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To amend sections 1751.12 and 3905.01 and to enact | 1 |
sections 3905.47, 3905.471, 3905.472, 3905.473, | 2 |
and 3905.474 of the Revised Code to specify | 3 |
licensing and continuing education requirements | 4 |
for insurance agents involved in selling, | 5 |
soliciting, or negotiating sickness and accident | 6 |
insurance through a health benefit exchange and to | 7 |
make changes to copayments, cost sharing, and | 8 |
deductibles for health insuring corporations. | 9 |
Section 1. That sections 1751.12 and 3905.01 be amended and | 10 |
sections 3905.47, 3905.471, 3905.472, 3905.473, and 3905.474 of | 11 |
the Revised Code be enacted to read as follows: | 12 |
Sec. 1751.12. (A)(1) No contractual periodic prepayment and | 13 |
no premium rate for nongroup and conversion policies for health | 14 |
care services, or any amendment to them, may be used by any health | 15 |
insuring corporation at any time until the contractual periodic | 16 |
prepayment and premium rate, or amendment, have been filed with | 17 |
the superintendent of insurance, and shall not be effective until | 18 |
the expiration of sixty days after their filing unless the | 19 |
superintendent sooner gives approval. The filing shall be | 20 |
accompanied by an actuarial certification in the form prescribed | 21 |
by the superintendent. The superintendent shall disapprove the | 22 |
filing, if the superintendent determines within the sixty-day | 23 |
period that the contractual periodic prepayment or premium rate, | 24 |
or amendment, is not in accordance with sound actuarial principles | 25 |
or is not reasonably related to the applicable coverage and | 26 |
characteristics of the applicable class of enrollees. The | 27 |
superintendent shall notify the health insuring corporation of the | 28 |
disapproval, and it shall thereafter be unlawful for the health | 29 |
insuring corporation to use the contractual periodic prepayment or | 30 |
premium rate, or amendment. | 31 |
(2) No contractual periodic prepayment for group policies for | 32 |
health care services shall be used until the contractual periodic | 33 |
prepayment has been filed with the superintendent. The filing | 34 |
shall be accompanied by an actuarial certification in the form | 35 |
prescribed by the superintendent. The superintendent may reject a | 36 |
filing made under division (A)(2) of this section at any time, | 37 |
with at least thirty days' written notice to a health insuring | 38 |
corporation, if the contractual periodic prepayment is not in | 39 |
accordance with sound actuarial principles or is not reasonably | 40 |
related to the applicable coverage and characteristics of the | 41 |
applicable class of enrollees. | 42 |
(3) At any time, the superintendent, upon at least thirty | 43 |
days' written notice to a health insuring corporation, may | 44 |
withdraw the approval given under division (A)(1) of this section, | 45 |
deemed or actual, of any contractual periodic prepayment or | 46 |
premium rate, or amendment, based on information that either of | 47 |
the following applies: | 48 |
(a) The contractual periodic prepayment or premium rate, or | 49 |
amendment, is not in accordance with sound actuarial principles. | 50 |
(b) The contractual periodic prepayment or premium rate, or | 51 |
amendment, is not reasonably related to the applicable coverage | 52 |
and characteristics of the applicable class of enrollees. | 53 |
(4) Any disapproval under division (A)(1) of this section, | 54 |
any rejection of a filing made under division (A)(2) of this | 55 |
section, or any withdrawal of approval under division (A)(3) of | 56 |
this section, shall be effected by a written notice, which shall | 57 |
state the specific basis for the disapproval, rejection, or | 58 |
withdrawal and shall be issued in accordance with Chapter 119. of | 59 |
the Revised Code. | 60 |
(B) Notwithstanding division (A) of this section, a health | 61 |
insuring corporation may use a contractual periodic prepayment or | 62 |
premium rate for policies used for the coverage of beneficiaries | 63 |
enrolled in medicare pursuant to a medicare risk contract or | 64 |
medicare cost contract, or for policies used for the coverage of | 65 |
beneficiaries enrolled in the federal employees health benefits | 66 |
program pursuant to 5 U.S.C.A. 8905, or for policies used for the | 67 |
coverage of medicaid recipients, or for policies used for the | 68 |
coverage of beneficiaries under any other federal health care | 69 |
program regulated by a federal regulatory body, or for policies | 70 |
used for the coverage of beneficiaries under any contract covering | 71 |
officers or employees of the state that has been entered into by | 72 |
the department of administrative services, if both of the | 73 |
following apply: | 74 |
(1) The contractual periodic prepayment or premium rate has | 75 |
been approved by the United States department of health and human | 76 |
services, the United States office of personnel management, the | 77 |
department of job and family services, or the department of | 78 |
administrative services. | 79 |
(2) The contractual periodic prepayment or premium rate is | 80 |
filed with the superintendent prior to use and is accompanied by | 81 |
documentation of approval from the United States department of | 82 |
health and human services, the United States office of personnel | 83 |
management, the department of job and family services, or the | 84 |
department of administrative services. | 85 |
(C) The administrative expense portion of all contractual | 86 |
periodic prepayment or premium rate filings submitted to the | 87 |
superintendent for review must reflect the actual cost of | 88 |
administering the product. The superintendent may require that the | 89 |
administrative expense portion of the filings be itemized and | 90 |
supported. | 91 |
(D)(1) Copayments, cost sharing, and deductibles must be | 92 |
reasonable and must not be a barrier to the necessary utilization | 93 |
of services by enrollees. | 94 |
(2) A health insuring corporation, in order to ensure that | 95 |
copayments, cost sharing, and deductibles are reasonable and not a | 96 |
barrier to the necessary utilization of basic health care services | 97 |
by enrollees | 98 |
| 99 |
100 | |
101 | |
102 |
| 103 |
deductible charges that annually do not exceed
| 104 |
cent of the total annual cost to the health insuring corporation | 105 |
of providing all covered | 106 |
107 | |
108 | |
standard population expected to be covered under the filed product | 109 |
in question. | 110 |
111 | |
112 | |
113 | |
114 | |
The total annual cost of providing a health care service is the | 115 |
cost to the health insuring corporation of providing the health | 116 |
care service to its enrollees as reduced by any applicable | 117 |
provider discount. This requirement shall be demonstrated by an | 118 |
actuary who is a member of the American academy of actuaries and | 119 |
qualified to provide such certifications as described in the | 120 |
United States qualification standards promulgated by the American | 121 |
academy of actuaries pursuant to the code of professional conduct. | 122 |
(3) | 123 |
124 | |
125 | |
126 | |
127 | |
128 |
| 129 |
the following apply: | 130 |
(a) Copayments imposed by health insuring corporations in | 131 |
connection with a high deductible health plan that is linked to a | 132 |
health savings account are reasonable and are not a barrier to the | 133 |
necessary utilization of services by enrollees. | 134 |
(b) | 135 |
not apply to a high deductible health plan that is linked to a | 136 |
health savings account. | 137 |
(c) Catastrophic-only plans, as defined under the "Patient | 138 |
Protection and Affordable Care Act," 124 Stat. 119, 42 U.S.C. | 139 |
18022 and any related regulations, are not subject to the limits | 140 |
prescribed in division (D) of this section, provided that such | 141 |
plans meet all applicable minimum federal requirements. | 142 |
(E) A health insuring corporation shall not impose lifetime | 143 |
maximums on basic health care services. However, a health insuring | 144 |
corporation may establish a benefit limit for inpatient hospital | 145 |
services that are provided pursuant to a policy, contract, | 146 |
certificate, or agreement for supplemental health care services. | 147 |
(F) | 148 |
149 | |
150 | |
151 |
| 152 |
153 | |
154 |
| 155 |
156 | |
with a medical savings account, health reimbursement arrangement, | 157 |
flexible spending account, or similar account; | 158 |
| 159 |
160 | |
health plans if requested by the group contract, policy, | 161 |
certificate, or agreement holder, or an individual seeking | 162 |
coverage under an individual health plan. This shall not be | 163 |
construed as requiring the health insuring corporation to create | 164 |
customized health plans for group contract holders or individuals. | 165 |
| 166 |
"high deductible health plan" have the same meanings as in the | 167 |
"Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C. 223, as | 168 |
amended. | 169 |
Sec. 3905.01. As used in this chapter: | 170 |
(A) "Affordable Care Act" means the "Patient Protection and | 171 |
Affordable Care Act," 124 Stat. 119, 42 U.S.C. 18031 (2011). | 172 |
(B) "Business entity" means a corporation, association, | 173 |
partnership, limited liability company, limited liability | 174 |
partnership, or other legal entity. | 175 |
| 176 |
United States, including the District of Columbia, in which an | 177 |
insurance agent maintains the insurance agent's principal place of | 178 |
residence or principal place of business and is licensed to act as | 179 |
an insurance agent. | 180 |
| 181 |
receives funding from the centers for medicare and medicaid | 182 |
services for the purpose of developing and operating an in-person | 183 |
assistance program within an exchange. | 184 |
(E) "Insurance" means any of the lines of authority set forth | 185 |
in Chapter 1739., 1751., or 1761. or Title XXXIX of the Revised | 186 |
Code, or as additionally determined by the superintendent of | 187 |
insurance. | 188 |
| 189 |
order to sell, solicit, or negotiate insurance, is required to be | 190 |
licensed under the laws of this state, including limited lines | 191 |
insurance agents and surplus line brokers. | 192 |
| 193 |
of the Revised Code. | 194 |
| 195 |
superintendent to a person to act as an insurance agent for the | 196 |
lines of authority specified, but that does not create any actual, | 197 |
apparent, or inherent authority in the person to represent or | 198 |
commit an insurer. | 199 |
| 200 |
credit disability, credit property, credit unemployment, | 201 |
involuntary unemployment, mortgage life, mortgage guaranty, | 202 |
mortgage disability, guaranteed automobile protection insurance, | 203 |
or any other form of insurance offered in connection with an | 204 |
extension of credit that is limited to partially or wholly | 205 |
extinguishing that credit obligation and that is designated by the | 206 |
superintendent as limited line credit insurance. | 207 |
| 208 |
that sells, solicits, or negotiates one or more forms of limited | 209 |
line credit insurance to individuals through a master, corporate, | 210 |
group, or individual policy. | 211 |
| 212 |
authority set forth in divisions (B)(7) to (11) of section 3905.06 | 213 |
of the Revised Code or in rules adopted by the superintendent, or | 214 |
any lines of authority the superintendent considers necessary to | 215 |
recognize for purposes of complying with section 3905.072 of the | 216 |
Revised Code. | 217 |
| 218 |
authorized by the superintendent to sell, solicit, or negotiate | 219 |
limited lines insurance. | 220 |
| 221 |
commissioners. | 222 |
| 223 |
activities and duties identified in division (i) of section 1311 | 224 |
of the Affordable Care Act that is certified by the superintendent | 225 |
of insurance under section 3905.471 of the Revised Code. | 226 |
(O) "Negotiate" means to confer directly with, or offer | 227 |
advice directly to, a purchaser or prospective purchaser of a | 228 |
particular contract of insurance with respect to the substantive | 229 |
benefits, terms, or conditions of the contract, provided the | 230 |
person that is conferring or offering advice either sells | 231 |
insurance or obtains insurance from insurers for purchasers. | 232 |
| 233 |
| 234 |
any means, for money or its equivalent, on behalf of an insurer. | 235 |
| 236 |
ask or urge a person to apply for a particular kind of insurance | 237 |
from a particular insurer. | 238 |
| 239 |
means the superintendent of insurance of this state. | 240 |
| 241 |
an insurance agent and the insurer or to terminate an insurance | 242 |
agent's authority to transact insurance. | 243 |
| 244 |
application for resident and nonresident agent licensing, as | 245 |
amended by the NAIC from time to time. | 246 |
| 247 |
uniform business entity application for resident and nonresident | 248 |
business entities, as amended by the NAIC from time to time. | 249 |
(W) "Exchange" means a health benefit exchange established by | 250 |
the state government of Ohio or an exchange established by the | 251 |
United States department of health and human services in | 252 |
accordance with the "Patient Protection and Affordable Care Act," | 253 |
124 Stat. 119, 42 U.S.C. 18031 (2011). | 254 |
Sec. 3905.47. (A)(1) No agent shall sell, solicit, or | 255 |
negotiate insurance through an exchange, or enroll or offer to | 256 |
enroll a person in a health benefit plan offered through an | 257 |
exchange, on or after October 1, 2013, without first completing a | 258 |
training program either required by an exchange or approved by the | 259 |
superintendent of insurance in accordance with division (B) of | 260 |
this section. | 261 |
(2) If an exchange does not require the completion of a | 262 |
training program pursuant to division (A)(1) of this section, the | 263 |
superintendent shall establish such a program. | 264 |
(B) The superintendent shall approve courses to be used for | 265 |
compliance with division (A) of this section and shall approve | 266 |
courses established by an exchange, provided that the courses are | 267 |
in accordance with section 3905.484 of the Revised Code. Any | 268 |
course the superintendent approves shall consist of topics related | 269 |
to insurance offered within an exchange, including all of the | 270 |
following: | 271 |
(1) The levels of coverage provided in an exchange; | 272 |
(2) The eligibility requirements for individuals to purchase | 273 |
insurance through an exchange; | 274 |
(3) The eligibility requirements for employers to make | 275 |
insurance available to their employees through a small business | 276 |
health options program; | 277 |
(4) Individual eligibility requirements for medicaid; | 278 |
(5) The use of enrollment forms used in an exchange; | 279 |
(6) Any other topics as required by the superintendent. | 280 |
(C) Agents that complete the training program required under | 281 |
division (A) of this section shall receive continuing education | 282 |
course credit under sections 3905.481 to 3905.486 of the Revised | 283 |
Code. All such credit shall count toward satisfying the continuing | 284 |
education requirement in section 3905.481 of the Revised Code. | 285 |
Sec. 3905.471. (A) No individual or entity shall act as or | 286 |
hold itself out to be a navigator or shall receive navigator | 287 |
funding from the state or an exchange unless certified as a | 288 |
navigator under this section. | 289 |
(B) A navigator who complies with the requirements of this | 290 |
section may do any of the following: | 291 |
(1) Conduct public education activities to raise awareness of | 292 |
the availability of qualified health plans; | 293 |
(2) Distribute fair and impartial general information | 294 |
concerning enrollment in all qualified health plans offered within | 295 |
the exchange and the availability of the premium tax credits under | 296 |
section 36B of the Internal Revenue Code of 1986, 26 U.S.C. 36B, | 297 |
and cost-sharing reductions under section 1402 of the Affordable | 298 |
Care Act; | 299 |
(3) Facilitate enrollment in qualified health plans, without | 300 |
suggesting that an individual select a particular plan; | 301 |
(4) Provide referrals to appropriate state agencies for any | 302 |
enrollee with a grievance, complaint, or question regarding their | 303 |
health plan, coverage, or a determination under such plan | 304 |
coverage; | 305 |
(5) Provide information in a manner that is culturally and | 306 |
linguistically appropriate to the needs of the population being | 307 |
served by the exchange. | 308 |
(C) A navigator shall not do any of the following: | 309 |
(1) Sell, solicit, or negotiate health insurance; | 310 |
(2) Provide advice concerning the substantive benefits, | 311 |
terms, and conditions of a particular health benefit plan or offer | 312 |
advice about which health benefit plan is better or worse or | 313 |
suitable for a particular individual or entity; | 314 |
(3) Recommend a particular health plan or advise consumers | 315 |
about which health benefit plan to choose; | 316 |
(4) Provide any information or services related to health | 317 |
benefit plans or other products not offered in the exchange. | 318 |
(D) An individual shall not act in the capacity of a | 319 |
navigator, or perform navigator duties on behalf of an | 320 |
organization serving as a navigator, unless the individual has | 321 |
applied for certification and the superintendent finds that the | 322 |
applicant meets all of the following requirements: | 323 |
(1) Is at least eighteen years of age; | 324 |
(2) Has completed and submitted the application and | 325 |
disclosure form required under division (F)(2) of this section and | 326 |
has declared, under penalty of refusal, suspension, or revocation | 327 |
of the navigator's certification, that the statements made in the | 328 |
form are true, correct, and complete to the best of the | 329 |
applicant's knowledge and belief; | 330 |
(3) Has successfully completed a criminal records check under | 331 |
section 3905.051 of the Revised Code, as required by the | 332 |
superintendent; | 333 |
(4) Has successfully completed the certification and training | 334 |
requirements adopted by the superintendent in accordance with | 335 |
division (F) of this section; | 336 |
(5) Has paid all fees required by the superintendent. | 337 |
(E)(1) A business entity that acts as a navigator, supervises | 338 |
the activities of individual navigators, or receives funding to | 339 |
provide navigator services shall obtain a navigator business | 340 |
entity certification. | 341 |
(2) Any entity applying for a business entity certification | 342 |
shall apply in a form specified, and provide any information | 343 |
required by, the superintendent. | 344 |
(3) A business entity certified as a navigator shall, in a | 345 |
manner prescribed by the superintendent, make available a list of | 346 |
all individual navigators that the business entity employs, | 347 |
supervises, or with which the business entity is affiliated. | 348 |
(F) The superintendent of insurance shall, prior to any | 349 |
exchange becoming operational in this state, do all of the | 350 |
following: | 351 |
(1)(a) Adopt rules to establish a certification and training | 352 |
program for a prospective navigator and the navigator's employees | 353 |
that includes screening via a criminal records check performed in | 354 |
accordance with section 3905.051 of the Revised Code, initial and | 355 |
continuing education requirements, and an examination; | 356 |
(b) The certification and training program shall include | 357 |
training on compliance with the "Health Insurance Portability and | 358 |
Accountability Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et | 359 |
seq., as amended, training on ethics, and training on provisions | 360 |
of the Affordable Care Act relating to navigators and exchanges. | 361 |
(2) Develop an application and disclosure form by which a | 362 |
navigator may disclose any potential conflicts of interest, as | 363 |
well as any other information the superintendent considers | 364 |
pertinent. | 365 |
(G)(1) The superintendent may suspend, revoke, or refuse to | 366 |
issue or renew the navigator certification of any person, or levy | 367 |
a civil penalty against any person, that violates the requirements | 368 |
of this section or commits any act that would be a ground for | 369 |
denial, suspension, or revocation of an insurance agent license, | 370 |
as prescribed in section 3905.14 of the Revised Code. | 371 |
(2) The superintendent shall have the power to examine and | 372 |
investigate the business affairs and records of any navigator. | 373 |
(3) The superintendent shall not certify as a navigator, and | 374 |
shall revoke any existing navigator certification of, any | 375 |
individual, organization, or business entity that is receiving | 376 |
financial compensation, including monetary and in-kind | 377 |
compensation, gifts, or grants, on or after October 1, 2013, from | 378 |
an insurer offering a qualified health benefit plan through an | 379 |
exchange operating in this state. | 380 |
(4)(a) If the superintendent finds that a violation of this | 381 |
section made by an individual navigator was made with the | 382 |
knowledge of the employing or supervising entity, or that the | 383 |
employing or supervising entity should reasonably have been aware | 384 |
of the individual navigator's violation, and the violation was not | 385 |
reported to the superintendent and no corrective action was | 386 |
undertaken on a timely basis, then the superintendent may suspend, | 387 |
revoke, or refuse to renew the navigator certification of the | 388 |
supervising or employing entity. | 389 |
(b) In addition to, or in lieu of, any disciplinary action | 390 |
taken under division (G)(4)(a) of this section, the superintendent | 391 |
may levy a civil penalty against such an entity. | 392 |
(H) A business entity that terminates the employment, | 393 |
engagement, affiliation, or other relationship with an individual | 394 |
navigator shall notify the superintendent within thirty days | 395 |
following the effective date of the termination, using a format | 396 |
prescribed by the superintendent, if the reason for termination is | 397 |
one of the reasons set forth in section 3905.14 of the Revised | 398 |
Code, or the entity has knowledge that the navigator was found by | 399 |
a court or government body to have engaged in any of the | 400 |
activities in section 3905.14 of the Revised Code. | 401 |
(I) Navigators are subject to the laws of this chapter, and | 402 |
any rules adopted pursuant to the chapter, in so far as such laws | 403 |
are applicable. | 404 |
(J) The superintendent may deny, suspend, approve, renew, or | 405 |
revoke the certification of a navigator if the superintendent | 406 |
determines that doing so would be in the interest of Ohio insureds | 407 |
or the general public. Such an action is not subject to Chapter | 408 |
119. of the Revised Code. | 409 |
(K) The superintendent may adopt rules in accordance with | 410 |
Chapter 119. of the Revised Code to implement sections 3905.47 to | 411 |
3905.473 of the Revised Code. | 412 |
(L) Any fees collected under this section shall be paid into | 413 |
the state treasury to the credit of the department of insurance | 414 |
operating fund created under section 3901.021 of the Revised Code. | 415 |
Sec. 3905.472. An exchange shall permit an insurer to offer | 416 |
any health benefit plan that the insurer seeks to offer through | 417 |
the exchange, so long as the health benefit plan in question is a | 418 |
qualified health plan under the Affordable Care Act, as approved | 419 |
by the superintendent of insurance. Nothing in this section shall | 420 |
be construed to allow the superintendent of insurance to impose | 421 |
any additional state certification requirements in order to be a | 422 |
qualified health plan. | 423 |
Sec. 3905.473. (A) An exchange operating in this state shall | 424 |
maintain a current list of both of the following: | 425 |
(1) Licensed insurance agents that have met all of the | 426 |
requirements necessary to offer or sell insurance through an | 427 |
exchange; | 428 |
(2) Individuals and business entities that have been | 429 |
certified by the superintendent as a navigator. | 430 |
(B) An exchange shall make available a list of insurance | 431 |
agents operating near the individual's residence address that are | 432 |
certified to sell a health benefit plan through an exchange and | 433 |
navigators that are certified under section 3905.471 of the | 434 |
Revised Code. An exchange operating in this state shall maintain a | 435 |
means of communication by which an individual may make such a | 436 |
request. | 437 |
(C) Any web site, software application, or other electronic | 438 |
medium, or an exchange-sanctioned outreach event that enables a | 439 |
consumer to determine eligibility for and to purchase a qualified | 440 |
health plan through an exchange shall include information on how | 441 |
an individual can obtain from an exchange the contact information | 442 |
of insurance agents operating near the individual's residence | 443 |
address that are certified to sell health benefit plans through an | 444 |
exchange and navigators that are certified under section 3905.471 | 445 |
of the Revised Code. | 446 |
Sec. 3905.474. An individual shall not be considered an | 447 |
in-person assister unless that individual is either a licensed | 448 |
insurance agent certified to sell insurance through an exchange | 449 |
under section 3905.47 of the Revised Code or a navigator certified | 450 |
under section 3905.471 of the Revised Code. | 451 |
Section 2. That existing sections 1751.12 and 3905.01 of the | 452 |
Revised Code are hereby repealed. | 453 |