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As Reported by the House Insurance Committee
122nd General Assembly
Regular Session
1997-1998 | Sub. H. B. No. 361 |
REPRESENTATIVES VAN VYVEN-TAVARES-BENDER-BOYD-BRADING-CAREY-
CLANCY-CORBIN-COUGHLIN-FORD-GARCIA-GERBERRY-HOTTINGER-KRUPINSKI-
LAWRENCE-MAIER-MILLER-MOTTLEY-O'BRIEN-OLMAN-OPFER-PADGETT-PERZ-
SALERNO-SAWYER-SCHULER-SCHURING-STAPLETON-TAYLOR-TERWILLEGER-
TIBERI-VESPER-WACHTMANN-WISE-ROMAN-METELSKY-LEWIS-NETZLEY
A BILL
To amend sections 1751.02 to 1751.04, 1751.12, 1751.13, 3901.04, 3901.041,
3901.16, and
3924.10 and to enact sections 1751.521,
1751.73 to 1751.75,
1751.77 to 1751.86, 1753.01, 1753.03
to 1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 1753.24, 1753.28,
and 1753.30 of the Revised Code to adopt the
Physician-Health Plan Partnership
Act.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.02, 1751.03, 1751.04, 1751.12, 1751.13, 3901.04,
3901.041, 3901.16, and 3924.10 be amended and sections 1751.521,
1751.73, 1751.74, 1751.75, 1751.77, 1751.78, 1751.79, 1751.80, 1751.81,
1751.82, 1751.83, 1751.84, 1751.85, 1751.86, 1753.01, 1753.03, 1753.04,
1753.05,
1753.06, 1753.07, 1753.08,
1753.09, 1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 1753.24, 1753.28, and
1753.30 of
the Revised Code be enacted to read as follows:
Sec. 1751.02. (A) Notwithstanding any law in this state to the
contrary, any
corporation, as defined in section 1751.01 of the
Revised Code, may apply to the
superintendent of insurance for a certificate of authority to
establish and operate a health insuring corporation. If the corporation
applying for a certificate of authority is a
foreign corporation domiciled in a state without laws
similar to those of this chapter,
the corporation must form a domestic corporation to apply for, obtain, and
maintain a certificate of authority under this chapter.
(B) No person shall
establish, operate, or perform the services of a health insuring corporation
in this state
without obtaining a certificate of authority under this
chapter.
(C) Except as provided by division (D) of this section,
no political subdivision or department, office, or
institution of this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of this state,
shall establish, operate, or perform the services of a health insuring
corporation.
Nothing in this
section shall be construed to preclude a board of county
commissioners, a county board of mental retardation and
developmental disabilities, an alcohol and drug addiction
services board, a board of alcohol, drug addiction, and mental
health services, or a community mental health board, or a public
entity formed by or on behalf of any of these boards, from using
managed care techniques in carrying out the board's or public
entity's duties pursuant to the requirements of
Chapters 307., 329., 340., and
5126. of the Revised
Code. However, no such board
or public entity may operate so as to compete in the private
sector with health insuring corporations holding certificates of
authority under this chapter.
(D) A corporation formed by or on behalf of a publicly owned,
operated, or funded hospital or health care facility may apply to the
superintendent for
a certificate of authority under division (A) of this section to
establish and operate a health insuring corporation.
(E) A health insuring
corporation shall operate in this state in compliance with this
chapter AND CHAPTER 1753. of the Revised Code, and with sections
3702.51 to 3702.62 of the
Revised
Code, and shall operate in
conformity with its filings with the superintendent under this
chapter, including filings made pursuant to sections 1751.03,
1751.11, 1751.12, and 1751.31 of the
Revised
Code.
(F) An insurer licensed under Title XXXIX of
the
Revised Code need not obtain a certificate of
authority as a health insuring corporation to offer an open
panel plan as long as the providers and health care facilities
participating in the open panel plan receive their compensation
directly from the insurer. If the providers and health care
facilities participating in the open panel plan receive their
compensation from any person other than the insurer, or if the
insurer offers a closed panel plan, the insurer must obtain a
certificate of authority as a health insuring corporation.
(G) An intermediary
organization need not obtain a certificate of authority as a
health insuring corporation, regardless of the method of reimbursement to the
intermediary organization,
as long as a health insuring
corporation or a self-insured employer maintains the ultimate responsibility
to assure delivery of all health care services required by the contract
between the health insuring corporation and the subscriber and
the laws of this state or between the self-insured employer and its
employees.
Nothing in this section shall be construed to require any
health care facility, provider, health delivery network, or
intermediary organization that contracts with a health insuring
corporation or self-insured employer, regardless of the method
of reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a
certificate of authority as a health insuring corporation under
this chapter, unless otherwise provided, in the case of
contracts with a self-insured employer, by operation of the
"Employee
Retirement
Income
Security
Act of 1974," 88
Stat. 829, 29
U.S.C.A.
1001, as amended.
(H) Any health delivery
network doing business in this state that is not required to
obtain a certificate of authority under this chapter shall
certify to the superintendent annually, not later than the
first day of July, and shall
provide a statement signed by the highest ranking official which
includes the following information:
(1) The health delivery network's full name and the
address of its principal place of business;
(2) A statement that the health delivery network is not
required to obtain a certificate of authority under this chapter
to conduct its business.
(I) The superintendent
shall not issue a certificate of authority to a health insuring
corporation that is a provider sponsored organization unless all
health care plans to be offered by the health insuring
corporation provide basic health care services.
Substantially all of the physicians and hospitals with
ownership or control of the provider sponsored organization, as
defined in division (W) of
section 1751.01 of the Revised
Code, shall also be
participating providers for the provision of basic health care
services for health care plans offered by the provider sponsored
organization. If a health insuring corporation that is a
provider sponsored organization offers health care plans that do
not provide basic health care services, the health insuring
corporation shall be deemed, for purposes of section 1751.35 of
the Revised Code, to have failed to substantially
comply with this chapter.
Except as specifically provided in this division and in division
(C) of section 1751.28 of the Revised Code,
the provisions of this chapter shall apply to all health insuring corporations
that are provider sponsored organizations in the same manner that these
provisions apply to all health insuring corporations that are not provider
sponsored organizations.
(J) Nothing in this section shall be construed to apply to any
multiple employer welfare arrangement operating pursuant to Chapter
1739. of the Revised Code.
(K) Any person who
violates division (B) of this
section, and any health delivery network that fails to comply
with division (H) of this
section, is subject to the penalties set forth in section
1751.45 of the Revised
Code.
Sec. 1751.03. (A) Each
application for a certificate of authority under this chapter
shall be verified by an officer or authorized representative of
the applicant, shall be in a format prescribed by the
superintendent of insurance, and shall set forth or be
accompanied by the following:
(1) A certified copy of the applicant's articles of
incorporation and all amendments to the articles of
incorporation;
(2) A copy of any regulations adopted for the government
of the corporation, any bylaws, and any similar documents, and a
copy of all amendments to these regulations, bylaws, and
documents. The corporate secretary shall certify that these
regulations, bylaws, documents, and amendments have been
properly adopted or approved.
(3) A list of the names, addresses, and official
positions of the persons responsible for the conduct of the
applicant, including all members of the board, the principal
officers, and the person responsible for completing or filing
financial statements with the department of insurance,
accompanied by a completed original biographical affidavit and
release of information for each of these persons on forms
acceptable to the department;
(4) A full and complete disclosure of the extent and
nature of any contractual or other financial arrangement between
the applicant and any provider or a person listed in division
(A)(3) of this section,
including, but not limited to, a full and complete disclosure of
the financial interest held by any such provider or person in
any health care facility, provider, or insurer that has entered
into a financial relationship with the health insuring
corporation;
(5) A description of the applicant, its facilities, and
its personnel, including, but not limited to, the location,
hours of operation, and telephone numbers of all contracted
facilities;
(6) The applicant's projected annual enrollee population
over a three-year period;
(7) A clear and specific description of the health care
plan or plans to be used by the applicant, including a
description of the proposed providers, procedures for accessing
care, and the form of all proposed and existing contracts
relating to the administration, delivery, or financing of health
care services;
(8) A copy of each type of evidence of coverage and
identification card or similar document to be issued to
subscribers;
(9) A copy of each type of individual or group policy,
contract, or agreement to be used;
(10) The schedule of the proposed contractual periodic
prepayments or premium rates, or both, accompanied by appropriate supporting
data;
(11) A financial plan which provides a three-year
projection of operating results, including the projected
expenses, income, and sources of working capital;
(12) The enrollee complaint procedure to be utilized as
required under section 1751.19 of the
Revised
Code;
(13) A description of the procedures and programs to be implemented on an
ongoing basis to assure the quality of health care services delivered to
enrollees, INCLUDING, IF APPLICABLE, A DESCRIPTION OF A QUALITY
ASSURANCE PROGRAM
COMPLYING WITH THE REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 of the Revised Code;
(14) A statement describing the geographic area or areas
to be served, by county;
(15) A copy of all solicitation documents;
(16) A balance sheet and other financial statements
showing the applicant's assets, liabilities, income, and other
sources of financial support;
(17) A description of the nature and extent of any
reinsurance program to be implemented, and a demonstration that
errors and omission insurance and, if appropriate, fidelity
insurance, will be in place upon the applicant's receipt of a
certificate of authority;
(18) Copies of all proposed or in force related-party or
intercompany agreements with an explanation of the financial
impact of these agreements on the applicant. If the applicant
intends to enter into a contract for managerial or
administrative services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed description
of the person to
provide these services. The description shall include that person's
experience in managing or administering health care plans, a
copy of that person's most recent audited financial statement,
and a completed biographical affidavit on a form acceptable to
the superintendent for each of that person's principal officers
and board members and for any additional employee to be directly
involved in providing managerial or administrative services to
the health insuring corporation. If the person to provide
managerial or administrative services is affiliated with the
health insuring corporation, the contract must provide for
payment for services based on actual costs.
(19) A statement from the applicant's board that the
admitted assets of the applicant have not been and will not be
pledged or hypothecated;
(20) A statement from the applicant's board that the
applicant will submit monthly financial statements during the
first year of operations;
(21) The name and address of the applicant's
Ohio statutory agent for
service of process, notice, or demand;
(22) Copies of all documents the applicant filed with the secretary of
state;
(23) The location of those books and records of the
applicant that must be maintained in Ohio;
(24) The applicant's federal identification number,
corporate address, and mailing address;
(25) An internal and external organizational
chart;
(26) A list of the assets representing the initial net
worth of the applicant;
(27) If the applicant has a parent company, the parent
company's guaranty, on a form acceptable to the superintendent,
that the applicant will maintain
Ohio's minimum net worth. If
no parent company exists, a statement regarding the availability
of future funds if needed.
(28) The names and addresses of the applicant's actuary
and external auditors;
(29) If the applicant is a foreign corporation, a copy of the
most recent financial statements filed with the insurance
regulatory agency in the applicant's state of domicile;
(30) If the applicant is a foreign corporation, a statement
from the insurance regulatory agency of the applicant's state of
domicile stating that the regulatory agency has no objection to
the applicant applying for an Ohio license and that the
applicant is in good standing in the applicant's state of
domicile;
(31) Any other information that the superintendent may
require.
(B)(1) A health insuring
corporation, unless otherwise provided for in this chapter,
shall file a timely notice with the superintendent describing
any change to the corporation's articles of incorporation or
regulations, or any major modification to its operations as set
out in the information required by division
(A) of this section that
affects any of the following:
(a) The solvency of the
health insuring corporation;
(b) The health insuring
corporation's continued provision of services that it has
contracted to provide;
(c) The manner in which
the health insuring corporation conducts its business.
(2) If the change or modification is to be the result of an action
to be taken by the health insuring corporation, the notice shall
be filed with the superintendent prior to the health insuring corporation
taking
the action. The action shall be deemed approved if the
superintendent does not disapprove it within sixty days of
filing.
(C)(1) No health
insuring corporation shall expand its approved service area
until a copy of the request for expansion, accompanied by
documentation of the network of providers, enrollment
projections, plan of operation, and any other changes have been
filed with the superintendent.
(2) Within ten calendar days after receipt of a complete
filing under division (C)(1) of
this section, the superintendent shall refer the appropriate
jurisdictional issues to the director of health pursuant to
section 1751.04 of the Revised
Code.
(3) Within seventy-five days after the superintendent's receipt
of a complete filing under division
(C)(1) of this section, the
superintendent shall determine whether the plan for expansion is
lawful, fair, and reasonable. The superintendent may not make a
determination until the superintendent has received the
director's certification of compliance, which the director shall
furnish within forty-five days after referral under division
(C)(2) of this section. The
director shall not certify that the requirements of section
1751.04 of the Revised
Code are not met, unless the
applicant has been given an opportunity for a hearing as
provided in division (D) of
section 1751.04 of the Revised
Code. The forty-five-day and
seventy-five-day review periods provided for in division
(C)(3) of this section shall
cease to run as of the date on which the notice of the
applicant's right to request a hearing is mailed and shall
remain suspended until the director issues a final
certification.
(4) If the superintendent has not approved or disapproved
all or a portion of a service area expansion within the
seventy-five-day period provided for in division
(C)(3) of this section, the
filing shall be deemed approved.
(5) Disapproval of all or a portion of the filing shall
be effected by written notice, which shall state the grounds for
the order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code.
Sec. 1751.04. (A) Upon the
receipt by the superintendent of insurance of a complete
application for a certificate of authority to establish or
operate a health insuring corporation, which application sets
forth or is accompanied by the information and documents
required by division (A) of
section 1751.03 of the Revised
Code, the superintendent shall
transmit copies of the application and accompanying documents to
the director of health.
(B) The director shall
review the application and accompanying documents and make
findings as to whether the applicant for a certificate of
authority has done all of the following with respect to any basic health care
services and supplemental
health care services to be furnished:
(1) Demonstrated the willingness and potential ability to
ensure that all basic health care services and supplemental
health care services described in the
evidence of coverage will
be provided to all its enrollees as promptly as is appropriate
and in a manner that assures continuity;
(2) Made effective arrangements to ensure that its
enrollees have reliable access to qualified providers in those
specialties that are generally available in the geographic area
or areas to be served by the applicant and that are necessary to
provide all basic health care services and supplemental health
care services described in the evidence of
coverage;
(3) Made appropriate arrangements for the availability of
short-term health care services in emergencies within the
geographic area or areas to be served by the applicant,
twenty-four hours per day, seven days per week, and for the
provision of adequate coverage whenever an out-of-area emergency
arises;
(4) Made appropriate arrangements for an ongoing evaluation and assurance
of the quality of health care services provided to enrollees,
INCLUDING, IF APPLICABLE, THE DEVELOPMENT OF A QUALITY ASSURANCE PROGRAM
COMPLYING WITH THE
REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 of the Revised Code, and the adequacy
of the personnel, facilities, and equipment by or through which the services
are rendered;
(5) Developed a procedure to gather and report statistics
relating to the cost and effectiveness of its operations, the
pattern of utilization of its services, and the quality,
availability, and accessibility of its services.
(C) Within ninety days of the director's receipt of the
application for
issuance of a certificate of authority, the director shall
certify to the superintendent whether or not the applicant meets
the requirements of division (B) of this section and sections 3702.51
to 3702.62 of the Revised Code. If the director
certifies that the applicant does not meet these requirements,
the director shall specify in what respects it is deficient.
However, the director shall not certify that the requirements of
this section are not met unless the applicant has been given an
opportunity for a hearing.
(D) If the applicant
requests a hearing, the director shall hold a hearing before
certifying that the applicant does not meet the requirements of
this section. The hearing shall be held in accordance with
Chapter 119. of the
Revised Code.
(E) The
ninety-day review period provided for under division
(C) of this section shall cease
to run as of the date on which the notice of the applicant's
right to request a hearing is mailed and shall remain suspended
until the director issues a final certification order.
Sec. 1751.12. (A)(1) No
contractual periodic prepayment and no premium rate for nongroup and
conversion policies for health care services, or any amendment
to them, may be used by any health insuring corporation at any
time until the contractual periodic prepayment and premium rate, or
amendment, have been filed with the superintendent of insurance,
and shall not be effective until the expiration of sixty days
after their filing unless the superintendent sooner gives
approval. The superintendent shall disapprove the filing, if
the superintendent determines within the sixty-day period that
the contractual periodic prepayment or premium rate, or amendment, is
not in accordance with sound actuarial principles or is not
reasonably related to the applicable coverage and
characteristics of the applicable class of enrollees. The
superintendent shall notify the health insuring corporation of
the disapproval, and it shall thereafter be unlawful for the
health insuring corporation to use the contractual periodic
prepayment or premium rate, or amendment.
(2) No contractual periodic prepayment for group
policies for health care services shall be used until the
contractual periodic prepayment has been filed with
the superintendent. The superintendent may reject a filing made
under division (A)(2) of this section at any time, with
at least thirty days' written notice to a health insuring
corporation, if the contractual periodic prepayment is not
in accordance with sound
actuarial principles or is not reasonably related to the
applicable coverage and characteristics of the applicable class
of enrollees.
(3) At any time, the superintendent, upon at least thirty
days' written notice to a health insuring corporation, may
withdraw the approval given under division (A)(1) of this section,
deemed or actual, of any contractual
periodic prepayment or premium rate, or amendment, based on
information that either of the following applies:
(a) The contractual
periodic prepayment or premium rate, or amendment, is not in
accordance with sound actuarial principles.
(b) The contractual
periodic prepayment or premium rate, or amendment, is not reasonably
related to the applicable coverage and characteristics of the
applicable class of enrollees.
(4) Any disapproval under division (A)(1) of this section,
any rejection of a filing made under division (A)(2) of
this section, or any
withdrawal of approval under division (A)(3) of this section, shall
be effected by a written notice, which shall state the specific
basis for the disapproval, rejection, or withdrawal and shall be issued
in accordance with Chapter 119. of the
Revised Code.
(B) Notwithstanding division (A) of this section, a
health insuring corporation may use a contractual periodic
prepayment or premium rate for policies used for the coverage of
beneficiaries enrolled in Title
XVIII of the "Social Security Act," 49
Stat. 620 (1935), 42
U.S.C.A.
301, as amended, pursuant to a medicare risk contract or
medicare cost contract, or for policies used for the coverage of
beneficiaries enrolled in the federal employees health benefits
program pursuant to 5
U.S.C.A.
8905, or for policies used for the coverage of beneficiaries
enrolled in Title
XIX of the "Social Security Act," 49
Stat. 620 (1935), 42
U.S.C.A.
301, as amended, known as the
medical assistance program or medicaid, provided
by the Ohio department of human services under Chapter 5111.
of the Revised Code, or for policies used for the coverage
of beneficiaries under any other federal health care program regulated by a
federal regulatory body, if both of the following
apply:
(1) The contractual periodic prepayment or premium rate has been approved
by the United States department of health and
human services, the United States office of personnel
management, or the Ohio department of human services.
(2) The contractual periodic prepayment or premium rate is filed with the
superintendent prior to use and is accompanied by
documentation of approval from the
United States department of health and
human services, the United
States office of personnel
management, or the Ohio
department of human services.
(C) The administrative
expense portion of all contractual periodic prepayment or
premium rate filings submitted to the superintendent for review must
reflect the actual cost of administering the product. The
superintendent may require that the administrative expense portion of the
filings be itemized and supported.
(D)(1) Copayments and
deductibles must be reasonable and must not be a barrier to the
necessary utilization of services by enrollees.
(2) A health insuring corporation may not impose
copayment charges on basic health care services that exceed
thirty per cent of the total cost of providing any single
covered health care service, except for PHYSICIAN OFFICE VISITS,
emergency health
services, and urgent care services. The total cost of providing
a health care service is the cost to the health insuring
corporation of providing the health care service to the enrollee ITS
ENROLLEES
as reduced by any applicable provider discount.
An open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of
providing any single covered health care service.
(3) To ensure that copayments are not a barrier to the
utilization of basic health care services, a health insuring
corporation may not impose, in any contract year, on any
subscriber or enrollee, copayments that exceed two hundred per
cent of the total annual premium rate to the subscriber or enrollees. This
limitation of
two hundred per cent does not include any reasonable copayments
that are not a barrier to the necessary utilization of health
care services by enrollees and that are imposed on physician
office visits, emergency health services, urgent care services,
supplemental health care services, or specialty health care services.
(E) A health insuring
corporation shall not impose lifetime maximums on basic health
care services. However, a health insuring corporation may
establish a benefit limit for inpatient hospital services that
are provided pursuant to a policy, contract, certificate, or
agreement for supplemental health care services.
Sec. 1751.13. (A)(1)(a) A health
insuring corporation shall, either directly or indirectly, enter
into contracts for the provision of health care services with a
sufficient number and types of providers and health care
facilities to ensure that all covered health care services will
be accessible to enrollees from a contracted provider or health
care facility.
(b) A HEALTH INSURING CORPORATION SHALL NOT REFUSE
TO CONTRACT WITH A PHYSICIAN FOR THE PROVISION OF HEALTH CARE
SERVICES OR REFUSE TO RECOGNIZE A PHYSICIAN AS A SPECIALIST ON
THE BASIS THAT THE PHYSICIAN ATTENDED AN EDUCATIONAL PROGRAM OR
A RESIDENCY PROGRAM APPROVED OR CERTIFIED BY THE
AMERICAN OSTEOPATHIC
ASSOCIATION. A HEALTH INSURING CORPORATION SHALL NOT REFUSE TO
CONTRACT WITH A HEALTH CARE FACILITY FOR THE PROVISION OF HEALTH
CARE SERVICES ON THE BASIS THAT THE HEALTH CARE FACILITY IS
CERTIFIED OR ACCREDITED BY THE
AMERICAN OSTEOPATHIC
ASSOCIATION OR THAT THE HEALTH CARE FACILITY IS AN OSTEOPATHIC
HOSPITAL AS DEFINED IN SECTION 3702.51 OF THE
REVISED
CODE.
(c) NOTHING IN DIVISION
(A)(1)(b)
OF THIS SECTION SHALL BE CONSTRUED TO REQUIRE A HEALTH INSURING
CORPORATION TO MAKE A BENEFIT PAYMENT UNDER A CLOSED PANEL PLAN
TO A PHYSICIAN OR HEALTH CARE FACILITY WITH WHICH THE HEALTH
INSURING CORPORATION DOES NOT HAVE A CONTRACT, PROVIDED THAT
NONE OF THE BASES SET FORTH IN THAT DIVISION ARE USED AS A
REASON FOR FAILING TO MAKE A BENEFIT PAYMENT.
(2) When a health insuring corporation is unable to
provide a covered health care service from a contracted provider
or health care facility, the health insuring corporation must
provide that health care service from a noncontracted provider
or health care facility consistent with the terms of the
enrollee's policy, contract, certificate, or agreement. The
health insuring corporation shall either ensure that the health
care service be provided at no greater cost to the enrollee than
if the enrollee had obtained the health care service from a
contracted provider or health care facility, or make other
arrangements acceptable to the superintendent of
insurance.
(3) Nothing in this section shall prohibit a health
insuring corporation from entering into contracts with
out-of-state providers or health care facilities that are
licensed, certified, accredited, or otherwise authorized in that
state.
(B)(1) A health insuring
corporation shall, either directly or indirectly, enter into
contracts with all providers and health care facilities through
which health care services are provided to its enrollees.
(2) A health insuring corporation, upon written request, shall assist its
contracted providers in finding stop-loss or reinsurance carriers.
(C) A health insuring corporation shall file an annual
certificate with the superintendent certifying that all provider contracts
and contracts with health care facilities through which health
care services are being provided contain the following:
(1) A description of the method by which the provider or
health care facility will be notified of the specific health
care services for which the provider or health care facility
will be responsible, including any limitations or conditions on
such services;
(2) The specific hold harmless provision specifying
protection of enrollees set forth as follows:
"[Provider/Health Care
Facility] agrees that in no event, including but not limited to
nonpayment by the health insuring corporation, insolvency of the health
insuring corporation, or breach of this agreement, shall
[Provider/Health Care
Facility] bill, charge, collect a deposit from, seek
remuneration or reimbursement from, or have any recourse
against, a subscriber,
enrollee, person to whom health care services have been
provided, or person acting on behalf of the covered enrollee,
for health care services provided pursuant to this agreement.
This does not prohibit [Provider/Health
Care Facility] from collecting
co-insurance, deductibles, or copayments as specifically
provided in the evidence of coverage, or fees for uncovered
health care services delivered on a fee-for-service basis to
persons referenced above, nor from any recourse against the
health insuring corporation or its successor."
(3) Provisions requiring the provider or health care
facility to continue to provide covered health care services to
enrollees in the event of the health insuring corporation's
insolvency or discontinuance of operations. The
provisions shall require the provider or health care facility to
continue to provide covered health care services to enrollees as
needed to complete any medically necessary procedures commenced
but unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. If an enrollee is
receiving necessary inpatient care at a hospital, the provisions
may limit the required provision of covered health care services
relating to that inpatient care in accordance with division
(D)(3) of section 1751.11 of the Revised
Code, and may also limit such required provision of
covered health care services to the period ending thirty days
after the health insuring corporation's insolvency or
discontinuance of operations.
The provisions required by division (C)(3) of this
section shall not require any provider or health care facility
to continue to provide any covered health care service after the
occurrence of any of the following:
(a) The end of the thirty-day period following the entry
of a liquidation order under Chapter 3903. of the
Revised Code;
(b) The end of the enrollee's period of coverage for a
contractual prepayment or premium;
(c) The enrollee obtains equivalent coverage with another
health insuring corporation or insurer, or the enrollee's
employer obtains such coverage for the enrollee;
(d) The enrollee or the enrollee's employer terminates
coverage under the contract;
(e) A liquidator effects a transfer of the health
insuring corporation's obligations under the contract under
division (A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and
responsibilities of the health insuring corporation, and of the
contracted providers and health care facilities, with respect to
administrative policies and programs, including, but not limited
to, payments systems, utilization review, quality ASSURANCE,
assessment, and improvement programs, credentialing, confidentiality
requirements, and any applicable federal or state
programs;
(5) A provision regarding the availability and
confidentiality of those health records maintained by providers
and health care facilities to monitor and evaluate the quality
of care, to conduct evaluations and audits, and to determine on
a concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees.
The provision shall include terms requiring the provider or
health care facility to make these health records available to
appropriate state and federal authorities involved in assessing
the quality of care or in investigating the grievances or
complaints of enrollees, and requiring the provider or health
care facility to comply with applicable state and federal laws
related to the confidentiality of medical or health
records.
(6) A provision that states that contractual rights and
responsibilities may not be assigned or delegated by the
provider or health care facility without the prior written
consent of the health insuring corporation;
(7) A provision requiring the provider or health care
facility to maintain adequate professional liability and
malpractice insurance. The provision shall also require the
provider or health care facility to notify the health insuring
corporation not more than ten days after the provider's or
health care facility's receipt of notice of any reduction or
cancellation of such coverage.
(8) A provision requiring the provider or health care
facility to observe, protect, and promote the rights of
enrollees as patients;
(9) A provision requiring the provider or health care
facility to provide health care services without discrimination
on the basis of a patient's participation in the health care
plan, age, sex, ethnicity, religion, sexual preference, health
status, or disability, and without regard to the source of
payments made for health care services rendered to a patient.
This requirement shall not apply to circumstances when the
provider or health care facility appropriately does not render
services due to limitations arising from the provider's or
health care facility's lack of training, experience, or skill,
or due to licensing restrictions.
(10) A provision containing the specifics of any
obligation on the provider or health care facility to provide,
or to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week;
(11) A provision setting forth procedures for the
resolution of disputes arising out of the contract;
(12) A provision stating that the hold harmless provision
required by division (C)(2) of
this section shall survive the termination of the contract with respect to
services covered and provided under the contract during the time the contract
was in effect, regardless of the reason for the termination, including the
insolvency of the health insuring corporation;
(13) A provision requiring those terms that are used in
the contract and that are defined by this chapter, be used in
the contract in a manner consistent with those
definitions.
(D)(1) No health insuring
corporation contract with a provider or health care facility
shall do either CONTAIN ANY of the following:
(1) Offer (a) A PROVISION THAT DIRECTLY OR INDIRECTLY
OFFERS an inducement to the provider or health care
facility, directly or indirectly, to reduce or limit medically
necessary health care services to a covered enrollee;
(2) Penalize (b) A PROVISION THAT PENALIZES a
provider or health care facility that
assists an enrollee to seek a reconsideration of the health
insuring corporation's decision to deny or limit benefits to the
enrollee;
(c) A PROVISION THAT LIMITS OR OTHERWISE RESTRICTS
THE PROVIDER'S OR HEALTH CARE FACILITY'S ETHICAL AND LEGAL
RESPONSIBILITY TO FULLY ADVISE ENROLLEES ABOUT THEIR MEDICAL
CONDITION AND ABOUT MEDICALLY APPROPRIATE TREATMENT
OPTIONS;
(d) A PROVISION THAT PENALIZES A PROVIDER OR
HEALTH CARE FACILITY FOR PRINCIPALLY ADVOCATING FOR MEDICALLY
NECESSARY HEALTH CARE SERVICES;
(e) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE
FACILITY FOR PROVIDING INFORMATION OR TESTIMONY TO A LEGISLATIVE
OR REGULATORY BODY OR AGENCY. THIS SHALL NOT BE CONSTRUED TO
PROHIBIT A HEALTH INSURING CORPORATION FROM PENALIZING A
PROVIDER OR HEALTH CARE FACILITY THAT PROVIDES INFORMATION OR
TESTIMONY THAT IS LIBELOUS OR SLANDEROUS OR THAT DISCLOSES TRADE
SECRETS WHICH THE PROVIDER OR HEALTH CARE FACILITY HAS NO
PRIVILEGE OR PERMISSION TO DISCLOSE.
(2) NOTHING IN THIS DIVISION SHALL BE CONSTRUED TO
PROHIBIT A HEALTH INSURING CORPORATION FROM DOING EITHER OF THE
FOLLOWING:
(a) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY
FOR A PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE
SERVICE;
(b) ENFORCING REASONABLE PEER REVIEW OR
UTILIZATION REVIEW PROTOCOLS, OR DETERMINING WHETHER A
PARTICULAR PROVIDER OR HEALTH CARE FACILITY HAS COMPLIED WITH
THESE PROTOCOLS.
(E) Any contract between
a health insuring corporation and an intermediary organization
shall clearly specify that the health insuring corporation must
approve or disapprove the participation of any provider or
health care facility with which the intermediary organization
contracts.
(F) If an intermediary organization that is not a health delivery
network contracting solely with self-insured employers subcontracts with a
provider or health care facility, the subcontract with the provider or health
care facility shall do all of the following:
(1) Contain the provisions required by divisions
(C) and (G) of this section, as made
applicable to an intermediary organization, without the inclusion of
inducements or penalties described in division (D) of this
section;
(2) Acknowledge that the health insuring corporation is a
third-party beneficiary to the agreement;
(3) Acknowledge the health insuring corporation's role in
approving the participation of the provider or health care
facility, pursuant to division
(E) of this section.
(G) Any provider
contract or contract with a health care facility shall clearly
specify the health insuring corporation's statutory
responsibility to monitor and oversee the offering of covered
health care services to its enrollees.
(H)(1) A health insuring
corporation shall maintain its provider contracts and its contracts with
health care facilities at one or more of its places of business in
this state, and shall provide copies of these contracts to
facilitate regulatory review upon written notice by the
superintendent of insurance.
(2) Any contract with an intermediary organization shall
include provisions requiring the intermediary organization to
provide the superintendent with regulatory access to all books,
records, financial information, and documents related to the
provision of health care services to subscribers and enrollees
under the contract. The contract shall require the intermediary
organization to maintain such books, records, financial
information, and documents at its principal place of business in
this state and to preserve them for at least three years in a
manner that facilitates regulatory review.
(I) A health insuring corporation shall provide notice
of the termination of any contract with a primary care physician
or hospital.
(J) Divisions (A) and (B) of this section do
not apply to any health insuring corporation that, on the effective
date of this section JUNE 4, 1997, holds a
certificate of authority or
license to operate under Chapter 1740. of the Revised
Code.
(K) NOTHING IN THIS SECTION SHALL RESTRICT THE GOVERNING BODY OF
A HOSPITAL FROM EXERCISING THE AUTHORITY GRANTED IT PURSUANT TO SECTION
3701.351 of the Revised Code.
Sec. 1751.521. IF AN ENROLLEE SIGNS A MEDICAL INFORMATION RELEASE UPON THE
REQUEST OF A HEALTH INSURING CORPORATION, THE RELEASE SHALL CLEARLY EXPLAIN
WHAT INFORMATION MAY BE DISCLOSED UNDER THE TERMS OF THE RELEASE. IF A HEALTH
INSURING CORPORATION UTILIZES THIS RELEASE TO REQUEST MEDICAL INFORMATION FROM
A HEALTH CARE FACILITY OR PROVIDER, THE HEALTH INSURING CORPORATION
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE FACILITY OR
PROVIDER, UPON REQUEST.
Sec. 1751.73. EACH HEALTH INSURING CORPORATION
PROVIDING BASIC HEALTH CARE SERVICES SHALL IMPLEMENT A QUALITY
ASSURANCE PROGRAM FOR USE IN CONNECTION WITH THOSE POLICIES,
CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES.
EACH HEALTH INSURING CORPORATION REQUIRED TO IMPLEMENT A QUALITY
ASSURANCE PROGRAM SHALL ANNUALLY FILE A
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING THAT ITS QUALITY
ASSURANCE PROGRAM DOES ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR DESIGNATES AN
EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM IMPLEMENTATION AND COMPLIANCE;
(B) INCLUDES A PROCESS ENABLING THE SELECTION AND RETENTION OF
QUALITY PROVIDERS AND HEALTH CARE FACILITIES THROUGH CREDENTIALING,
RECREDENTIALING, AND MONITORING PROCEDURES;
(C) PROVIDES FOR ONGOING MONITORING OF THE QUALITY ASSURANCE
PROGRAM;
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR ENTITIES
WITH WHICH THE HEALTH INSURING CORPORATION CONTRACTS FOR SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT QUALITY
PROBLEMS.
Sec. 1751.74. (A) TO IMPLEMENT A QUALITY ASSURANCE PROGRAM
REQUIRED BY SECTION 1715.73 of the Revised Code, A HEALTH INSURING CORPORATION SHALL DO BOTH
OF THE FOLLOWING:
(1) DEVELOP AND MAINTAIN THE
APPROPRIATE INFRASTRUCTURE AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE
AND REPORT, ON A REGULAR BASIS, THE QUALITY OF HEALTH CARE
SERVICES PROVIDED TO ENROLLEES,
BASED ON A SYSTEMATIC COLLECTION, ANALYSIS, AND REPORTING OF
RELEVANT DATA. THE HEALTH INSURING CORPORATION SHALL ASSURE THAT A COMMITTEE
THAT INCLUDES PARTICIPATING
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING,
IMPLEMENTING, AND EVALUATING THE QUALITY ASSURANCE PROGRAM
AND ALL OTHER PROGRAMS IMPLEMENTED BY THE HEALTH INSURING CORPORATION THAT
RELATE
TO THE UTILIZATION OF HEALTH CARE SERVICES. A COMMITTEE THAT INCLUDES
PARTICIPATING PHYSICIANS SHALL ALSO HAVE THE OPPORTUNITY TO PARTICIPATE IN THE
DERIVATION OF DATA
ASSESSMENTS, STATISTICAL ANALYSES,
AND OUTCOME INTERPRETATIONS FROM PROGRAMS
MONITORING THE UTILIZATION OF HEALTH CARE SERVICES.
(2) DEVELOP AND MAINTAIN
AN ORGANIZATIONAL PROGRAM FOR DESIGNING, MEASURING, ASSESSING,
AND IMPROVING THE PROCESSES AND OUTCOMES OF HEALTH CARE.
(B) A QUALITY ASSURANCE PROGRAM SHALL:
(1) ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING
OPPORTUNITIES TO IMPROVE HEALTH CARE, WHICH SYSTEM IS STRUCTURED TO
IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE OUTCOMES,
TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO IDENTIFY THOSE
PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER EXEMPLARY OR
PROBLEMATIC PATTERNS. THE QUALITY ASSURANCE PROGRAM SHALL USE THE FINDINGS
GENERATED BY THE
SYSTEM TO WORK ON A CONTINUING BASIS WITH PARTICIPATING
PROVIDERS AND OTHER STAFF TO IMPROVE THE QUALITY OF HEALTH CARE SERVICES
PROVIDED
TO ENROLLEES.
(2) DEVELOP A WRITTEN STATEMENT OF ITS OBJECTIVES, LINES OF AUTHORITY
AND ACCOUNTABILITY, EVALUATION TOOLS, AND PERFORMANCE
IMPROVEMENT ACTIVITIES;
(3) REQUIRE AN ANNUAL EFFECTIVENESS REVIEW
OF THE PROGRAM;
(4) PROVIDE A DESCRIPTION OF
HOW THE HEALTH INSURING CORPORATION INTENDS TO DO ALL OF THE
FOLLOWING:
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF HEALTH CARE, INCLUDING
FOCUSED
REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO DISCERN THE CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE REVIEWED
BY THE QUALITY ASSURANCE PROGRAM EACH YEAR, BASED ON CONSIDERATION OF
PRACTICES AND DIAGNOSES THAT AFFECT A SUBSTANTIAL NUMBER OF THE HEALTH
INSURING CORPORATION'S ENROLLEES OR THAT COULD PLACE ENROLLEES AT SERIOUS
RISK;
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY OF
HEALTH CARE,
INCLUDING COLLECTION AND ANALYSIS OF INFORMATION ON OVER-UTILIZATION AND
UNDER-UTILIZATION OF HEALTH CARE SERVICES; EVALUATION OF COURSES OF TREATMENT
AND OUTCOMES
BASED ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC TO
ENROLLEES OR PROVIDERS;
(d) COMPARE QUALITY ASSURANCE PROGRAM FINDINGS WITH PAST
PERFORMANCE, INTERNAL
GOALS, AND EXTERNAL STANDARDS;
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND
CONDUCT PEER REVIEW ACTIVITIES;
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS DEVELOPED
WITH APPROPRIATE CLINICAL INPUT;
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO QUALITY ASSURANCE
PROGRAM FINDINGS;
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES.
Sec. 1751.75. A HEALTH INSURING CORPORATION MAY PRESENT EVIDENCE OF
COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.73 AND 1751.74 of the Revised Code BY
SUBMITTING CERTIFICATION TO THE SUPERINTENDENT OF INSURANCE OF ITS
ACCREDITATION BY AN INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION
REVIEW ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON
REVIEW OF THE ORGANIZATION'S ACCREDITATION PROCESS, MAY
DETERMINE THAT SUCH ACCREDITATION CONSTITUTES COMPLIANCE BY THE
HEALTH INSURING CORPORATION WITH THE REQUIREMENTS OF THESE
SECTIONS.
Sec. 1751.77. AS USED IN SECTIONS 1751.77 TO 1751.86 of the Revised Code, UNLESS
OTHERWISE SPECIFICALLY PROVIDED:
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A HEALTH
INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION THAT AN
ADMISSION,
AVAILABILITY OF CARE, CONTINUED STAY, OR OTHER HEALTH CARE SERVICE
COVERED UNDER A POLICY, CONTRACT, OR AGREEMENT OF THE HEALTH INSURING
CORPORATION
HAS BEEN
REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE HEALTH CARE SERVICE
DOES NOT MEET THE HEALTH
INSURING CORPORATION'S REQUIREMENTS FOR BENEFIT PAYMENT, AND IS
THEREFORE DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH CARE
SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING.
(C) "CASE MANAGEMENT" MEANS A COORDINATED SET OF ACTIVITIES
CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF SERIOUS, COMPLICATED,
PROTRACTED, OR OTHER SPECIFIED HEALTH CONDITIONS.
(D) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH INSURING
CORPORATION OR
ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION THAT AN ADMISSION, AVAILABILITY
OF CARE, CONTINUED STAY, OR OTHER HEALTH CARE SERVICE
COVERED UNDER A POLICY, CONTRACT, OR AGREEMENT OF THE HEALTH INSURING
CORPORATION
HAS BEEN REVIEWED AND,
BASED UPON THE INFORMATION PROVIDED, THE HEALTH CARE SERVICE SATISFIES THE
HEALTH INSURING CORPORATION'S REQUIREMENTS
FOR BENEFIT PAYMENT.
(E) "CLINICAL PEER" MEANS A
PHYSICIAN WHEN AN EVALUATION IS TO BE MADE OF THE CLINICAL
APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED BY A PHYSICIAN.
IF AN EVALUATION IS TO BE MADE OF THE CLINICAL APPROPRIATENESS
OF HEALTH CARE SERVICES PROVIDED BY A PROVIDER WHO IS NOT A
PHYSICIAN, "CLINICAL PEER" MEANS EITHER A PHYSICIAN OR A
PROVIDER HOLDING THE SAME LICENSE AS THE PROVIDER WHO PROVIDED
THE HEALTH CARE SERVICES.
(F) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE GUIDELINES
USED BY A HEALTH INSURING CORPORATION TO DETERMINE THE NECESSITY AND
APPROPRIATENESS OF
HEALTH CARE SERVICES.
(G) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED DURING
A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT.
(H) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR
DETERMINING, PRIOR TO A PATIENT'S DISCHARGE FROM A HEALTH CARE FACILITY, THE
COORDINATION AND
MANAGEMENT OF THE CARE THAT THE PATIENT IS TO RECEIVE FOLLOWING DISCHARGE FROM
A HEALTH CARE
FACILITY.
(I) "PARTICIPATING PROVIDER" MEANS A PROVIDER OR HEALTH CARE
FACILITY THAT, UNDER A
CONTRACT WITH A HEALTH INSURING CORPORATION OR WITH ITS CONTRACTOR OR
SUBCONTRACTOR, HAS
AGREED TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR DEDUCTIBLES,
DIRECTLY OR INDIRECTLY FROM THE HEALTH INSURING CORPORATION.
(J) "PHYSICIAN" MEANS A PROVIDER AUTHORIZED UNDER
CHAPTER 4731. OF THE
REVISED
CODE TO PRACTICE MEDICINE AND
SURGERY OR OSTEOPATHIC MEDICINE AND SURGERY.
(K) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT.
(L) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF MEDICAL
NECESSITY THAT IS CONDUCTED AFTER HEALTH CARE SERVICES HAVE BEEN PROVIDED TO A
PATIENT.
"RETROSPECTIVE REVIEW" DOES NOT INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED
TO AN EVALUATION OF REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY
OF CODING, OR ADJUDICATION OF PAYMENT.
(M) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT TO
OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE PROVIDER ORIGINALLY
MAKING A RECOMMENDATION FOR PROPOSED HEALTH CARE SERVICES TO ASSESS THE
CLINICAL NECESSITY AND APPROPRIATENESS OF THE PROPOSED HEALTH CARE
SERVICES.
(N) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR THE USE
OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, EFFICACY, OR
EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR SETTINGS. AREAS OF REVIEW
MAY INCLUDE AMBULATORY REVIEW, PROSPECTIVE REVIEW, SECOND OPINION,
CERTIFICATION, CONCURRENT REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR
RETROSPECTIVE REVIEW.
(O) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH INSURING CORPORATION
PERFORMING A
REVIEW OF ITS OWN HEALTH CARE PLANS.
Sec. 1751.78. (A)(1) SECTIONS 1751.77 TO 1751.86 OF THE
REVISED CODE APPLY TO ANY HEALTH
INSURING CORPORATION THAT PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES
IN CONNECTION WITH ITS POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC
HEALTH CARE SERVICES AND TO ANY DESIGNEE OF THE HEALTH INSURING CORPORATION,
OR TO ANY UTILIZATION
REVIEW ORGANIZATION THAT PERFORMS UTILIZATION REVIEW FUNCTIONS
ON BEHALF OF THE HEALTH INSURING CORPORATION IN CONNECTION WITH POLICIES,
CONTRACTS, OR AGREEMENTS OF THE HEALTH INSURING CORPORATION PROVIDING BASIC
HEALTH CARE SERVICES.
(2) NOTHING IN SECTIONS 1751.77 TO 1751.82 OR SECTION
1751.85 OF THE REVISED CODE SHALL BE CONSTRUED TO
REQUIRE A HEALTH INSURING CORPORATION TO PROVIDE OR PERFORM
UTILIZATION REVIEW SERVICES IN CONNECTION WITH HEALTH CARE
SERVICES PROVIDED UNDER A POLICY, PLAN, OR AGREEMENT OF
SUPPLEMENTAL HEALTH CARE SERVICES OR SPECIALTY HEALTH CARE
SERVICES.
(B)(1) EACH HEALTH
INSURING CORPORATION SHALL BE RESPONSIBLE FOR MONITORING ALL UTILIZATION
REVIEW ACTIVITIES CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH
INSURING CORPORATION AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS
1751.77 TO 1751.86 OF THE REVISED CODE, AND ANY RULES
ADOPTED
THEREUNDER, ARE MET. THE HEALTH INSURING CORPORATION SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE
CONDUCT OF THE HEALTH INSURING CORPORATION'S UTILIZATION REVIEW
PROGRAM.
(2) IF A HEALTH INSURING CORPORATION CONTRACTS TO HAVE A UTILIZATION
REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE UTILIZATION
REVIEW FUNCTIONS REQUIRED BY SECTIONS 1751.77 TO 1751.86 OF THE
REVISED
CODE, AND ANY RULES ADOPTED
THEREUNDER, THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE
HEALTH INSURING CORPORATION RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE
MET.
Sec. 1751.79. A HEALTH INSURING CORPORATION THAT CONDUCTS UTILIZATION
REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW PROGRAM THAT DESCRIBES ALL
REVIEW ACTIVITIES, BOTH DELEGATED AND NONDELEGATED, FOR COVERED HEALTH CARE
SERVICES
PROVIDED, INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY,
APPROPRIATENESS,
EFFICACY, OR EFFICIENCY OF HEALTH CARE SERVICES;
(B) THE USE OF DATA SOURCES AND CLINICAL REVIEW CRITERIA IN
MAKING
DECISIONS;
(C) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF CRITERIA AND
COMPATIBLE DECISIONS;
(D) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED IN
ASSESSING
UTILIZATION OF HEALTH CARE SERVICES;
(E) MECHANISMS FOR ASSURING CONFIDENTIALITY OF CLINICAL AND
PROPRIETARY INFORMATION;
(F) THE PERIODIC ASSESSMENT OF UTILIZATION REVIEW
ACTIVITIES, AND THE REPORTING OF THESE ASSESSMENTS TO THE HEALTH INSURING
CORPORATION'S BOARD, BY A UTILIZATION REVIEW COMMITTEE, A QUALITY ASSURANCE
COMMITTEE, OR ANY SIMILAR COMMITTEE;
(G) THE FUNCTIONAL RESPONSIBILITY FOR DAY-TO-DAY
PROGRAM MANAGEMENT BY STAFF;
(H) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND
COMMUNICATED TO PROVIDERS AND HEALTH CARE FACILITIES.
Sec. 1751.80. THE UTILIZATION REVIEW PROGRAM OF A HEALTH
INSURING CORPORATION SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL OF THE
FOLLOWING:
(A) THE PROGRAM SHALL
USE DOCUMENTED CLINICAL REVIEW CRITERIA THAT ARE BASED ON SOUND
CLINICAL EVIDENCE AND ARE EVALUATED PERIODICALLY TO ASSURE
ONGOING EFFICACY. A HEALTH INSURING CORPORATION MAY DEVELOP ITS OWN CLINICAL
REVIEW CRITERIA OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM
QUALIFIED VENDORS. A HEALTH INSURING CORPORATION SHALL MAKE ITS CLINICAL
REVIEW RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES. THE RATIONALE MADE AVAILABLE TO AUTHORIZED GOVERNMENT
AGENCIES IS CONFIDENTIAL AND IS NOT A PUBLIC RECORD AS DEFINED
IN SECTION 149.43 OF THE
REVISED
CODE.
(B) QUALIFIED PROVIDERS
SHALL ADMINISTER THE PROGRAM AND OVERSEE
REVIEW DETERMINATIONS. A CLINICAL PEER
IN THE SAME, OR IN A SIMILAR, SPECIALTY AS TYPICALLY MANAGES THE MEDICAL
CONDITION, PROCEDURE, OR TREATMENT UNDER REVIEW SHALL EVALUATE THE CLINICAL
APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE THE SUBJECT OF AN
APPEAL.
(C) THE HEALTH INSURING CORPORATION
SHALL ISSUE UTILIZATION REVIEW DETERMINATIONS IN A TIMELY MANNER
PURSUANT TO THE REQUIREMENTS OF SECTIONS 1751.81 AND 1751.82 OF
THE REVISED
CODE AND THE ENROLLEE GRIEVANCE
REQUIREMENTS. THE HEALTH INSURING CORPORATION SHALL OBTAIN INFORMATION
REQUIRED TO
MAKE A UTILIZATION REVIEW DETERMINATION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA
CONSISTENTLY.
(D) IF THE HEALTH
INSURING CORPORATION DELEGATES ANY UTILIZATION REVIEW ACTIVITIES TO A
UTILIZATION REVIEW ORGANIZATION, THE HEALTH INSURING CORPORATION SHALL
MAINTAIN
ADEQUATE OVERSIGHT, INCLUDING A PROCESS BY WHICH THE HEALTH INSURING
CORPORATION EVALUATES THE PERFORMANCE OF THE ORGANIZATION, AND SHALL MAINTAIN
COPIES OF BOTH OF THE
FOLLOWING:
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S
ACTIVITIES AND RESPONSIBILITIES, INCLUDING REPORTING
REQUIREMENTS;
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S
PROGRAM BY THE HEALTH INSURING CORPORATION.
(E) THE HEALTH INSURING CORPORATION
OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE
ENROLLEES AND PARTICIPATING PROVIDERS WITH ACCESS TO ITS
REVIEW STAFF BY MEANS OF A TOLL-FREE TELEPHONE
NUMBER OR COLLECT-CALL TELEPHONE LINE.
(F) WHEN CONDUCTING
PROSPECTIVE OR CONCURRENT REVIEW, THE HEALTH INSURING CORPORATION OR ITS
DESIGNEE UTILIZATION REVIEW ORGANIZATION SHALL COLLECT ONLY THE
INFORMATION NECESSARY TO CERTIFY THE ADMISSION, PROCEDURE OR
TREATMENT, LENGTH OF STAY, FREQUENCY, AND DURATION OF HEALTH CARE
SERVICES.
(G) COMPENSATION TO
PERSONS PROVIDING UTILIZATION REVIEW SERVICES FOR THE HEALTH
INSURING CORPORATION SHALL NOT CONTAIN INCENTIVES, DIRECT OR INDIRECT, FOR
THEM TO MAKE INAPPROPRIATE REVIEW DECISIONS.
Sec. 1751.81. (A) AS USED IN THIS SECTION:
(1) "ENROLLEE" INCLUDES THE REPRESENTATIVE OF AN ENROLLEE.
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY FACE-TO-FACE
CLINICAL
EVALUATION OR SECOND OPINION THAT MAY BE REQUIRED.
(B) A HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN
PROCEDURES FOR MAKING
UTILIZATION REVIEW DETERMINATIONS AND FOR NOTIFYING ENROLLEES, AND
PARTICIPATING PROVIDERS AND
HEALTH CARE FACILITIES
ACTING ON BEHALF OF ENROLLEES, OF ITS DETERMINATIONS.
(C) FOR INITIAL DETERMINATIONS, A HEALTH INSURING CORPORATION
SHALL MAKE THE
DETERMINATION WITHIN TWO BUSINESS DAYS AFTER OBTAINING ALL NECESSARY
INFORMATION
REGARDING A PROPOSED ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE REQUIRING A
REVIEW
DETERMINATION.
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN ADMISSION, PROCEDURE, OR
HEALTH CARE SERVICE, THE HEALTH INSURING CORPORATION SHALL NOTIFY THE PROVIDER
OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE BY
TELEPHONE WITHIN THREE BUSINESS DAYS AFTER MAKING THE INITIAL CERTIFICATION,
AND
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE NOTIFICATION
TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE FACILITY WITHIN TWO BUSINESS
DAYS AFTER MAKING THE
TELEPHONE NOTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH INSURING
CORPORATION SHALL NOTIFY THE
PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE BY
TELEPHONE WITHIN THREE BUSINESS DAYS AFTER MAKING
THE ADVERSE DETERMINATION, AND SHALL PROVIDE WRITTEN OR ELECTRONIC
CONFIRMATION OF THE TELEPHONE NOTIFICATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER MAKING THE
TELEPHONE NOTIFICATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH INSURING
CORPORATION SHALL
MAKE THE DETERMINATION WITHIN ONE BUSINESS DAY AFTER OBTAINING ALL NECESSARY
INFORMATION.
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED STAY OR
ADDITIONAL HEALTH CARE SERVICES, THE HEALTH INSURING CORPORATION SHALL NOTIFY
THE PROVIDER OR HEALTH CARE FACILITY
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE BUSINESS DAY AFTER
MAKING THE CERTIFICATION, AND
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER THE TELEPHONE
NOTIFICATION. THE WRITTEN NOTIFICATION SHALL INCLUDE THE NUMBER OF EXTENDED
DAYS OR NEXT REVIEW DATE, THE NEW TOTAL NUMBER OF DAYS OF HEALTH CARE SERVICES
APPROVED,
AND THE DATE OF ADMISSION OR INITIATION OF HEALTH CARE SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH INSURING
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE
HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE BUSINESS DAY AFTER
MAKING THE ADVERSE DETERMINATION, AND SHALL PROVIDE WRITTEN OR ELECTRONIC
CONFIRMATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE FACILITY
WITHIN ONE BUSINESS DAY AFTER
THE TELEPHONE NOTIFICATION. THE HEALTH CARE SERVICE TO THE ENROLLEE SHALL BE
CONTINUED, WITH
STANDARD COPAYMENTS AND DEDUCTIBLES, IF APPLICABLE, UNTIL THE ENROLLEE HAS
BEEN NOTIFIED OF THE
DETERMINATION.
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH INSURING
CORPORATION
SHALL MAKE
THE DETERMINATION WITHIN THIRTY BUSINESS DAYS AFTER RECEIVING ALL NECESSARY
INFORMATION.
(1) IN THE CASE OF A CERTIFICATION, THE HEALTH INSURING CORPORATION MAY
NOTIFY THE
ENROLLEE AND THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE
SERVICE IN WRITING.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH INSURING
CORPORATION SHALL NOTIFY
THE ENROLLEE AND THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH
CARE SERVICE, IN WRITING, WITHIN FIVE
BUSINESS DAYS AFTER MAKING THE ADVERSE DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C),
(D), AND (E) OF THIS SECTION FOR DETERMINATIONS AND
NOTIFICATIONS SHALL PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF
THE ENROLLEE OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE HEALTH
INSURING CORPORATION. THE HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN
PROCEDURES FOR
MAKING EXPEDITED UTILIZATION REVIEW DETERMINATIONS AND NOTIFICATIONS OF
ENROLLEES AND
PROVIDERS OR HEALTH CARE FACILITIES WHEN WARRANTED BY THE MEDICAL CONDITION
OF THE ENROLLEE.
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION SHALL
INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE DETERMINATION, INSTRUCTIONS
FOR INITIATING AN APPEAL OR RECONSIDERATION OF THE DETERMINATION, AND
INSTRUCTIONS FOR REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE
USED TO MAKE THE DETERMINATION. A HEALTH INSURING CORPORATION SHALL PROVIDE
THE CLINICAL
RATIONALE FOR AN ADVERSE DETERMINATION IN WRITING
TO ANY PARTY WHO RECEIVED
NOTICE OF THE ADVERSE DETERMINATION AND WHO FOLLOWS THE INSTRUCTIONS FOR A
REQUEST.
(H) A HEALTH INSURING CORPORATION SHALL HAVE WRITTEN PROCEDURES
TO
ADDRESS THE
FAILURE OR INABILITY OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO
PROVIDE ALL
NECESSARY INFORMATION FOR REVIEW. IF THE HEALTH CARE FACILITY, PROVIDER, OR
ENROLLEE WILL NOT
RELEASE NECESSARY INFORMATION, THE HEALTH INSURING CORPORATION MAY DENY
CERTIFICATION.
Sec. 1751.82. (A) IN A
CASE INVOLVING AN INITIAL DETERMINATION OR A CONCURRENT REVIEW
DETERMINATION, A HEALTH INSURING CORPORATION SHALL GIVE THE PROVIDER OR HEALTH
CARE FACILITY
RENDERING THE HEALTH CARE SERVICE AN OPPORTUNITY TO REQUEST IN WRITING ON
BEHALF OF THE ENROLLEE A RECONSIDERATION OF AN ADVERSE
DETERMINATION BY THE REVIEWER MAKING THE ADVERSE DETERMINATION.
THE RECONSIDERATION SHALL OCCUR WITHIN THREE BUSINESS DAYS AFTER
THE HEALTH INSURING CORPORATION'S RECEIPT OF THE WRITTEN REQUEST FOR
RECONSIDERATION, AND SHALL BE CONDUCTED BETWEEN
THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE AND THE
REVIEWER WHO MADE THE
ADVERSE DETERMINATION. IF THAT REVIEWER CANNOT BE AVAILABLE
WITHIN THREE BUSINESS DAYS, THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION
(A) OF THIS SECTION DOES NOT
RESOLVE THE DIFFERENCE OF OPINION, THE ADVERSE DETERMINATION MAY
BE APPEALED BY THE ENROLLEE OR THE PROVIDER OR HEALTH CARE FACILITY ON BEHALF
OF THE ENROLLEE.
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION.
(D) THE TIME PERIOD
ALLOWED BY DIVISION (A) OF THIS SECTION FOR A
RECONSIDERATION OF AN ADVERSE DETERMINATION SHALL NOT APPLY IF
THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE ENROLLEE
REQUIRES A MORE EXPEDITED RECONSIDERATION. THE HEALTH INSURING
CORPORATION SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING SUCH AN
EXPEDITED RECONSIDERATION.
Sec. 1751.83. A HEALTH INSURING
CORPORATION MAY PRESENT EVIDENCE OF COMPLIANCE WITH THE
REQUIREMENTS OF SECTIONS 1751.77 TO 1751.82 of the Revised Code BY SUBMITTING EVIDENCE
TO THE SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN INDEPENDENT,
PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE NATIONAL COMMITTEE
ON QUALITY ASSURANCE, THE JOINT COMMISSION ON ACCREDITATION OF
HEALTH CARE ORGANIZATIONS, OR THE AMERICAN ACCREDITATION HEALTHCARE
COMMISSION/UTILIZATION REVIEW
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF
THE ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT
SUCH ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS.
Sec. 1751.84. EACH PARTICIPATING PROVIDER OR HEALTH CARE FACILITY
SUBMITTING A CLAIM SHALL COOPERATE WITH THE
UTILIZATION REVIEW PROGRAM OF A HEALTH INSURING CORPORATION OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE HEALTH INSURING CORPORATION OR ITS
DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL RECORDS DURING REGULAR
BUSINESS HOURS, OR COPIES OF THOSE RECORDS AT A REASONABLE
COST.
Sec. 1751.85. A HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS
COMPLIANCE WITH SECTIONS 1751.77 TO 1751.82 OF THE
REVISED
CODE.
Sec. 1751.86. (A) NO
HEALTH INSURING CORPORATION SHALL FAIL TO COMPLY WITH SECTIONS 1751.77 TO
1751.82 OF THE REVISED CODE.
(B) WHOEVER VIOLATES
DIVISION (A) OF THIS SECTION IS
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR
PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO
3901.26 OF THE REVISED CODE.
Sec. 1753.01. AS USED IN THIS CHAPTER:
(A) "ECONOMIC PROFILING" MEANS A HEALTH INSURING
CORPORATION'S USE OF ECONOMIC PERFORMANCE DATA AND ECONOMIC
INFORMATION IN DETERMINING WHETHER TO CONTRACT WITH A PROVIDER
FOR THE PROVISION OF COVERED HEALTH CARE SERVICES TO ENROLLEES
AS A PARTICIPATING PROVIDER.
(B) "BASIC HEALTH CARE SERVICES," "ENROLLEE," "HEALTH CARE
FACILITY," "HEALTH CARE SERVICES," "HEALTH INSURING CORPORATION," "MEDICAL
RECORD," "PROVIDER," AND "SUPPLEMENTAL HEALTH CARE SERVICES" HAVE THE SAME
MEANINGS AS IN SECTION 1751.01 OF
THE REVISED CODE.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL
PRESCRIBE A STANDARD CREDENTIALING FORM TO BE USED BY ALL HEALTH
INSURING CORPORATIONS WHEN CREDENTIALING PROVIDERS IN CONNECTION WITH
POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. THE
DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS TO THE
SUPERINTENDENT FOR SUCH A STANDARD CREDENTIALING FORM. IF THE
DIRECTOR MAKES SUCH RECOMMENDATIONS, THE DIRECTOR SHALL TAKE
INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY
THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE
AMERICAN MEDICAL ASSOCIATION,
THE AMERICAN ASSOCIATION OF
HEALTH PLANS, AND ANY OTHER NATIONAL ORGANIZATION THAT HAS
DEVELOPED SUCH A FORM. IN PRESCRIBING A STANDARD CREDENTIALING
FORM, THE SUPERINTENDENT SHALL CONSIDER ANY RECOMMENDATIONS MADE
BY THE DIRECTOR. THE SUPERINTENDENT MAY AMEND OR REVISE THE
PRESCRIBED STANDARD CREDENTIALING FORM AS NECESSARY.
Sec. 1753.04. BEGINNING ONE HUNDRED TWENTY DAYS AFTER THE
SUPERINTENDENT OF INSURANCE PRESCRIBES A STANDARD CREDENTIALING
FORM UNDER SECTION 1753.03 OF THE
REVISED
CODE, NO HEALTH INSURING
CORPORATION SHALL FAIL TO USE THE PRESCRIBED STANDARD
CREDENTIALING FORM WHEN INITIALLY CREDENTIALING OR
RECREDENTIALING PROVIDERS IN CONNECTION WITH POLICIES, CONTRACTS, AND
AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. IF THE SUPERINTENDENT AMENDS
OR
REVISES THE STANDARD CREDENTIALING FORM, A HEALTH INSURING
CORPORATION SHALL USE THE AMENDED OR REVISED FORM TO CREDENTIAL
OR RECREDENTIAL PROVIDERS.
A HEALTH INSURING CORPORATION MAY REQUEST SUCH
INFORMATION FROM A PROVIDER, IN ADDITION TO THAT INFORMATION TO BE PROVIDED ON
THE STANDARD CREDENTIALING FORM, AS NECESSITATED BY THE
HEALTH INSURING CORPORATION'S CREDENTIALING STANDARDS.
Sec. 1753.05. (A) A HEALTH INSURING CORPORATION
MAY USE ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A
PROVIDER, HOWEVER, SUCH ECONOMIC PROFILING SHALL TAKE INTO
CONSIDERATION THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF
PATIENTS.
(B) FOR AN INITIAL APPLICANT, A HEALTH INSURING
CORPORATION MAY REQUEST INFORMATION NECESSARY TO PERFORM AN
ECONOMIC PROFILE. IF INFORMATION ON CASE MIX, SEVERITY OF
ILLNESS, AND AGE OF PATIENTS IS REQUESTED BY A HEALTH INSURING
CORPORATION AND NOT PRODUCED BY THE APPLICANT, THE HEALTH
INSURING CORPORATION IS NOT REQUIRED TO TAKE THESE FACTORS INTO
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PROVIDER.
(C) NOTHING IN THIS SECTION PROHIBITS A HEALTH
INSURING CORPORATION FROM TAKING INTO CONSIDERATION THE QUALITY
AND APPROPRIATENESS OF CARE PROVIDED BY A PROVIDER WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE
PROVIDER.
Sec. 1753.06. A HEALTH INSURING CORPORATION SHALL NOTIFY
A PROVIDER SEEKING TO ENTER INTO A PARTICIPATION CONTRACT WITH THE HEALTH
INSURING CORPORATION OF THE STATUS OF THE PROVIDER'S APPLICATION WITHIN
ONE HUNDRED TWENTY DAYS AFTER THE HEALTH INSURING CORPORATION'S RECEIPT OF
THE PROVIDER'S COMPLETED APPLICATION. THAT TIME PERIOD MAY BE
EXTENDED BY A HEALTH INSURING CORPORATION IF, DUE TO EXTENUATING
CIRCUMSTANCES, THE HEALTH INSURING CORPORATION NEEDS ADDITIONAL
TIME TO CONSIDER THE APPLICATION AND NOTIFIES THE PROVIDER OF
THE REASON FOR THE DELAY.
Sec. 1753.07. (A) PRIOR TO ENTERING INTO A
PARTICIPATION CONTRACT WITH A PROVIDER UNDER
SECTION 1751.13 OF THE REVISED CODE, A HEALTH INSURING
CORPORATION SHALL DISCLOSE BASIC INFORMATION REGARDING ITS
PROGRAMS AND PROCEDURES TO THE PROVIDER, UPON THE PROVIDER'S
REQUEST. THE INFORMATION SHALL INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PARTICIPATING PROVIDER IS REIMBURSED FOR THE PARTICIPATING
PROVIDER'S
SERVICES, INCLUDING THE RANGE AND STRUCTURE OF
ANY FINANCIAL RISK SHARING ARRANGEMENTS, A DESCRIPTION OF
ANY INCENTIVE PLANS, AND, IF REIMBURSED ACCORDING TO A TYPE OF
FEE-FOR-SERVICE ARRANGEMENT, THE LEVEL OF REIMBURSEMENT FOR THE
PARTICIPATING PROVIDER'S SERVICES;
(2) HOW REFERRALS TO OTHER PARTICIPATING PROVIDERS OR TO
NONPARTICIPATING PROVIDERS ARE MADE;
(3) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND
THE POTENTIAL FOR COST TO BE INCURRED;
(4) HOW A PARTICIPATING PROVIDER'S NAME AND ADDRESS WILL BE USED IN
MARKETING MATERIALS.
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE
ALL OF THE FOLLOWING TO A PARTICIPATING PROVIDER:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE
PARTICIPATION CONTRACT, THAT IS NOT OTHERWISE AVAILABLE AS A PUBLIC RECORD, IF
SUCH MATERIAL AFFECTS THE PARTICIPATING PROVIDER;
(2) ADMINISTRATIVE MANUALS RELATED TO PROVIDER
PARTICIPATION, IF ANY;
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION
CONTRACT.
Sec. 1753.08. (A) A HEALTH INSURING CORPORATION SHALL NOTIFY A
PARTICIPATING
PROVIDER PRIOR TO THE EFFECTIVE DATE OF AN AMENDMENT TO THE PARTICIPATING
PROVIDER'S CONTRACT
WITH THE HEALTH INSURING CORPORATION, AND PRIOR TO THE EFFECTIVE DATE OF AN
AMENDMENT TO ANY
DOCUMENT INCORPORATED BY REFERENCE INTO THE CONTRACT IF THE
AMENDMENT OF THE DOCUMENT DIRECTLY AND MATERIALLY AFFECTS THE PARTICIPATING
PROVIDER.
SUCH AMENDMENTS SHALL NOT BE EFFECTIVE WITH REGARD TO A
PARTICIPATING PROVIDER UNTIL THE PARTICIPATING PROVIDER HAS HAD
REASONABLE TIME, AS DEFINED IN THE CONTRACT, TO EXERCISE THE
PARTICIPATING PROVIDER'S RIGHT TO TERMINATE ITS PARTICIPATION
STATUS IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF THE
CONTRACT.
(B) DIVISION (A)
OF THIS SECTION DOES NOT APPLY IF THE DELAY CAUSED BY COMPLIANCE
WITH THAT DIVISION COULD RESULT IN IMMINENT HARM TO AN ENROLLEE
OR IF THE AMENDMENT IS REQUIRED BY STATE OR FEDERAL LAW, RULE,
OR REGULATION.
Sec. 1753.09. (A) EXCEPT AS PROVIDED IN DIVISION
(D) OF THIS SECTION, PRIOR TO
TERMINATING THE PARTICIPATION OF A PROVIDER ON THE
BASIS OF THE PARTICIPATING PROVIDER'S FAILURE TO MEET THE HEALTH INSURING
CORPORATION'S STANDARDS FOR QUALITY OR UTILIZATION IN THE DELIVERY OF HEALTH
CARE
SERVICES, A HEALTH INSURING CORPORATION SHALL GIVE THE
PARTICIPATING PROVIDER NOTICE OF THE REASON OR REASONS FOR ITS
DECISION TO TERMINATE THE PROVIDER'S PARTICIPATION AND AN OPPORTUNITY TO TAKE
CORRECTIVE ACTION. THE HEALTH INSURING CORPORATION SHALL
DEVELOP A PERFORMANCE IMPROVEMENT PLAN IN CONJUNCTION WITH THE
PARTICIPATING PROVIDER. IF AFTER BEING AFFORDED THE OPPORTUNITY
TO COMPLY WITH THE PERFORMANCE IMPROVEMENT PLAN, THE PARTICIPATING PROVIDER
FAILS TO DO SO, THE HEALTH INSURING CORPORATION MAY TERMINATE THE
PARTICIPATION OF THE PROVIDER.
(B)(1) A PARTICIPATING PROVIDER WHOSE PARTICIPATION HAS
BEEN TERMINATED UNDER DIVISION
(A) OF THIS SECTION MAY APPEAL
THE TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE
HEALTH INSURING CORPORATION. THE MEDICAL DIRECTOR SHALL GIVE
THE PARTICIPATING PROVIDER AN OPPORTUNITY TO DISCUSS WITH THE
MEDICAL DIRECTOR THE REASON OR REASONS FOR THE TERMINATION.
(2) IF A SATISFACTORY RESOLUTION OF A PARTICIPATING
PROVIDER'S APPEAL CANNOT BE REACHED UNDER DIVISION
(B)(1)OF THIS SECTION, THE PARTICIPATING PROVIDER
MAY APPEAL THE TERMINATION TO A PANEL COMPOSED OF PARTICIPATING
PROVIDERS
WHO HAVE COMPARABLE OR HIGHER LEVELS OF
EDUCATION AND TRAINING THAN THE PARTICIPATING PROVIDER MAKING
THE APPEAL. A REPRESENTATIVE OF THE PARTICIPATING PROVIDER'S
SPECIALTY SHALL BE A MEMBER OF THE PANEL, IF POSSIBLE. THIS
PANEL SHALL HOLD A HEARING, AND SHALL RENDER ITS RECOMMENDATION IN THE
APPEAL WITHIN THIRTY DAYS AFTER HOLDING THE HEARING. THE
RECOMMENDATION SHALL BE PRESENTED TO THE MEDICAL DIRECTOR AND TO THE
PARTICIPATING PROVIDER.
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE
PANEL'S RECOMMENDATION BEFORE MAKING A DECISION. THE DECISION
RENDERED BY THE MEDICAL DIRECTOR SHALL BE FINAL.
(C) A
PROVIDER'S STATUS AS A PARTICIPATING PROVIDER SHALL REMAIN IN EFFECT DURING
THE APPEAL
PROCESS SET FORTH IN DIVISION (B) OF THIS
SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF THE REASONS
LISTED IN DIVISION (D) OF THIS
SECTION.
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A
PROVIDER'S PARTICIPATION MAY BE
IMMEDIATELY TERMINATED IF THE PARTICIPATING PROVIDER'S CONDUCT PRESENTS AN
IMMINENT RISK OF HARM TO
AN ENROLLEE OR ENROLLEES; OR IF THERE HAS OCCURRED UNACCEPTABLE
QUALITY OF CARE, FRAUD, PATIENT ABUSE, LOSS OF CLINICAL
PRIVILEGES, LOSS OF PROFESSIONAL LIABILITY COVERAGE, INCOMPETENCE, OR LOSS OF
AUTHORITY TO PRACTICE IN THE PARTICIPATING PROVIDER'S FIELD; OR IF A
GOVERNMENTAL ACTION HAS
IMPAIRED THE PARTICIPATING PROVIDER'S ABILITY TO PRACTICE.
(E) DIVISIONS (A) TO (D) OF THIS SECTION APPLY
ONLY TO PROVIDERS WHO ARE NATURAL PERSONS.
(F)(1) NOTHING IN THIS
SECTION PROHIBITS A HEALTH INSURING CORPORATION FROM REJECTING A
PROVIDER'S APPLICATION FOR PARTICIPATION, OR FROM
TERMINATING A PARTICIPATING PROVIDER'S CONTRACT, IF THE HEALTH
INSURING CORPORATION DETERMINES THAT THE HEALTH CARE NEEDS OF
ITS ENROLLEES ARE BEING MET AND NO NEED EXISTS FOR THE
PROVIDER'S OR PARTICIPATING PROVIDER'S SERVICES.
(2) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS PROHIBITING A HEALTH
INSURING CORPORATION FROM TERMINATING A PARTICIPATING PROVIDER WHO DOES NOT
MEET THE TERMS
AND CONDITIONS OF THE PARTICIPATING PROVIDER'S CONTRACT.
(G) THE SUPERINTENDENT OF INSURANCE MAY ADOPT
RULES AS NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO
1753.09 OF THE REVISED
CODE. SUCH RULES SHALL BE
ADOPTED IN ACCORDANCE WITH
CHAPTER 119. OF THE
REVISED
CODE. THE DIRECTOR OF HEALTH
MAY MAKE RECOMMENDATIONS TO THE SUPERINTENDENT FOR RULES
NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09
OF THE REVISED
CODE. IN ADOPTING ANY RULES
PURSUANT TO THIS DIVISION, THE SUPERINTENDENT SHALL CONSIDER THE
RECOMMENDATIONS OF THE DIRECTOR.
Sec. 1753.10. NOTHING IN THIS CHAPTER OR
CHAPTER 1751. OF THE
REVISED
CODE REQUIRES A HEALTH INSURING
CORPORATION TO EMPLOY OR CONTRACT WITH, OR PROHIBITS A HEALTH
INSURING CORPORATION FROM EMPLOYING OR CONTRACTING WITH, ANY
CATEGORY OF PROVIDER FOR THE PROVISION OF BASIC OR SUPPLEMENTAL
HEALTH CARE SERVICES, WHICH HEALTH CARE SERVICES ARE WITHIN THE
RECOGNIZED SCOPE OF PRACTICE OF THAT CATEGORY OF
PROVIDER.
Sec. 1753.14. (A) A HEALTH INSURING CORPORATION
THAT DOES NOT ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL
ESTABLISH AND IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY
RECEIVE A STANDING REFERRAL TO A SPECIALIST. THE PROCEDURE
SHALL PROVIDE FOR A STANDING REFERRAL TO A SPECIALIST IF A
PRIMARY CARE PROVIDER DETERMINES IN CONSULTATION WITH A
SPECIALIST THAT AN ENROLLEE NEEDS CONTINUING CARE FROM
A SPECIALIST. THE REFERRAL SHALL BE MADE PURSUANT TO A
TREATMENT PLAN APPROVED BY THE HEALTH INSURING CORPORATION IN
CONSULTATION WITH THE PRIMARY CARE PROVIDER, A SPECIALIST,
AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE NUMBER OF
VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT THE
VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE
THE PRIMARY CARE PROVIDER WITH REGULAR REPORTS ON THE HEALTH
CARE PROVIDED TO THE ENROLLEE.
(B) A HEALTH INSURING
CORPORATION SHALL ESTABLISH AND IMPLEMENT A PROCEDURE BY WHICH
AN ENROLLEE WITH A CONDITION OR DISEASE THAT REQUIRES
SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME AND IS
LIFE-THREATENING, DEGENERATIVE, OR DISABLING MAY RECEIVE A
REFERRAL TO A SPECIALIST WHO HAS EXPERTISE IN TREATING THE
CONDITION OR DISEASE FOR THE PURPOSE OF HAVING THE SPECIALIST
COORDINATE THE ENROLLEE'S HEALTH CARE.
THE PROCEDURE SHALL PROVIDE FOR SUCH A REFERRAL IF A
PRIMARY CARE PROVIDER DETERMINES IN CONSULTATION WITH THE
SPECIALIST THAT THE ENROLLEE NEEDS THE SPECIALIST'S
EXPERTISE.
THE REFERRAL SHALL BE
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH
INSURING CORPORATION IN CONSULTATION WITH THE PRIMARY CARE
PROVIDER, THE SPECIALIST, AND THE ENROLLEE. AFTER THE REFERRAL IS
MADE, THE SPECIALIST IS AUTHORIZED TO PROVIDE HEALTH CARE
SERVICES TO THE ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S
PRIMARY CARE PROVIDER, SUBJECT TO THE TERMS OF THE TREATMENT
PLAN.
(C) THE DETERMINATIONS
DESCRIBED IN DIVISIONS (A) AND
(B) OF THIS SECTION SHALL BE
MADE WITHIN THREE BUSINESS DAYS AFTER A REQUEST FOR THE
DETERMINATION IS MADE BY THE ENROLLEE OR THE ENROLLEE'S PRIMARY
CARE PROVIDER AND ALL APPROPRIATE MEDICAL RECORDS AND OTHER
ITEMS OF INFORMATION NECESSARY TO MAKE THE DETERMINATION HAVE BEEN
PROVIDED.
(D) ONCE A DETERMINATION IN FAVOR OF A REFERRAL IS MADE, THE
REFERRAL SHALL BE
MADE WITHIN FOUR BUSINESS DAYS AFTER THE DETERMINATION.
THIS TIME PERIOD DOES NOT APPLY TO STANDING REFERRALS
INVOLVING A RARE OR UNUSUAL CONDITION FOR WHICH APPROPRIATE
SPECIALISTS ARE LIMITED IN NUMBER OR OTHERWISE DIFFICULT TO
IDENTIFY.
DIVISIONS (A) AND
(B) OF THIS SECTION DO NOT
REQUIRE A HEALTH INSURING CORPORATION TO PERMIT AN ENROLLEE TO
ELECT REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER
CONTRACT WITH THE HEALTH INSURING CORPORATION FOR THE PROVISION
OF HEALTH CARE SERVICES TO THE HEALTH INSURING CORPORATION'S
ENROLLEES.
Sec. 1753.16. A HEALTH INSURING CORPORATION OR
UTILIZATION REVIEW ORGANIZATION THAT AUTHORIZES A PROPOSED
ADMISSION, TREATMENT, OR HEALTH CARE SERVICE BY A PARTICIPATING PROVIDER
BASED UPON THE COMPLETE AND ACCURATE SUBMISSION OF ALL NECESSARY INFORMATION
RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT RETROACTIVELY DENY
THIS AUTHORIZATION IF THE PROVIDER RENDERS THE HEALTH CARE
SERVICE IN GOOD FAITH AND PURSUANT TO THE AUTHORIZATION AND ALL
OF THE TERMS AND CONDITIONS OF THE PROVIDER'S CONTRACT WITH THE
HEALTH INSURING CORPORATION.
Sec. 1753.21. (A) IF A POLICY, CONTRACT, OR AGREEMENT OF A
HEALTH INSURING
CORPORATION USES A
RESTRICTED FORMULARY OF PRESCRIPTION DRUGS, THE HEALTH
INSURING CORPORATION SHALL DO BOTH OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND
WITH THE APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A
MAJORITY OF THE MEMBERS OF WHICH ARE PHYSICIANS AFFILIATED WITH
THE HEALTH INSURING CORPORATION WHO MAY PRESCRIBE PRESCRIPTION
DRUGS AND PHARMACISTS AFFILIATED WITH THE HEALTH INSURING
CORPORATION; OR IN CONSULTATION WITH AND WITH THE APPROVAL OF A
PHARMACY AND THERAPEUTICS COMMITTEE
THAT IS INDEPENDENT OF THE HEALTH INSURING
CORPORATION CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS
WHO ARE AUTHORIZED TO PRACTICE IN THEIR STATE OF
LICENSURE;
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY
OBTAIN, WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT
PROVIDED FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH
THE HEALTH INSURING CORPORATION, COVERAGE OF A SPECIFIC
NONFORMULARY DRUG WHEN THE PRESCRIBER DOCUMENTS IN THE
ENROLLEE'S MEDICAL RECORD AND CERTIFIES THAT THE FORMULARY
ALTERNATIVE HAS BEEN INEFFECTIVE IN THE TREATMENT OF THE
ENROLLEE'S DISEASE OR CONDITION, OR THAT THE FORMULARY
ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE PRESCRIBER
TO CAUSE A HARMFUL OR ADVERSE REACTION IN THE ENROLLEE.
(B) NOTHING IN THIS
SECTION SHALL BE CONSTRUED TO REQUIRE A HEALTH INSURING
CORPORATION TO PLACE ANY PARTICULAR PHARMACEUTICAL PRODUCT OR
THERAPEUTIC CLASS OF PRODUCT ON ANY FORMULARY, OR TO PROHIBIT A
HEALTH INSURING CORPORATION FROM RESTRICTING PAYMENTS FOR ANY
SPECIFIC PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT,
INCLUDING, BUT NOT LIMITED TO, A REQUIREMENT THAT THE PRODUCT BE
PRESCRIBED ONLY BY A DEFINED SPECIALIST OR SUBSPECIALIST.
Sec. 1753.23. A HEALTH INSURING CORPORATION
SHALL ESTABLISH OR USE AN INTERNAL TECHNOLOGY ASSESSMENT PROCESS FOR
ASSESSING WHETHER A DRUG, DEVICE, PROTOCOL, PROCEDURE, OR OTHER
THERAPY IS PROVEN TO BE SAFE AND EFFICACIOUS FOR A PARTICULAR
INDICATION OR CONDITION WHEN COMPARED TO ALTERNATIVE THERAPIES,
OR WHETHER IT REMAINS EXPERIMENTAL OR INVESTIGATIONAL. THE
HEALTH INSURING CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT
PROCESS SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(A) DECISIONS ARE MADE
BY MEDICAL PROFESSIONALS, INCLUDING PHYSICIANS.
(B) THE PROCESS INCLUDES
A REVIEW OF RELEVANT MEDICAL EVIDENCE, INCLUDING THE FOLLOWING,
IF AVAILABLE:
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON
THE SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH
AS THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER
INSTITUTE, THE UNITED
STATES FOOD AND DRUG
ADMINISTRATION, THE HEALTH CARE FINANCE ADMINISTRATION, AND THE AGENCY FOR
HEALTH CARE POLICY AND
RESEARCH;
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED
SPECIALTY SOCIETIES.
(C) GENERAL COVERAGE
DECISIONS, MADE PURSUANT TO THIS PROCESS, THAT EXCLUDE DRUGS,
DEVICES, PROTOCOLS, PROCEDURES, OR OTHER THERAPIES ON THE BASIS
THAT THEY ARE NOT SAFE OR EFFICACIOUS AND REMAIN EXPERIMENTAL OR
INVESTIGATIONAL, ARE REVIEWED AND UPDATED AS NEW SCIENTIFIC
EVIDENCE BECOMES AVAILABLE.
(D) A DESCRIPTION OF THE
HEALTH INSURING CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT
PROCESS IS MADE AVAILABLE TO PARTICIPATING PROVIDERS AND
ENROLLEES, UPON REQUEST.
(E) A COPY OF THE
HEALTH INSURING CORPORATION'S SPECIFIC COVERAGE PROTOCOLS AND
PROCEDURES IS MADE AVAILABLE TO PARTICIPATING PROVIDERS AND
ENROLLEES UPON THE REQUEST OF AN ENROLLEE WHO HAS BEEN DENIED
COVERAGE FOR A DRUG, DEVICE, PROTOCOL, PROCEDURE, OR OTHER
THERAPY ON THE BASIS THAT IT HAS BEEN ASSESSED AS NOT BEING SAFE
OR EFFICACIOUS FOR A PARTICULAR INDICATION OR CONDITION.
SPECIFIC COVERAGE PROTOCOLS AND PROCEDURES SHALL
INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH THE PROTOCOL OR
PROCEDURE IS BASED, AND SHALL CONTAIN THE DATE THE PROTOCOL OR
PROCEDURE WAS ADOPTED.
Sec. 1753.24. (A) EACH HEALTH INSURING CORPORATION SHALL
ESTABLISH A
REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO EXAMINE THE HEALTH INSURING
CORPORATION'S COVERAGE
DECISIONS FOR ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING TO THE CURRENT
DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH PROBABILITY OF CAUSING
DEATH WITHIN TWO YEARS.
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE HAS THE CONDITION
DESCRIBED IN DIVISION (A)(1) OF THIS SECTION
AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE:
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN IMPROVING THE
CONDITION OF THE
ENROLLEE;
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE
FOR THE ENROLLEE;
(c) THERE IS NO STANDARD THERAPY
COVERED BY THE HEALTH INSURING CORPORATION THAT IS MORE BENEFICIAL THAN
THERAPY DESCRIBED IN DIVISION (A)(3) OF
THIS SECTION.
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, DEVICE, PROCEDURE, OR
OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, IN WRITING,
IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE, IN THE PHYSICIAN'S OPINION,
THAN STANDARD
THERAPIES, OR, THE ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED WITH
EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION.
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE HEALTH INSURING
CORPORATION FOR A DRUG,
DEVICE,
PROCEDURE, OR OTHER THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION
(A)(3) OF THIS SECTION, AND HAS EXHAUSTED ALL INTERNAL APPEALS.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, RECOMMENDED OR
REQUESTED PURSUANT TO
DIVISION (A)(3) OF THIS SECTION, WOULD BE A COVERED HEALTH CARE
SERVICE EXCEPT
FOR THE HEALTH INSURING CORPORATION'S DETERMINATION THAT THE DRUG, DEVICE,
PROCEDURE, OR OTHER
THERAPY IS EXPERIMENTAL OR INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED BY A
HEALTH INSURING CORPORATION SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, THE
PROCESS SHALL OFFER ALL ENROLLEES WHO MEET THE CRITERIA SET FORTH
IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE
THE HEALTH INSURING CORPORATION'S DECISION TO DENY
COVERAGE OF THE RECOMMENDED OR REQUESTED
THERAPY REVIEWED UNDER THE PROCESS. EACH ELIGIBLE ENROLLEE SHALL BE NOTIFIED
OF THAT OPPORTUNITY WITHIN FIVE BUSINESS DAYS AFTER THE
HEALTH INSURING CORPORATION DENIES COVERAGE.
(2) THE REVIEW OF THE HEALTH INSURING CORPORATION'S DECISION SHALL
BE CONDUCTED BY EXPERTS SELECTED BY AN INDEPENDENT ENTITY THAT
HAS BEEN RETAINED BY THE HEALTH INSURING CORPORATION FOR THIS
PURPOSE. THE INDEPENDENT ENTITY SHALL BE EITHER AN ACADEMIC
MEDICAL CENTER OR AN ENTITY THAT HAS AS ITS PRIMARY FUNCTION,
AND THAT RECEIVES A MAJORITY OF ITS REVENUE FROM, THE PROVISION
OF EXPERT REVIEWS AND RELATED SERVICES.
THE INDEPENDENT ENTITY SHALL SELECT A PANEL TO CONDUCT
THE REVIEW, WHICH PANEL SHALL BE COMPOSED
OF AT LEAST THREE PHYSICIANS OR OTHER
PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF THE ENROLLEE'S MEDICAL CONDITION
AND KNOWLEDGEABLE ABOUT THE RECOMMENDED OR REQUESTED THERAPY. IF THE
INDEPENDENT ENTITY
RETAINED BY THE HEALTH INSURING
CORPORATION IS AN ACADEMIC MEDICAL CENTER, THE PANEL MAY INCLUDE
EXPERTS AFFILIATED WITH OR EMPLOYED BY THE ACADEMIC MEDICAL
CENTER.
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION
MAY BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY
AN EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR
OTHER PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY
AN EXPERT PANEL COMPOSED OF ONLY TWO PHYSICIANS OR OTHER
PROVIDERS IF AN ENROLLEE HAS CONSENTED IN WRITING TO A REVIEW BY
THE SMALLER PANEL;
(b) A REVIEW MAY BE CONDUCTED BY A
SINGLE EXPERT PHYSICIAN OR OTHER PROVIDER IF ONLY ONE EXPERT
PHYSICIAN OR OTHER PROVIDER IS AVAILABLE FOR THE REVIEW.
(3) NEITHER THE HEALTH INSURING CORPORATION NOR THE ENROLLEE SHALL CHOOSE,
OR CONTROL THE CHOICE OF,
THE PHYSICIAN OR OTHER PROVIDER EXPERTS.
(4) NEITHER THE EXPERTS NOR THE INDEPENDENT ENTITY ARRANGING FOR THE
EXPERTS' REVIEW SHALL HAVE ANY PROFESSIONAL, FAMILIAL, OR FINANCIAL
AFFILIATION
WITH THE HEALTH INSURING CORPORATION, EXCEPT THAT EXPERTS AFFILIATED WITH
ACADEMIC MEDICAL CENTERS
WHO PROVIDE HEALTHCARE SERVICES TO ENROLLEES OF THE HEALTH INSURING
CORPORATION MAY SERVE AS EXPERTS ON THE REVIEW
PANEL. THIS NONAFFILIATION PROVISION DOES NOT
PRECLUDE A HEALTH INSURING CORPORATION FROM PAYING FOR THE EXPERTS' REVIEW, AS
SPECIFIED IN
DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL HAVE NO
PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH AN ENROLLEE WHOSE
REQUEST FOR THERAPY IS UNDER REVIEW OR WITH A PROVIDER WHOSE RECOMMENDATION
FOR THERAPY IS UNDER REVIEW.
(5) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE EXTERNAL, INDEPENDENT
REVIEW. THE COSTS OF THE REVIEW SHALL BE BORNE BY THE HEALTH INSURING
CORPORATION.
(6) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE INDEPENDENT
ENTITY ARRANGING FOR THE EXPERTS'
REVIEW AND TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE
MEDICAL RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION THAT ARE
RELEVANT TO THE ENROLLEE'S
CONDITION FOR WHICH
THERAPY HAS BEEN RECOMMENDED OR REQUESTED. THE MEDICAL RECORDS SHALL BE
DISCLOSED SOLELY
TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE PURPOSE OF THIS
SECTION.
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL SHALL BE RENDERED WITHIN
THIRTY
DAYS AFTER THE ENROLLEE'S REQUEST FOR REVIEW. IF THE ENROLLEE'S PHYSICIAN
DETERMINES
THAT A THERAPY WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT
PROMPTLY INITIATED, THE OPINIONS SHALL BE RENDERED WITHIN SEVEN DAYS AFTER THE
ENROLLEE'S REQUEST FOR REVIEW.
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT ENTITY WITH A
PROFESSIONAL OPINION AS TO WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE
THAT THE RECOMMENDED OR REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO
THE ENROLLEE THAN
STANDARD THERAPIES.
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN FORM AND SHALL
INCLUDE THE
FOLLOWING INFORMATION:
(a) A DESCRIPTION OF THE ENROLLEE'S CONDITION;
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO DETERMINING
WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED OR
REQUESTED THERAPY
IS MORE LIKELY THAN NOT TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD
THERAPIES;
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS PUBLISHED
IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR THE PUBLISHED OPINIONS OF
MEDICAL EXPERTS OR SPECIALTY SOCIETIES;
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE THE
RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT PROTOCOL IN A
CLINICAL TRIAL, IF
APPLICABLE.
(10) THE INDEPENDENT ENTITY SHALL PROVIDE THE HEALTH INSURING CORPORATION
WITH THE OPINIONS OF THE
EXPERTS. THE HEALTH INSURING CORPORATION SHALL MAKE THE EXPERTS' OPINIONS
AVAILABLE TO THE ENROLLEE
AND THE ENROLLEE'S PHYSICIAN, UPON REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE PANEL, RENDERED
PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS BINDING ON THE HEALTH
INSURING CORPORATION.
IF THE OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO WHETHER
THE THERAPY SHOULD BE COVERED, THEN THE HEALTH INSURING CORPORATION'S FINAL
DECISION SHALL BE IN
FAVOR OF
COVERAGE. IF LESS THAN A MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND
COVERAGE OF THE THERAPY, THE HEALTH INSURING CORPORATION MAY, IN ITS
DISCRETION, COVER THE THERAPY.
HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO DIVISION (B)(11) OF THIS
SECTION IS SUBJECT TO THE TERMS AND CONDITIONS OF THE ENROLLEE'S CONTRACT WITH
THE HEALTH INSURING CORPORATION.
(12) THE HEALTH INSURING CORPORATION SHALL HAVE WRITTEN POLICIES
DESCRIBING THE EXTERNAL, INDEPENDENT
REVIEW PROCESS. THE HEALTH INSURING CORPORATION SHALL DISCLOSE THE
AVAILABILITY OF THE EXTERNAL,
INDEPENDENT REVIEW PROCESS IN THE HEALTH INSURING CORPORATION'S EVIDENCE OF
COVERAGE AND DISCLOSURE
FORMS.
(C) IF A HEALTH INSURING CORPORATION'S INITIAL DENIAL OF COVERAGE
FOR A THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION
(A)(3) OF THIS SECTION IS BASED UPON AN EXTERNAL,
INDEPENDENT REVIEW OF THAT THERAPY MEETING THE REQUIREMENTS OF
DIVISION (B) OF THIS SECTION, THIS SECTION SHALL NOT BE A
BASIS FOR REQUIRING A SECOND EXTERNAL, INDEPENDENT REVIEW OF THE
RECOMMENDED OR REQUESTED THERAPY.
(D) THE HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS
COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION.
Sec. 1753.28. (A) AS USED IN THIS SECTION:
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO
RESULT IN ANY OF THE FOLLOWING:
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR,
WITH RESPECT TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER
UNBORN CHILD, IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY
FUNCTIONS;
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR
PART.
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING:
(a) A MEDICAL SCREENING EXAMINATION, AS
REQUIRED BY FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE
EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES
ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN
EMERGENCY MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION
AND TREATMENT THAT ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN
EMERGENCY MEDICAL CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND BURN CENTER OF
THE HOSPITAL.
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH
MEDICAL TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN
REASONABLE MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION
OF AN INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR
OCCUR DURING A TRANSFER, IF THE MEDICAL
CONDITION COULD RESULT IN ANY OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR,
WITH RESPECT TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER
UNBORN CHILD, IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY
FUNCTIONS;
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN
OR PART.
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS,
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO
DELIVER, INCLUDING THE PLACENTA.
(4) "TRANSFER" HAS THE SAME MEANING AS IN SECTION 1867 OF THE
"SOCIAL SECURITY ACT," 49 STAT. 620
(1935), 42 U.S.C.A. 1395dd, AS AMENDED.
(B) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT
PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES
SHALL COVER EMERGENCY
SERVICES FOR ENROLLEES WITH EMERGENCY MEDICAL CONDITIONS WITHOUT
REGARD TO THE DAY OR TIME THE EMERGENCY SERVICES ARE RENDERED OR TO
WHETHER THE ENROLLEE, THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE SERVICES
ARE RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE
ENROLLEE, OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY SERVICES.
(C) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR AGREEMENT
PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES
SHALL COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE PRESENTS
SELF WITH AN EMERGENCY MEDICAL CONDITION;
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT
IF THE ENROLLEE PRESENTS SELF WITH
AN EMERGENCY MEDICAL CONDITION AND ONE OF THE FOLLOWING
CIRCUMSTANCES APPLIES:
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S
CONTROL, THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR
HEALTH.
(b) A PRUDENT LAYPERSON WITH AN AVERAGE
KNOWLEDGE OF HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED
THAT, UNDER THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE
OF THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION
(A)(1) OF THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH INSURING CORPORATION
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT.
(d) AN AMBULANCE TAKES THE ENROLLEE TO A NONPARTICIPATING
HOSPITAL OTHER THAN AT THE DIRECTION OF THE ENROLLEE.
(e) THE ENROLLEE IS UNCONSCIOUS.
(f) A NATURAL DISASTER PRECLUDED THE USE OF A PARTICIPATING
EMERGENCY DEPARTMENT.
(g) THE STATUS OF A HOSPITAL CHANGED FROM PARTICIPATING TO
NONPARTICIPATING WITH RESPECT TO EMERGENCY SERVICES DURING A CONTRACT YEAR AND
NO GOOD FAITH EFFORT WAS MADE BY THE HEALTH INSURING CORPORATION TO INFORM
ENROLLEES OF THIS CHANGE.
(D) A HEALTH INSURING CORPORATION
THAT PROVIDES COVERAGE FOR EMERGENCY SERVICES SHALL
INFORM ENROLLEES OF ALL OF THE FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES;
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES,
INCLUDING THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE
ACCESS SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY
SERVICES;
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES;
(4) THE PROCEDURES FOR OBTAINING EMERGENCY SERVICES AND OTHER
MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS AND WITH THE
LOCATION AND AVAILABILITY OF OTHER PARTICIPATING FACILITIES OR
SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL SERVICES.
Sec. 1753.30. NOTHING IN THIS CHAPTER SHALL PREVENT OR
OTHERWISE AFFECT THE APPLICATION TO ANY HEALTH CARE PLAN OF THOSE PROVISIONS
OF TITLE XVII OR XXXIX OF THE REVISED
CODE THAT WOULD OTHERWISE APPLY.
Sec. 3901.04. (A) As used in this section:
(1) "Laws of this state relating to insurance" include but
are not limited to Chapter
1751. notwithstanding section 1751.08, CHAPTER 1753.,
Title XXXIX, sections 5725.18 to 5725.25, and
Chapter 5729. of the Revised Code.
(2) "Person" has the meaning defined in division (A) of
section 3901.19 of the Revised Code.
(B) Whenever it appears to the superintendent of
insurance, from the superintendent's files, upon complaint
or otherwise, that any person has engaged in, is engaged in, or is about to
engage in any act or practice declared to be illegal or prohibited by the
laws of this state relating to insurance, or defined as unfair or
deceptive by such laws, or when the superintendent believes it to
be in the best interest of the public and necessary for the
protection of the people in this state, the superintendent or
anyone designated by the superintendent under the
superintendent's official seal may do any one or more of the following:
(1) Require any person to file with the superintendent, on
a form that is appropriate for review by the superintendent, an
original or additional statement or report in writing, under oath
or otherwise, as to any facts or circumstances concerning the
person's conduct of the business of insurance within this state
and as to any other information that the superintendent considers
to be material or relevant to such business;
(2) Administer oaths, summon and compel by order or
subpoena the attendance of witnesses to testify in relation to
any matter which, by the laws of this state relating to
insurance, is the subject of inquiry and investigation, and
require the production of any book, paper, or document pertaining
to such matter. A subpoena, notice, or order under this section
may be served by certified mail, return receipt requested. If
the subpoena, notice, or order is returned because of inability
to deliver, or if no return is received within thirty days of the
date of mailing, the subpoena, notice, or order may be served by
ordinary mail. If no return of ordinary mail is received within
thirty days after the date of mailing, service shall be deemed to
have been made. If the subpoena, notice, or order is returned
because of inability to deliver, the superintendent may designate
a person or persons to effect either personal or residence
service upon the witness. Service of any subpoena, notice, or
order and return may also be made in any manner authorized under
the Rules of Civil Procedure. Such service shall be made by an
employee of the department designated by the superintendent, a
sheriff, a deputy sheriff, an attorney, or any person authorized
by the Rules of Civil Procedure to serve process.
In the case of disobedience of any notice, order, or
subpoena served on a person or the refusal of a witness to
testify to a matter regarding which the person may lawfully
be interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel
obedience by attachment proceedings for contempt, as in the case
of disobedience of the requirements of a subpoena issued from
such court, or a refusal to testify therein. Witnesses shall
receive the fees and mileage allowed by section 2335.06 of the
Revised Code. All such fees, upon the presentation of proper
vouchers approved by the superintendent, shall be paid out of the
appropriation for the contingent fund of the department of
insurance. The fees and mileage of witnesses not summoned by the
superintendent or the superintendent's designee shall not be
paid by the state.
(3) In a case in which there is no administrative
procedure available to the superintendent to resolve a matter at
issue, request the attorney general to commence an action for a
declaratory judgment under Chapter 2721. of the Revised Code with
respect to the matter.
(4) Initiate criminal proceedings by presenting evidence
of the commission of any criminal offense established under the
laws of this state relating to insurance to the prosecuting
attorney of any county in which the offense may be prosecuted.
At the request of the prosecuting attorney, the attorney general
may assist in the prosecution of the violation with all the
rights, privileges, and powers conferred by law on prosecuting
attorneys including, but not limited to, the power to appear
before grand juries and to interrogate witnesses before grand
juries.
Sec. 3901.041. The superintendent of insurance shall adopt, amend, and
rescind rules and make adjudications, necessary to discharge the
superintendent's duties and exercise the
superintendent's powers, including, but not limited to, the
superintendent's duties and powers under Chapter
CHAPTERS 1751. AND 1753. and Title XXXIX of
the Revised Code, subject to Chapter 119. of the Revised Code.
Sec. 3901.16. Any association, company, or corporation, including a
health insuring corporation, which violates any law
relating to the superintendent of insurance, any provision of
Chapter 1751. OR 1753. of the Revised Code, or any insurance
law of this state,
for the violation of which no forfeiture or penalty is elsewhere provided in
the Revised Code, shall forfeit and pay not less than one thousand
nor more than ten thousand dollars, to be recovered by an action in the name
of the state and on collection to be paid to the superintendent, who shall pay
such sum into the state treasury.
Sec. 3924.10. (A) The board of directors of the Ohio health reinsurance
program shall design the SEHC
plan which, when offered by a carrier, is eligible for
reinsurance under the program. The board shall establish the
form and level of coverage to be made available by carriers in
their SEHC plan. In designing the plan the board shall
also establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan. The forms and levels
of coverage established by the board shall specify which
components of a health benefit plan offered by a
carrier may be reinsured. The SEHC plan is subject
to division (C) of section 3924.02 of the Revised Code and
to the provisions in Chapters 1751., 1753., 3923., and any
other
chapter of the Revised Code that require coverage or the
offer of coverage of a health care service or benefit.
(B) The board shall adopt the SEHC plan within one
hundred eighty days after its appointment. The plan may include
cost containment features including any of the following:
(1) Utilization review of health care services, including
review of the medical necessity of hospital and physician
services;
(2) Case management benefit alternatives;
(3) Selective contracting with hospitals, physicians, and
other health care providers;
(4) Reasonable benefit differentials applicable to
participating and nonparticipating providers;
(5) Employee assistance program options that provide
preventive and early intervention mental health and substance
abuse services;
(6) Other provisions for the cost-effective management of
the plan.
(C) An SEHC plan established for use by health
insuring corporations shall be
consistent with the basic
method of operation of such corporations.
(D) Each carrier shall certify to the superintendent of
insurance, in the form and manner prescribed by the
superintendent, that the SEHC plan filed by the carrier
is in substantial compliance with the provisions of the board
SEHC plan. Upon receipt by the superintendent of the
certification, the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the
date that the program becomes operational and as a condition of
transacting business in this state, renew coverage provided to
any individual or group under its SEHC plan.
Section 2. That existing sections 1751.02, 1751.03, 1751.04, 1751.12, 1751.13,
3901.04,
3901.041, 3901.16, and 3924.10 of the Revised Code are hereby
repealed.
Section 3. Sections 1 and 2 of this act, except for section 1751.12 of the
Revised Code, shall take effect October 1, 1998. Section 1751.12 of the
Revised Code shall take effect at the earliest time permitted by law.
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