis and treatment of biologically based mental illnesses | 616 |
pursuant to division (B) of this section if all of the following | 617 |
apply: | 618 |
(1) The insurer submits documentation certified by an | 619 |
independent member of the American academy of actuaries to the | 620 |
superintendent of insurance showing that incurred claims for | 621 |
diagnostic and treatment services for biologically based mental | 622 |
illnesses for a period of at least six months independently caused | 623 |
the insurer's costs for claims and administrative expenses for the | 624 |
coverage of all other physical diseases and disorders to increase | 625 |
by more than one per cent per year. | 626 |
(2) The insurer submits a signed letter from an independent | 627 |
member of the American academy of actuaries to the superintendent | 628 |
of insurance opining that the increase described in division | 629 |
(E)(1) of this section could reasonably justify an increase of | 630 |
more than one per cent in the annual premiums or rates charged by | 631 |
the insurer for the coverage of all other physical diseases and | 632 |
disorders. | 633 |
(3) The superintendent of insurance makes the following | 634 |
determinations from the documentation and opinion submitted | 635 |
pursuant to divisions (E)(1) and (2) of this section: | 636 |
(a) Incurred claims for diagnostic and treatment services for | 637 |
biologically based mental illnesses for a period of at least six | 638 |
months independently caused the insurer's costs for claims and | 639 |
administrative expenses for the coverage of all other physical | 640 |
diseases and disorders to increase by more than one per cent per | 641 |
year. | 642 |
(b) The increase in costs reasonably justifies an increase of | 643 |
more than one per cent in the annual premiums or rates charged by | 644 |
the insurer for the coverage of all other physical diseases and | 645 |
disorders. | 646 |
Any determination made by the superintendent under this | 647 |
division is subject to Chapter 119. of the Revised Code. | 648 |
Sec. 3923.57. Notwithstanding any provision of this chapter, | 649 |
every individual policy of sickness and accident insurance that is | 650 |
delivered, issued for delivery, or renewed in this state is | 651 |
subject to the following conditions, as applicable: | 652 |
(A) Pre-existing conditions provisions shall not exclude or | 653 |
limit coverage for a period beyond twelve months following the | 654 |
policyholder's effective date of coverage and may only relate to | 655 |
conditions during the six months immediately preceding the | 656 |
effective date of coverage. | 657 |
(B) In determining whether a pre-existing conditions | 658 |
provision applies to a policyholder or dependent, each policy | 659 |
shall credit the time the policyholder or dependent was covered | 660 |
under a previous policy, contract, or plan if the previous | 661 |
coverage was continuous to a date not more than thirty days prior | 662 |
to the effective date of the new coverage, exclusive of any | 663 |
applicable service waiting period under the policy. | 664 |
(C)(1) Except as otherwise provided in division (C) of this | 665 |
section, an insurer that provides an individual sickness and | 666 |
accident insurance policy to an individual shall renew or continue | 667 |
in force such coverage at the option of the individual. | 668 |
(2) An insurer may nonrenew or discontinue coverage of an | 669 |
individual in the individual market based only on one or more of | 670 |
the following reasons: | 671 |
(a) The individual failed to pay premiums or contributions in | 672 |
accordance with the terms of the policy or the insurer has not | 673 |
received timely premium payments. | 674 |
(b) The individual performed an act or practice that | 675 |
constitutes fraud or made an intentional misrepresentation of | 676 |
material fact under the terms of the policy. | 677 |
(c) The insurer is ceasing to offer coverage in the | 678 |
individual market in accordance with division (D) of this section | 679 |
and the applicable laws of this state. | 680 |
(d) If the insurer offers coverage in the market through a | 681 |
network plan, the individual no longer resides, lives, or works in | 682 |
the service area, or in an area for which the insurer is | 683 |
authorized to do business; provided, however, that such coverage | 684 |
is terminated uniformly without regard to any health | 685 |
status-related factor of covered individuals. | 686 |
(e) If the coverage is made available in the individual | 687 |
market only through one or more bona fide associations, the | 688 |
membership of the individual in the association, on the basis of | 689 |
which the coverage is provided, ceases; provided, however, that | 690 |
such coverage is terminated under division (C)(2)(e) of this | 691 |
section uniformly without regard to any health status-related | 692 |
factor of covered individuals. | 693 |
An insurer offering coverage to individuals solely through | 694 |
membership in a bona fide association shall not be deemed, by | 695 |
virtue of that offering, to be in the individual market for | 696 |
purposes of sections 3923.58 and 3923.581 of the Revised Code. | 697 |
Such an insurer shall not be required to accept applicants for | 698 |
coverage in the individual market pursuant to sections 3923.58 and | 699 |
3923.581 of the Revised Code unless the insurer also offers | 700 |
coverage to individuals other than through bona fide associations. | 701 |
(3) An insurer may cancel or decide not to renew the coverage | 702 |
of a dependent of an individual if the dependent has performed an | 703 |
act or practice that constitutes fraud or made an intentional | 704 |
misrepresentation of material fact under the terms of the coverage | 705 |
and if the cancellation or nonrenewal is not based, either | 706 |
directly or indirectly, on any health status-related factor in | 707 |
relation to the dependent. | 708 |
(D)(1) If an insurer decides to discontinue offering a | 709 |
particular type of health insurance coverage offered in the | 710 |
individual market, coverage of such type may be discontinued by | 711 |
the insurer if the insurer does all of the following: | 712 |
(a) Provides notice to each individual provided coverage of | 713 |
this type in such market of the discontinuation at least ninety | 714 |
days prior to the date of the discontinuation of the coverage; | 715 |
(b) Offers to each individual provided coverage of this type | 716 |
in such market, the option to purchase any other individual health | 717 |
insurance coverage currently being offered by the insurer for | 718 |
individuals in that market; | 719 |
(c) In exercising the option to discontinue coverage of this | 720 |
type and in offering the option of coverage under division | 721 |
(D)(1)(b) of this section, acts uniformly without regard to any | 722 |
health status-related factor of covered individuals or of | 723 |
individuals who may become eligible for such coverage. | 724 |
(2) If an insurer elects to discontinue offering all health | 725 |
insurance coverage in the individual market in this state, health | 726 |
insurance coverage may be discontinued by the insurer only if both | 727 |
of the following apply: | 728 |
(a) The insurer provides notice to the department of | 729 |
insurance and to each individual of the discontinuation at least | 730 |
one hundred eighty days prior to the date of the expiration of the | 731 |
coverage. | 732 |
(b) All health insurance delivered or issued for delivery in | 733 |
this state in such market is discontinued and coverage under that | 734 |
health insurance in that market is not renewed. | 735 |
(3) In the event of a discontinuation under division (D)(2) | 736 |
of this section in the individual market, the insurer shall not | 737 |
provide for the issuance of any health insurance coverage in the | 738 |
market and this state during the five-year period beginning on the | 739 |
date of the discontinuation of the last health insurance coverage | 740 |
not so renewed. | 741 |
(E) Notwithstanding divisions (C) and (D) of this section, an | 742 |
insurer may, at the time of coverage renewal, modify the health | 743 |
insurance coverage for a policy form offered to individuals in the | 744 |
individual market if the modification is consistent with the law | 745 |
of this state and effective on a uniform basis among all | 746 |
individuals with that policy form. | 747 |
(F) Such policies are subject to sections 2743 and 2747 of | 748 |
the "Health Insurance Portability and Accountability Act of 1996," | 749 |
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and | 750 |
300gg-47, as amended. | 751 |
(G) Sections 3924.031 and 3924.032 of the Revised Code shall | 752 |
apply to sickness and accident insurance policies offered in the | 753 |
individual market in the same manner as they apply to health | 754 |
benefit plans offered in the small employer market. | 755 |
In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of | 756 |
this section also apply to all group sickness and accident | 757 |
insurance policies that are not sold in connection with an | 758 |
employment-related group health plan and that provide more than | 759 |
short-term, limited duration coverage. | 760 |
In applying divisions (C) to (G) of this section with respect | 761 |
to health insurance coverage that is made available by an insurer | 762 |
in the individual market to individuals only through one or more | 763 |
associations, the term "individual" includes the association of | 764 |
which the individual is a member. | 765 |
For purposes of this section, any policy issued pursuant to | 766 |
division (C) of section 3923.13 of the Revised Code in connection | 767 |
with a public or private college or university student health | 768 |
insurance program is considered to be issued to a bona fide | 769 |
association. | 770 |
As used in this section, "bona fide association" has the same | 771 |
meaning as in section 3924.03 of the Revised Code, and "health | 772 |
status-related factor" and "network plan" have the same meanings | 773 |
as in section 3924.031 of the Revised Code. | 774 |
This section does not apply to any policy that provides | 775 |
coverage for specific diseases or accidents only, or to any | 776 |
hospital indemnity, medicare supplement, long-term care, | 777 |
disability income, one-time-limited-duration policy | 778 |
that is less than | 779 |
only supplemental benefits. | 780 |
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 of | 781 |
the Revised Code: | 782 |
(1) "Base rate" means, as to any health benefit plan that is | 783 |
issued by a carrier in the individual market, the lowest premium | 784 |
rate for new or existing business prescribed by the carrier for | 785 |
the same or similar coverage under a plan or arrangement covering | 786 |
any individual with similar case characteristics. | 787 |
(2) "Carrier," "health benefit plan," and "MEWA" have the | 788 |
same meanings as in section 3924.01 of the Revised Code. | 789 |
(3) "Network plan" means a health benefit plan of a carrier | 790 |
under which the financing and delivery of medical care, including | 791 |
items and services paid for as medical care, are provided, in | 792 |
whole or in part, through a defined set of providers under | 793 |
contract with the carrier. | 794 |
(4) "Ohio health care basic and standard plans" means those | 795 |
plans established under section 3924.10 of the Revised Code. | 796 |
(5) "Pre-existing conditions provision" means a policy | 797 |
provision that excludes or limits coverage for charges or expenses | 798 |
incurred during a specified period following the insured's | 799 |
effective date of coverage as to a condition which, during a | 800 |
specified period immediately preceding the effective date of | 801 |
coverage, had manifested itself in such a manner as would cause an | 802 |
ordinarily prudent person to seek medical advice, diagnosis, care, | 803 |
or treatment or for which medical advice, diagnosis, care, or | 804 |
treatment was recommended or received, or a pregnancy existing on | 805 |
the effective date of coverage. | 806 |
(B) Beginning in January of each year, carriers in the | 807 |
business of issuing health benefit plans to individuals and | 808 |
nonemployer groups, except individual health benefit plans issued | 809 |
pursuant to sections 1751.16 and 3923.122 of the Revised Code, | 810 |
shall accept applicants for open enrollment coverage, as set forth | 811 |
in this division, in the order in which they apply for coverage | 812 |
and subject to the limitation set forth in division (G) of this | 813 |
section. Carriers shall accept for coverage pursuant to this | 814 |
section individuals to whom both of the following conditions | 815 |
apply: | 816 |
(1) The individual is not applying for coverage as an | 817 |
employee of an employer, as a member of an association, or as a | 818 |
member of any other group. | 819 |
(2) The individual is not covered, and is not eligible for | 820 |
coverage, under any other private or public health benefits | 821 |
arrangement, including the medicare program established under | 822 |
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 | 823 |
U.S.C.A. 301, as amended, or any other act of congress or law of | 824 |
this or any other state of the United States that provides | 825 |
benefits comparable to the benefits provided under this section, | 826 |
any medicare supplement policy, or any continuation of coverage | 827 |
policy under state or federal law. | 828 |
(C) A carrier shall offer to any individual accepted under | 829 |
this section the Ohio health care basic and standard plans or | 830 |
health benefit plans that are substantially similar to the Ohio | 831 |
health care basic and standard plans in benefit plan design and | 832 |
scope of covered services. | 833 |
A carrier may offer other health benefit plans in addition | 834 |
to, but not in lieu of, the plans required to be offered under | 835 |
this division. A basic health benefit plan shall provide, at a | 836 |
minimum, the coverage provided by the Ohio health care basic plan | 837 |
or any health benefit plan that is substantially similar to the | 838 |
Ohio health care basic plan in benefit plan design and scope of | 839 |
covered services. A standard health benefit plan shall provide, at | 840 |
a minimum, the coverage provided by the Ohio health care standard | 841 |
plan or any health benefit plan that is substantially similar to | 842 |
the Ohio health care standard plan in benefit plan design and | 843 |
scope of covered services. | 844 |
For purposes of this division, the superintendent of | 845 |
insurance shall determine whether a health benefit plan is | 846 |
substantially similar to the Ohio health care basic and standard | 847 |
plans in benefit plan design and scope of covered services. | 848 |
(D)(1) Health benefit plans issued under this section may | 849 |
establish pre-existing conditions provisions that exclude or limit | 850 |
coverage for a period of up to twelve months following the | 851 |
individual's effective date of coverage and that may relate only | 852 |
to conditions during the six months immediately preceding the | 853 |
effective date of coverage. A health insuring corporation may | 854 |
apply a pre-existing condition provision for any basic health care | 855 |
service related to a transplant of a body organ if the transplant | 856 |
occurs within one year after the effective date of an enrollee's | 857 |
coverage under this section except with respect to a newly born | 858 |
child who meets the requirements for coverage under section | 859 |
1751.61 of the Revised Code. | 860 |
(2) In determining whether a pre-existing conditions | 861 |
provision applies to an insured or dependent, each policy shall | 862 |
credit the time the insured or dependent was covered under a | 863 |
previous policy, contract, or plan if the previous coverage was | 864 |
continuous to a date not more than sixty-three days prior to the | 865 |
effective date of the new coverage, exclusive of any applicable | 866 |
service waiting period under the policy. | 867 |
(E) Premiums charged to individuals under this section may | 868 |
not exceed the amounts specified below: | 869 |
(1) For calendar years 2010 and 2011, an amount that is two | 870 |
times the base rate for coverage offered to any other individual | 871 |
to which the carrier is currently accepting new business, and for | 872 |
which similar copayments and deductibles are applied; | 873 |
(2) For calendar year 2012 and every year thereafter, an | 874 |
amount that is one and one-half times the base rate for coverage | 875 |
offered to any other individual to which the carrier is currently | 876 |
accepting new business and for which similar copayments and | 877 |
deductibles are applied, unless the superintendent of insurance | 878 |
determines that the amendments by this act to this section and | 879 |
section 3923.581 of the Revised Code, have resulted in the | 880 |
market-wide average medical loss ratio for coverage sold to | 881 |
individual insureds and nonemployer group insureds in this state, | 882 |
including open enrollment insureds, to increase by more than five | 883 |
and one quarter percentage points during calendar year 2010. If | 884 |
the superintendent makes that determination, the premium limit | 885 |
established by division (E)(1) of this section shall remain in | 886 |
effect. The superintendent's determination shall be supported by a | 887 |
signed letter from a member of the American academy of actuaries. | 888 |
(F) In offering health benefit plans under this section, a | 889 |
carrier may require the purchase of health benefit plans that | 890 |
condition the reimbursement of health services upon the use of a | 891 |
specific network of providers. | 892 |
(G)(1) A carrier shall not be required to accept new | 893 |
applicants under this section if the total number of the carrier's | 894 |
current insureds with open enrollment coverage issued under this | 895 |
section calculated as of the immediately preceding thirty-first | 896 |
day of December and excluding the carrier's medicare supplement | 897 |
policies and conversion or continuation of coverage policies under | 898 |
state or federal law and any policies described in division (L) of | 899 |
this section meets the following limits: | 900 |
(a) For calendar years 2010 and 2011, four per cent of the | 901 |
carrier's total number of individual or nonemployer group insureds | 902 |
in this state; | 903 |
(b) For calendar year 2012 and every year thereafter, eight | 904 |
per cent of the carrier's total number of insured individuals and | 905 |
nonemployer group insureds in this state, unless the | 906 |
superintendent of insurance determines that the amendments by this | 907 |
act to this section and section 3923.581 of the Revised Code, have | 908 |
resulted in the market-wide average medical loss ratio for | 909 |
coverage sold to individual insureds and nonemployer group | 910 |
insureds in this state, including open enrollment insureds, to | 911 |
increase by more than five and one quarter percentage points | 912 |
during calendar year 2010. If the superintendent makes that | 913 |
determination, the enrollment limit established by division | 914 |
(G)(1)(a) of this section shall remain in effect. The | 915 |
superintendent's determination shall be supported by a signed | 916 |
letter from a member of the American academy of actuaries. | 917 |
(2) An officer of the carrier shall certify to the department | 918 |
of insurance when it has met the enrollment limit set forth in | 919 |
division (G)(1) of this section. Upon providing such | 920 |
certification, the carrier shall be relieved of its open | 921 |
enrollment requirement under this section as long as the carrier | 922 |
continues to meet the open enrollment limit. If the total number | 923 |
of the carrier's current insureds with open enrollment coverage | 924 |
issued under this section falls below the enrollment limit, the | 925 |
carrier shall accept new applicants. A carrier may establish a | 926 |
waiting list if the carrier has met the open enrollment limit and | 927 |
shall notify the superintendent if the carrier has a waiting list | 928 |
in effect. | 929 |
(H) A carrier shall not be required to accept under this | 930 |
section applicants who, at the time of enrollment, are confined to | 931 |
a health care facility because of chronic illness, permanent | 932 |
injury, or other infirmity that would cause economic impairment to | 933 |
the carrier if the applicants were accepted. A carrier shall not | 934 |
be required to make the effective date of benefits for individuals | 935 |
accepted under this section earlier than ninety days after the | 936 |
date of acceptance, except that when the individual had prior | 937 |
coverage with a health benefit plan that was terminated by a | 938 |
carrier because the carrier exited the market and the individual | 939 |
was accepted for open enrollment under this section within | 940 |
sixty-three days of that termination, the effective date of | 941 |
benefits shall be the date of enrollment. | 942 |
(I) The requirements of this section do not apply to any | 943 |
carrier that is currently in a state of supervision, insolvency, | 944 |
or liquidation. If a carrier demonstrates to the satisfaction of | 945 |
the superintendent that the requirements of this section would | 946 |
place the carrier in a state of supervision, insolvency, or | 947 |
liquidation, or would otherwise jeopardize the carrier's economic | 948 |
viability overall or in the individual market, the superintendent | 949 |
may waive or modify the requirements of division (B) or (G) of | 950 |
this section. The actions of the superintendent under this | 951 |
division shall be effective for a period of not more than one | 952 |
year. At the expiration of such time, a new showing of need for a | 953 |
waiver or modification by the carrier shall be made before a new | 954 |
waiver or modification is issued or imposed. | 955 |
(J) No hospital, health care facility, or health care | 956 |
practitioner, and no person who employs any health care | 957 |
practitioner, shall balance bill any individual or dependent of an | 958 |
individual for any health care supplies or services provided to | 959 |
the individual or dependent who is insured under a policy issued | 960 |
under this section. The hospital, health care facility, or health | 961 |
care practitioner, or any person that employs the health care | 962 |
practitioner, shall accept payments made to it by the carrier | 963 |
under the terms of the policy or contract insuring or covering | 964 |
such individual as payment in full for such health care supplies | 965 |
or services. | 966 |
As used in this division, "hospital" has the same meaning as | 967 |
in section 3727.01 of the Revised Code; "health care practitioner" | 968 |
has the same meaning as in section 4769.01 of the Revised Code; | 969 |
and "balance bill" means charging or collecting an amount in | 970 |
excess of the amount reimbursable or payable under the policy or | 971 |
health care service contract issued to an individual under this | 972 |
section for such health care supply or service. "Balance bill" | 973 |
does not include charging for or collecting copayments or | 974 |
deductibles required by the policy or contract. | 975 |
(K) A carrier may pay an agent a commission in the amount of | 976 |
not more than five per cent of the premium charged for initial | 977 |
placement or for otherwise securing the issuance of a policy or | 978 |
contract issued to an individual under this section, and not more | 979 |
than four per cent of the premium charged for the renewal of such | 980 |
a policy or contract. The superintendent may adopt, in accordance | 981 |
with Chapter 119. of the Revised Code, such rules as are necessary | 982 |
to enforce this division. | 983 |
(L) This section does not apply to any policy that provides | 984 |
coverage for specific diseases or accidents only, or to any | 985 |
hospital indemnity, medicare supplement, long-term care, | 986 |
disability income, one-time-limited-duration policy | 987 |
that is less than | 988 |
only supplemental benefits. | 989 |
(M) If a carrier offers a health benefit plan in the | 990 |
individual market through a network plan, the carrier may do both | 991 |
of the following: | 992 |
(1) Limit the individuals that may apply for such coverage to | 993 |
those who live, work, or reside in the service area of the network | 994 |
plan; | 995 |
(2) Within the service area of the network plan, deny the | 996 |
coverage to individuals if the carrier has demonstrated both of | 997 |
the following to the superintendent: | 998 |
(a) The carrier will not have the capacity to deliver | 999 |
services adequately to any additional individuals because of the | 1000 |
carrier's obligations to existing group contract holders and | 1001 |
individuals. | 1002 |
(b) The carrier is applying division (M)(2) of this section | 1003 |
uniformly to all individuals without regard to any health | 1004 |
status-related factors of those individuals. | 1005 |
(N) A carrier that, pursuant to division (M)(2) of this | 1006 |
section, denies coverage to an individual in the service area of a | 1007 |
network plan, shall not offer coverage in the individual market | 1008 |
within that service area for at least one hundred eighty days | 1009 |
after the date the carrier denies the coverage. | 1010 |
Sec. 3923.601. (A)(1) This section applies to both of the | 1011 |
following: | 1012 |
(a) A sickness and accident insurer that issues or requires | 1013 |
the use of a standardized identification card or an electronic | 1014 |
technology for submission and routing of prescription drug claims | 1015 |
pursuant to a policy, contract, or agreement for health care | 1016 |
services; | 1017 |
(b) A person that a sickness and accident insurer contracts | 1018 |
with to issue a standardized identification card or an electronic | 1019 |
technology described in division (A)(1)(a) of this section. | 1020 |
(2) Notwithstanding division (A)(1) of this section, this | 1021 |
section does not apply to the issuance or required use of a | 1022 |
standardized identification card or an electronic technology for | 1023 |
the submission and routing of prescription drug claims in | 1024 |
connection with any of the following: | 1025 |
(a) Any individual or group policy of sickness and accident | 1026 |
insurance covering only accident, credit, dental, disability | 1027 |
income, long-term care, hospital indemnity, medicare supplement, | 1028 |
medicare, tricare, specified disease, or vision care; coverage | 1029 |
under a one-time-limited-duration policy | 1030 |
less than | 1031 |
liability insurance; insurance arising out of workers' | 1032 |
compensation or similar law; automobile medical payment insurance; | 1033 |
or insurance under which benefits are payable with or without | 1034 |
regard to fault and which is statutorily required to be contained | 1035 |
in any liability insurance policy or equivalent self-insurance. | 1036 |
(b) Coverage provided under the medicaid program. | 1037 |
(c) Coverage provided under an employer's self-insurance plan | 1038 |
or by any of its administrators, as defined in section 3959.01 of | 1039 |
the Revised Code, to the extent that federal law supersedes, | 1040 |
preempts, prohibits, or otherwise precludes the application of | 1041 |
this section to the plan and its administrators. | 1042 |
(B) A standardized identification card or an electronic | 1043 |
technology issued or required to be used as provided in division | 1044 |
(A)(1) of this section shall contain uniform prescription drug | 1045 |
information in accordance with either division (B)(1) or (2) of | 1046 |
this section. | 1047 |
(1) The standardized identification card or the electronic | 1048 |
technology shall be in a format and contain information fields | 1049 |
approved by the national council for prescription drug programs or | 1050 |
a successor organization, as specified in the council's or | 1051 |
successor organization's pharmacy identification card | 1052 |
implementation guide in effect on the first day of October most | 1053 |
immediately preceding the issuance or required use of the | 1054 |
standardized identification card or the electronic technology. | 1055 |
(2) If the insurer or person under contract with the insurer | 1056 |
to issue a standardized identification card or an electronic | 1057 |
technology requires the information for the submission and routing | 1058 |
of a claim, the standardized identification card or the electronic | 1059 |
technology shall contain any of the following information: | 1060 |
(a) The insurer's name; | 1061 |
(b) The insured's name, group number, and identification | 1062 |
number; | 1063 |
(c) A telephone number to inquire about pharmacy-related | 1064 |
issues; | 1065 |
(d) The issuer's international identification number, labeled | 1066 |
as "ANSI BIN" or "RxBIN"; | 1067 |
(e) The processor's control number, labeled as "RxPCN"; | 1068 |
(f) The insured's pharmacy benefits group number if different | 1069 |
from the insured's medical group number, labeled as "RxGrp." | 1070 |
(C) If the standardized identification card or the electronic | 1071 |
technology issued or required to be used as provided in division | 1072 |
(A)(1) of this section is also used for submission and routing of | 1073 |
nonpharmacy claims, the designation "Rx" is required to be | 1074 |
included as part of the labels identified in divisions (B)(2)(d) | 1075 |
and (e) of this section if the issuer's international | 1076 |
identification number or the processor's control number is | 1077 |
different for medical and pharmacy claims. | 1078 |
(D) Each sickness and accident insurer described in division | 1079 |
(A) of this section shall annually file a certificate with the | 1080 |
superintendent of insurance certifying that it or any person it | 1081 |
contracts with to issue a standardized identification card or | 1082 |
electronic technology for submission and routing of prescription | 1083 |
drug claims complies with this section. | 1084 |
(E)(1) Except as provided in division (E)(2) of this section, | 1085 |
if there is a change in the information contained in the | 1086 |
standardized identification card or the electronic technology | 1087 |
issued to an insured, the insurer or person under contract with | 1088 |
the insurer to issue a standardized identification card or an | 1089 |
electronic technology shall issue a new card or electronic | 1090 |
technology to the insured. | 1091 |
(2) An insurer or person under contract with the insurer is | 1092 |
not required under division (E)(1) of this section to issue a new | 1093 |
card or electronic technology to an insured more than once during | 1094 |
a twelve-month period. | 1095 |
(F) Nothing in this section shall be construed as requiring | 1096 |
an insurer to produce more than one standardized identification | 1097 |
card or one electronic technology for use by insureds accessing | 1098 |
health care benefits provided under a policy of sickness and | 1099 |
accident insurance. | 1100 |
Sec. 3923.65. (A) As used in this section: | 1101 |
(1) "Emergency medical condition" means a medical condition | 1102 |
that manifests itself by such acute symptoms of sufficient | 1103 |
severity, including severe pain, that a prudent layperson with | 1104 |
average knowledge of health and medicine could reasonably expect | 1105 |
the absence of immediate medical attention to result in any of the | 1106 |
following: | 1107 |
(a) Placing the health of the individual or, with respect to | 1108 |
a pregnant woman, the health of the woman or her unborn child, in | 1109 |
serious jeopardy; | 1110 |
(b) Serious impairment to bodily functions; | 1111 |
(c) Serious dysfunction of any bodily organ or part. | 1112 |
(2) "Emergency services" means the following: | 1113 |
(a) A medical screening examination, as required by federal | 1114 |
law, that is within the capability of the emergency department of | 1115 |
a hospital, including ancillary services routinely available to | 1116 |
the emergency department, to evaluate an emergency medical | 1117 |
condition; | 1118 |
(b) Such further medical examination and treatment that are | 1119 |
required by federal law to stabilize an emergency medical | 1120 |
condition and are within the capabilities of the staff and | 1121 |
facilities available at the hospital, including any trauma and | 1122 |
burn center of the hospital. | 1123 |
(B) Every individual or group policy of sickness and accident | 1124 |
insurance that provides hospital, surgical, or medical expense | 1125 |
coverage shall cover emergency services without regard to the day | 1126 |
or time the emergency services are rendered or to whether the | 1127 |
policyholder, the hospital's emergency department where the | 1128 |
services are rendered, or an emergency physician treating the | 1129 |
policyholder, obtained prior authorization for the emergency | 1130 |
services. | 1131 |
(C) Every individual policy or certificate furnished by an | 1132 |
insurer in connection with any sickness and accident insurance | 1133 |
policy shall provide information regarding the following: | 1134 |
(1) The scope of coverage for emergency services; | 1135 |
(2) The appropriate use of emergency services, including the | 1136 |
use of the 9-1-1 system and any other telephone access systems | 1137 |
utilized to access prehospital emergency services; | 1138 |
(3) Any copayments for emergency services. | 1139 |
(D) This section does not apply to any individual or group | 1140 |
policy of sickness and accident insurance covering only accident, | 1141 |
credit, dental, disability income, long-term care, hospital | 1142 |
indemnity, medicare supplement, medicare, tricare, specified | 1143 |
disease, or vision care; coverage under a one-time limited | 1144 |
duration policy | 1145 |
coverage issued as a supplement to liability insurance; insurance | 1146 |
arising out of workers' compensation or similar law; automobile | 1147 |
medical payment insurance; or insurance under which benefits are | 1148 |
payable with or without regard to fault and which is statutorily | 1149 |
required to be contained in any liability insurance policy or | 1150 |
equivalent self-insurance. | 1151 |
Sec. 3923.83. (A)(1) This section applies to both of the | 1152 |
following: | 1153 |
(a) A public employee benefit plan that issues or requires | 1154 |
the use of a standardized identification card or an electronic | 1155 |
technology for submission and routing of prescription drug claims | 1156 |
pursuant to a policy, contract, or agreement for health care | 1157 |
services; | 1158 |
(b) A person or entity that a public employee benefit plan | 1159 |
contracts with to issue a standardized identification card or an | 1160 |
electronic technology described in division (A)(1)(a) of this | 1161 |
section. | 1162 |
(2) Notwithstanding division (A)(1) of this section, this | 1163 |
section does not apply to the issuance or required use of a | 1164 |
standardized identification card or an electronic technology for | 1165 |
the submission and routing of prescription drug claims in | 1166 |
connection with either of the following: | 1167 |
(a) Any individual or group policy of insurance covering only | 1168 |
accident, credit, dental, disability income, long-term care, | 1169 |
hospital indemnity, medicare supplement, medicare, tricare, | 1170 |
specified disease, or vision care; coverage under a | 1171 |
one-time-limited-duration policy | 1172 |
1173 | |
insurance; insurance arising out of workers' compensation or | 1174 |
similar law; automobile medical payment insurance; or insurance | 1175 |
under which benefits are payable with or without regard to fault | 1176 |
and which is statutorily required to be contained in any liability | 1177 |
insurance policy or equivalent self-insurance. | 1178 |
(b) Coverage provided under the medicaid program. | 1179 |
(B) A standardized identification card or an electronic | 1180 |
technology issued or required to be used as provided in division | 1181 |
(A)(1) of this section shall contain uniform prescription drug | 1182 |
information in accordance with either division (B)(1) or (2) of | 1183 |
this section. | 1184 |
(1) The standardized identification card or the electronic | 1185 |
technology shall be in a format and contain information fields | 1186 |
approved by the national council for prescription drug programs or | 1187 |
a successor organization, as specified in the council's or | 1188 |
successor organization's pharmacy identification card | 1189 |
implementation guide in effect on the first day of October most | 1190 |
immediately preceding the issuance or required use of the | 1191 |
standardized identification card or the electronic technology. | 1192 |
(2) If the public employee benefit plan or person under | 1193 |
contract with the plan to issue a standardized identification card | 1194 |
or an electronic technology requires the information for the | 1195 |
submission and routing of a claim, the standardized identification | 1196 |
card or the electronic technology shall contain any of the | 1197 |
following information: | 1198 |
(a) The plan's name; | 1199 |
(b) The insured's name, group number, and identification | 1200 |
number; | 1201 |
(c) A telephone number to inquire about pharmacy-related | 1202 |
issues; | 1203 |
(d) The issuer's international identification number, labeled | 1204 |
as "ANSI BIN" or "RxBIN"; | 1205 |
(e) The processor's control number, labeled as "RxPCN"; | 1206 |
(f) The insured's pharmacy benefits group number if different | 1207 |
from the insured's medical group number, labeled as "RxGrp." | 1208 |
(C) If the standardized identification card or the electronic | 1209 |
technology issued or required to be used as provided in division | 1210 |
(A)(1) of this section is also used for submission and routing of | 1211 |
nonpharmacy claims, the designation "Rx" is required to be | 1212 |
included as part of the labels identified in divisions (B)(2)(d) | 1213 |
and (e) of this section if the issuer's international | 1214 |
identification number or the processor's control number is | 1215 |
different for medical and pharmacy claims. | 1216 |
(D)(1) Except as provided in division (D)(2) of this section, | 1217 |
if there is a change in the information contained in the | 1218 |
standardized identification card or the electronic technology | 1219 |
issued to an insured, the public employee benefit plan or person | 1220 |
under contract with the plan to issue a standardized | 1221 |
identification card or electronic technology shall issue a new | 1222 |
card or electronic technology to the insured. | 1223 |
(2) A public employee benefit plan or person under contract | 1224 |
with the plan is not required under division (D)(1) of this | 1225 |
section to issue a new card or electronic technology to an insured | 1226 |
more than once during a twelve-month period. | 1227 |
(E) Nothing in this section shall be construed as requiring a | 1228 |
public employee benefit plan to produce more than one standardized | 1229 |
identification card or one electronic technology for use by | 1230 |
insureds accessing health care benefits provided under a health | 1231 |
benefit plan. | 1232 |
Sec. 3923.85. (A) As used in this section, "cost sharing" | 1233 |
means the cost to an individual insured under an individual or | 1234 |
group policy of sickness and accident insurance or a public | 1235 |
employee benefit plan according to any coverage limit, copayment, | 1236 |
coinsurance, deductible, or other out-of-pocket expense | 1237 |
requirements imposed by the policy or plan. | 1238 |
(B) Notwithstanding section 3901.71 of the Revised Code and | 1239 |
subject to division (D) of this section, no individual or group | 1240 |
policy of sickness and accident insurance that is delivered, | 1241 |
issued for delivery, or renewed in this state and no public | 1242 |
employee benefit plan that is established or modified in this | 1243 |
state shall fail to comply with either of the following: | 1244 |
(1) The policy or plan shall not provide coverage or impose | 1245 |
cost sharing for a prescribed, orally administered cancer | 1246 |
medication on a less favorable basis than the coverage it provides | 1247 |
or cost sharing it imposes for intraveneously administered or | 1248 |
injected cancer medications. | 1249 |
(2) The policy or plan shall not comply with division (B)(1) | 1250 |
of this section by imposing an increase in cost sharing solely for | 1251 |
orally administered, intravenously administered, or injected | 1252 |
cancer medications. | 1253 |
(C) Notwithstanding any provision of this section to the | 1254 |
contrary, a policy or plan shall be deemed to be in compliance | 1255 |
with this section if the cost sharing imposed under such a policy | 1256 |
or plan for orally administered cancer treatments does not exceed | 1257 |
one hundred dollars per prescription fill. The cost sharing limit | 1258 |
of one hundred dollars per prescription fill shall apply to a high | 1259 |
deductible plan, as defined in 26 U.S.C. 223, or a catastrophic | 1260 |
plan, as defined in 42 U.S.C. 18022, only after the deductible has | 1261 |
been met. | 1262 |
(D)(1) The prohibitions in division (B) of this section do | 1263 |
not preclude an individual or group policy of sickness and | 1264 |
accident insurance or public employee benefit plan from requiring | 1265 |
an insured or plan member to obtain prior authorization before | 1266 |
orally administered cancer medication is dispensed to the insured | 1267 |
or plan member. | 1268 |
(2) Division (B) of this section does not apply to the offer | 1269 |
or renewal of any individual or group policy of sickness and | 1270 |
accident insurance that provides coverage for specific diseases or | 1271 |
accidents only, or to any hospital indemnity, medicare supplement, | 1272 |
disability income, or other policy that offers only supplemental | 1273 |
benefits. | 1274 |
(E) An insurer that offers any sickness and accident | 1275 |
insurance or any public employee benefit plan that offers coverage | 1276 |
for basic health care services is not required to comply with | 1277 |
division (B) of this section if all of the following apply: | 1278 |
(1) The insurer or plan submits documentation certified by an | 1279 |
independent member of the American academy of actuaries to the | 1280 |
superintendent of insurance showing that compliance with division | 1281 |
(B)(1) of this section for a period of at least six months | 1282 |
independently caused the insurer or plan's costs for claims and | 1283 |
administrative expenses for the coverage of basic health care | 1284 |
services to increase by more than one per cent per year. | 1285 |
(2) The insurer or plan submits a signed letter from an | 1286 |
independent member of the American academy of actuaries to the | 1287 |
superintendent of insurance opining that the increase in costs | 1288 |
described in division (E)(1) of this section could reasonably | 1289 |
justify an increase of more than one per cent in the annual | 1290 |
premiums or rates charged by the insurer or plan for the coverage | 1291 |
of basic health care services. | 1292 |
(3)(a) The superintendent of insurance makes the following | 1293 |
determinations from the documentation and opinion submitted | 1294 |
pursuant to divisions (E)(1) and (2) of this section: | 1295 |
(i) Compliance with division (B)(1) of this section for a | 1296 |
period of at least six months independently caused the insurer or | 1297 |
plan's costs for claims and administrative expenses for the | 1298 |
coverage of basic health care services to increase more than one | 1299 |
per cent per year. | 1300 |
(ii) The increase in costs reasonably justifies an increase | 1301 |
of more than one per cent in the annual premiums or rates charged | 1302 |
by the insurer or plan for the coverage of basic health care | 1303 |
services. | 1304 |
(b) Any determination made by the superintendent under | 1305 |
division (E)(3) of this section is subject to Chapter 119. of the | 1306 |
Revised Code. | 1307 |
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of the | 1308 |
Revised Code: | 1309 |
(A) "Actuarial certification" means a written statement | 1310 |
prepared by a member of the American academy of actuaries, or by | 1311 |
any other person acceptable to the superintendent of insurance, | 1312 |
that states that, based upon the person's examination, a carrier | 1313 |
offering health benefit plans to small employers is in compliance | 1314 |
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial | 1315 |
certification" shall include a review of the appropriate records | 1316 |
of, and the actuarial assumptions and methods used by, the carrier | 1317 |
relative to establishing premium rates for the health benefit | 1318 |
plans. | 1319 |
(B) "Adjusted average market premium price" means the average | 1320 |
market premium price as determined by the board of directors of | 1321 |
the Ohio health reinsurance program either on the basis of the | 1322 |
arithmetic mean of all carriers' premium rates for an OHC plan | 1323 |
sold to groups with similar case characteristics by all carriers | 1324 |
selling OHC plans in the state, or on any other equitable basis | 1325 |
determined by the board. | 1326 |
(C) "Base premium rate" means, as to any health benefit plan | 1327 |
that is issued by a carrier and that covers at least two but no | 1328 |
more than fifty employees of a small employer, the lowest premium | 1329 |
rate for a new or existing business prescribed by the carrier for | 1330 |
the same or similar coverage under a plan or arrangement covering | 1331 |
any small employer with similar case characteristics. | 1332 |
(D) "Carrier" means any sickness and accident insurance | 1333 |
company or health insuring corporation authorized to issue health | 1334 |
benefit plans in this state or a MEWA. A sickness and accident | 1335 |
insurance company that owns or operates a health insuring | 1336 |
corporation, either as a separate corporation or as a line of | 1337 |
business, shall be considered as a separate carrier from that | 1338 |
health insuring corporation for purposes of sections 3924.01 to | 1339 |
3924.14 of the Revised Code. | 1340 |
(E) "Case characteristics" means, with respect to a small | 1341 |
employer, the geographic area in which the employees work; the age | 1342 |
and sex of the individual employees and their dependents; the | 1343 |
appropriate industry classification as determined by the carrier; | 1344 |
the number of employees and dependents; and such other objective | 1345 |
criteria as may be established by the carrier. "Case | 1346 |
characteristics" does not include claims experience, health | 1347 |
status, or duration of coverage from the date of issue. | 1348 |
(F) "Dependent" means the spouse or child of an eligible | 1349 |
employee, subject to applicable terms of the health benefits plan | 1350 |
covering the employee. | 1351 |
(G) "Eligible employee" means an employee who works a normal | 1352 |
work week of | 1353 |
does not include a temporary or substitute employee, or a seasonal | 1354 |
employee who works only part of the calendar year on the basis of | 1355 |
natural or suitable times or circumstances. | 1356 |
(H) "Health benefit plan" means any hospital or medical | 1357 |
expense policy or certificate or any health plan provided by a | 1358 |
carrier, that is delivered, issued for delivery, renewed, or used | 1359 |
in this state on or after the date occurring six months after | 1360 |
November 24, 1995. "Health benefit plan" does not include policies | 1361 |
covering only accident, credit, dental, disability income, | 1362 |
long-term care, hospital indemnity, medicare supplement, specified | 1363 |
disease, or vision care; coverage under a | 1364 |
one-time-limited-duration policy | 1365 |
1366 | |
insurance; insurance arising out of a workers' compensation or | 1367 |
similar law; automobile medical-payment insurance; or insurance | 1368 |
under which benefits are payable with or without regard to fault | 1369 |
and which is statutorily required to be contained in any liability | 1370 |
insurance policy or equivalent self-insurance. | 1371 |
(I) "Late enrollee" means an eligible employee or dependent | 1372 |
who enrolls in a small employer's health benefit plan other than | 1373 |
during the first period in which the employee or dependent is | 1374 |
eligible to enroll under the plan or during a special enrollment | 1375 |
period described in section 2701(f) of the "Health Insurance | 1376 |
Portability and Accountability Act of 1996," Pub. L. No. 104-191, | 1377 |
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended. | 1378 |
(J) "MEWA" means any "multiple employer welfare arrangement" | 1379 |
as defined in section 3 of the "Federal Employee Retirement Income | 1380 |
Security Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended, | 1381 |
except for any arrangement which is fully insured as defined in | 1382 |
division (b)(6)(D) of section 514 of that act. | 1383 |
(K) "Midpoint rate" means, for small employers with similar | 1384 |
case characteristics and plan designs and as determined by the | 1385 |
applicable carrier for a rating period, the arithmetic average of | 1386 |
the applicable base premium rate and the corresponding highest | 1387 |
premium rate. | 1388 |
(L) "Pre-existing conditions provision" means a policy | 1389 |
provision that excludes or limits coverage for charges or expenses | 1390 |
incurred during a specified period following the insured's | 1391 |
enrollment date as to a condition for which medical advice, | 1392 |
diagnosis, care, or treatment was recommended or received during a | 1393 |
specified period immediately preceding the enrollment date. | 1394 |
Genetic information shall not be treated as such a condition in | 1395 |
the absence of a diagnosis of the condition related to such | 1396 |
information. | 1397 |
For purposes of this division, "enrollment date" means, with | 1398 |
respect to an individual covered under a group health benefit | 1399 |
plan, the date of enrollment of the individual in the plan or, if | 1400 |
earlier, the first day of the waiting period for such enrollment. | 1401 |
(M) "Service waiting period" means the period of time after | 1402 |
employment begins before an employee is eligible to be covered for | 1403 |
benefits under the terms of any applicable health benefit plan | 1404 |
offered by the small employer. | 1405 |
(N)(1) "Small employer" means, in connection with a group | 1406 |
health benefit plan and with respect to a calendar year and a plan | 1407 |
year, an employer who employed an average of at least two but no | 1408 |
more than fifty eligible employees on business days during the | 1409 |
preceding calendar year and who employs at least two employees on | 1410 |
the first day of the plan year. | 1411 |
(2) For purposes of division (N)(1) of this section, all | 1412 |
persons treated as a single employer under subsection (b), (c), | 1413 |
(m), or (o) of section 414 of the "Internal Revenue Code of 1986," | 1414 |
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one | 1415 |
employer. In the case of an employer that was not in existence | 1416 |
throughout the preceding calendar year, the determination of | 1417 |
whether the employer is a small or large employer shall be based | 1418 |
on the average number of eligible employees that it is reasonably | 1419 |
expected the employer will employ on business days in the current | 1420 |
calendar year. Any reference in division (N) of this section to an | 1421 |
"employer" includes any predecessor of the employer. Except as | 1422 |
otherwise specifically provided, provisions of sections 3924.01 to | 1423 |
3924.14 of the Revised Code that apply to a small employer that | 1424 |
has a health benefit plan shall continue to apply until the plan | 1425 |
anniversary following the date the employer no longer meets the | 1426 |
requirements of this division. | 1427 |
(O) "OHC plan" means an Ohio health care plan, which is the | 1428 |
basic, standard, or carrier reimbursement plan for small employers | 1429 |
and individuals established in accordance with section 3924.10 of | 1430 |
the Revised Code. | 1431 |
Sec. 4729.291. (A) When a licensed health professional | 1432 |
authorized to prescribe drugs personally furnishes drugs to a | 1433 |
patient pursuant to division (B) of section 4729.29 of the Revised | 1434 |
Code, the prescriber shall ensure that the drugs are labeled and | 1435 |
packaged in accordance with state and federal drug laws and any | 1436 |
rules and regulations adopted pursuant to those laws. Records of | 1437 |
purchase and disposition of all drugs personally furnished to | 1438 |
patients shall be maintained by the prescriber in accordance with | 1439 |
state and federal drug statutes and any rules adopted pursuant to | 1440 |
those statutes. | 1441 |
(B) When personally furnishing to a patient RU-486 | 1442 |
(mifepristone), a prescriber is subject to section 2919.123 of the | 1443 |
Revised Code. A prescription for RU-486 (mifepristone) shall be in | 1444 |
writing and in accordance with section 2919.123 of the Revised | 1445 |
Code. | 1446 |
(C)(1) Except as provided in division (D) of this section, a | 1447 |
prescriber | 1448 |
(a) In any thirty-day period, personally furnish to or for | 1449 |
patients, taken as a whole, controlled substances in an amount | 1450 |
that exceeds a total of two thousand five hundred dosage units; | 1451 |
(b) In any seventy-two-hour period, personally furnish to or | 1452 |
for a patient an amount of a controlled substance that exceeds the | 1453 |
amount necessary for the patient's use in a seventy-two-hour | 1454 |
period. | 1455 |
(2) The state board of pharmacy may impose a fine of not more | 1456 |
than five thousand dollars on a prescriber who fails to comply | 1457 |
with the limits established under division (C)(1) of this section. | 1458 |
A separate fine may be imposed for each instance of failing to | 1459 |
comply with the limits. In imposing the fine, the board's actions | 1460 |
shall be taken in accordance with Chapter 119. of the Revised | 1461 |
Code. | 1462 |
(D)(1) None of the following shall be counted in determining | 1463 |
whether the amounts specified in division (C)(1) of this section | 1464 |
have been exceeded: | 1465 |
(a) Methadone provided to patients for the purpose of | 1466 |
treating drug dependence or addiction, if the prescriber meets the | 1467 |
conditions specified in 21 C.F.R. 1306.07; | 1468 |
(b) Buprenorphine provided to patients for the purpose of | 1469 |
treating drug dependence or addiction | 1470 |
1471 | |
1472 | |
subject of a current, valid certification from the substance abuse | 1473 |
and mental health services administration of the United States | 1474 |
department of health and human services pursuant to | 1475 |
1476 |
(c) Controlled substances provided to research subjects by a | 1477 |
facility conducting clinical research in studies approved by a | 1478 |
hospital-based institutional review board or an institutional | 1479 |
review board accredited by the association for the accreditation | 1480 |
of human research protection programs. | 1481 |
(2) Division (C)(1) of this section does not apply to a | 1482 |
prescriber who is a veterinarian. | 1483 |
Sec. 4729.541. (A) Except as provided in divisions (B) and | 1484 |
(C) of this section, a business entity described in division | 1485 |
(B)(1)(j) or (k) of section 4729.51 of the Revised Code may | 1486 |
possess, have custody or control of, and distribute the dangerous | 1487 |
drugs in category I, category II, and category III, as defined in | 1488 |
section 4729.54 of the Revised Code, without holding a terminal | 1489 |
distributor of dangerous drugs license issued under that section. | 1490 |
(B) If a business entity described in division (B)(1)(j) or | 1491 |
(k) of section 4729.51 of the Revised Code is a pain management | 1492 |
clinic or is operating a pain management clinic, the entity shall | 1493 |
hold a license as a terminal distributor of dangerous drugs with a | 1494 |
pain management clinic classification issued under section | 1495 |
4729.552 of the Revised Code. | 1496 |
(C) Beginning April 1, 2015, a business entity described in | 1497 |
division (B)(1)(j) or (k) of section 4729.51 of the Revised Code | 1498 |
shall hold a license as a terminal distributor of dangerous drugs | 1499 |
in order to possess, have custody or control of, and distribute | 1500 |
1501 |
(1) Dangerous drugs that are compounded or used for the | 1502 |
purpose of compounding; | 1503 |
(2) Controlled substances containing buprenorphine that are | 1504 |
used for the purpose of treating drug dependence or addiction. | 1505 |
Sec. 4731.056. (A) As used in this section: | 1506 |
(1) "Controlled substance," "schedule III," "schedule IV," | 1507 |
and "schedule V" have the same meanings as in section 3719.01 of | 1508 |
the Revised Code. | 1509 |
(2) "Physician" means an individual authorized by this | 1510 |
chapter to practice medicine and surgery or osteopathic medicine | 1511 |
and surgery. | 1512 |
(B) The state medical board shall adopt rules in accordance | 1513 |
with Chapter 119. of the Revised Code that establish standards and | 1514 |
procedures to be followed by physicians in the use of controlled | 1515 |
substances in schedule III, IV, or V to treat opioid dependence or | 1516 |
addiction. The board may limit the application of the rules to | 1517 |
treatment provided through an office-based practice or other | 1518 |
practice type or location specified by the board. | 1519 |
Section 2. That existing sections 1739.061, 1751.14, | 1520 |
1751.69, 3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, | 1521 |
3923.601, 3923.65, 3923.83, 3923.85, 3924.01, 4729.291, and | 1522 |
4729.541 of the Revised Code are hereby repealed. | 1523 |
Section 3. Section 1751.14 and division (G) of section | 1524 |
3924.01 of the Revised Code, as amended by this act, apply only to | 1525 |
policies, contracts, and agreements that are delivered, issued for | 1526 |
delivery, or renewed in this state on or after January 1, 2016. | 1527 |
Division (A)(1) of section 3923.24 and division (A)(1) of section | 1528 |
3923.241 of the Revised Code, as amended by this act, apply only | 1529 |
to policies of sickness and accident insurance delivered, issued | 1530 |
for delivery, or renewed in this state and public employee benefit | 1531 |
plans or multiple employer welfare arrangement contracts and | 1532 |
certificates that are established or modified in this state on or | 1533 |
after January 1, 2016. | 1534 |
Section 4. The General Assembly declares that the amendments | 1535 |
made to section 3923.58 of the Revised Code by this act are not to | 1536 |
supersede the suspension of the operation of this section enacted | 1537 |
by Section 3 of Sub. S.B. 9 of the 130th General Assembly. Rather, | 1538 |
it is the intent of the General Assembly to ensure consistency in | 1539 |
Ohio Insurance Law should this suspension be nullified. | 1540 |