As Reported by the Senate Insurance and Financial Institutions Committee

130th General Assembly
Regular Session
2013-2014
Sub. S. B. No. 9


Senator Bacon 

Cosponsors: Senators Beagle, Hite, Jones, Seitz, Widener 



A BILL
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


BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

       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, may do one of the following:98

       (a) Impose copayment charges on any single covered basic 99
health care service that does not exceed forty per cent of the 100
average cost to the health insuring corporation of providing the 101
service;102

       (b) Imposeshall impose copayment charges, cost sharing, and 103
deductible charges that annually do not exceed twentyforty per 104
cent of the total annual cost to the health insuring corporation 105
of providing all covered basic health care services, including 106
physician office visits, urgent care services, and emergency 107
health services, when aggregated as to all personsapplied to a 108
standard population expected to be covered under the filed product 109
in question. In addition, annual copayment charges as to each 110
enrollee shall not exceed twenty per cent of the total annual cost 111
to the health insuring corporation of providing all covered basic 112
health care services, including physician office visits, urgent 113
care services, and emergency health services, as to such enrollee.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) To ensure that copayments are reasonable and not a 123
barrier to the utilization of basic health care services, a health 124
insuring corporation may not impose, in any contract year, on any 125
subscriber or enrollee, copayments that exceed two hundred per 126
cent of the average annual premium rate to subscribers or 127
enrollees.128

       (4) For purposes of division (D) of this section, bothall of 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) DivisionsDivision (D)(2) and (3) of this section dodoes135
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) A health insuring corporation may require that an 148
enrollee pay an annual deductible that does not exceed one 149
thousand dollars per enrollee or two thousand dollars per family, 150
except that:151

       (1) A health insuring corporation may impose higher 152
deductibles for high deductible health plans that are linked to 153
health savings accounts;154

       (2) The superintendent may adopt rules allowing different 155
annualcopayment, cost sharing, and deductible amounts for plans 156
with a medical savings account, health reimbursement arrangement, 157
flexible spending account, or similar account;158

       (3)(G) A health insuring corporation may impose higher 159
deductiblescopayment, cost sharing, and deductible charges under 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

        (G)(H) As used in this section, "health savings account" and 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

       (B)(C) "Home state" means the state or territory of the 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

       (C)(D) "In-person assister" means any entity or person that 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. The superintendent may, by 184
rule, apply the requirements of this chapter to any additional 185
entity or person delineated by the federal government to assist 186
consumers or participate in exchange activities.187

       (E) "Insurance" means any of the lines of authority set forth 188
in Chapter 1739., 1751., or 1761. or Title XXXIX of the Revised 189
Code, or as additionally determined by the superintendent of 190
insurance.191

       (D)(F) "Insurance agent" or "agent" means any person that, in 192
order to sell, solicit, or negotiate insurance, is required to be 193
licensed under the laws of this state, including limited lines 194
insurance agents and surplus line brokers.195

       (E)(G) "Insurer" has the same meaning as in section 3901.32 196
of the Revised Code.197

       (F)(H) "License" means the authority issued by the 198
superintendent to a person to act as an insurance agent for the 199
lines of authority specified, but that does not create any actual, 200
apparent, or inherent authority in the person to represent or 201
commit an insurer.202

       (G)(I) "Limited line credit insurance" means credit life, 203
credit disability, credit property, credit unemployment, 204
involuntary unemployment, mortgage life, mortgage guaranty, 205
mortgage disability, guaranteed automobile protection insurance, 206
or any other form of insurance offered in connection with an 207
extension of credit that is limited to partially or wholly 208
extinguishing that credit obligation and that is designated by the 209
superintendent as limited line credit insurance.210

       (H)(J) "Limited line credit insurance agent" means a person 211
that sells, solicits, or negotiates one or more forms of limited 212
line credit insurance to individuals through a master, corporate, 213
group, or individual policy.214

       (I)(K) "Limited lines insurance" means those lines of 215
authority set forth in divisions (B)(7) to (11) of section 3905.06 216
of the Revised Code or in rules adopted by the superintendent, or 217
any lines of authority the superintendent considers necessary to 218
recognize for purposes of complying with section 3905.072 of the 219
Revised Code.220

       (J)(L) "Limited lines insurance agent" means a person 221
authorized by the superintendent to sell, solicit, or negotiate 222
limited lines insurance.223

       (K)(M) "NAIC" means the national association of insurance 224
commissioners.225

       (L)(N) "Insurance navigator" means a person selected to 226
perform the activities and duties identified in division (i) of 227
section 1311 of the Affordable Care Act that is certified by the 228
superintendent of insurance under section 3905.471 of the Revised 229
Code. "Insurance navigator" refers to a navigator specified in 230
section 1311 of the Affordable Care Act, 42 U.S.C. 13031.231

       (O) "Negotiate" means to confer directly with, or offer 232
advice directly to, a purchaser or prospective purchaser of a 233
particular contract of insurance with respect to the substantive 234
benefits, terms, or conditions of the contract, provided the 235
person that is conferring or offering advice either sells 236
insurance or obtains insurance from insurers for purchasers.237

       (M)(P) "Person" means an individual or a business entity.238

       (N)(Q) "Sell" means to exchange a contract of insurance by 239
any means, for money or its equivalent, on behalf of an insurer.240

       (O)(R) "Solicit" means to attempt to sell insurance, or to 241
ask or urge a person to apply for a particular kind of insurance 242
from a particular insurer.243

       (P)(S) "Superintendent" or "superintendent of insurance" 244
means the superintendent of insurance of this state.245

       (Q)(T) "Terminate" means to cancel the relationship between 246
an insurance agent and the insurer or to terminate an insurance 247
agent's authority to transact insurance.248

       (R)(U) "Uniform application" means the NAIC uniform 249
application for resident and nonresident agent licensing, as 250
amended by the NAIC from time to time.251

       (S)(V) "Uniform business entity application" means the NAIC 252
uniform business entity application for resident and nonresident 253
business entities, as amended by the NAIC from time to time.254

       (W) "Exchange" means a health benefit exchange established by 255
the state government of Ohio or an exchange established by the 256
United States department of health and human services in 257
accordance with the "Patient Protection and Affordable Care Act," 258
124 Stat. 119, 42 U.S.C. 18031 (2011).259

       Sec. 3905.47. (A)(1) No agent shall sell, solicit, or 260
negotiate insurance through an exchange, or enroll or offer to 261
enroll a person in a health benefit plan offered through an 262
exchange, on or after October 1, 2013, without first completing a 263
training program either required by an exchange or approved by the 264
superintendent of insurance in accordance with division (B) of 265
this section.266

       (2) If an exchange does not require the completion of a 267
training program pursuant to division (A)(1) of this section, the 268
superintendent shall establish such a program.269

       (B) The superintendent shall approve courses to be used for 270
compliance with division (A) of this section and shall approve 271
courses established by an exchange, provided that the courses are 272
in accordance with section 3905.484 of the Revised Code. Any 273
course the superintendent approves shall consist of topics related 274
to insurance offered within an exchange, including all of the 275
following:276

       (1) The levels of coverage provided in an exchange;277

       (2) The eligibility requirements for individuals to purchase 278
insurance through an exchange;279

       (3) The eligibility requirements for employers to make 280
insurance available to their employees through a small business 281
health options program;282

       (4) Individual eligibility requirements for medicaid;283

       (5) The use of enrollment forms used in an exchange;284

       (6) Any other topics as required by the superintendent.285

       (C) Agents that complete the training program required under 286
division (A) of this section shall receive continuing education 287
course credit under sections 3905.481 to 3905.486 of the Revised 288
Code. All such credit shall count toward satisfying the continuing 289
education requirement in section 3905.481 of the Revised Code.290

       Sec. 3905.471. (A) No individual or entity shall act as or 291
hold itself out to be an insurance navigator or shall receive 292
insurance navigator funding from the state or an exchange unless 293
certified as an insurance navigator under this section.294

       (B) An insurance navigator who complies with the requirements 295
of this section may do any of the following:296

        (1) Conduct public education activities to raise awareness of 297
the availability of qualified health plans;298

        (2) Distribute fair and impartial general information 299
concerning enrollment in all qualified health plans offered within 300
the exchange and the availability of the premium tax credits under 301
section 36B of the Internal Revenue Code of 1986, 26 U.S.C. 36B, 302
and cost-sharing reductions under section 1402 of the Affordable 303
Care Act;304

        (3) Facilitate enrollment in qualified health plans, without 305
suggesting that an individual select a particular plan;306

       (4) Provide referrals to appropriate state agencies for any 307
enrollee with a grievance, complaint, or question regarding their 308
health plan, coverage, or a determination under such plan 309
coverage;310

       (5) Provide information in a manner that is culturally and 311
linguistically appropriate to the needs of the population being 312
served by the exchange.313

        (C) An insurance navigator shall not do any of the following:314

       (1) Sell, solicit, or negotiate health insurance; 315

       (2) Provide advice concerning the substantive benefits, 316
terms, and conditions of a particular health benefit plan or offer 317
advice about which health benefit plan is better or worse or 318
suitable for a particular individual or entity;319

       (3) Recommend a particular health plan or advise consumers 320
about which health benefit plan to choose; 321

       (4) Provide any information or services related to health 322
benefit plans or other products not offered in the exchange. 323
Division (C)(4) of this section shall not be interpreted as 324
prohibiting an insurance navigator from providing information on 325
eligibility for medicaid.326

       (D) An individual shall not act in the capacity of an 327
insurance navigator, or perform insurance navigator duties on 328
behalf of an organization serving as an insurance navigator, 329
unless the individual has applied for certification and the 330
superintendent finds that the applicant meets all of the following 331
requirements:332

       (1) Is at least eighteen years of age; 333

       (2) Has completed and submitted the application and 334
disclosure form required under division (F)(2) of this section and 335
has declared, under penalty of refusal, suspension, or revocation 336
of the insurance navigator's certification, that the statements 337
made in the form are true, correct, and complete to the best of 338
the applicant's knowledge and belief; 339

       (3) Has successfully completed a criminal records check under 340
section 3905.051 of the Revised Code, as required by the 341
superintendent; 342

       (4) Has successfully completed the certification and training 343
requirements adopted by the superintendent in accordance with 344
division (F) of this section; 345

       (5) Has paid all fees required by the superintendent. 346

       (E)(1) A business entity that acts as an insurance navigator, 347
supervises the activities of individual insurance navigators, or 348
receives funding to provide insurance navigator services shall 349
obtain an insurance navigator business entity certification.350

       (2) Any entity applying for a business entity certification 351
shall apply in a form specified, and provide any information 352
required by, the superintendent.353

       (3) A business entity certified as an insurance navigator 354
shall, in a manner prescribed by the superintendent, make 355
available a list of all individual insurance navigators that the 356
business entity employs, supervises, or with which the business 357
entity is affiliated.358

        (F) The superintendent of insurance shall, prior to any 359
exchange becoming operational in this state, do all of the 360
following:361

       (1)(a) Adopt rules to establish a certification and training 362
program for a prospective insurance navigator and the insurance 363
navigator's employees that includes screening via a criminal 364
records check performed in accordance with section 3905.051 of the 365
Revised Code, initial and continuing education requirements, and 366
an examination;367

       (b) The certification and training program shall include 368
training on compliance with the "Health Insurance Portability and 369
Accountability Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et 370
seq., as amended, training on ethics, and training on provisions 371
of the Affordable Care Act relating to insurance navigators and 372
exchanges. 373

       (2) Develop an application and disclosure form by which an 374
insurance navigator may disclose any potential conflicts of 375
interest, as well as any other information the superintendent 376
considers pertinent. 377

       (G)(1) The superintendent may suspend, revoke, or refuse to 378
issue or renew the insurance navigator certification of any 379
person, or levy a civil penalty against any person, that violates 380
the requirements of this section or commits any act that would be 381
a ground for denial, suspension, or revocation of an insurance 382
agent license, as prescribed in section 3905.14 of the Revised 383
Code.384

       (2) The superintendent shall have the power to examine and 385
investigate the business affairs and records of any insurance 386
navigator.387

       (3) The superintendent shall not certify as an insurance 388
navigator, and shall revoke any existing insurance navigator 389
certification of, any individual, organization, or business entity 390
that is receiving financial compensation, including monetary and 391
in-kind compensation, gifts, or grants, on or after October 1, 392
2013, from an insurer offering a qualified health benefit plan 393
through an exchange operating in this state.394

       (4)(a) If the superintendent finds that a violation of this 395
section made by an individual insurance navigator was made with 396
the knowledge of the employing or supervising entity, or that the 397
employing or supervising entity should reasonably have been aware 398
of the individual insurance navigator's violation, and the 399
violation was not reported to the superintendent and no corrective 400
action was undertaken on a timely basis, then the superintendent 401
may suspend, revoke, or refuse to renew the insurance navigator 402
certification of the supervising or employing entity.403

       (b) In addition to, or in lieu of, any disciplinary action 404
taken under division (G)(4)(a) of this section, the superintendent 405
may levy a civil penalty against such an entity.406

       (H) A business entity that terminates the employment, 407
engagement, affiliation, or other relationship with an individual 408
insurance navigator shall notify the superintendent within thirty 409
days following the effective date of the termination, using a 410
format prescribed by the superintendent, if the reason for 411
termination is one of the reasons set forth in section 3905.14 of 412
the Revised Code, or the entity has knowledge that the insurance 413
navigator was found by a court or government body to have engaged 414
in any of the activities in section 3905.14 of the Revised Code.415

       (I) Insurance navigators are subject to the laws of this 416
chapter, and any rules adopted pursuant to the chapter, in so far 417
as such laws are applicable. 418

       (J) The superintendent may deny, suspend, approve, renew, or 419
revoke the certification of an insurance navigator if the 420
superintendent determines that doing so would be in the interest 421
of Ohio insureds or the general public. Such an action is not 422
subject to Chapter 119. of the Revised Code. 423

       (K) The superintendent may adopt rules in accordance with 424
Chapter 119. of the Revised Code to implement sections 3905.47 to 425
3905.473 of the Revised Code. 426

       (L) Any fees collected under this section shall be paid into 427
the state treasury to the credit of the department of insurance 428
operating fund created under section 3901.021 of the Revised Code.429

       Sec. 3905.472. An exchange shall permit an insurer to offer 430
any health benefit plan that the insurer seeks to offer through 431
the exchange, so long as the health benefit plan in question is a 432
qualified health plan under the Affordable Care Act, as approved 433
by the superintendent of insurance. Nothing in this section shall 434
be construed to allow the superintendent of insurance to impose 435
any additional state certification requirements in order to be a 436
qualified health plan.437

       Sec. 3905.473. (A) An exchange operating in this state shall 438
maintain a current list of both of the following:439

       (1) Licensed insurance agents that have met all of the 440
requirements necessary to offer or sell insurance through an 441
exchange;442

       (2) Individuals and business entities that have been 443
certified by the superintendent as an insurance navigator.444

       (B) An exchange shall make available a list of insurance 445
agents operating near the individual's residence address that are 446
certified to sell a health benefit plan through an exchange and 447
insurance navigators that are certified under section 3905.471 of 448
the Revised Code. An exchange operating in this state shall 449
maintain a means of communication by which an individual may make 450
such a request.451

       (C) Any web site, software application, or other electronic 452
medium, or an exchange-sanctioned outreach event that enables a 453
consumer to determine eligibility for and to purchase a qualified 454
health plan through an exchange shall include information on how 455
an individual can obtain from an exchange the contact information 456
of insurance agents operating near the individual's residence 457
address that are certified to sell health benefit plans through an 458
exchange and insurance navigators that are certified under section 459
3905.471 of the Revised Code.460

       Sec. 3905.474. No person shall act as or hold self out to be 461
an in-person assister unless that person is either a licensed 462
insurance agent certified to sell insurance through an exchange 463
under section 3905.47 of the Revised Code or an insurance 464
navigator certified under section 3905.471 of the Revised Code.465

       Section 2.  That existing sections 1751.12 and 3905.01 of the 466
Revised Code are hereby repealed.467