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| To amend sections 1739.05 and 5162.20 and to enact | 1 |
| sections 1751.69, 3923.85, and 5164.09 of the | 2 |
| Revised Code regarding insurance and Medicaid | 3 |
| coverage for orally administered cancer | 4 |
| medications. | 5 |
| Section 1. That sections 1739.05 and 5162.20 be amended and | 6 |
| sections 1751.69, 3923.85, and 5164.09 of the Revised Code be | 7 |
| enacted to read as follows: | 8 |
| Sec. 1739.05. (A) A multiple employer welfare arrangement | 9 |
| that is created pursuant to sections 1739.01 to 1739.22 of the | 10 |
| Revised Code and that operates a group self-insurance program may | 11 |
| be established only if any of the following applies: | 12 |
| (1) The arrangement has and maintains a minimum enrollment of | 13 |
| three hundred employees of two or more employers. | 14 |
| (2) The arrangement has and maintains a minimum enrollment of | 15 |
| three hundred self-employed individuals. | 16 |
| (3) The arrangement has and maintains a minimum enrollment of | 17 |
| three hundred employees or self-employed individuals in any | 18 |
| combination of divisions (A)(1) and (2) of this section. | 19 |
| (B) A multiple employer welfare arrangement that is created | 20 |
| pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 21 |
| that operates a group self-insurance program shall comply with all | 22 |
| laws applicable to self-funded programs in this state, including | 23 |
| sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 24 |
| to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 25 |
| 3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, | 26 |
| 3923.80, 3923.85, 3924.031, 3924.032, and 3924.27 of the Revised | 27 |
| Code. | 28 |
| (C) A multiple employer welfare arrangement created pursuant | 29 |
| to sections 1739.01 to 1739.22 of the Revised Code shall solicit | 30 |
| enrollments only through agents or solicitors licensed pursuant to | 31 |
| Chapter 3905. of the Revised Code to sell or solicit sickness and | 32 |
| accident insurance. | 33 |
| (D) A multiple employer welfare arrangement created pursuant | 34 |
| to sections 1739.01 to 1739.22 of the Revised Code shall provide | 35 |
| benefits only to individuals who are members, employees of | 36 |
| members, or the dependents of members or employees, or are | 37 |
| eligible for continuation of coverage under section 1751.53 or | 38 |
| 3923.38 of the Revised Code or under Title X of the "Consolidated | 39 |
| Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 40 |
| U.S.C.A. 1161, as amended. | 41 |
| Sec. 1751.69. (A) As used in this section, "cost sharing" | 42 |
| means the cost to an individual insured under an individual or | 43 |
| group health insuring corporation policy, contract, or agreement | 44 |
| according to any coverage limit, copayment, coinsurance, | 45 |
| deductible, or other out-of-pocket expense requirements imposed by | 46 |
| the policy, contract, or agreement. | 47 |
| (B) Notwithstanding section 3901.71 of the Revised Code and | 48 |
| subject to division (D) of this section, no individual or group | 49 |
| health insuring corporation policy, contract, or agreement | 50 |
| providing basic health care services or prescription drug services | 51 |
| that is delivered, issued for delivery, or renewed in this state, | 52 |
| if the policy, contract, or agreement provides coverage for cancer | 53 |
| chemotherapy treatment, shall fail to comply with either of the | 54 |
| following: | 55 |
| (1) The policy, contract, or agreement shall not provide | 56 |
| coverage or impose cost sharing for a prescribed, orally | 57 |
| administered cancer medication on a less favorable basis than the | 58 |
| coverage it provides or cost sharing it imposes for intraveneously | 59 |
| administered or injected cancer medications. | 60 |
| (2) The policy, contract, or agreement shall not comply with | 61 |
| division (B)(1) of this section by imposing an increase in cost | 62 |
| sharing solely for orally administered, intravenously | 63 |
| administered, or injected cancer medications. | 64 |
| (C) Notwithstanding any provision of this section to the | 65 |
| contrary, an individual or group health insuring corporation | 66 |
| policy, contract, or agreement shall be deemed to be in compliance | 67 |
| with this section if the cost sharing imposed under such a policy, | 68 |
| contract, or agreement for orally administered cancer treatments | 69 |
| does not exceed one hundred dollars per prescription fill. | 70 |
| (D) The prohibitions in division (B) of this section do not | 71 |
| preclude an individual or group health insuring corporation | 72 |
| policy, contract, or agreement from requiring an enrollee to | 73 |
| obtain prior authorization before orally administered cancer | 74 |
| medication is dispensed to the enrollee. | 75 |
| (E) A health insuring corporation that offers coverage for | 76 |
| basic health care services is not required to comply with division | 77 |
| (B) of this section if all of the following apply: | 78 |
| (1) The health insuring corporation submits documentation | 79 |
| certified by an independent member of the American academy of | 80 |
| actuaries to the superintendent of insurance showing that | 81 |
| compliance with division (B)(1) of this section for a period of at | 82 |
| least six months independently caused the health insuring | 83 |
| corporation's costs for claims and administrative expenses for the | 84 |
| coverage of basic health care services to increase by more than | 85 |
| one per cent per year. | 86 |
| (2) The health insuring corporation submits a signed letter | 87 |
| from an independent member of the American academy of actuaries to | 88 |
| the superintendent of insurance opining that the increase in costs | 89 |
| described in division (E)(1) of this section could reasonably | 90 |
| justify an increase of more than one per cent in the annual | 91 |
| premiums or rates charged by the health insuring corporation for | 92 |
| the coverage of basic health care services. | 93 |
| (3)(a) The superintendent of insurance makes the following | 94 |
| determinations from the documentation and opinion submitted | 95 |
| pursuant to divisions (E)(1) and (2) of this section: | 96 |
| (i) Compliance with division (B)(1) of this section for a | 97 |
| period of at least six months independently caused the health | 98 |
| insuring corporation's costs for claims and administrative | 99 |
| expenses for the coverage of basic health care services to | 100 |
| increase more than one per cent per year. | 101 |
| (ii) The increase in costs reasonably justifies an increase | 102 |
| of more than one per cent in the annual premiums or rates charged | 103 |
| by the health insuring corporation for the coverage of basic | 104 |
| health care services. | 105 |
| (b) Any determination made by the superintendent under | 106 |
| division (E)(3) of this section is subject to Chapter 119. of the | 107 |
| Revised Code. | 108 |
| Sec. 3923.85. (A) As used in this section, "cost sharing" | 109 |
| means the cost to an individual insured under an individual or | 110 |
| group policy of sickness and accident insurance or a public | 111 |
| employee benefit plan according to any coverage limit, copayment, | 112 |
| coinsurance, deductible, or other out-of-pocket expense | 113 |
| requirements imposed by the policy or plan. | 114 |
| (B) Notwithstanding section 3901.71 of the Revised Code and | 115 |
| subject to division (D) of this section, no individual or group | 116 |
| policy of sickness and accident insurance that is delivered, | 117 |
| issued for delivery, or renewed in this state and no public | 118 |
| employee benefit plan that is established or modified in this | 119 |
| state shall fail to comply with either of the following: | 120 |
| (1) The policy or plan shall not provide coverage or impose | 121 |
| cost sharing for a prescribed, orally administered cancer | 122 |
| medication on a less favorable basis than the coverage it provides | 123 |
| or cost sharing it imposes for intraveneously administered or | 124 |
| injected cancer medications. | 125 |
| (2) The policy or plan shall not comply with division (B)(1) | 126 |
| of this section by imposing an increase in cost sharing solely for | 127 |
| orally administered, intravenously administered, or injected | 128 |
| cancer medications. | 129 |
| (C) Notwithstanding any provision of this section to the | 130 |
| contrary, a policy or plan shall be deemed to be in compliance | 131 |
| with this section if the cost sharing imposed under such a policy | 132 |
| or plan for orally administered cancer treatments does not exceed | 133 |
| one hundred dollars per prescription fill. | 134 |
| (D)(1) The prohibitions in division (B) of this section do | 135 |
| not preclude an individual or group policy of sickness and | 136 |
| accident insurance or public employee benefit plan from requiring | 137 |
| an insured or plan member to obtain prior authorization before | 138 |
| orally administered cancer medication is dispensed to the insured | 139 |
| or plan member. | 140 |
| (2) Division (B) of this section does not apply to the offer | 141 |
| or renewal of any individual or group policy of sickness and | 142 |
| accident insurance that provides coverage for specific diseases or | 143 |
| accidents only, or to any hospital indemnity, medicare supplement, | 144 |
| disability income, or other policy that offers only supplemental | 145 |
| benefits. | 146 |
| (E) An insurer that offers any sickness and accident | 147 |
| insurance or any public employee benefit plan that offers coverage | 148 |
| for basic health care services is not required to comply with | 149 |
| division (B) of this section if all of the following apply: | 150 |
| (1) The insurer or plan submits documentation certified by an | 151 |
| independent member of the American academy of actuaries to the | 152 |
| superintendent of insurance showing that compliance with division | 153 |
| (B)(1) of this section for a period of at least six months | 154 |
| independently caused the insurer or plan's costs for claims and | 155 |
| administrative expenses for the coverage of basic health care | 156 |
| services to increase by more than one per cent per year. | 157 |
| (2) The insurer or plan submits a signed letter from an | 158 |
| independent member of the American academy of actuaries to the | 159 |
| superintendent of insurance opining that the increase in costs | 160 |
| described in division (E)(1) of this section could reasonably | 161 |
| justify an increase of more than one per cent in the annual | 162 |
| premiums or rates charged by the insurer or plan for the coverage | 163 |
| of basic health care services. | 164 |
| (3)(a) The superintendent of insurance makes the following | 165 |
| determinations from the documentation and opinion submitted | 166 |
| pursuant to divisions (E)(1) and (2) of this section: | 167 |
| (i) Compliance with division (B)(1) of this section for a | 168 |
| period of at least six months independently caused the insurer or | 169 |
| plan's costs for claims and administrative expenses for the | 170 |
| coverage of basic health care services to increase more than one | 171 |
| per cent per year. | 172 |
| (ii) The increase in costs reasonably justifies an increase | 173 |
| of more than one per cent in the annual premiums or rates charged | 174 |
| by the insurer or plan for the coverage of basic health care | 175 |
| services. | 176 |
| (b) Any determination made by the superintendent under | 177 |
| division (E)(3) of this section is subject to Chapter 119. of the | 178 |
| Revised Code. | 179 |
| Sec. 5162.20. (A) The department of medicaid shall institute | 180 |
| cost-sharing requirements for the medicaid program. The department | 181 |
| shall not institute cost-sharing requirements in a manner that | 182 |
| 183 |
| (1) Disproportionately impacts the ability of medicaid | 184 |
| recipients with chronic illnesses to obtain medically necessary | 185 |
| medicaid services; | 186 |
| (2) Violates section 5164.09 of the Revised Code. | 187 |
| (B)(1) No provider shall refuse to provide a service to a | 188 |
| medicaid recipient who is unable to pay a required copayment for | 189 |
| the service. | 190 |
| (2) Division (B)(1) of this section shall not be considered | 191 |
| to do either of the following with regard to a medicaid recipient | 192 |
| who is unable to pay a required copayment: | 193 |
| (a) Relieve the medicaid recipient from the obligation to pay | 194 |
| a copayment; | 195 |
| (b) Prohibit the provider from attempting to collect an | 196 |
| unpaid copayment. | 197 |
| (C) Except as provided in division (F) of this section, no | 198 |
| provider shall waive a medicaid recipient's obligation to pay the | 199 |
| provider a copayment. | 200 |
| (D) No provider or drug manufacturer, including the | 201 |
| manufacturer's representative, employee, independent contractor, | 202 |
| or agent, shall pay any copayment on behalf of a medicaid | 203 |
| recipient. | 204 |
| (E) If it is the routine business practice of a provider to | 205 |
| refuse service to any individual who owes an outstanding debt to | 206 |
| the provider, the provider may consider an unpaid copayment | 207 |
| imposed by the cost-sharing requirements as an outstanding debt | 208 |
| and may refuse service to a medicaid recipient who owes the | 209 |
| provider an outstanding debt. If the provider intends to refuse | 210 |
| service to a medicaid recipient who owes the provider an | 211 |
| outstanding debt, the provider shall notify the recipient of the | 212 |
| provider's intent to refuse service. | 213 |
| (F) In the case of a provider that is a hospital, the | 214 |
| cost-sharing program shall permit the hospital to take action to | 215 |
| collect a copayment by providing, at the time services are | 216 |
| rendered to a medicaid recipient, notice that a copayment may be | 217 |
| owed. If the hospital provides the notice and chooses not to take | 218 |
| any further action to pursue collection of the copayment, the | 219 |
| prohibition against waiving copayments specified in division (C) | 220 |
| of this section does not apply. | 221 |
| (G) The department of medicaid may collaborate with a state | 222 |
| agency that is administering, pursuant to a contract entered into | 223 |
| under section 5162.35 of the Revised Code, one or more components, | 224 |
| or one or more aspects of a component, of the medicaid program as | 225 |
| necessary for the state agency to apply the cost-sharing | 226 |
| requirements to the components or aspects of a component that the | 227 |
| state agency administers. | 228 |
| Sec. 5164.09. (A) Except as provided in division (C) of this | 229 |
| section, the medicaid program shall cover prescribed, orally | 230 |
| administered cancer medications on at least the same basis that it | 231 |
| covers intraveneously administered or injected cancer medications. | 232 |
| In implementing this section, the department of medicaid shall not | 233 |
| institute cost-sharing requirements under section 5162.20 of the | 234 |
| Revised Code for prescribed, orally administered cancer | 235 |
| medications that are greater than any cost-sharing requirements | 236 |
| instituted under that section for intraveneously administered or | 237 |
| injected cancer medications. | 238 |
| (B) Division (A) of this section does not preclude the | 239 |
| department from requiring a medicaid recipient to obtain prior | 240 |
| authorization before a prescribed, orally administered cancer | 241 |
| medication is dispensed to the recipient. | 242 |
| (C) This section shall not be implemented during a fiscal | 243 |
| year if the medicaid director determines that this section's | 244 |
| implementation would cause the costs of the medicaid program's | 245 |
| coverage of prescribed drugs to increase by more than one per cent | 246 |
| over such costs for the most recent previous fiscal year for which | 247 |
| the amount of such costs is known. | 248 |
| Section 2. That existing sections 1739.05 and 5162.20 of the | 249 |
| Revised Code are hereby repealed. | 250 |
| Section 3. Sections 5162.20 and 5164.09 of the Revised Code | 251 |
| as amended or enacted by this act shall take effect January 1, | 252 |
| 2015. | 253 |
| Section 4. This act shall be known as the "Robert L. Schuler | 254 |
| Act" in honor of the late Robert L. Schuler who served in both the | 255 |
| Ohio House of Representatives and the Ohio Senate. | 256 |
| Section 5. Sections 1739.05 and 1751.69 of the Revised Code, | 257 |
| as amended or enacted by this act, apply only to policies, | 258 |
| contracts, and agreements that are delivered, issued for delivery, | 259 |
| or renewed in this state on or after January 1, 2015. Section | 260 |
| 3923.85 of the Revised Code, as enacted by this act, applies only | 261 |
| to policies of sickness and accident insurance delivered, issued | 262 |
| for delivery, or renewed in this state and public employee benefit | 263 |
| plans that are established or modified in this state on or after | 264 |
| January 1, 2015. | 265 |